Crash of a Piper PA-31-350 Navajo Chieftain in Grand Lac Germain: 1 killed

Date & Time: Apr 1, 2007 at 0700 LT
Operator:
Registration:
C-FTIW
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Seven Islands - Wabush
MSN:
31-7752123
YOM:
1977
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
5475
Captain / Total hours on type:
790.00
Circumstances:
The aircraft, operated by Aéropro, was on a visual flight rules (VFR) flight from Sept-Îles, Quebec, to Wabush, Newfoundland and Labrador. The pilot, who was the sole occupant, took off around 0630 eastern daylight time. Shortly before 0700, the aircraft turned off its route and proceeded to Grand lac Germain to fly over the cottage of friends. Around 0700, the aircraft overflew the southeast bay of Grand lac Germain. The pilot then overflew a second time. The aircraft proceeded northeast and disappeared behind the trees. A few seconds later, the twin-engine aircraft crashed on the frozen surface of the lake. The pilot was fatally injured; the aircraft was destroyed by impact forces.
Probable cause:
Finding as to Causes and Contributing Factors:
1. The aircraft stalled at an altitude that was too low for the pilot to recover.
Findings as to Risk:
1. The aircraft was flying at an altitude that could lead to a collision with an obstacle and that did not allow time for recovery.
2. The steep right bank of the aircraft considerably increased the aircraft’s stall speed.
3. The form used to record the pilot’s flight time, flight duty time, and rest periods had not been updated for over a month; this did not allow the company manager to monitor the pilot’s hours.
4. At the time of the occurrence, the Aéropro company operations manual did not make provision for the restrictions on daytime VFR flights prescribed in Section 703.27 of the Canadian Aviation Regulations.
Other Findings:
1. The fact that the aircraft was not equipped with a flight data recorder (FDR) or a cockpit voice recorder (CVR) limited the information available for the investigation and limited the scope of the investigation.
2. Since the aircraft was on a medical evacuation (MEDEVAC) flight, the company mistakenly advised the search and rescue centre that there were two pilots on board the aircraft when it was reported missing.
Final Report:

Crash of a Beechcraft 200C Super King Air off East Bay Cay: 1 killed

Date & Time: Feb 6, 2007 at 1842 LT
Operator:
Registration:
VQ-TIU
Flight Phase:
Survivors:
Yes
Schedule:
East Bay Cay - Grand Turk
MSN:
BL-131
YOM:
1988
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
8500
Captain / Total hours on type:
394.00
Aircraft flight hours:
24578
Aircraft flight cycles:
31684
Circumstances:
The aircraft was parked on the small apron at North Caicos Airport while the pilot went home to collect some personal items. One of the intended passengers saw the aircraft arrive. He remained in the vicinity until the pilot returned, and reported that the aircraft was unattended in the intervening time. When the pilot returned, four of the five passengers were gathered near the aircraft, and the last passenger arrived soon afterwards. The pilot, a local man well-known to the passengers, appeared to be his normal self and in good spirits. As most inter-island travel in the TCI is by air, the passengers were also familiar with the operator’s aircraft and used to travelling by air. Some had flown frequently on VQ-TIU. The pilot supervised embarkation and gave an emergency briefing. One passenger reported that the pilot made a mobile telephone call, which he presumed to be to Air Traffic Control (ATC) at Providenciales to notify them of the proposed flight. Prior to seating himself at the controls, the pilot told the passengers that they may expect some turbulence. The aircraft taxied onto the runway at its eastern end and along its length for a departure from Runway 08. It was about one hour after sunset and outside the airport’s normal operating hours, so there were no ATC personnel on duty. The runway lights were operated by the operator’s station manager. The aircraft took off at 1840 hrs. Soon after takeoff the aircraft was seen to start a turn to the right, which was consistent with its routing to Grand Turk, some 54 nm to the south-east. However, the aircraft reached a relatively large angle of bank and started to descend. The descent continued until it crashed with significant forward speed into an area of very shallow water. The aircraft broke up on impact, with the fuselage section coming to rest nearly inverted but comparatively intact. All those on board survived the impact sequence with varying degrees of injury. However, the pilot died before he could receive specialist medical treatment.
Probable cause:
The investigation identified the following causal factors:
1. The aircraft adopted an excessive degree of right bank soon after takeoff. This led to a descending, turning flight path which persisted until the aircraft was too low to make a safe recovery.
2. The pilot probably became spatially disoriented and was unable to recognise or correct the situation in time to prevent the accident.
The investigation identified the following contributory factors:
1. The environmental conditions were conducive to a spatial disorientation event.
2. The pilot had probably consumed alcohol prior to the flight, which made him more prone to becoming disorientated.
3. The flight was operated single-pilot when two pilots were required under applicable regulations. The presence of a second pilot would have provided a significant measure of protection against the effects of the flying pilot becoming disoriented.
Final Report:

Crash of a Cessna 207A Skywagon in the Cook Inlet: 1 killed

Date & Time: Jan 9, 2007 at 1035 LT
Operator:
Registration:
N9941M
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Kenai - Kokhanok
MSN:
207-0748
YOM:
1981
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
5291
Captain / Total hours on type:
512.00
Aircraft flight hours:
13774
Circumstances:
The commercial certificated pilot prepared for a VFR cross-country nonscheduled cargo flight under Title 14, CFR Part 135, by preflighting the wheel-equipped airplane and starting the engine. The airplane had been parked on the airport ramp overnight, with an electric engine heater and an engine cover on. A portion of the flight was over ocean waters to a remote village. After engine start, the pilot contacted the company owner and reported that the engine oil pressure appeared to be low, but within the operating range. The owner and the pilot discussed the possible reasons, such as cold ambient temperatures, which was about -20 degrees F. The pilot then departed, and reported to his company that the engine pressure was good. About 10 minutes later, he declared an emergency and stated he was ditching in the water, about 18 miles west of the departure airport. Retrieved track data from the pilot's GPS showed the airplane's maximum altitude was 1,439 feet msl, while crossing the ocean in an area that was about 22 miles wide. A review of the manufacturer's maximum glide distance chart revealed that from an altitude of about 1,500 feet, the airplane could glide about 2.1 nautical miles. The airplane was located about two hours after the accident, floating nose down next to a segment of pan ice, about 8.8 miles from the initial accident location. The pilot was not recovered with the airplane, and subsequent searches did not locate him. Following recovery of the airplane, examination of the engine revealed a 8 X 5 inch hole in the top of the case, adjacent to the number 2 cylinder. The number 2 connecting rod was broken from its crankshaft journal, and broken from the bottom of the piston. The number 1 connecting rod bearing was missing from its normal position on the crankshaft journal and the rod had evidence of high heat. Evidence of oil starvation and high heat signatures to several crankshaft and connecting rod bearings was found throughout the engine, along with a large amount of fragmented bearing material. The pilot was not wearing any personal flotation equipment, and the expected survival time in the 29 degree F ocean water was about 30 minutes. The company's operations manual does not contain a written policy requiring pilot's to maintain sufficient altitude to reach shore when crossing ocean waters.
Probable cause:
The total loss of engine power during cruise flight due to the disintegration of engine bearings and the fracture of a connecting rod, which resulted in a ditching into ice covered ocean water. Factors contributing to the survivability of the accident were the pilot's improper decision to fly over frigid water without sufficient altitude to reach a suitable landing area, the lack of written policy and procedures by the operator requiring sufficient altitude to reach shore when crossing ocean waters, temperature extremes consisting of sub-zero air and below freezing water temperatures, and the lack of personal flotation/survival equipment.
Final Report:

Crash of a Boeing 737-4Q8 off Ujung Pandang: 102 killed

Date & Time: Jan 1, 2007 at 1459 LT
Type of aircraft:
Operator:
Registration:
PK-KKW
Flight Phase:
Survivors:
No
Schedule:
Jakarta – Surabaya – Manado
MSN:
24070
YOM:
1989
Flight number:
DHI574
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
96
Pax fatalities:
Other fatalities:
Total fatalities:
102
Captain / Total flying hours:
13356
Captain / Total hours on type:
3856.00
Copilot / Total flying hours:
4200
Copilot / Total hours on type:
998
Aircraft flight hours:
45371
Aircraft flight cycles:
26725
Circumstances:
On 1 January 2007, a Boeing Company 737-4Q8 aircraft, registered PK-KKW, operated by Adam SkyConnection Airlines (AdamAir) as flight number DHI574, was on a scheduled passenger flight from Surabaya (SUB), East Java to Manado (MDC), Sulawesi, at FL350 (35,000 feet) when it disappeared from radar. The aircraft departed from Djuanda Airport, Surabaya at 05:59 Coordinated Universal Time (UTC) under the instrument flight rules (IFR), with an estimated time of arrival (ETA) at Sam Ratulangi Airport, Manado of 08:14. The fuel endurance on departure from Surabaya was hours 30 minutes, and the crew had flight planned for an alternate of Gorontalo (GTO). The pilot in command (PIC) was the pilot flying for the sector to Manado and the copilot was the monitoring/support pilot. There were 102 people on board; two pilots, 4 cabin crew, and 96 passengers comprised of 85 adults, 7 children and 4 infants.
Probable cause:
The following findings were identified:
1) Flight crew coordination was less than effective. The PIC did not manage the task sharing; crew resource management practices were not followed.
2) The crew focused their attention on troubleshooting the Inertial Reference System (IRS) failure and neither pilot was flying the aircraft.
3) After the autopilot disengaged and the aircraft exceeded 30 degrees right bank, the pilots appeared to have become spatially disoriented.
4) The AdamAir syllabus of pilot training did not cover complete or partial IRS failure.
5) The pilots had not received training in aircraft upset recovery, including spatial disorientation.
Other Causal Factors:
1) At the time of the accident, AdamAir had not resolved the airworthiness problems with the IRS that had been reoccurring on their Boeing 737 fleet for more than 3 months.
2) The AdamAir maintenance engineering supervision and oversight was not effective and did not ensure that repetitive defects were rectified.
Final Report:

Crash of a Britten-Norman BN-2A-27 Islander off Tauranga

Date & Time: Dec 28, 2006 at 1000 LT
Type of aircraft:
Operator:
Registration:
ZK-WNZ
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Tauranga - Hamilton
MSN:
278
YOM:
1971
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The pilot was ferrying the aircraft from Tauranga to a Hamilton maintenance facility when one of the engines failed. The pilot elected to turn back to Tauranga but, shortly after, the remaining engine failed. The pilot carried out a forced landing into a tidal estuary. The aircraft incurred substantial damage to the nose landing gear. Subsequent CAA safety investigation determined that on an earlier flight, the aircraft's electrical system incurred a defect that rendered several electrical components unserviceable, including the two tip/main fuel tank selector valves. No engineering inspection or rectification ensued and the operator ferried the aircraft from Great Barrier Island unaware that the engines were being fed from the tip tanks only. The operator departed Tauranga for Hamilton under similar circumstances, reaching the vicinity of the Kaimai Ranges when the tip tanks became empty.
Probable cause:
Fuel exhaustion.

Crash of an Antonov AN-32B off Pie de la Cuesta AFB: 4 killed

Date & Time: Dec 16, 2006 at 0925 LT
Type of aircraft:
Operator:
Registration:
3103
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Pie de la Cuesta AFB - Santa Lucía AFB
MSN:
31 06
YOM:
1992
Country:
Crew on board:
4
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
4
Circumstances:
The aircraft departed Pie de la Cuesta AFB on a routine flight ro Santa Lucia AFB near Mexico City. Few minutes after takeoff, the aircraft went out of control and crashed in the sea about 9 km southeast of the airbase. All four crew members were killed.

Crash of a De Havilland DHC-3 Otter off Flamingo Bay

Date & Time: Dec 9, 2006
Type of aircraft:
Registration:
N335AK
Flight Phase:
Flight Type:
Survivors:
Yes
MSN:
263
YOM:
1958
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Shortly after takeoff from Flamingo Bay, the single engine aircraft crashed in the sea few dozen metres offshore. The pilot was injured and the aircraft was destroyed.

Crash of a Rockwell Shrike Commander 500S off Kingstown: 2 killed

Date & Time: Nov 19, 2006 at 1853 LT
Operator:
Registration:
J8-VAX
Survivors:
No
Schedule:
Canouan - Kingstown
MSN:
500-1869-45
YOM:
1969
Flight number:
SVD360
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
The twin engine aircraft departed Canouan Island Airport at 1842LT on a short flight to Kingstown, Saint Vincent & Grenadines, carrying one passenger and one pilot. Shortly after takeoff, the pilot was instructed to report once passing over Bequia Island. Few minutes later, after passing Bequia Island, the pilot contacted ATC and reported he was at the altitude of 1,100 feet with an ETA in Kingstown in four minutes. At 1853LT, the aircraft crashed in unknown circumstances in the sea. The next morning, few debris were found floating on water and no trace of both occupants was ever found. The passenger was the Director of American Eagle for the Canouan Island. All SAR operations were abandoned few days later and the wreckage was not found.
Probable cause:
Due to the absence of evidences, the cause of the accident could not be determined.

Crash of a Casa 212 Aviocar 400 off Progreso

Date & Time: Nov 15, 2006
Type of aircraft:
Operator:
Registration:
AMP-114
Flight Phase:
Survivors:
Yes
Schedule:
Cancún - Cancún
Country:
Crew on board:
7
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The crew departed Cancún Airport for a routine maritime patrol flight over the Gulf of Mexico. After 5 hours of flight, while returning to his base and approaching the coast, the crew informed ATC that an engine failed. Few seconds later, the second engine stopped as well. The crew reduced his altitude and ditched the aircraft 3,5 km off Progreso, some 40 km north of Mérida. All 7 occupants were rescued while the aircraft was lost.
Probable cause:
Double engine failure for unknown reasons. Fuel exhaustion suspected.

Crash of a Partenavia P.68B Victor off Rottnest Island

Date & Time: Nov 12, 2006 at 1500 LT
Type of aircraft:
Operator:
Registration:
VH-IYK
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Rottnest Island - Perth
MSN:
138
YOM:
1978
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Shortly after takeoff from Rottnest Island Airport, while in initial climb, the twin engine aircraft suffered a bird strike and crashed in a salt lake located near the airport. The aircraft was destroyed upon impact and all six occupants were injured.
Probable cause:
Loss of control during initial climb following a bird strike.