Lake, Sea, Ocean, River

The aircraft departed runway 25L at Jakarta-Soekarno-Hatta Airport at 0621LT bound for Pangkal Pinang, carrying 181 passengers and 8 crew members. The crew was cleared to climb but apparently encountered technical problems and was unable to reach a higher altitude than 5,375 feet. At this time, the flight shows erratic speed and altitude values. The pilot declared an emergency and elected to return to Jakarta when control was lost while at an altitude of 3,650 feet and at a speed of 345 knots. The airplane entered a dive and crashed 12 minutes after takeoff into the Kerawang Sea, about 63 km northeast from its departure point. The airplane disintegrated on impact and few debris were already recovered but unfortunately no survivors. It has been reported that the aircraft suffered various technical issues during the previous flight on Sunday night but was released for service on Monday morning. Brand new, the airplane was delivered to Lion Air last August 18. At the time of the accident, weather conditions were considered as good. The Cockpit Voice Recorder (CVR) was found on 14 January 2019. In the initial stages of the investigation, it was found that there is a potential for repeated automatic nose down trim commands of the horizontal stabilizer when the flight control system on a Boeing 737 MAX aircraft receives an erroneously high single AOA sensor input. Such a specific condition could among others potentially result in the stick shaker activating on the affected side and IAS, ALT and/or AOA DISAGREE alerts. The logic behind the automatic nose down trim lies in the aircraft's MCAS (Maneuvering Characteristics Augmentation System) that was introduced by Boeing on the MAX series aircraft. This feature was added to prevent the aircraft from entering a stall under specific conditions. On November 6, 2018, Boeing issued an Operations Manual Bulletin (OMB) directing operators to existing flight crew procedures to address circumstances where there is erroneous input from an AOA sensor. On November 7, the FAA issued an emergency Airworthiness Directive requiring "revising certificate limitations and operating procedures of the airplane flight manual (AFM) to provide the flight crew with runaway horizontal stabilizer trim procedures to follow under certain conditions.

The two pilots and three passengers were conducting a cross-country flight over the ocean from South Carolina to the Bahamas. About 30 minutes into the flight, while climbing through 24,300 ft to 25,000 ft about 95 miles beyond the coast, the pilot made a garbled radio transmission indicating an emergency and intent to return. At the time of the transmission the airplane had drifted slightly right of course. The airplane then began a descent and returned on course. After the controller requested several times for the pilot to repeat the radio transmission, the pilot replied, "we're descending." About 15 seconds later, at an altitude of about 23,500 ft, the airplane turned sharply toward the left, and the descent rate increased to greater than 4,000 ft per minute, consistent with a loss of control. Attempts by the air traffic controller to clarify the nature of the emergency and the pilot's intentions were unsuccessful. About 1 minute after the sharp left turn and increased descent, the pilot again declared an emergency. No further communications were received. Search efforts coordinated by the U.S. Coast Guard observed an oil slick and some debris on the water in the vicinity of where the airplane was last observed via radar, however the debris was not identified or recovered. According to recorded weather information, a shallow layer favorable for light rime icing was present at 23,000 ft. However, because the airplane was not recovered, the investigation could not determine whether airframe icing or any other more-specific issues contributed to the loss of control. One air traffic control communication audio recording intermittently captured the sound of an emergency locator transmitter (ELT) "homing" signal for about 45 minutes, beginning near the time of takeoff, and ending about 5 minutes after radar contact was lost. Due to the intermittent nature of the signal, and the duration of the recording, it could not be determined if the ELT signal had begun transmitting before or ceased transmitting after these times. Because ELT homing signals sound the same for all airplanes, the source could not be determined. However, the ELT sound was recorded by only the second of two geographic areas that the airplane flew through and began before the airplane arrived near either of those areas. Had the accident airplane's ELT been activated near the start of the flight, it is unlikely that it would be detected in the second area and not the first. Additionally, the intermittent nature of the ELT signal is more consistent with an ELT located on the ground, rather than an airborne activation. An airborne ELT is more likely to have a direct line-of-sight to one or more of the ground based receiving antennas, particularly at higher altitudes, resulting in more consistent reception. The pilot's initial emergency and subsequent radio transmissions contained notably louder background noise compared to the previous transmissions. The source or reason for the for the increase in noise could not be determined.

On 28 September 2018, at 23:24:19 UTC2 (09:24 local time), a Boeing 737-8BK aircraft, registered P2-PXE (PXE), operated by Air Niugini Limited, was on a scheduled passenger flight number PX073, from Pohnpei to Chuuk, in the Federated States of Micronesia (FSM) when, during its final approach, the aircraft impacted the water of the Chuuk Lagoon, about 1,500 ft (460 m) short of the runway 04 threshold. The aircraft deflected across the water several times before it settled in the water and turned clockwise through 210 deg and drifted 460 ft (140 m) south east of the runway 04 extended centreline, with the nose of the aircraft pointing about 265°. The pilot in command (PIC) was the pilot flying, and the copilot was the support/monitoring pilot. An Aircraft Maintenance Engineer occupied the cockpit jump seat. The engineer videoed the final approach on his iPhone, which predominantly showed the cockpit instruments. Local boaters rescued 28 passengers and two cabin crew from the left over-wing exits. Two cabin crew, the two pilots and the engineer were rescued by local boaters from the forward door 1L. One life raft was launched from the left aft over-wing exit by cabin crew CC5 with the assistance of a passenger. The US Navy divers rescued six passengers and four cabin crew and the Load Master from the right aft over-wing exit. All injured passengers were evacuated from the left over-wing exits. One passenger was fatally injured, and local divers located his body in the aircraft three days after the accident. The Government of the Federated States of Micronesia commenced the investigation and on 14th February 2019 delegated the whole of the investigation to the PNG Accident Investigation Commission. The investigation determined that the flight crew’s level of compliance with Air Niugini Standard Operating Procedures Manual (SOPM) was not at a standard that would promote safe aircraft operations. The PIC intended to conduct an RNAV GPS approach to runway 04 at Chuuk International Airport and briefed the copilot accordingly. The descent and approach were initially conducted in Visual Meteorological Conditions (VMC), but from 546 ft (600 ft)4 the aircraft was flown in Instrument Meteorological Conditions (IMC). The flight crew did not adhere to Air Niugini SOPM and the approach and pre-landing checklists. The RNAV (GPS) Rwy 04 Approach chart procedure was not adequately briefed. The RNAV approach specified a flight path descent angle guide of 3º. The aircraft was flown at a high rate of descent and a steep variable flight path angle averaging 4.5º during the approach, with lateral over-controlling; the approach was unstabilised. The Flight Data Recorder (FDR) recorded a total of 17 Enhanced Ground Proximity Warning System (EGPWS) alerts, specifically eight “Sink Rate” and nine “Glideslope”. The recorded information from the Cockpit Voice Recorder (CVR) showed that a total of 14 EGPWS aural alerts sounded after passing the Minimum Descent Altitude (MDA), between 307 ft (364 ft) and the impact point. A “100 ft” advisory was annunciated, in accordance with design standards, overriding one of the “Glideslope” aural alert. The other aural alerts were seven “Glideslope” and six “Sink Rate”. The investigation observed that the flight crew disregarded the alerts, and did not acknowledge the “minimums” and 100 ft alerts; a symptom of fixation and channelised attention. The crew were fixated on cues associated with the landing and control inputs due to the extension of 40° flap. Both pilots were not situationally aware and did not recognise the developing significant unsafe condition during the approach after passing the Missed Approach Point (MAP) when the aircraft entered a storm cell and heavy rain. The weather radar on the PIC’s Navigation Display showed a large red area indicating a storm cell immediately after the MAP, between the MAP and the runway. The copilot as the support/monitoring pilot was ineffective and was oblivious to the rapidly unfolding unsafe situation. He did not recognise the significant unsafe condition and therefore did not realise the need to challenge the PIC and take control of the aircraft, as required by the Air Niugini SOPM. The Air Niugini SOPM instructs a non-flying pilot to take control of the aircraft from the flying pilot, and restore a safe flight condition, when an unsafe condition continues to be uncorrected. The records showed that the copilot had been checked in the Simulator for EGPWS Alert (Terrain) however there was no evidence of simulator check sessions covering the vital actions and responses required to retrieve a perceived or real situation that might compromise the safe operation of the aircraft. Specifically sustained unstabilised approach below 1,000 ft amsl in IMC. The PIC did not conduct the missed approach at the MAP despite the criteria required for visually continuing the approach not being met, including visually acquiring the runway or the PAPI. The PIC did not conduct a go around after passing the MAP and subsequently the MDA although:
• The aircraft had entered IMC;
• the approach was unstable;
• the glideslope indicator on the Primary Flight Display (PFD) was showing a rapid glideslope deviation from a half-dot low to 2-dots high within 9 seconds after passing the MDA;
• the rate of descent high (more than 1,000 ft/min) and increasing;
• there were EGPWS Sink Rate and Glideslope aural alerts; and
• the EGPWS visual PULL UP warning message was displayed on the PFD.
The report highlights that deviations from recommended practice and SOPs are a potential hazard, particularly during the approach and landing phase of flight, and increase the risk of approach and landing accidents. It also highlights that crew coordination is less than effective if crew members do not work together as an integrated team. Support crew members have a duty and responsibility to ensure that the safety of a flight is not compromised by non-compliance with SOPs, standard phraseology and recommended practices. The investigation found that the Civil Aviation Safety Authority of PNG (CASA PNG) policy and procedures of accepting manuals rather than approving manuals, while in accordance with the Civil Aviation Rules requirements, placed a burden of responsibility on CASA PNG as the State Regulator to ensure accuracy and that safety standards are met. In accepting the Air Niugini manuals, CASA PNG did not meet the high standard of evidence-based assessment required for safety assurance, resulting in numerous deficiencies and errors in the Air Niugini Operational, Technical, and Safety manuals as noted in this report and the associated Safety Recommendations. The report includes a number of recommendations made by the AIC, with the intention of enhancing the safety of flight (See Part 4 of this report). It is important to note that none of the safety deficiencies brought to the attention of Air Niugini caused the accident. However, in accordance with Annex 13 Standards, identified safety deficiencies and concerns must be raised with the persons or organisations best placed to take safety action. Unless safety action is taken to address the identified safety deficiencies, death or injury might result in a future accident. The AIC notes that Air Niugini Limited took prompt action to address all safety deficiencies identified by the AIC in the 12 Safety Recommendations issued to Air Niugini, in an average time of 23 days. The quickest safety action being taken by Air Niugini was in 6 days. The AIC has closed all 12 Safety Recommendations issued to Air Niugini Limited. One safety concern prompting an AIC Safety Recommendation was issued to Honeywell Aerospace and the US FAA. The safety deficiency/concern that prompted this Safety Recommendation may have been a contributing factor in this accident. The PNG AIC is in continued discussion with the US NTSB, Honeywell, Boeing and US FAA. This recommendation is the subject of ongoing research and the AIC Recommendation will remain ACTIVE pending the results of that research.

The pilot of a Cessna 208B aircraft, registered VH-FAY (FAY), was contracted to ferry the aircraft from Jandakot Airport, Western Australia (WA), to Greenwood, Mississippi in the United States (US). The pilot planned to fly via the ‘North Pacific Route’. At 0146 Coordinated Universal Time (UTC) on 15 September 2018, the aircraft took off from Jandakot Airport, WA, and landed in Alice Springs, Northern Territory at 0743. After landing, the pilot advised the aircraft operator that the aircraft had a standby alternator fault indication. In response, two company licenced aircraft maintenance engineers went to Alice Springs and changed the alternator control unit, which fixed the problem. Late the next morning, the aircraft departed Alice Springs for Weipa, Queensland, where the pilot refuelled the aircraft and stayed overnight. On the morning of 17 September, the pilot conducted a 1-hour flight to Horn Island, Queensland. About an hour later, the aircraft departed Horn Island with the planned destination of Guam, Micronesia. While en route, the pilot sent a message to the aircraft operator advising that he would not land in Guam, but would continue another 218 km (118 NM) to Saipan, Northern Mariana Islands. At 1003, the aircraft landed at Saipan International Airport. The next morning, the pilot refuelled the aircraft and detected damage to the propeller anti-ice boot. The aircraft was delayed for more than a week while a company engineer travelled to Saipan and replaced the anti-ice boot. At 2300 UTC on 26 September, the aircraft departed Saipan, bound for New Chitose Airport, Hokkaido, Japan. Once airborne, the pilot sent a message from his Garmin device, indicating that the weather was clear and that he had an expected flight time of 9.5 hours. About an hour after departure, the aircraft levelled out at flight level (FL) 220. Once in the cruise, the pilot sent a message that he was at 22,000 feet, had a tailwind and the weather was clear. This was followed by a message at 0010 that he was at FL 220, with a true airspeed of 167 kt and fuel flow of 288 lb/hr (163 L/hr). At 0121, while overhead reporting point TEGOD, the pilot contacted Tokyo Radio flight information service on HF radio. The pilot was next due to report when the aircraft reached reporting point SAGOP, which the pilot estimated would occur at 0244. GPS recorded track showed that the aircraft passed SAGOP at 0241, but the pilot did not contact Tokyo Radio as expected. At 0249, Tokyo Radio made several attempts to communicate with the pilot on two different HF frequencies, but did not receive a response. Tokyo Radio made further attempts to contact the pilot between 0249 and 0251, and at 0341, 0351 and 0405. About 4.5 hours after the pilot’s last communication, two Japan Air Self-Defense Force (JASDF) aircraft intercepted FAY. The pilot did not respond to the intercept in accordance with international intercept protocols, either by rocking the aircraft wings or turning, and the aircraft continued to track at FL 220 on its planned flight route. The JASDF pilots were unable to see into the cockpit to determine whether the pilot was in his seat or whether there was any indication that he was incapacitated. The JASDF pilots flew around FAY for about 30 minutes, until the aircraft descended into cloud. At 0626 UTC, the aircraft’s GPS tracker stopped reporting, with the last recorded position at FL 220, about 100 km off the Japanese coast and 589 km (318 NM) short of the destination airport. Radar data showed that the aircraft descended rapidly from this point and collided with water approximately 2 minutes later. The Japanese authorities launched a search and rescue mission and, within 2 hours, searchers found the aircraft’s rear passenger door. The search continued until the next day, when a typhoon passed through the area and the search was suspended for two days. After resuming, the search continued until 27 October with no further parts of the aircraft found. The pilot was not located.

The four engine aircraft departed Hmeimim AFB located southeast of Latakia at 2031LT on a maritime patrol and reconnaissance mission over the Mediterranean Sea. About an one hour and a half later, while returning to its base, the airplane was hit by a S-200 surface-to-air missile shot by the Syrian ground forces. At the time of the accident, four Israel F-16 fighters were involved in a ground attack onto several infrastructures located in the region of Latakia. Out of control, the airplane crashed into the Mediterranean Sea some 35 km west of Latakia. The following morning, Russian Authorities confirmed the loss of the aircraft that was inadvertently shot down by the Syrian Army forces and that all 15 crew members were killed.

On approach to Yiral Airport in poor visibility due to fog, the twin engine aircraft descended too low, impacted the surface of the Yirol Lake and crashed about 2 km north of the airfield. The aircraft was destroyed upon impact and four occupants were rescued while 19 others were killed. A day later, one of the survivor died from his injuries. The three survivors are two children and a Italian doctor. The flight was completed on behalf of the Slaver Company based in Ukraine.

The crew departed Elizabeth City CGAS in North Carolina to deploy weather buoys in the Atlantic Ocean. Several landings were completed successfully. While taking off, the seaplane struck an unkknown object floating on water and came to rest some 680 km east off Cape Hatteras, North Carolina. All five crew members evacuated the cabin and were later recovered by the crew of a container vessel. The aircraft sank and was lost.

The twin engine airplane departed Guarantã do Norte on a flight to a remote area located on km 180 on the Transamazonica Road. En route, both passengers started to fight in the cabin and one of them was killed. The pilot was apparently able to kill the assassin and later decided to attempt an emergency landing. He ditched the airplane in the Rio Novo near Jardim do Ouro. The pilot was later arrested but no drugs, no weapons, no ammunition as well a both passengers bodies were not found. Apparently, the goal of the flight was illegal but Brazilian Authorities were unable to prove it.

Two wheel-equipped, high-wing airplanes, a Cessna 207 and a Cessna 175, collided midair while in cruise flight in day visual meteorological conditions. Both airplanes were operating under visual flight rules, and neither airplane was in communication with an air traffic control facility. The Cessna 175 pilot stated that he was making position reports during cruise flight about 1,000ft above mean sea level when he established contact with the pilot of another airplane, which was passing in the opposite direction. As he watched that airplane pass well below him, he noticed the shadow of a second airplane converging with the shadow of his airplane from the opposite direction. He looked forward and saw the spinner of the converging airplane in his windscreen and immediately pulled aft on the control yoke; the airplanes subsequently collided. The Cessna 207 descended uncontrolled into the river. Although damaged, the Cessna 175 continued to fly, and the pilot proceeded to an airport and landed safely. An examination of both airplanes revealed impact signatures consistent with the two airplanes colliding nearly head-on. About 4 years before the accident, following a series of midair collisions in the Matanuska Susitna (MatSu) Valley (the area where the accident occurred), the FAA made significant changes to the common traffic advisory frequencies (CTAF) assigned north and west of Anchorage, Alaska. The FAA established geographic CTAF areas based, in part, on flight patterns, traffic flow, private and public airports, and off-airport landing sites. The CTAF for the area where the accident occurred was at a frequency changeover point with westbound Cook Inlet traffic communicating on 122.70 and eastbound traffic on 122.90 Mhz. The pilot of the Cessna 175, which was traveling on an eastbound heading at the time of the accident, reported that he had a primary active radio frequency of 122.90 Mhz, and a nonactive secondary frequency 135.25 Mhz in his transceiver at the time of the collision. The transceivers from the other airplane were not recovered, and it could not be determined whether the pilot of the Cessna 207 was monitoring the CTAF or making position reports.

The commercial pilot of the multiengine airplane was the first of a flight of two airplanes to depart on the cross-country flight, most of which was over the Atlantic Ocean. The pilot of the second airplane stated that he and the accident pilot reviewed the weather for the route and the destination before departing; however, there was no record of the accident pilot receiving an official weather briefing and the information the pilots accessed before the flight could not be determined. The second pilot departed and contacted air traffic control, which advised him of thunderstorms near the destination; he subsequently altered his route of flight and landed uneventfully at the destination. The second pilot stated that he did not hear the accident pilot on the en route air traffic control frequency. Two inflight weather advisories were issued for the route and the area of the destination about 42 and 15 minutes before the accident flight departed, respectively, and warned of heavy to extreme precipitation associated with thunderstorms. It could not be determined whether the accident pilot received these advisories. Review of air traffic control communications and radar data revealed that, about 5 miles from the destination airport, the pilot of the accident airplane reported to the tower controller that he was flying at 700 ft and "coming in below" the thunderstorm. There were no further communications from the pilot. The airplane's last radar target indicated 532 ft about 2 miles south of the shoreline. The airplane was found in about 50 ft of water and was fragmented in several pieces. Postaccident examination revealed no preimpact anomalies with the airplane or engines that would have precluded normal operation. A local resident about 1/2 mile from the accident site took several photos of the approaching thunderstorm, which documented a shelf cloud and cumulus mammatus clouds along the leading edge of the storm, indicative of potential severe turbulence. Review of weather imagery and the airplane's flight path showed that the airplane entered the leading edge of "extreme" intensity echoes with tops near 48,000 ft. Imagery also depicted heavy to extreme intensity radar echoes over the accident site extending to the destination airport. It is likely that the pilot encountered gusting winds, turbulence, restricted visibility in heavy rain, and low cloud ceilings in the vicinity of the accident site and experienced an in-flight loss of control at low altitude. Such conditions are conducive to the development of spatial disorientation; however, the reason for the pilot's loss of control could not be determined based on the available information.