Crash of a Piper PA-46-310P Malibu near Invermere: 3 killed

Date & Time: Oct 26, 2007 at 1912 LT
Registration:
C-GTCS
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Salem – Calgary
MSN:
46-08065
YOM:
1987
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Circumstances:
The privately operated Piper Malibu PA-46-310P was en route from Salem, Oregon, to Springbank, Alberta, on an instrument flight rules flight plan. During the descent through 17 000 feet at approximately 55 nautical miles (nm) southwest of Calgary, the pilot declared an emergency with the Edmonton Area Control Centre, indicating that the engine had failed. The pilot attempted an emergency landing at the Fairmont Hot Springs airport in British Columbia, but crashed at night at about 1912 mountain daylight time 11 nm east of Invermere, British Columbia, in wooded terrain. The pilot and two passengers were fatally injured.
Probable cause:
Findings as to Causes and Contributing Factors:
1. An unapproved part was installed in the alternator coupling. This resulted in debris from the coupling causing a partial blockage of oil flow to the number two connecting rod bearing. This low oil flow caused overheating and failure of the bearings, connecting rod cap bolts and nuts, and the subsequent engine failure.
2. The engine failure occurred after sunset and the low-lighting conditions in the valley would have made selecting a suitable landing area difficult.
3. The engine knocking was not reported to maintenance personnel which prevented an opportunity to discover the deteriorating engine condition.
Finding as to Risk:
1. All flights on the day of the accident were carried out without the oil filler cap in place. The absence of the oil filler cap could have resulted in the loss of engine oil.
Other Findings:
1. There were no current instrument flight rules charts or approach plates on board the aircraft for the intended flight.
2. The Teledyne Continental Motors Service Bulletin M84-5 addressed only the 520 series engines and did not include other gear-driven alternator equipped engines.
Final Report:

Crash of a Britten-Norman BN-2A-21 Islander in Guadalcanal: 1 killed

Date & Time: Oct 17, 2007 at 1930 LT
Type of aircraft:
Registration:
G-CHES
Flight Phase:
Flight Type:
Survivors:
Yes
Site:
Schedule:
Guadalcanal - Guadalcanal
MSN:
2011
YOM:
1977
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Copilot / Total flying hours:
2400
Aircraft flight hours:
8500
Aircraft flight cycles:
8900
Circumstances:
The Britten Norman “Islander” aircraft, registration G-CHES, had flown on the morning of 17 October 2007 over various points of the Sierra Morena and the north part of the province of Seville. Its mission had been to scout the various flight fields which would be available to the aircraft in future operations. The purpose of that day’s flight was to land at a temporary runway in the town of Guadalcanal, in the province of Seville on the border with the province of Badajoz. This runway, used by airplanes on agricultural flights, is some five kilometers SW of the town. The pilot, however, mistakenly landed at another temporary field, with the same bearing and approximately halfway between the town and the other runway on Guadalcanal. The runway on which it landed, called Los Tomillares (after the name of the ranch on which it is located), is considerably shorter. The distance available was sufficient for the airplane’s sole pilot to land normally. In order to be able to depart from that strip, which measured only 400 m in length, the pilot telephoned for help and guidance in order to make the short four-kilometer flight from that strip to the runway in Guadalcanal, his original destination. In response to his call for help, a pilot with experience on that type of airplane reported to the strip early in the afternoon and joined the pilot as a crew advisor on the aircraft in order to aid the pilot in command. Two other persons on the ground provided assistance loading fuel in the main tanks. The gasoline was taken to the aerodrome in 50-liter plastic drums, which were placed inside the aircraft once emptied, since they were operating between runways in which there was no refueling service. A total of 250 liters of AV100LL fuel was deposited in the main tanks. Both pilots walked the length of the field at Los Tomillares to check its condition and dimensions. They determined its length by counting their steps. They also determined its gradient. Although the surface was made of uncompacted dirt, they calculated that it was sufficient for takeoff, which they decided to do toward the southeast to take advantage of the favorable negative slope. Specifically, they planned to depart on a SE heading, turn 90° right, and continue flying south until they were lined up with the Guadalcanal runway. They planned to land on a NW course. They postponed the operation until late in the afternoon, before sunset, so as to avoid glare from the setting sun while landing at Guadalcanal. According to eyewitness accounts, the pilot in command did the pre-flight check and dismissed the ground assistants, who left before the airplane took off. A few minutes later, at 19:30, half an hour prior to sunset, the aircraft headed for the runway threshold. Shortly thereafter it started its takeoff, gaining speed and becoming airborne prior to reaching the opposite threshold. The right engine then started to fail partially, causing the airplane to yaw hard to the right. The pilot in command, seated to the left, was flying the airplane. According to the statement of the accompanying pilot, who was seated in the RH seat, when the engine failed, the pilot asked him to take the flight controls while he attempted to restore power to the right engine. After lowering the nose, they started to descend slightly, managing to correct the right yaw by applying left rudder. They had practically managed to regain directional control of the aircraft when the right engine started to run at full power once more, propelling the aircraft, which caused it to veer left, toward higher ground. They were unable to avoid the impact. The aircraft’s left wingtip impacted first, hitting some bushes on the hillside. A few meters later the left gear wheel made contact. After crossing a small river bed, the aircraft’s left wing and forward fuselage impacted, with the airplane coming to a stop after traveling along the ground for a few meters. The impact site was on the runway centerline extension and some 400 m from the southeast threshold, which they had overflown a few seconds earlier when taking off. The aircraft was seriously damaged and was essentially destroyed. There was no fire after the impact.
Probable cause:
It is believed that the fault and abnormal operation of the right engine was probably caused by the presence of water in the fuel being supplied to it. This water could have come from condensation inside the tanks that was not properly drained when the airplane was serviced. Alternatively, the water could have come from the jugs that were used to transport the fuel prior to the refueling in the field. The cause behind the airplane’s loss of lateral control and its ability to climb was probably the result of the oscillating condition of the high asymmetric drag as the stationary propeller, and the counteracting forces being applied by the rudder, were suddenly and immediately replaced by a condition of high symmetric thrust with the left rudder pedal still fully depressed.
Final Report:

Crash of a Let L-410UVP-E10A near Cubarral: 17 killed

Date & Time: Oct 8, 2007 at 1550 LT
Type of aircraft:
Operator:
Registration:
HK-4055
Flight Phase:
Survivors:
No
Site:
Schedule:
Villavicencio - Uribe
MSN:
90 25 21
YOM:
1991
Location:
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
15
Pax fatalities:
Other fatalities:
Total fatalities:
17
Captain / Total flying hours:
5550
Captain / Total hours on type:
432.00
Copilot / Total flying hours:
287
Copilot / Total hours on type:
134
Aircraft flight hours:
2435
Circumstances:
The twin engine aircraft departed Villavicencio-La Vanguardia Airport at 1530LT on a flight to Uribe with 15 passengers and 2 pilots on board. En route, while cruising in poor weather conditions, the crew reported his ETA in Uribe at 1550LT. At an altitude of 11,800 feet, the aircraft struck the slope of a mountain and disintegrated on impact. The wreckage was found 3 days later on Mt Páramo El Nevado, about 33 km northeast of Cubarral. The aircraft was totally destroyed upon impact and all 17 occupants were killed.
Probable cause:
Controlled flight into terrain after the crew decided to continue the flight under VFR mode in IMC conditions. The following contributing factors were identified:
- Erroneous navigation,
- Low situational awareness regarding the geographical orientation at the beginning and during the flight,
- Failure to observe the warnings of closeness with terrain for three minutes, issued by the TAWS equipment.
Final Report:

Crash of a Cessna 208B Grand Caravan near Naches: 10 killed

Date & Time: Oct 7, 2007 at 1959 LT
Type of aircraft:
Operator:
Registration:
N430A
Flight Phase:
Survivors:
No
Site:
Schedule:
Star - Shelton
MSN:
208B-0415
YOM:
1995
Crew on board:
1
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
10
Captain / Total flying hours:
2054
Captain / Total hours on type:
296.00
Aircraft flight hours:
9604
Circumstances:
The pilot was returning a group of skydivers to their home base after a weekend of skydiving. He flew several jump flights, and then stopped early in the afternoon to prepare the airplane for the flight home. The flight was planned into an area of clouds, turbulence, and icing, which the pilot had researched. He delayed the departure until he decided that he could complete the planned flight under visual flight rules (VFR). The accident occurred at night with little illumination of the moon, and the airplane was in an area of layered clouds. A detailed analysis of the weather conditions revealed that the flight probably encountered broken to overcast layers both below and above its flight altitude. The satellite and sounding images suggested that it was possibly in an area of mountain wave conditions, which can enhance icing. The recorded radar data indicated that the pilot was likely maneuvering to go around, above, or below rain showers or clouds while attempting to maintain VFR. The airplane likely entered clouds during the last 3 minutes of flight, and possibly icing and turbulence. It was turning when it departed from controlled flight, and a performance study showed that the angle-of-attack at this point in the flight was increasing rapidly. The study determined that the
departure from controlled flight was consistent with an aerodynamic stall. The unpressurized airplane was flying at over 14,000 feet mean sea level for more than 1 hour during the flight. It reached 15,000 feet just prior to the accident in sequential 360-degree turns while climbing and descending. Supplemental oxygen was not being used. At these altitudes, the pilot would be substantially impaired by hypoxia, but would have virtually no subjective symptoms, and would likely be unaware of his impairment. The pilot had logged over 2,000 hours of total flight time, with nearly 300 hours in this make and model of airplane. He was instrument rated, but had only logged a total of 2 hours of actual instrument flight time. Company policy was to fly under visual flight rules only, and they had not flight-checked the pilot for instrument flight.
Probable cause:
The pilot's failure to maintain an adequate airspeed to avoid an aerodynamic stall while maneuvering. Contributing to the accident were the pilot's impaired physiological state due to hypoxia, the pilot's inadequate preflight weather evaluation, and his attempted flight into areas of known adverse weather. Also contributing were the pilot's inadvertent flight into instrument meteorological conditions that included clouds, turbulence, and dark night conditions.
Final Report:

Crash of a Beechcraft C90A King Air near Pagosa Springs: 3 killed

Date & Time: Oct 4, 2007 at 2317 LT
Type of aircraft:
Operator:
Registration:
N590GM
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Chinle - Alamosa
MSN:
LJ-1594
YOM:
2000
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
12650
Captain / Total hours on type:
84.00
Aircraft flight hours:
3925
Circumstances:
The pilot contacted air traffic control, using the wrong call sign, requesting radar flight following. The airplane initially climbed to 13,500 feet, descended to 11,500 feet, climbed to 13,500 feet, and then began a descent until it impacted terrain at 11,900 feet. One minute prior to impact, the pilot asked the air traffic controller about various minimum altitudes for his route of flight. The controller responded with a minimum instrument altitude of 15,000 to 15,300 feet. A review of the handling of the accident flight showed that the controller was aware of the airplane's position, altitude, general route of flight, and its proximity to terrain. No safety alert was issued to the accident flight. Weather depiction charts, infrared satellite imagery, and local weather observations indicate instrument meteorological conditions prevailed along the route of flight, closest to the accident location. The moon had set at 1539 on the day of the accident. The pilot reported a planned flight altitude of 12,500 feet to his dispatcher. No record of a preflight weather briefing was located. An examination of the airplane, engines, and related systems revealed no anomalies.
Probable cause:
The pilot's failure to maintain clearance from mountainous terrain. Contributing to the accident was the pilot's inadequate preflight planning, improper in-flight planning and decision making, the dark night, and the controller's failure to issue a safety alert to the pilot.
Final Report:

Crash of a PAC Cresco 08-600 near Tully: 1 killed

Date & Time: Aug 16, 2007 at 1513 LT
Type of aircraft:
Registration:
VH-XMN
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Ingham - Tully
MSN:
036
YOM:
2002
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Total fatalities:
1
Captain / Total flying hours:
397
Captain / Total hours on type:
138.00
Circumstances:
The pilot was ferrying the aircraft under the visual flight rules (VFR) from the operator’s base at Tully, Qld to Ingham and return. The flights, conducted in the private category without passengers, were to allow aircraft maintenance to be conducted at Ingham. The flight from Tully to Ingham was conducted in the morning, with no reported difficulties. At 1454 Eastern Standard Time, the pilot departed Ingham on the return flight to Tully. The aircraft did not arrive at Tully. It was not until the next day that the pilot and aircraft were reported missing. Australian Search and Rescue (AusSAR) was notified and a search, based on the last air traffic control radar observed position of an unidentified aircraft from a replay of recorded radar data together with witness reports from the area, was initiated. Searchers located the aircraft wreckage on the morning of 18 August. The aircraft had impacted mountainous terrain in a state forest 24 km south of Tully. The pilot was fatally injured and the aircraft was destroyed.
Probable cause:
Contributing safety factors:
• The aircraft probably entered an area of weather that deteriorated below visual meteorological conditions and for which the pilot was not experienced or qualified.
• The pilot probably became unsure of his position in poor visibility, leading to controlled flight into terrain, fatally injuring the pilot and destroying the aircraft.
Other safety factors:
• The aircraft had not been configured for poor visibility operations, possibly increasing the pilot’s difficulty in navigating.
• The pilot did not submit any form of flight notification such as a SARTIME or Flight Note, as required for a flight in a designated remote area, resulting in a delay to the search and rescue response.
• The operator did not have procedures to provide assurance that a search and rescue would be initiated in a timely way if one of their aircraft did not arrive at the planned destination. [Safety issue]
• As a result of damage to the emergency locator beacon antenna, the beacon did not alert search and rescue organisations to the aircraft accident.
Final Report:

Crash of a Rockwell Shrike Commander 500S in Clonbinane: 2 killed

Date & Time: Jul 31, 2007 at 2000 LT
Operator:
Registration:
VH-YJB
Flight Phase:
Survivors:
No
Site:
Schedule:
Melbourne – Shepparton
MSN:
500-3299
YOM:
1977
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
2342
Captain / Total hours on type:
970.00
Aircraft flight hours:
4558
Circumstances:
At 1946 Eastern Standard Time on 31 July 2007, a Rockwell International Aero Commander 500S, registered VH-YJB (YJB), departed Essendon Airport, Vic. on a business flight to Shepparton that was conducted at night under the instrument flight rules (IFR). On board were the pilot and one passenger. At 1958, while in the cruise at 7,000 ft above mean sea level (AMSL) in Class C controlled airspace, radar and radio contact with the aircraft was lost simultaneously by air traffic control when it was about 25 NM (46 km) north-north-east of Essendon. The air traffic controller declared a distress phase after a number of unsuccessful attempts to contact the pilot. At 2003, the Operations Director at Melbourne Centre declared the aircraft as probably lost and advised AusSAR. A search was commenced using a helicopter and an aeroplane in addition to ground search parties. No emergency locator transmitter signal was reported. At 2147, aircraft wreckage was located by a searching aircraft in timbered ranges near Clonbinane, approximately 50 km north of Melbourne. At about 2200, a ground search party confirmed that the wreckage was that of YJB and that there were no survivors. The flight was arranged to take the company owner, who was also a licensed aircraft maintenance engineer (LAME), to Shepparton to replace an unserviceable starter motor in another of the operator‟s aircraft. The pilot, who had landed at Essendon at 1915 from a previous flight in another of the operator‟s aircraft, was tasked to fly the owner to Shepparton. The pilot transferred to YJB, which had previously been prepared for flight by another company pilot. At 1938, while taxiing for takeoff, the pilot advised the aerodrome controller of the intention to conduct the IFR flight, adding, „…and request a big favour for a submission of a flight plan, with an urgent departure Essendon [to] Shepparton [and] return‟. The aerodrome controller did not have the facilities for processing flight notifications and sought the assistance of a controller in the Melbourne air traffic control centre. There were no eyewitnesses to the accident. Residents living in the vicinity of the accident site were inside their homes and reported difficulty hearing anything above the noise made by the wind and the foliage being blown about. One of the residents reported hearing a brief, loud engine noise. Another resident thought the noise was that of a noisy vehicle on the road. The noise was described as being constant, „…not spluttering or misfiring‟ and lasted for only a few seconds. Some of those residents near the accident site reported hearing and feeling an impact only moments after the engine noise ceased. The aircraft was seriously damaged by excessive in-flight aerodynamic forces and impact with the terrain. The vegetation in the immediate vicinity of the main aircraft wreckage was slightly damaged as the aircraft descended, nearly vertically, through the trees. The pilot and passenger were fatally injured.
Probable cause:
Structural failure and damage:
From the detailed examination and study of the aircraft wreckage undertaken by ATSB investigation staff, it was evident that all principal structural failures had occurred under gross overstress conditions i.e. stresses significantly in excess of the physical strength of the respective structures. The examination found no evidence of pre-existing cracking, damage or material degradation that could have appreciably reduced the strength of the failed sections, nor was there any indication that the original manufacture, maintenance or repair processes carried out on the aircraft were in any way contributory to the failures sustained.

Breakup sequence:
From the localised deformation associated with the spar failures, it was evident that the aircraft had sustained a large negative (downward) loading on the wing structure. That downward load resulted in the localised bending failure of the wing around the station 145 position (145” outboard of the aircraft centreline). The symmetry of both wing failures and the absence of axial twisting within the fuselage section suggested that the load encountered was sudden and well in excess of the ultimate strength of the wing structure. Based upon the witness marks on both wing under-surfaces and the crushing and paint transfer along the leading edges of the horizontal stabilisers, it was concluded that after separating from the inboard structure, both wings had moved aft in an axial twisting and rotating fashion; simultaneously impacting the leading edges of both horizontal tailplanes. Forces imparted into the empennage structure from that impact subsequently produced the rearward separation of the complete empennage from the fuselage. The loss of the left engine nacelle fairing was likely brought about through an impact with a section of wing leading edge as it rotated under and to the rear. The damage sustained by all of the aircraft‟s control surfaces was consistent with failure and separation from their respective primary structure under overstress conditions associated with the breakup of the aircraft. There was no evidence of cyclic or oscillatory movement of the surfaces before separation that might have suggested the contribution of an aerodynamic flutter effects.

Findings
The following statements are a summary of the verified findings made during the progress of the aircraft wreckage structural examination and analysis:
- All principal failures within the aircraft wings, tailplanes and empennage had occurred as a result of exposure to gross overstress conditions.
- The damage sustained by the aircraft wreckage was consistent with the aircraft having sustained multiple in-flight structural failures.
- The damage sustained by the aircraft wreckage was consistent with the structural failure sequence being initiated by the symmetric, downward bending failure of both wing sections, outboard of the engine nacelles.
- Breakup and separation of the empennage was consistent with having been initiated by impact of the separated outboard wings with the leading edges of the horizontal stabilisers.
- There was no evidence of material or manufacturing abnormalities within the aircraft structure that could be implicated in the failures and breakup sustained.
- There was no evidence of service-related degradation mechanisms (such as corrosion, fatigue cracking or environmental cracking) having affected the aircraft structure in the areas of failure.
Final Report:

Crash of a Canadair CL-415-6B11 near Acciano: 1 killed

Date & Time: Jul 23, 2007 at 1806 LT
Type of aircraft:
Operator:
Registration:
I-DPCX
Flight Phase:
Flight Type:
Survivors:
Yes
Site:
Schedule:
Pescara - Pescara
MSN:
2045
YOM:
2000
Flight number:
CAN19
Location:
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
6240
Captain / Total hours on type:
1321.00
Copilot / Total flying hours:
1200
Copilot / Total hours on type:
55
Aircraft flight hours:
2742
Circumstances:
The crew departed Pescara-Liberi Airport at 1719LT on a fire fighting mission in the Sirente-Velino Regional Natural Park under callsign CAN19. While approaching the area under fire, the aircraft initiated a slight turn to the right when it collided with the top of a hill and disintegrated, bursting into flames. The wreckage was found at an altitude of 1,155 metres near Acciano. While the copilot was seriously injured, the captain was killed.
Probable cause:
Even if it was not possible to define with certainty why the aircraft impacted against the ground, it is nevertheless considered reasonable that the impact occurred as a result of improper management of the manoeuvre by the crew, the result of an inadequate assessment by the crew of the flight altitude with respect to the top of the hill and the critical environmental conditions, characterized by the presence of strong turbulence, strong wind and visibility affected by the presence of smoke. (The cause of the accident would therefore be substantially due to human and environmental factors).
Final Report:

Crash of an Antonov AN-24B near Sihanoukville: 22 killed

Date & Time: Jun 25, 2007 at 1040 LT
Type of aircraft:
Operator:
Registration:
XU-U4A
Survivors:
No
Site:
Schedule:
Siem Reap - Sihanoukville
MSN:
9 99 019 08
YOM:
1969
Flight number:
PMT241
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
16
Pax fatalities:
Other fatalities:
Total fatalities:
22
Circumstances:
The aircraft departed Siem Reap Airport on a flight to Sihanoukville, carrying 16 passengers (13 South Korean and 3 Czech) and 6 crew members. While descending to Sihanoukville Airport in marginal weather conditions, the aircraft struck the slope of Mt Phnom Damrey located in the Elephant Mountain Range, about 50 km northeast of the Sihanoukville Airport. The aircraft was totally destroyed and all 22 occupants were killed.
Probable cause:
Controlled flight into terrain.

Crash of a Yakovlev Yak-40 near Naryn

Date & Time: Jun 23, 2007 at 1114 LT
Type of aircraft:
Registration:
EX-901
Flight Phase:
Flight Type:
Survivors:
Yes
Site:
Schedule:
Bishkek – Issyk Kul – Naryn
MSN:
9411030A
YOM:
1974
Flight number:
KR4452
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The crew departed Bishkek on a special flight to Issyk Kul and Naryn to proceed with the calibration of the ILS systems. About 30 minutes into the flight from Issyk Kul to Naryn, the right engine started to vibrate while the left engine temperature increased. After the right engine was shut down, the captain asked the flight engineer to reduce the power on the left engine by 80%. While flying in the Karakuzhur Valley and unable to maintain a safe altitude, the pilot remembered he was using in the past an old dirt strip for agricultural operations as he was flying Antonov AN-2. He attempted to land on this airstrip located at an altitude of 2,700 metres. Upon landing, the aircraft collided with rocks (larger than 40 cm) and drainage ditches and came to rest, bursting into flames. All 14 occupants escaped uninjured while the aircraft was destroyed.