Plain, Valley

Site:

Schedule:

Aberdeen - Pine Ridge

MSN:

303-00210

YOM:

1983

Location:

Batesland

South Dakota

Country:

Region:

Cessna 525 CitationJet CJ1

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Captain / Total flying hours:

5655

Captain / Total hours on type:

4403.00

Aircraft flight hours:

8929

Circumstances:

Before the air taxi flight, the commercial pilot obtained a weather briefing via the company computer system and reviewed the weather information with the company chief pilot. The pilot stated that based on the computer briefing, which did not include icing conditions, he was aware of the forecasted weather conditions along the route of flight and at the intended destination. However, the briefing was incomplete as it did not contain any in-flight weather advisories, which would have alerted the pilot of moderate icing conditions expected over the flight route in the form of AIRMET Zulu. After takeoff and during the climb to 12,000 ft mean sea level (msl), the airplane encountered light rime ice, and the pilot activated the de-ice equipment with no issues noted. After hearing reports of better weather at a lower altitude, the pilot requested a descent to between 5,000 and 6,000 ft. During the descent to 6,000 ft msl and with the airplane clear of ice, the airplane encountered light to moderate icing conditions. The pilot considered turning back to another airport but could not get clearance until the airplane was closer to his destination. Shortly thereafter, the pilot stated that it felt “like a sheet of ice fell on us” as the airplane encountered severe icing conditions. The pilot applied full engine power in an attempt to maintain altitude. The airplane exited the overcast cloud layer about 500 ft above ground level. The pilot chose to execute an off-airport emergency landing because the airplane could not maintain altitude. During the landing, the landing gear separated; the airplane came to rest upright and sustained substantial damage to the wings and fuselage. The pilot reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation and that the airplane was within its maximum gross weight. Structural icing was observed on the airframe after the landing. Based on the weather information, which indicated the probability of icing between 5,000 and 9,000 ft over the region and a high threat of supercooled large droplets between 5,000 and 7,000 ft, it is likely that the airplane, which was equipped for flight in icing conditions, inadvertently encountered severe icing conditions consistent with supercooled large droplets, which resulted in structural icing that exceeded the airplane’s capabilities to maintain altitude.

Probable cause:

The airplane’s inadvertent encounter with severe icing conditions during descent, which resulted in structural icing, the pilot’s inability to maintain altitude, and an emergency landing. Contributing to the accident was an incomplete preflight weather briefing.

Final Report:

Crash of a Cessna 525 CJ1 in Crozet: 1 killed

Date & Time: Apr 15, 2018 at 2054 LT

Type of aircraft:

Operator:

Augusta Aviation LLC

Registration:

N525P

Flight Phase:

Flight

Flight Type:

Private

Survivors:

Site:

Schedule:

Rchmond - Weyers Cave

MSN:

525-0165

YOM:

1996

Location:

Crozet

Virginia

Country:

Region:

Cessna 208B Grand Caravan

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Captain / Total flying hours:

737

Captain / Total hours on type:

165.00

Aircraft flight hours:

3311

Circumstances:

The instrument rated private pilot was drinking alcohol before he arrived at the airport. Before the flight, he did not obtain a weather briefing or file an instrument flight rules flight plan for the flight that was conducted in instrument meteorological conditions. The pilot performed a 3-minute preflight inspection of the airplane and departed with a tailwind (even though he had initially taxied the airplane to the runway that favored the wind) and without communicating on the airport Unicom frequency. After departure, the airplane climbed to a maximum altitude of 11,500 feet mean sea level (msl), and then the airplane descended to 4,300 ft msl (which was 1,400 ft below the minimum safe altitude for the destination airport) and remained at that altitude for 9 minutes. Afterward, the airplane began a descending left turn, and radar contact was lost at 2054. The pilot did not talk to air traffic control during the flight and while operating in night instrument meteorological conditions. During the flight, the airplane flew through a line of severe thunderstorms with heavy rain, tornados, hail, and multiple lightning strikes. Before the airplane's descending left turn began, it encountered moderate-to-heavy rain. The airplane's high descent rate of at least 6,000 ft per minute and impact with a mountain that was about 450 ft from the last radar return, the damage to the airplane, and the distribution of the wreckage were consistent with a loss of control and a high-velocity impact. Examination of the airplane revealed no evidence of any preimpact mechanical anomalies. Based on the reported weather conditions at the time the flight, the pilot likely completed the entire flight in night instrument meteorological conditions. His decision to operate at night in an area with widespread thunderstorms and reduced visibility were conducive to the development of spatial disorientation. The airplane's descending left turn and its high-energy impact were consistent with the known effects of spatial disorientation. The pilot was not aware of the conditions near and at the destination airport because he failed to obtain a weather briefing and was not communicating with air traffic control. Also, the pilot's decision to operate an airplane within 8 hours of consuming alcohol was inconsistent with the Federal Aviation Administration's regulation prohibiting such operations, and the level of ethanol in the pilot's toxicology exceeded the level allowed by the regulation. Overall, the pilot's intoxication, combined with the impairing effects of cetirizine, affected his judgment; contributed to his unsafe decision-making; and increased his susceptibility to spatial disorientation, which resulted in the loss of control of the airplane.

Probable cause:

The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The pilot's loss of control while operating in night instrument meteorological conditions as a result of spatial disorientation. Contributing to the accident was the pilot's decision to operate
an airplane after consuming alcohol and his resulting intoxication, which degraded the pilot's judgment and decision-making.

Final Report:

Crash of a Cessna 208B Grand Caravan in Atqasuk

Date & Time: Apr 11, 2018 at 0818 LT

Type of aircraft:

Operator:

Registration:

N814GV

Flight Phase:

Landing (descent or approach)

Flight Type:

Postal (mail)

Survivors:

Site:

Schedule:

Utqiagvik – Atqasuk

MSN:

208B-0958

YOM:

2002

Location:

Atqasuk

Alaska

Country:

Region:

Beechcraft 200 Super King Air

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Captain / Total flying hours:

7713

Aircraft flight hours:

9778

Circumstances:

The pilot was on a visual flight rules flight transporting mail to a remote village. He reported that when he was about 15 minutes from the destination, he checked the automated weather observing system (AWOS) for updated weather information for the destination and recalled that the visibility was reported as 7 miles. However, the information he recalled was not consistent with what was actually reported by the AWOS; 18 minutes before the accident, the AWOS reported no more than 1 3/4 miles visibility. As he descended the airplane from 2,500 ft to 1,500 ft in the terminal area, he observed reduced visibility conditions that would require an instrument approach procedure. According to the pilot, while maneuvering toward the initial approach fix, he heard the autopilot disconnect, and the airplane began an uncommanded descent. He said that he remembered pulling on the control wheel and thought he had leveled off, but then the airplane impacted terrain, which resulted in substantial damage to the fuselage, vertical stabilizer, and rudder. He could not recall if he had heard terrain warnings or alerts before the impact. An airplane performance study indicated that the airplane was in a continuous descent from 2,500 ft until the final data point about 12 ft above the surface; the airplane was not leveled off at any time during the descent. In the final 15 seconds of recorded data, the rate of descent increased from about 500 fpm to about 2,300 fpm before decreasing to 1,460 fpm at the last recorded data point. Postaccident examinations of the airframe, engine, flight control, and autopilot components revealed no mechanical malfunctions or failures that would have precluded normal operation or affected flight controllability. It is likely that the unexpected instrument approach procedure increased the pilot's workload as he maneuvered to set up for the approach. Further, when the autopilot disconnected, the airplane continued to descend; although the pilot reported that he heard the autopilot disconnect, he did not arrest the airplane's descent rate. Given the low visibility conditions, it is likely that the pilot did not detect the airplane's descent, and the airplane descended into the terrain.

Probable cause:

The pilot's decision to continue a visual flight rules flight into an area of instrument meteorological conditions and his subsequent failure to level the airplane after the autopilot disconnected, which resulted in a collision with terrain.

Final Report:

Crash of a Cessna 401 in Pelagiada

Date & Time: Apr 1, 2018 at 1415 LT

Type of aircraft:

Cessna 401

Operator:

Registration:

RA-1272G

Flight Phase:

Flight Type:

Survivors:

Site:

Schedule:

Pelagiada - Pelagiada

MSN:

401-0112

YOM:

1968

Location:

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Captain / Total flying hours:

5672

Captain / Total hours on type:

150.00

Aircraft flight hours:

5100

Circumstances:

Few minutes after takeoff from Pelagiada, the pilot informed ATC about the failure of the right engine while the left engine lost power. The pilot completed an emergency belly landing in an open field located near Pelagiada, about 20 km north of Stavropol. The aircraft was damaged beyond repair and the pilot escaped uninjured.

Probable cause:

The failure of the right engine is most likely due to an interruption in the fuel supply due to the presence of dirt in the fuel filter. The left engine lost power presumably due to wear on the cylinders and pistons that had exceeded their life limit. A lack of an effective check of the fuel filters and the life of the various components of the left engines remains contributing factors.

Final Report:

Crash of a Beechcraft B200 Super King Air in Blue Creek

Date & Time: Mar 15, 2018 at 0200 LT

Type of aircraft:

Operator:

Registration:

YV3284

Flight Phase:

Landing (descent or approach)

Flight Type:

Illegal (smuggling)

Survivors:

Site:

MSN:

BB-1277

YOM:

1987

Location:

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Circumstances:

By night, the pilot attempted to land in a prairie located in Blue Creek, west Belize. The airplane belly landed and slid for few dozen metres before coming to rest, almost broken in two. The pilot leaved the scene but was quickly arrested by the local police. It is believed that it was an illegal flight as the registration on the aircraft (YV3224) is wrong. It appears that the correct registration was YV3284.

Crash of a Beechcraft B60 Duke near Ferris

Date & Time: Mar 1, 2018 at 1100 LT

Type of aircraft:

Beechcraft 60 Duke

Operator:

Mike & Mayo Partners

Registration:

N77MM

Flight Phase:

Flight Type:

Survivors:

Site:

Schedule:

Addison – Mexia

MSN:

P-587

YOM:

1982

Location:

Ferris

Texas

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Captain / Total flying hours:

6400

Captain / Total hours on type:

2200.00

Aircraft flight hours:

2210

Circumstances:

The pilot in the multi-engine, retractable landing gear airplane reported that, during an instrument flight rules cross-country flight, about 5,000 ft above mean sea level, the left engine surged several times and he performed an emergency engine shutdown. Shortly afterward, the right engine lost power. During the emergency descent, the airplane struck treetops, and landed hard in a field with the landing gear retracted. The airplane sustained substantial damage to both wings, the engine mounts, and the lower fuselage. The pilot reported that he had requested 200 gallons of fuel from his home airport fixed base operator, but they did not fuel the airplane. The pilot did not check the fuel quantity during his preflight inspection. According to the Federal Aviation Administration Airplane Flying Handbook, Chapter 2, page 2-7, pilots must always positively confirm the fuel quantity by visually inspecting the fuel level in each tank. The pilot reported that there were no mechanical malfunctions or failures with the airplane that would have precluded normal operation.

Probable cause:

The pilot's improper preflight inspection of the fuel level, which resulted in a loss of engine power due to fuel exhaustion. Contributing to the accident was the pilot's failure to lower the landing gear before the emergency landing.

Final Report:

Crash of a Cessna 441 Conquest II in Rossville: 3 killed

Date & Time: Feb 22, 2018 at 1939 LT

Type of aircraft:

Cessna 441 Conquest

Operator:

Registration:

N771XW

Flight Phase:

Flight

Flight Type:

Private

Survivors:

Site:

Schedule:

Eagle Creek Airpark - Green Bay

MSN:

441-0065

YOM:

1978

Location:

Rossville

Indiana

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Captain / Total flying hours:

2248

Captain / Total hours on type:

454.00

Aircraft flight hours:

6907

Circumstances:

The airline transport pilot and two passengers departed in the twin-engine, pressurized airplane on a business flight in night instrument meteorological conditions. Shortly after takeoff, the airplane began to deviate from its assigned altitude and course. The controller queried the pilot, who responded that the airplane was "… a little out of control." After regaining control of the airplane, the pilot reported that he had experienced a "trim issue." The airplane continued on course and, about 13 minutes later, the pilot again reported a trim malfunction and said that he was having difficulty controlling the airplane. The flight's heading and altitude began to deviate from the course for the last 8 minutes of radar data and became more erratic for the last 2 minutes of radar data; radar and radio communication were subsequently lost at an altitude of about 18,300 ft in the vicinity of the accident site. Several witnesses reported hearing the airplane flying overhead. They all described the airplane as being very loud and that the engine sound was continuous up until they heard the impact. The airplane impacted a field in a relatively level attitude at high speed. The wreckage was significantly fragmented and the wreckage path extended about 1/4 mile over several fields. Examination of the available airframe and engine components revealed no anomalies that would have precluded normal operation of the airplane. The accident airplane was equipped with elevator, rudder, and aileron trim systems; however, not all components of the trim system and avionics were located or in a condition allowing examination. Although the airplane was equipped with an electric elevator trim and autopilot that could both be turned off in an emergency, the investigation could not determine which trim system the pilot was reportedly experiencing difficulties with. It is likely that the pilot was unable to maintain control of the airplane as he attempted to address the trim issues that he reported to air traffic control.

Probable cause:

An in-flight loss of control for reasons that could not be determined based on the available evidence.

Final Report:

Crash of an Antonov AN-148-100B in Stepanovskoye: 71 killed

Date & Time: Feb 11, 2018 at 1427 LT

Type of aircraft:

Antonov AN-148

Operator:

Registration:

RA-61704

Flight Phase:

Takeoff (climb)

Flight Type:

Scheduled Revenue Flight

Survivors:

Site:

Cessna 207 Skywagon/Stationair

Schedule:

Moscow – Orsk

MSN:

27015040004

YOM:

2010

Flight number:

6W703

Location:

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Captain / Total flying hours:

5039

Captain / Total hours on type:

1323.00

Copilot / Total flying hours:

860

Copilot / Total hours on type:

720

Aircraft flight hours:

16249

Aircraft flight cycles:

8397

Circumstances:

The twin engine aircraft departed runway 14R at Moscow-Domodedovo Airport at 1421LT. Six minutes later, while climbing to an altitude of 6,000 feet in light snow showers, the airplane descended then disintegrated in a snow covered field located in Argunovo, about 37 km southeast of the Airport, one minute later. The aircraft was totally destroyed and debris were scattered on more than one km. All 71 occupants were killed. Both recording systems have been recovered. A day after the crash, Russian Authorities confirmed that the aircraft was intact until the final impact with the ground. Preliminary reports indicates speed variations on all three ASI's three minutes after rotation. 50 seconds after the automatic pilot was disconnected, the airplane experienced vertical loads between 0,5 and 1,5 G. then pitched down to an angle of 35°. Five seconds prior to impact, the airplane banked right to 25°. Preliminary investigations shows that the incorrect data on ASI's was caused by icing of the Pitot tubes as the heating systems was off, apparently because the crew failed to activate it.

Probable cause:

The accident was the consequence of erroneous actions on part of the crew while climbing in instrument meteorological conditions at unreliable readings of instrument speed caused by icing (blockage with ice) of all three Pitot tubes. This caused the aircraft to become uncontrollable, enter a dive and eventually collide with the ground. The accident was then considered as a loss of control in flight (LOC-I). The investigation revealed systemic weaknesses in the identification of hazards and risk control, the inoperability of the airline's flight safety management system and the lack of control over the level of training of crew members by aviation authorities at all levels, which led to the issuance of certificates of aviation personnel and the admission to the flights of the crew, which did not fully meet the qualification requirements. The following contributing factors were reported:
- Hurry of the crew in preparation for the flight due to the late arrival of the aircraft from the previous flight and attempts to "catch up" with the time,
- Skipping by the crew of the operation to switch on the Pitot tube heating before takeoff and failing to comply with the section of the check list "BEFORE TAKE-OFF", which provides for the control of this action,
- Design features of the An-148 aircraft in terms of the restrictions on the duration of Pitot tube heating operation on the ground, which led to the need to carry out operations to control the inclusion of Pitot tube heating and compliance with the principle of "dark cockpit" in a separate section of the "BEFORE THE FLIGHT" check list, which is performed immediately before the start of the takeoff run, which creates additional risks of missing these operations. These actions are provided in the section "ON THE RUNWAY START",
- Systematic failure of the airline's crews to comply with the "dark cockpit" principle and the requirements of the radar, which contributed to "getting used" to the takeoff with the presence of emergency and warning messages on the Integrated system and alarm indicator (KISS) and did not allow to identify the fact that the Pitot tube heating was not included. In the accident flight before takeoff, six warning messages were displayed on the KISS, including three messages about the absence of Pitot tube heating,
- Design features of the An-148 aircraft, connected with the impossibility to disable the display of a number of warning messages on the KISS even when performing the whole range of works provided for by the MMEL while ensuring the flight with delayed defects,
- Low safety culture in the airline, which was manifested in: systematic failure to record in the flight log the failures detected during the flight, as well as in the performance of flights with the failures not eliminated and/or not included in the list of delayed failures, accompanied by the corresponding messages on the KISS,
- Failure to take necessary measures in case of detection of previous facts of untimely activation of Pitot tube heating by crews based on the results of express analysis of flight information,
- Unreadiness of the crew to take actions in case of triggering the alarm "Speed of Emergency" due to the lack of appropriate theoretical training in the airline and the impossibility to work out this special situation on the flight simulation device and / or during airfield training and, as a consequence, failure to comply with the procedures provided for after triggering of this alarm,
- Absence of federal aviation regulations for certification of flight simulators, the development of which is provided for by the Air Code of the Russian Federation,
- Approval for the existing AN-148 flight simulators of the IFC Training LLC and the CTC of the Saint-Petersburg State University of Civil Aviation without taking into account their actual capabilities to reproduce special flight cases, as well as the provisions of FAR-128,
- Absence of specific values of flight parameters (engine operation mode, pitch and roll angles, etc.) in the aircraft's flight manual, which must be maintained by the crew of the airspeed alarm system, as well as absence of the situation with unreliable instrument speed readings (Unreliable Airspeed Procedure) in the list of special flight cases,
- Increased psycho-emotional tension of crew members at the final stage of the flight due to inability to understand the causes of speed fluctuations and, as a consequence, the captain falling under the influence of the "tunnel effect" with the formation of the dominating factor of speed control according to the "own" (left) airspeed indicator without a comprehensive assessment of flight parameters,
- Insufficient training of pilots in the field of human factor, methods of threat and error control and management of crew resources,
- Individual psychological peculiarities of pilots (for the captain - reduction of intellectual and behavioral flexibility, fixation on their own position with the inability (impossibility) to "hear" prompts from the second pilot; for the second pilot - violation of the organization and sequence of actions), which in a stressful situation in the absence of proper level of management of the crew resources came to the fore; loss of the captain's psychological performance (psychological stupor, psychological incapacitation), which resulted in complete loss of spatial orientation and did not allow reacting to correct prompts and actions of the co-pilot, including when triggering the PULL UP warning of the EGPWS system,
- Absence of psychological incapacitation criteria in the airline's AFM, which prevented the second pilot from taking more drastic measures,
- High annual leave arrears for special conditions, which could lead to fatigue and negatively affect the performance of the captain,
- Operation of the aircraft control system in the longitudinal channel in the reconfiguration mode with unreliable signals of instrument speed, not described in the operational documentation, related to a double increase in the transfer coefficient from the hand wheel to the steering wheel in the flight configuration and constant deviation of the steering wheel for diving (without deviation of the steering wheel) for about 60 seconds, which reduced the time required for the crew to recognize the situation.

Final Report:

Crash of a Cessna 207 Skywagon near Playa del Carmen

Date & Time: Dec 21, 2017 at 0950 LT

Type of aircraft:

Operator:

Registration:

XA-UHL

Flight Phase:

Takeoff (climb)

Flight Type:

Charter/Taxi (Non Scheduled Revenue Flight)

Survivors:

Site: