Crash of a De Havilland DHC-2 Beaver I on Mt Kahiltna: 5 killed

Date & Time: Aug 4, 2018 at 1753 LT
Type of aircraft:
Operator:
Registration:
N323KT
Flight Phase:
Survivors:
No
Site:
Schedule:
Talkeetna - Talkeetna
MSN:
1022
YOM:
1957
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
2550
Captain / Total hours on type:
346.00
Aircraft flight hours:
15495
Circumstances:
The commercial pilot was conducting a 1-hour commercial air tour flight over Denali National Park and Preserve with four passengers on board. About 48 minutes after departure, the Alaska Rescue Coordination Center received an alert from the airplane's emergency locator transmitter. About 7 minutes later, company personnel received a call from the pilot, who reported that the airplane had run "into the side of a mountain." Although a search was initiated almost immediately, due to poor weather conditions in the area, the wreckage was not located until almost 36 hours later in a crevasse on a glacier about 10,920 ft mean sea level. Due to the unique challenges posed by the steepness of terrain, the crevasse, avalanche hazard, and the condition of the airplane, neither the occupants nor the wreckage were recovered from the accident site. A weather model sounding for the area of the accident site estimated broken cloud bases at 700 ft above ground level (agl) with overcast clouds at 1,000 ft agl and cloud tops to 21,000 ft agl and higher clouds above. The freezing level was at 9,866 ft and supported light-to-moderate rime type icing in clouds and precipitation. The on-scene assessment indicated that the right wing impacted snow while the airplane was flying in a wings-level attitude; the right wing had separated from the remainder of the wreckage. Based upon available weather data and forecast models and the impact evidence, it is likely that the pilot entered an area of reduced visibility and was unable to see the terrain before the airplane's right wing impacted the snow. The company's organizational structure was such that one group of management personnel oversaw operations in both Anchorage and Talkeetna. Interviews with company management revealed that they were not always aware of the exact routing a pilot would take for a tour; the route was pilot's discretion based upon the weather at the time of the flight to provide the best tour experience. Regarding risk mitigation, the company did not utilize a formal risk assessment process, but rather relied on conversations between pilots and flight followers. This could lead to an oversight of actual risk associated with a particular flight route and weather conditions. About 8 months after the accident, an assessment flight conducted by the National Park Service determined that during the winter, the hazardous hanging glacier at the accident site calved, releasing an estimated 4,000 to 6,000 tons of ice and debris. There was no evidence of the airplane wreckage near the crash site, in the steep fall line, or on the glacier surface over 3,600 ft below. Although the known circumstances of the accident are consistent with a controlled flight into terrain event, the factual information available was limited because the wreckage was not recovered and no autopsy or toxicology of the pilot could be performed; therefore, whether other circumstances may have contributed to the accident could not be determined.
Probable cause:
Impact with terrain for reasons that could not be determined because the airplane was not recovered due to the inaccessible nature of the accident site.
Final Report:

Crash of a Junkers JU.52/3mg4e in Piz Segnas: 20 killed

Date & Time: Aug 4, 2018 at 1657 LT
Type of aircraft:
Operator:
Registration:
HB-HOT
Flight Phase:
Survivors:
No
Site:
Schedule:
Locarno - Dübendorf
MSN:
6595
YOM:
1939
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
17
Pax fatalities:
Other fatalities:
Total fatalities:
20
Captain / Total flying hours:
20714
Captain / Total hours on type:
297.00
Copilot / Total flying hours:
19751
Copilot / Total hours on type:
945
Aircraft flight hours:
10189
Circumstances:
At 16:14 on 4 August 2018, the historic Junkers Ju 52/3m g4e commercial aircraft, registered as HB-HOT and operated by Ju-Air, took off from Locarno Aerodrome (LSZL) for a commercial VFR flight to Dübendorf (LSMD). On this flight, pilot A was sitting in the left-hand seat in the cockpit and piloting the aircraft as the commander, while pilot B was assisting him as the co-pilot sitting on the right. Following take-off from concrete runway 26R westwards and a 180-degree turn over Lake Maggiore, the flight led into the Blenio valley via Bellinzona and Biasca. HB-HOT steadily gained altitude in the process. North of Olivone, the aircraft turned into the valley of the Lago di Luzzone reservoir and thus into the Adula/Greina/Medels/Vals countryside preservation quiet zone. This zone was crossed at between 120 and 300 m above ground and at times with a minimal lateral separation from the terrain. At 16:45, as the aircraft was flying over Alp Nadels, the ISP sent a text message to a friend in Ruschein (municipality of Ilanz) to say that the Ju 52 was approaching the area. The flight subsequently continued eastwards into the Surselva region at approximately 2,500 m AMSL. At 16:51, the aircraft crossed the Vorderrhein valley in the region of Ilanz on a north-easterly heading and initially made a relatively tight left turn, taking it over Ruschein. The flight path then led generally northwards past the Crap Sogn Gion mountain and towards the basin south-west of Piz Segnas. At first, the aircraft approached this basin on the left-hand, western side of the valley. HB-HOT was climbing at this time, and reached an altitude of 2,833 m AMSL in the Nagens region. The aircraft made a slight right turn when flying past the Berghaus Nagens lodge (see figure 2). During this phase, at 16:55, one of the pilots informed the passengers of the scenery over the speakers in the cabin and through the passengers’ personal headphones. To start with, the aircraft was flying at a ground speed of 165 km/h during this phase. By point F2, the ground speed had decreased to 135 km/h, and roughly remained so until shortly before point F3. Towards point F3, the aircraft’s altitude dropped slightly and the ground speed briefly increased by around 65 km/h to approximately 200 km/h. During this time, its pitch attitude3 was 5 to 7 degrees. Towards the end of this phase, just before point F4, the flight path angle4 changed from -3 degrees to approximately -1 degree and the speed of each of the three engines decreased steadily by approximately 20 revolutions per minute (rpm). At point F4, the aircraft was at an altitude of 2,742 m AMSL. At 16:56:02, shortly after point F4, the speed of each of the three engines increased by approximately 40 rpm. At 16:56:09, HB-HOT entered the basin southwest of Piz Segnas at an altitude of 2,755 m AMSL (point F5, see also figure 14) and was therefore approximately 130 m above the elevation of the Segnes pass. The flight crew then navigated the aircraft on a north-north-easterly heading almost in the centre of the valley. HB-HOT climbed slightly during this phase and its flight path angle was approximately 2 degrees; its pitch angle remained at 5 to 7 degrees. At 16:56:17, the aircraft reached an altitude of 2,767 m AMSL at point F7 and was therefore approximately 140 m above the elevation of the Segnes pass. HB-HOT flew past the Tschingelhörner mountain peaks and began to reduce in altitude, dropping more than 15 m in approximately 6 seconds. During this phase, the power of the engines was rapidly reduced by 30 to 50 rpm, which meant that the engines were increasingly running at a similar speed5 . During this process, the pitch angle increased and the flight path angle continuously became more negative. When the aircraft was approximately abeam the Martinsloch and at an altitude of approximately 2,766 m AMSL (point F8), the flight crew initiated a right turn during their descent and then made a left turn (point F109, see figure 5). The ground speed was approximately 170 km/h and the difference between the aircraft’s pitch and flight path angles increased to approximately 15 degrees during the right turn. When transitioning into the left turn (between points F9 and F10), the pitch angle was approximately 11 degrees and the flight path angle was around -10 degrees. At this time, the aircraft was flying at approximately 125 m above the elevation of the Segnes pass (see figure 3). During roughly the next 4 seconds, the aircraft descended by 25 m and the already negative flight path angle became even more negative, which is clearly apparent when comparing figures 3 and 4 as well as in figure 5. After point F13, the roll to the left increased steadily and did not decrease even when a significant aileron deflection to the right was made. The ailerons were then brought into a neutral position and temporarily deflected into a position for a left turn. At the same time, the pitch attitude began to decrease and the flight path ran increasingly steeper downwards whilst the left bank attitude constantly increased (see figure 6). During this last flight phase, the aircraft experienced low-frequency vibrations. Ultimately, when the aircraft was 108 m above ground (point F16, see figures 6 and 7), its longitudinal axis was pointing downwards by 68 degrees from horizontal. By this time, the elevator had deflected upwards by approximately 13 degrees and the rudder was pointing 2 degrees to the right. The speeds of the three engines had increased slightly compared to the beginning of the downward spiral trajectory and were between 1,720 and 1,750 rpm shortly before impact. The roll to the left accelerated significantly during this phase. Shortly after 16:57, the aircraft hit the ground in a vertical flight attitude with an almost vertical flight path and at a speed of approximately 200 km/h (see figure 8). All 20 people on board the aircraft lost their lives in the accident. The aircraft was destroyed. Fire did not break out. Reconstructions revealed that, at the time of the accident, HB-HOT’s centre of gravity was at 2.071 m behind the wing’s leading edge (see annex A1.6). In the images and video footage available that had been captured from inside HB-HOT, there was no evidence of anyone moving within the aircraft or not sitting in their seat between the period when the aeroplane entered the basin south-west of Piz Segnas and up to the beginning of its downward spiral trajectory. A detailed description of the reconstruction of the flight path and an illustration of the relevant parameters between position F1 and the site of the accident can be found in section 1.11.2. More information regarding the background and history of the flight can be found in annex A1.1.
Probable cause:
Direct cause:
The accident is attributable to the fact that after losing control of the aircraft there was insufficient space to regain control, thus the aircraft collided with the terrain.
The investigation identified the following direct causal factors of the accident:
- The flight crew piloted the aircraft in a very high-risk manner by navigating it into a narrow valley at low altitude and with no possibility of an alternative flight path.
- The flight crew chose a dangerously low airspeed as regard to the flight path. Both factors meant that the turbulence which was to be expected in such circumstances was able to lead not only to a short-term stall with loss of control but also to an unrectifiable situation.
Directly contributory factors:
The investigation identified the following factors as directly contributing to the accident:
- The flight crew was accustomed to not complying with recognized rules for safe flight operations and taking high risks.
- The aircraft involved in the accident was operated with a centre of gravity position that was beyond the rear limit. This situation facilitated the loss of control.
Systemic cause:
The investigation identified the following systemic cause of the accident:
- The requirements for operating the aircraft in commercial air transport operations with regard to the legal basis applicable at the time of the accident were
not met.
Systemically contributory factors:
The investigation identified the following factors as systemically contributing to the accident:
- Due to the air operator’s inadequate working equipment, it was not possible to calculate the accurate mass and centre of gravity of its Ju 52 aircraft.
- In particular, the air operator’s flight crews who were trained as Air Force pilots seemed to be accustomed to systematically failing to comply with generally recognized aviation rules and to taking high risks when flying Ju 52 aircraft.
- The air operator failed to identify or prevent both the deficits and risks which occurred during operations and the frequent violation of rules by its flight crews.
- Numerous incidents, including several serious incidents, were not reported to the competent bodies and authorities. This meant that they were unable to take
measures to improve safety.
- The supervisory authority failed to some extent to identify the numerous operational shortcomings and risks or to take effective, corrective action.
Other risks:
The investigation identified the following factors to risk, which had no or no demonstrable effect on the occurrence of the accident, but which should nevertheless be eliminated in order to improve aviation safety:
- The aircraft was in poor technical condition.
- The aircraft was no longer able to achieve the originally demonstrated flight performance.
- The maintenance of the air operator’s aircraft was not organized in a manner that was conducive to the objective.
- The training of flight crews with regard to the specific requirements for flight operations and crew resource management was inadequate.
- The flight crews had not been familiarized with all critical situations regarding the behavior of the aircraft in the event of a stall.
- The supervisory authority failed to identify numerous technical shortcomings or to take corrective action.
- The expertise of the individuals employed by the air operator, maintenance companies and the supervisory authority was in parts insufficient.
Final Report:

Crash of a Piper PA-31-310 Navajo C on Mt Rae: 2 killed

Date & Time: Aug 1, 2018 at 1336 LT
Type of aircraft:
Operator:
Registration:
C-FNCI
Flight Phase:
Survivors:
No
Site:
Schedule:
Penticton - Calgary
MSN:
31-8112007
YOM:
1981
Location:
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
4400
Captain / Total hours on type:
2800.00
Aircraft flight hours:
7277
Circumstances:
On 01 August 2018, after completing 2 hours of survey work near Penticton, British Columbia (BC), an Aries Aviation International Piper PA-31 aircraft (registration C-FNCI, serial number 31-8112007) proceeded on an instrument flight rules flight plan from Penticton Airport (CYYF), BC, to Calgary/Springbank Airport (CYBW), Alberta, at 15 000 feet above sea level. The pilot and a survey technician were on board. When the aircraft was approximately 40 nautical miles southwest of CYBW, air traffic control began sequencing the aircraft for arrival into the Calgary airspace and requested that the pilot slow the aircraft to 150 knots indicated airspeed and descend to 13 000 feet above sea level. At this time, the right engine began operating at a lower power setting than the left engine. About 90 seconds later, at approximately 13 500 feet above sea level, the aircraft departed controlled flight. It collided with terrain near the summit of Mount Rae at 1336 Mountain Daylight Time. A brief impact explosion and fire occurred during the collision with terrain. The pilot and survey technician both received fatal injuries. The Canadian Mission Control Centre received a 406 MHz emergency locator transmitter signal from the occurrence aircraft and notified the Trenton Joint Rescue Coordination Centre. Search and rescue arrived on site approximately 1 hour after the accident.
Probable cause:
Findings as to causes and contributing factors:
1. The pilot did not continuously use oxygen above 13 000 feet and likely became hypoxic as the aircraft climbed to 15 000 feet. The pilot did not recognize his symptoms or take action to restore his supply of oxygen.
2. As a result of hypoxia-related cognitive and perceptual degradations, the pilot was unable to maintain effective control of the aircraft or to respond appropriately to the asymmetric power condition.
3. The aircraft departed controlled flight and entered a spin to the right because the airspeed was below both the published minimum control speed in the air and the stall speed, and because there was a significant power asymmetry, a high angle of attack, and significant asymmetric drag from the windmilling propeller of the right engine.
4. When the aircraft exited cloud, the pilot completed only 1 of the 7 spin-recovery steps: reducing the power to idle. As the aircraft continued to descend, the pilot took no further recovery action, except to respond to air traffic control and inform the controller that there was an emergency.

Findings as to risk:
1. If flight crews do not undergo practical hypoxia training, there is a risk that they will not recognize the onset of hypoxia when flying above 13 000 feet without continuous use of supplemental oxygen.

Other findings:
1. The weather information collected during the investigation identified that the loss of control was not due to in-flight icing, thunderstorms, or turbulence.
2. Because the Appareo camera had been bumped and its position changed, the pilot’s actions on the power controls could not be determined. Therefore, the investigation was unable to determine whether the power asymmetry was the result of power-quadrant manipulation by the pilot or of an aircraft system malfunction.
3. The flight path data, audio files, and image files retrieved from the Appareo system enabled the investigators to better understand the underlying factors that contributed to the accident.
Final Report:

Crash of a De Havilland DHC-3T Otter near Hydaburg

Date & Time: Jul 10, 2018 at 0835 LT
Type of aircraft:
Operator:
Registration:
N3952B
Flight Phase:
Survivors:
Yes
Site:
Schedule:
Klawock – Ketchikan
MSN:
225
YOM:
1957
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
10
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
27400
Captain / Total hours on type:
306.00
Aircraft flight hours:
16918
Circumstances:
The airline transport pilot was conducting a commercial visual flight rules (VFR) flight transporting 10 passengers from a remote fishing lodge. According to the pilot, while in level cruise flight about 1,100 ft mean sea level (msl) and as the flight progressed into a mountain pass, visibility decreased rapidly. In an attempt to turn around and return to VFR conditions, the pilot initiated a climbing right turn. Before completing the 180° right turn, he saw what he believed to be a body of water and became momentarily disoriented, so he leveled the wings. Shortly thereafter, he realized that the airplane was approaching an area of snow-covered mountainous terrain, so he applied full power and initiated a steep climb; the airspeed decayed, and the airplane collided with an area of rocky, rising terrain, which resulted in substantial damage to the wings and fuselage. The pilot reported no mechanical malfunctions or anomalies that would have precluded normal operation, and the examination of the airframe and engine revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation. The weather forecast at the accident time included scattered clouds at 2,500 ft msl, overcast clouds at 5,000 ft msl with cloud tops to 14,000 ft and clouds layered above that to flight level 250, and isolated broken clouds at 2,500 ft with light rain. AIRMET advisory SIERRA for "mountains obscured in clouds/precipitation" was valid at the time of the accident. Conditions were expected to deteriorate. Passenger interviews revealed that through the course of the flight, the airplane was operating in marginal visual meteorological conditions and occasional instrument meteorological conditions (IMC) with areas of precipitation, reduced visibility, obscuration, and, at times, little to no forward visibility. Thus, based on weather reports and forecasts, and the pilot's and passengers' statements, it is likely that the flight encountered IMC as it approached mountainous terrain and that the pilot then lost situational awareness. The airplane was equipped with a terrain awareness and warning system (TAWS); however, the alerts were inhibited at the time of the accident. Although the TAWS was required to be installed per Federal Aviation Administration (FAA) regulations, there is no requirement for it to be used. All company pilots interviewed stated that the TAWS inhibit switch remained in the inhibit position unless a controlled flight into terrain (CFIT) escape maneuver was being accomplished. However, the check airman who last administered the accident pilot's competency check stated that the TAWS inhibit switch was never moved, even during a CFIT escape maneuver. The unwritten company policy to leave the TAWS in the inhibit mode and the failure of the pilot to move the TAWS out of the inhibit mode when weather conditions began to deteriorate were inconsistent with the goal of providing the highest level of safety. However, if the pilot had been using TAWS, due to the fact that he was operating at a lower altitude and thus would have likely received numerous nuisance alerts, the investigation could not determine the extent to which TAWS would have impacted the pilot's actions. At the time of the accident, the director of operations (DO) for the company resided in another city and served as DO for another air carrier as well. He traveled to the company's main base of operation about once per month but was available via telephone. According to the chief pilot, he had assumed a large percentage of the DO's duties. The president of the company said that the chief pilot had taken over "officer of the deck" and "we're just basically using him [the DO] for his recordkeeping." The FAA was aware that the company's DO was also DO for another commuter operation. FAA Flight Standards District Office management and principal operations inspectors allowed him to continue to hold those positions, although it was contrary to the guidance provided in FAA Order 8900.1. The company's General Operations Manual (GOM) only listed the DO, the chief pilot, and the president by name as having the authority to exercise operational control. However, numerous company personnel stated that operational control could be and was routinely delegated to senior pilots. The GOM stated that the DO "routinely" delegated the duty of operational control to flight coordinators, but the flight coordinator on duty at the time of the accident stated that she did not have operational control. In addition, the investigation revealed numerous inadequate and missing operational control procedures and processes in company manuals and operations specifications. Based on the FAA's inappropriate approval of the DO, the insufficient company onsite management, the inadequate operational control procedures, and the exercise of operational control by unapproved persons likely resulted in a lack of oversight of flight operations, inattentive and distracted management personnel, and a loss of operational control within the air carrier. However, the investigation could not determine the extent to which any changes to operational control, company management, and FAA oversight would have influenced the pilot's decision to continue the VFR flight into IMC.
Probable cause:
The pilot's decision to continue the visual flight rules flight into instrument meteorological conditions, which resulted in controlled flight into terrain.
Final Report:

Crash of a Let L-410UVP near Souguéta: 4 killed

Date & Time: Jun 24, 2018 at 1030 LT
Type of aircraft:
Registration:
3X-AAJ
Flight Phase:
Survivors:
No
Site:
Schedule:
Sal - Conakry – Lero
MSN:
85 14 03
YOM:
1985
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
4
Circumstances:
The twin engine airplane was carrying two technicians and two pilots bound for a mine field located near Lero, Kankan. It made an intermediate stop at Conakry on a flight from Sal, Cape Verde. En route, the crew encountered poor weather conditions with low clouds and fog when the airplane struck the slope of a mountain and disintegrated on impact. All four occupants were killed.

Crash of a Cessna 208B Grand Caravan in Mt Aberdare: 10 killed

Date & Time: Jun 5, 2018 at 1702 LT
Type of aircraft:
Operator:
Registration:
5Y-CAC
Flight Phase:
Survivors:
No
Site:
Schedule:
Kitale – Nairobi
MSN:
208B-0525
YOM:
1996
Flight number:
EXZ102
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
10
Captain / Total flying hours:
2352
Circumstances:
The aircraft took-off from Kitale Airstrip (HKKT) at 16.05 hours and set course to Jomo Kenyatta International Airport (HKJK) after climbing to FL 110 with ten onboard. Once established, there were slight peripheral variations in groundspeed and track. The aircraft Flight Level was sustained at 110 with some occasional deviations. Aircraft height above ground level (AGL) varied between 1,102 feet and 4,187 feet. One minute before its impact with the cliff, the aircraft was at 11,100 feet or 3,000 feet AGL, 159 knots ground speed, and tracking radial 338 NV. Immediately before radar signal was lost, the elevation of the highest ground level was 12,876 feet, the aircraft altitude was 11,200 feet, the ground speed was 156 knots, and track was radial 339 NV. Information retrieved from the Radar transcript recorded various parameters of the aircraft from 1605hrs up to 1702hrs, the time radar signal was lost. This information was consistent with information extracted from the on-board equipment the ST3400 and the aera GPS. The radar system transmits information including aircraft position in relation to NV VOR, Flight Level or altitude, ground speed, vertical speed and heading. Information retrieved from the GPS captured the last recorded time, date and location as 14:00:52, on 06/05/2018 and elevation 3,555.57 metres. The aircraft impacted the bamboo-covered terrain at an elevation of 3,645 metres at 0.36’56’’S 36 42’44’’ where the wreckage was sited. The aircraft was totally destroyed by impact forces and all 10 occupants were killed.
Probable cause:
The flight crew's inadequate flight planning and the decision to fly instrument flight rules (IFR) at an altitude below the published Minimum Sector Altitude in the Standard Instrument Arrival Chart under instrument meteorological conditions (IMC), and their failure to perform an immediate escape maneuver following TAWS alert, which resulted in controlled flight into terrain (CFIT).
Contributing Factors:
1. Contributing to the accident were the operator's inadequate crew resource management (CRM) training, inadequate procedures for operational control and flight release.
2. Also contributing to the accident was the Kenya Civil Aviation Authority's failure to hold the operator accountable for correcting known operational deficiencies and ensuring compliance with its operational control procedures.
3. There was no requirement for crew to be trained in CFIT avoidance ground training tailored to the company’s operations that need to address current CFIT-avoidance technologies.
4. Use of non-documented procedure and Clearance by the ATC to fly below the published minimum sector altitude.
5. Lack of situational awareness by the radar safety controller while monitoring flights within the radar service section.
Final Report:

Crash of a Cessna 208B Grand Caravan near Simikot: 2 killed

Date & Time: May 16, 2018 at 0645 LT
Type of aircraft:
Operator:
Registration:
9N-AJU
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Surkhet – Simikot
MSN:
208B-0770
YOM:
1999
Location:
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total hours on type:
414.00
Copilot / Total hours on type:
461
Aircraft flight hours:
15757
Aircraft flight cycles:
31540
Circumstances:
The single engine aircraft departed Surkhet Airport at 0612LT on a cargo flight to Simikot. At 0627LT, the crew made his last radio transmission with Nepalgunj Tower. About 18 minutes later, while cruising by night at an altitude of 12,800 feet, the airplane struck the slope of a mountain located near the Simikot Pass, some 12 km from Simikot Airport. The airplane disintegrated on impact and both crew members were killed.
Probable cause:
The Commission determines the most probable cause of this accident was to continue the flight despite unfavorable weather conditions resulting inadvertent flight into instrument
meteorological conditions and there by deviating from the normal track due to loss of situational awareness that aggravated the spatial disorientation leading to CFIT accident. The following contributing factors were reported:
- Possible effect of hypoxia due to flight for prolonged period in high altitude without oxygen supplement,
- Ineffective safety management of the company which prevented the organization from identifying and correcting latent deficiencies in risk management and inadequacies in pilot training.
Final Report:

Crash of a Cessna 208B Grand Caravan near Tuzantán: 3 killed

Date & Time: May 15, 2018 at 0900 LT
Type of aircraft:
Operator:
Flight Phase:
Flight Type:
Survivors:
No
Site:
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
3
Circumstances:
The single engine aircraft crashed in unknown circumstances in a wooded and hilly terrain located near Tuzantán. The airplane was totally destroyed by a post crash fire and all three occupants were killed. According to Mexican Authorities, the crew was completing an illegal flight.

Crash of a Canadair CL-600-2B16 Challenger 604 near Shahr-e-Kord: 11 killed

Date & Time: Mar 11, 2018 at 1840 LT
Type of aircraft:
Operator:
Registration:
TC-TRB
Flight Phase:
Survivors:
No
Site:
Schedule:
Sharjah – Istanbul
MSN:
5494
YOM:
2001
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
11
Captain / Total flying hours:
4880
Captain / Total hours on type:
1600.00
Copilot / Total flying hours:
1132
Copilot / Total hours on type:
114
Aircraft flight hours:
7935
Aircraft flight cycles:
3807
Circumstances:
A Turkish Challenger 604 corporate jet impacted a mountain near Shahr-e Kurd in Iran, killing all 11 on board. The aircraft departed Sharjah, UAE at 13:11 UTC on a flight to Istanbul, Turkey. The aircraft entered Tehran FIR fifteen minutes later and the Tehran ACC controller cleared the flight to climb to FL360 according to its flight plan. About 14:32, the pilot requested FL380, which was approved. Before reaching that altitude, the left and right airspeeds began to diverge by more than 10 knots. The left (captain's) airspeed indicator showed an increase while the right hand (copilot's) airspeed indicator showed a decrease. A caution aural alert notified the flight crew of the difference. Remarks by the flight crew suggested that an 'EFIS COMP MON' caution message appeared on the EICAS. As the aircraft was climbing, the crew reduced thrust to idle. Approximately 63 seconds later, while approaching FL380, the overspeed aural warning (clacker) began to sound, indicating that the indicated Mach had exceeded M 0.85. Based on the Quick Reference Handbook (QRH) of the aircraft, the pilot flying should validate the IAS based on the aircraft flight manual and define the reliable Air Data Computer (ADC) and select the reliable Air Data source. The pilot did not follow this procedure and directly reduced engine power to decrease the IAS after hearing the clacker. The actual airspeed thus reached a stall condition. The copilot tried to begin reading of the 'EFIS COMP MON' abnormal procedure for three times but due to pilot interruption, she could not complete it. Due to decreasing speed, the stall aural warning began to sound, in addition to stick shaker and stick pusher activating repeatedly. The crew then should have referred to another emergency procedure to recover from the stall condition. While the stick pusher acted to pitch down the aircraft to prevent a stall condition, the captain was mistakenly assumed an overspeed situation due to the previous erroneous overspeed warning and pulled on the control column. The aircraft entered a series of pitch and roll oscillations. The autopilot was disengaged by the crew before stall warning, which ended the oscillations. Engine power began to decrease on both sides until both engines flamed out in a stall condition. From that point on FDR data was lost because the electric bus did not continue to receive power from the engine generators. The CVR recording continued for a further approximately 1 minute and 20 seconds on emergency battery power. Stall warnings, stick shaker and stick pusher activations continued until the end of the recording. The aircraft then impacted mountainous terrain. Unstable weather conditions were present along the flight route over Iran, which included moderate up to severe turbulence and icing conditions up to 45000ft. These conditions could have caused ice crystals to block the left-hand pitot tube. It was also reported that the aircraft was parked at Sharjah Airport for three days in dusty weather condition. Initially the pitot covers had not been applied. The formation of dust inside the pitot tube was considered another possibility.
Probable cause:
The accident was caused by insufficient operational prerequisites for the management of erratic airspeed indication failure by the cockpit crew. The following contributing factors were identified:
- The aircraft designer/manufacturer provided insufficient technical and operational guidance about airspeed malfunctions that previously occurred.
- Lack of effective CRM.
Final Report:

Crash of an ATR72-212 on Mt Dena: 66 killed

Date & Time: Feb 18, 2018 at 0931 LT
Type of aircraft:
Operator:
Registration:
EP-ATS
Flight Phase:
Survivors:
No
Site:
Schedule:
Tehran – Yasuj
MSN:
391
YOM:
1993
Flight number:
EP3704
Location:
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
60
Pax fatalities:
Other fatalities:
Total fatalities:
66
Captain / Total flying hours:
17926
Captain / Total hours on type:
12519.00
Copilot / Total flying hours:
1880
Copilot / Total hours on type:
197
Aircraft flight hours:
28857
Aircraft flight cycles:
28497
Circumstances:
Iranian ATR72 aircraft registered EP-ATS operated by Iran Aseman Airlines was assigned to perform a domestic scheduled passenger flight from Tehran to Yasuj on 07:55 local time. The aircraft took off from Tehran Mehrabad International Airport (0III) at 04:35 UTC. (08:05 LMT) and the flight was the first flight of the day for aircraft and the crew. The cruise flight was conducted at FL210 on airway W144 and no abnormal situation was reported by the crew and the flight was continued on Tehran ACC frequency till the time the first officer requested latest weather information of the destination by contact to Yasuj tower then requested to leave FL210 to FL170 from Tehran ACC. When the aircraft was descending to FL170 and crew calling YSJ tower the aircraft descending was continued to altitude of 15000 ft. The aircraft was approved to join overhead of the airport and perform “circling NDB approach “to land on RWY 31 at the destination aerodrome. Finally the aircraft collided with a peak lee of DENA Mountains about 8.5 miles at North far from the airport and involved accident on 06:01 UTC. The aircraft was completely destroyed as a result of collision with the mountain at the altitude of approximately 13,300 ft.
Probable cause:
The accident was happened due to many chains of considered causes but the “Human Factor” had main roll for the conclusion of the scenario. The Cockpit Crew action which has caused dangerous conditions for the flight is considered as main cause. Based on provided evidences, the errors of cockpit crew were as follows:
- Continuing to the Yasouj airport for landing against Operation manual of the Company, due to low altitude ceiling of the cloud and related cloud mass. They should divert to alternate airport,
- Descending to unauthorized altitude below minimum of the route and MSA,
- Lack of enough CRM during flight,
- Failure to complete the stall recovery (flap setting, max RPM),
- Inappropriate use of Autopilot after Stall condition,
- Inadequate anticipation for bad weather based on OM (Clouds, Turbulence, and Icing ...),
- Quick action to switch off anti-ice system and AOA,
- Failure to follow the Check lists and standard call out by both pilots.
Contributing Factors:
The contributive factors to this accident include but are not limited to the following:
- The airline was not capable to detect systematic defectives about :
- Effectiveness of crew training about Meteorology, OM, SOP,
- Enough operational supervision on pilot behaviors,
- The lack of SIGMET about Mountain Wave or Severe Mountain wave,
- Unclear procedure for stall recovery in FCOM,
- Lack of warning in aircraft manuals by manufacturer for flight crew awareness about mountain wave.
- Lack of APM System to alert crew about performance degradation.
Other Deficiencies and Short Comes:
In the process of the accident investigation, some detailed deficiencies and short comes were found and should be considered as latent conditions by related authorities:
- AD accomplishment and related monitoring,
- Sanction on aviation industries and effect on Flight safety,
- Non-standard communication between ATC and crew,
- Unclear definition of the Fully Qualified Pilot and qualified copilot in Aircrew regulation.
- Weather forecast (TAF) in the airports based on annex 3 procedure in the Civil Aviation Organization for approving alternative method of compliance for aircraft AD,s
- Search and rescue Coordination with local authorities for aviation accidents,
- Time setting of aircraft flight data recording(FDR) either by technician or pilots.
Final Report: