Lake, Sea, Ocean, River

Transair flight 810, a Title 14 Code of Federal Regulations Part 121 cargo flight, experienced a partial loss of power involving the right engine shortly after takeoff and a water ditching in the
Pacific Ocean about 11.5 minutes later. This analysis summarizes the accident and evaluates (1) the right engine partial loss of power, (2) the captain's communications with air traffic control (ATC) and the first officer's left and right engine thrust reductions, (3) the first officer's misidentification of the affected engine and the captain's failure to verify the information, (4) checklist performance, and (5) survival factors. Maintenance was not a factor in this accident. The flight data recorder (FDR) showed that, when the initial thrust was set for takeoff, the engine pressure ratios (EPR) for the left and right engines were 2.00 and 1.97, respectively. Shortly after rotation, the cockpit voice recorder (CVR) recorded a “thud” and the sound of a low-frequency vibration. The captain (the pilot monitoring at the time) and the first officer (the pilot flying) reported that they heard a “whoosh” and a “pop,” respectively, at that time. As the airplane climbed through an altitude of about 390 ft while at an airspeed of 155 knots, the right EPR decreased to 1.43 during a 2-second period. The airplane then yawed to the right; the first officer countered the yaw with appropriate left rudder pedal inputs. The CVR showed that the captain and the first officer correctly determined that the No. 2 (right) engine had lost thrust within 5 seconds of hearing the thud sound. After moving the flaps to the UP position, the captain reduced thrust to maximum continuous thrust, causing the left EPR to decrease from 1.96 to 1.91 while the airplane was in a climb. (The right EPR remained at 1.43). The captain reported that he did not move the thrust levers again until after he became the pilot flying. The first officer stated that, after the airplane leveled off at an altitude of about 2,000 ft, he reduced thrust on both engines. FDR data showed that thrust was incrementally reduced to near flight idle (1.05 EPR on the left engine and then 1.09 EPR on the right engine) and that airspeed decreased from about 250 to 210 knots. (A decrease in airspeed to 210 knots was consistent with the operator’s simulator guide procedures for a single-engine failure after the takeoff decision speed [V1]. The simulator guide, which supplemented information in the company’s flight crew training manual, contained the most recent operator guidance for single-engine failure training at the time of the accident.) The captain was unaware of the first officer’s thrust changes because he was busy contacting the controller about the emergency. The captain told the controller, “we’ve lost an engine,” but he had declared the emergency to the controller twice before this point, as discussed later in this analysis. The captain instructed the first officer to maintain a target speed of 220 knots (which the captain thought would be “easy on the running engine”), a target altitude of 2,000 ft, and a target heading of 240°. (About 52 seconds earlier, the controller had issued the 240° heading instruction to another airplane on the same radio frequency.) About 3 minutes 14 seconds after the right engine loss of thrust occurred, the captain assumed control of the airplane; at that time, the airplane’s airspeed was 224 knots and heading was 242°, but the airplane’s altitude had decreased from about 2,100 ft (the maximum altitude that the airplane reached during the flight) to 1,690 ft. The captain increased the airplane’s pitch to 9°; the airplane’s altitude then increased to 1,878 ft, but the airspeed decreased to 196 knots. The captain subsequently stated, “let’s see what is the problem...which one...what's going on with the gauges,” and “who has the E-G-T [exhaust gas temperature]?” The first officer stated that the left engine was “gone” and “so we have number two” (the right engine), thus misidentifying the affected engine. The captain accepted the first officer’s assessment and did not take action to verify the information. Afterward, the EPR level on the right engine began to increase in response to the captain advancing the right thrust lever so that the airplane could maintain airspeed and altitude. Right EPR increased and decreased several times during the rest of the flight (coinciding with crew comments regarding the EGT on the right engine and low airspeed) while the left EPR remained near flight idle. The first officer asked the captain if they “should head back toward the airport” before the airplane traveled “too far away,” and the captain responded that the airplane would stay within 15 miles of the airport. During a postaccident interview, the captain stated that, because there was no fire and an engine “was running,” he intended to have the airplane climb to 2,000 ft and stay within 15 miles of the airport to avoid traffic and have time to address the engine issue. The captain also stated that he had been criticized by the company chief pilot for returning to the airport without completing the required abnormal checklist for a previous in-flight emergency. Although the captain’s decision resulted in the accident airplane flying farther away from the airport and farther over the ocean at night, the captain’s decision was reasonable for a single-engine failure event. The captain directed the first officer to begin the Engine Failure or Shutdown checklist and stated that he would continue handling the radios. The first officer began to read aloud the conditions for executing the Engine Failure or Shutdown checklist but then stopped to tell the captain that the right EGT was at the “red line” and that thrust should be reduced on the right engine. The captain then decided that the airplane should return to the airport and contacted the controller to request vectors. The flight crew continued to express concern about the right engine. The first officer stated, “just have to watch this though…the number two.” The captain asked the first officer to check the EGT for the right engine, and the first officer responded that it was “beyond max.” Afterward, the captain told the first officer to continue with the Engine Failure or Shutdown checklist and finish as much as possible. The first officer resumed reading aloud the conditions for performing the checklist but then stopped to state, “we have to fly the airplane though,” because the airplane was continuing to lose altitude and airspeed. The captain replied “okay.” As a result, the flight crew did not perform key steps of the checklist, including identifying, confirming, and shutting down the affected (right) engine. The first officer told the captain that the airplane was losing altitude; at that time, the airplane’s altitude was 592 ft, and its airspeed was 160 knots. The captain agreed to select flaps 1 (which the first officer had previously suggested likely because the airplane was slowing). The CVR then recorded the first enhanced ground proximity warning system (EGPWS) annunciation (500 ft above ground level); various EGPWS callouts and alerts continued to be annunciated through the remainder of the flight. The captain then told the controller that “we’ve lost number one [left] engine…there’s a chance we’re gonna lose the other engine too it’s running very hot….we’re pretty low on the speed it doesn't look good out here.” Also, the captain mentioned that the controller should notify the US Coast Guard (USCG) because he was anticipating a water ditching in the Pacific Ocean. Because of the high temperature readings on the right engine, the flight crew thought, at this point in the flight, that a dual-engine failure was imminent. During a postaccident interview, the captain stated that his priority at that time was figuring out how the airplane could stay in the air and return safely to the airport. The captain also stated that he attempted to resolve the airplane’s deteriorating energy state by advancing the right engine thrust lever. However, with the left engine remaining near flight idle, the right engine was not producing sufficient thrust to enable the airplane to maintain altitude or climb. The captain’s communication with the controller continued, and the first officer stated, “fly the airplane please.” The controller asked if the airport was in sight, and the captain then asked the first officer whether he could see the airport. The first officer responded “pull up we’re low” to the captain and “negative” to the controller; the captain was likely unable to respond to the controller because he was trying to control the airplane. The captain asked the first officer about the EGT for the right engine; the first officer replied “hot…way over.” The captain then asked about, and the controller responded by providing, the location of the closest airport. Afterward, the CVR recorded a sound similar to the stick shaker, which continued intermittently through the rest of the flight. The CVR then recorded sounds consistent with water impact. The airplane came down into the Pacific Ocean about two miles offshore and sank. Both crew members were rescued, one was slightly injured and a second was seriously injured. The wreckage was later recovered for investigation purposes.

The instrument-rated pilot of the business jet airplane, pilot-rated passenger, and five passengers departed on a cross-country flight and entered the clouds while performing a climbing right turn. The airplane then began to descend, and air traffic control (ATC) asked the pilot to confirm altitude and heading. The pilot did not respond. After a second query from ATC, the pilot acknowledged the instructions. The airplane entered a climbing right turn followed by a left turn. After ATC made several attempts to contact the pilot, the airplane entered a rapid descending left turn and impacted a shallow reservoir at a high rate of speed. Postaccident examination of the recovered wreckage and both engines revealed no evidence of any preimpact mechanical malfunctions or failures that would have precluded normal operation. Flight track data revealed that after takeoff, the airplane entered the clouds and made a series of heading changes, along with several climbs and descents, before it entered a steep, descending left turn. This type of maneuvering was consistent with the onset of a type of spatial disorientation known as somatogravic illusion. According to a National Transportation Safety Board performance study, accelerations associated with the airplane’s increasing airspeed were likely perceived by the pilot as the airplane pitching up although it was in a continuous descent. This occurred because the pilot was experiencing spatial disorientation and he likely did not effectively use his instrumentation during takeoff and climb. As a result of the pilot experiencing spatial disorientation, he likely experienced a high workload managing the flight profile, which would have had a further adverse effect on his performance. As such, the airplane entered a high acceleration, unusual attitude, descending left turn from which the pilot was not able to recover. The pilot and the pilot-rated passenger did not report any medication use or medical conditions to the Federal Aviation Administration on their recent and only medical certification examinations. Postaccident specimens were insufficient to evaluate the presence of any natural disease during autopsy. However, given the circumstances of this accident, it is unlikely that the pilot’s or pilot-rated passenger’s medical condition were factors in this accident. Low levels of ethanol were detected in the pilot’s muscle tissue and the pilot-rated passenger’s muscle and kidney tissue; n-butanol was also detected in the pilot’s muscle tissue. Given the length of time to recover the airplane occupants from the water and the circumstances of this accident, it is reasonable that some or all of the identified ethanol in the pilot and the pilot-rated passenger were from sources other than ingestion. Thus, the identified ethanol in the pilot and the pilot-rated passenger did not contribute to this accident.

The airplane crashed moments after takeoff from the South Bimini Int’l Airport (MYBS), Bimini, Bahamas. The private flight departed MYBS with intended final destination of Opa Locka Airport (KOPF), Opa Locka, Florida, USA. The pilot sustained serious injuries and after being seen by medical personnel in South Bimini, was flown to Nassau, Bahamas for further medical attention. The passenger who occupied the right seat of the aircraft, succumbed to injuries he sustained as a result of the initial impact and subsequent crash sequence and subsequent submersion in the waters at the end of the runway environment. The pilot was a US certified commercial pilot with ratings for airplane land, single and multi-engine as well as an instrument airplane rating. The pilot’s medical certificate was valid at the time of the accident. The passenger (pilot’s son) also held a valid US certified private pilot – single engine land – airplane certificate. It is unknown what role (if any) the passenger (son) played during the takeoff to crash sequence. The weather conditions at the time of the accident was night (instrument meteorological conditions). A weak high pressure ridging was forecasted to continue to dominate the weather over the Bahamas throughout the night. However, no significant weather was anticipated.

The twin engine airplane (a PA-31 Panther II variant) departed Nueva Loja-Lago Agrio Airport at 1023LT on an ambulance flight to Guayaquil, carrying one patient, one nurse, two doctors and two pilots. The descent to Guayaquil-José Joaquín de Olmedo Airport was started when the aircraft crashed in unknown circumstances in the Río Salitre, near Salitre, about 35 km north of Guayaquil Airport. The aircraft was destroyed and all six occupants were killed.

On Saturday January 23, 2021, a Sabreliner with registration XB-JMR on a domestic Flight Plan with two pilots on board departed Guadalajara for Queretaro in Mexico. On reaching a cruising altitude of 20,000 feet the crew changed destination and shortly after disappeared off Mexican Radar. Mexican Authorities suspect the Transponder was turned off by the crew. The aircraft entered the Kingston Flight Information Region (KIN FIR) without a filed Flight Plan, south of Jamaica and at approximately 6:14pm local the crew declared an emergency. The crew reported to Air Traffic Control that they were at 10,000 feet and 14 miles from land and on a heading of 055 degrees (heading north-east). The crew requested instructions to land at the nearest airport due to one engine shut down. The aircraft was observed on radar heading in a north-east direction in the vicinity of the Vernamfield area then changed direction to a south-east heading. The aircraft began circling the Portland Cottage area in Clarendon, 'squawking' Transponder code A1327 and climbing out of 17,000 feet at 6:20pm local. Search and Rescue was initiated with the Jamaica Defence Force at 6:22pm local. On reaching 18,000 feet the aircraft disappeared from radar at 6:34pm local - Transponder possibly turned off by crew. The Aircraft impacted the shoreline south-east of the White Sand Beach area of Rocky Point in Clarendon (17°45'55.69"N 77°15'42.94"W) at approximately 6:39pm local. On Sunday January 24, 2021, a site visit was conducted by personnel from the Operations and Airworthiness units of the Flight Safety Division. With assistance from the Security Forces, photographic evidence of the site was collected. The crash site and the aircraft were vandalized. The aircraft may have made a gear up/flaps up landing. Left-wing leading-edge slats were deployed indicating low airspeed and possible high angle of attack at time of impact.

On 9 January 2021, a Boeing 737-500 aircraft, registration PK-CLC, was being operated by PT. Sriwijaya Air on a scheduled passenger flight from Soekarno-Hatta International Airport (WIII), Jakarta to Supadio International Airport (WIOO), Pontianak . The flight number was SJY182. According to the flight plan filed, the fuel endurance was 3 hours 50 minutes. At 0736 UTC (1436 LT) in daylight conditions, Flight SJY182 departed from Runway 25R of Jakarta. There were two pilots, four flight attendants, and 56 passengers onboard the aircraft. At 14:36:46 LT, the SJY182 pilot contacted the Terminal East (TE) controller and was instructed “SJY182 identified on departure, via SID (Standard Instrument Departure) unrestricted climb level 290”. The instruction was read back by the pilot. At 14:36:51 LT, the Flight Data Recorder (FDR) data recorded that the Autopilot (AP) system engaged at altitude of 1,980 feet. At 14:38:42 LT, the FDR data recorded that as the aircraft climbed past 8,150 feet, the thrust lever of the left engine started reducing, while the thrust lever position of the right engine remained. The FDR data also recorded the left engine N1 was decreasing whereas the right engine N1 remained. At 14:38:51 LT, the SJY182 pilot requested to the TE controller for a heading change to 075° to avoid weather conditions and the TE controller approved the request. At 14:39:01 LT, the TE controller instructed SJY182 pilot to stop their climb at 11,000 feet to avoid conflict with another aircraft with the same destination that was departing from Runway 25L. The instruction was read back by the SJY182 pilot. At 14:39:47 LT, the FDR data recorded the aircraft’s altitude was about 10,600 feet with a heading of 046° and continuously decreasing (i.e., the aircraft was turning to the left). The thrust lever of the left engine continued decreasing. The thrust lever of the right engine remained. At 14:39:54 LT, the TE controller instructed SJY182 to climb to an altitude of 13,000 feet, and the instruction was read back by an SJY182 pilot at 14:39:59 LT. This was the last known recorded radio transmission by the flight. At 14:40:05 LT, the FDR data recorded the aircraft altitude was about 10,900 feet, which was the highest altitude recorded in the FDR before the aircraft started its descent. The AP system then disengaged at that point with a heading of 016°, the pitch angle was about 4.5° nose up, and the aircraft rolled to the left to more than 45°. The thrust lever position of the left engine continued decreasing while the right engine thrust lever remained. At 14:40:10 LT, the FDR data recorded the autothrottle (A/T) system disengaged and the pitch angle was more than 10° nose down. About 20 seconds later the FDR stopped recording. The last aircraft coordinate recorded was 5°57'56.21" S 106°34'24.86" E. At 14:40:37 LT, the TE controller called SJY182 to request for the aircraft heading but did not receive any response from the pilot. At 14:40:48 LT, the radar target of the aircraft disappeared from the TE controller radar screen. At 14:40:46 LT, the TE controller again called SJY182 but did not receive any response from the pilot. The TE controller then put a measurement vector on the last known position of SJY182 and advised the supervisor of the disappearance of SJY182. The supervisor then reported the occurrence to the operation manager. The TE controller repeatedly called SJY182 several times and also asked other aircraft that flew near the last known location of SJY182 to call the SJY182. The TE controller then activated the emergency frequency of 121.5 MHz and called SJY182 on that frequency. All efforts were unsuccessful to get any responses from the SJY182 pilot. About 1455 LT, the operation manager reported the occurrence to the Indonesian Search and Rescue Agency (Badan Nasional Pencarian dan Pertolongan/BNPP). At 1542 LT, the Air Traffic Services (ATS) provider declared the uncertainty phase (INCERFA) of the SJY182. The distress phase of SJY182 (DETRESFA) was subsequently declared at 1643 LT.

After takeoff from his home airport with about 50 gallons of fuel in each fuel tank, the pilot climbed to 7,000 ft and proceeded to his destination. When he was about halfway there, he switched from the right fuel tank to the left fuel tank. Immediately after switching fuel tanks, the engine started to sputter and lost power. The pilot switched back to the right fuel tank but there was no change. He then tried different power settings, adjusted the mixture to full rich and switched tanks again without regaining engine power. The pilot advised air traffic control (ATC) that he was having an engine problem and needed to land at the nearest airport. ATC instructed him contact the control tower at the nearest airport and cleared him to land. The pilot advised the controller that he was not going to be able to make it to the airport and that he was going to land in the water. During the water landing, the airplane came to a sudden stop. The pilot and his passenger then egressed, and the airplane sank. An annual inspection of the airplane had been completed about 2 months prior to the accident and test flights associated with the annual inspection had all been done with the fuel selector selected to the right fuel tank, and this was the first time he had selected the left fuel tank since before the annual inspection. The airplane was equipped with an engine monitor that was capable of recording engine parameters. Examination of the data revealed that around the time of the loss of engine power, exhaust gas temperature and cylinder head temperature experienced a rapid decrease on all cylinders along with a rapid decrease of turbine inlet temperature, which was indicative of the engine being starved of fuel. Examination of the wreckage did not reveal any evidence of any preimpact failures or malfunctions of the airplane or engine that would have precluded normal operation. During examination of the fuel system, the fuel selector was observed in the RIGHT fuel tank position and was confirmed to be in the right fuel tank position with low pressure air. However, when the fuel selector was positioned to the LEFT fuel tank position, continuity could not be established with low pressure air. Further examination revealed that a fuel selector valve labeled FERRY TANK was installed in the left fuel line between the factory-installed fuel selector and the left fuel tank. The ferry tank fuel selector was observed to be in the ON position, which blocked continuity from the left fuel tank to the engine. Continuity could only be established when the ferry tank fuel selector was positioned to the OFF position. With low pressure air, no continuity could be established from the ferry tank fuel line that attached to the ferry tank’s fuel selector. The ferry tank fuel selector valve was mounted between the pilot and copilot seats on the forward side of the main wing spar in the area where the pilot and copilot would normally enter and exit the cockpit. This location was such that the selector handle could easily be inadvertently kicked or moved by a person or object. A guard was not installed over the ferry tank fuel selector valve nor was the selector valve handle safety wired in the OFF position to deactivate the valve even though a ferry tank was not installed. Review of the airplane’s history revealed that about 3 years before the accident, the airplane had been used for an around-the-world flight by the pilot and that prior to the flight, a ferry tank had been installed. A review of maintenance records did not reveal any logbook entries or associated paperwork for the ferry tank installation and/or removal, except for a copy of the one-page fuel system schematic from the maintenance manual with a handwritten annotation (“Tank”), and hand drawn lines, both added to it in blue ink. A review of Federal Aviation Administration records did not reveal any record of a FAA Form 337 (Major Repair or Alteration) or a supplemental type certificate for installation of the ferry tank or the modification to the fuel system.

On November 6, 2020, about 1600 Pacific standard time, a Pilatus PC-12, N400PW, was substantially damaged when it was ditched in the Pacific Ocean about 1000 miles east of Hilo, Hawaii. The two pilots sustained no injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 ferry flight. According to the pilot-in-command (PIC), who was also the ferry company owner, he and another pilot were ferrying a new airplane from California to Australia. The first transoceanic leg was planned for 10 hours from Santa Maria Airport (KSMX), Santa Maria, California to Hilo Airport (PHTO), Hilo, Hawaii. The manufacturer had an auxiliary ferry fuel line and check valve installed in the left wing before delivery. About 1 month before the trip, the pilot hired a ferry company to install an internal temporary ferry fuel system for the trip. The crew attempted the first transoceanic flight on November 2, but the ferry fuel system did not transfer properly, so the crew diverted to Merced Airport (KMCE), Merced, California. The system was modified with the addition of two 30 psi fuel transfer pumps that could overcome the ferry system check valve. The final system consisted of 2 aluminum tanks, 2 transfer pumps, transfer and tank valves, and associated fuel lines and fittings. The ferry fuel supply line was connected to the factory installed ferry fuel line fitting at the left wing bulkhead, which then fed directly to the main fuel line through a check valve and directly to the turbine engine. The installed system was ground and flight checked before the trip. According to Federal Aviation Administration automatic dependent surveillance broadcast (ADS-B) data, the airplane departed KSMX about 1000. The pilots each stated that the ferry fuel system worked as designed during the flight and they utilized the operating procedures that were supplied by the installer. About 5 hours after takeoff, approaching ETNIC intersection, the PIC climbed the airplane to flight level 280. At that time, the rear ferry fuel tank was almost empty, and the forward tank was about 1/2 full. The crew was concerned about introducing air into the engine as they emptied the rear ferry tank, so the PIC placed the ignition switch to ON. According to the copilot (CP), she went to the cabin to monitor the transparent fuel line from the transfer pumps to ensure positive fuel flow while she transferred the last of the available rear tank fuel to the main fuel line. When she determined that all of the usable fuel was transferred, and fuel still remained in the pressurized fuel line, she turned the transfer pumps to off and before she could access the transfer and tank valves, the engine surged and flamed out. The PIC stated that the crew alerting system (CAS) fuel low pressure light illuminated about 5 to 15 seconds after the transfer pumps were turned off, and then the engine lost power and the propeller auto feathered. The PIC immediately placed the fuel boost pumps from AUTO to ON. The CP went back to her crew seat and they commenced the pilot operating handbook’s emergency checklist procedures for emergency descent and then loss of engine power in flight. According to both crew members, they attempted an engine air start. The propeller unfeathered and the engine started; however, it did not reach flight idle and movement of the power control lever did not affect the engine. The crew secured the engine and attempted another air start. The engine did not restart and grinding sounds and a loud bang were heard. The propeller never unfeathered and multiple CAS warning lights illuminated, including the EPECS FAIL light (Engine and Propeller Electronic Control System). The crew performed the procedures for a restart with EPECS FAIL light and multiple other starts that were unsuccessful. There were no flames nor smoke from either exhaust pipe during the air start attempts. About 8,000 ft mean sea level, the crew committed to ditching in the ocean. About 1600, after preparing the survival gear, donning life vests, and making mayday calls on VHF 121.5, the PIC performed a full flaps gear up landing at an angle to the sea swells and into the wind. He estimated that the swells were 5 to 10 ft high with crests 20 feet apart. During the landing, the pilot held back elevator pressure for as long as possible and the airplane landed upright. The crew evacuated through the right over wing exit and boarded the 6 man covered life raft. A photograph of the airplane revealed that the bottom of the rudder was substantially damaged. The airplane remained afloat after landing. The crew utilized a satellite phone to communicate with Oakland Center. The USCG coordinated a rescue mission. About 4 hours later, a C-130 arrived on scene and coordinated with a nearby oil tanker, the M/V Ariel, for rescue of the crew. According to the pilots, during the night, many rescue attempts were made by the M/V Ariel; however, the ship was too fast for them to grab lines and the seas were too rough. After a night of high seas, the M/V Ariel attempted rescue again; however, they were unsuccessful. That afternoon, a container ship in the area, the M/V Horizon Reliance, successfully maneuvered slowly to the raft, then the ship’s crew shot rope cannons that propelled lines to the raft, and they were able to assist the survivors onboard. The pilots had been in the raft for about 22 hours. The airplane was a new 2020 production PC-12 47E with a newly designed Pratt and Whitney PT6E-67XP engine which featured an Engine and Propeller Electronic Control System. The airplane is presumed to be lost at sea.

Probably engaged in an illegal flight, the aircraft crashed in unknown circumstances in an isolated and swampy area located in the Laguna del Tigre National Park. The wreckage was found on November 2 about 7 km south from the Mexican border. Two dead bodies were found and the aircraft was destroyed.

The aircraft entered the Venezuelan airspace without flight plan and authorisation. While flying over the Paraguaña Peninsula at low altitude, the crew was forced to land when control was lost. The aircraft crashed in shallow water few meters offshore, lost its tail and both wings. Both pilots were killed.