Crash of a Beechcraft B60 Duke in Duette: 2 killed

Date & Time: Mar 4, 2017 at 1330 LT
Type of aircraft:
Registration:
N39AG
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Sarasota - Sarasota
MSN:
P-425
YOM:
1977
Location:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
1120
Captain / Total hours on type:
200.00
Copilot / Total flying hours:
20900
Copilot / Total hours on type:
165
Aircraft flight hours:
3271
Circumstances:
The private pilot, who had recently purchased the airplane, and the flight instructor were conducting an instructional flight in the multi-engine airplane to meet insurance requirements. Radar data for the accident flight, which occurred on the second day of 2 days of training, showed the airplane maneuvering between 1,000 ft and 1,200 ft above ground level (agl) just before the accident. The witness descriptions of the accident were consistent with the airplane transitioning from slow flight into a stall that developed into a spin from which the pilots were unable to recover before the airplane impacted terrain. Examination of the wreckage did not reveal evidence of any preexisting mechanical malfunctions or anomalies that would have precluded normal operation of the airplane. After the first day of training, the pilot told friends and fellow pilots that the instructor provided non-standard training that included stall practice that required emergency recoveries at low airspeed and low altitude. The instructor used techniques that were not in keeping with established flight training standards and were not what would be expected from an individual with his extensive background in general aviation flight instruction. Most critically, the instructor used two techniques that introduced unnecessary risk: increasing power before reducing the angle of attack during a stall recovery and introducing asymmetric power while recovering from a stall in a multi-engine airplane; both techniques are dangerous errors because they can lead to an airplane entering a spin. At one point during the first day of training, the airplane entered a full stall and spun before control was regained at very low altitude. The procedures performed contradicted standard practice and Federal Aviation Administration guidance; yet, despite the pilot's experience in multi-engine airplanes and in the accident airplane make and model, he chose to continue the second day of training with the instructor instead of seeking a replacement to complete the insurance check out. The spin encountered on the accident flight likely resulted from the stall recovery errors advocated by the instructor and practiced on the prior day's flight. Unlike the previous flight, the accident flight did not have sufficient altitude for recovery because of the low altitude it was operating at, which was below the safe altitude required for stall training (one which allows recovery no lower than 3,000 ft agl).
Probable cause:
The pilots' decision to perform flight training maneuvers at low airspeed at an altitude that was insufficient for stall recovery. Contributing to the accident was the flight instructor's inappropriate use of non-standard stall recovery techniques.
Final Report:

Crash of a Beechcraft C90B King Air in Rattan

Date & Time: Feb 14, 2017 at 1145 LT
Type of aircraft:
Operator:
Registration:
N1551C
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
McAlester – Idabel
MSN:
LJ-1365
YOM:
1994
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
22000
Captain / Total hours on type:
400.00
Aircraft flight hours:
7862
Circumstances:
The pilot stated that the engine start and airplane power-up were normal for the air medical flight with two medical crewmembers. The engine ice vanes were lowered (as required for ground operations) and then were subsequently raised before takeoff. Takeoff and climbout were routine, and the pilot leveled off the airplane at the assigned cruise altitude. The air traffic controller informed the pilot of heavy showers near the destination airport, and the pilot "put the ice vanes down." The pilot indicated that, shortly afterward, the airplane experienced two "quick" electrical power fluctuations in which "everything went away and then came back," and "[s]econds later the entire [electrical] system failed." Due to the associated loss of navigation capability while operating in instrument meteorological conditions (IMC), the pilot set a general course for better weather conditions based on information from his preflight weather briefing. While the pilot attempted to find a suitable hole in the clouds to descend through under visual conditions, the left engine lost power. The pilot ultimately located a field through the cloud cover and executed a single-engine off-airport landing, which resulted in substantial damage to the right engine mount and firewall. A postaccident examination of the airplane and systems did not reveal any anomalies consistent with an in-flight electrical system malfunction. The three-position ignition and engine start/starter-only switches were in the ON position, and the engine anti-ice switches were in the ON position. When the airplane battery was initially checked during the examination, the voltmeter indicated 10.7 volts (normal voltage is 12 volts); the battery was charged and appeared to function normally thereafter. The loss of electrical power was likely initiated by the pilot inadvertently selecting the engine start switches instead of the engine anti-ice (ice vane) switches. This resulted in the starter/generators changing to starter operation and taking the generator function offline. Airplane electrical power was then being supplied solely by the battery, which caused it to deplete and led to a subsequent loss of electrical power to the airplane. A postaccident examination revealed that neither wing fuel tank contained any visible fuel. The left nacelle fuel tank did not contain any visible fuel, and the right nacelle fuel tank appeared to contain about 1 quart of fuel. The lack of fuel onboard at the time of the accident is consistent with a loss of engine power due to fuel exhaustion. This was a result of the extended flight time as the pilot attempted to exit instrument conditions after the loss of electrical power to locate a suitable airport. Further, the operator reported that 253 gallons (1,720 lbs) of fuel were on board at takeoff, and the accident flight duration was 3.65 hours. At maximum range power, the expected fuel consumption was about 406 lbs/hour, resulting in an endurance of about 4.2 hours. Thus, the pilot did not have the adequate fuel reserves required for flying in IMC. Both the pilot and medical crewmembers described a lack of communication and coordination among crewmembers as the emergency transpired. This resulted in multiple course adjustments that hindered the pilot's ability to locate visual meteorological conditions before the left engine fuel supply was exhausted.
Probable cause:
The loss of electrical power due to the pilot's inadvertent selection of the engine start switches and the subsequent fuel exhaustion to the left engine as the pilot attempted to locate visual meteorological conditions. Contributing to the accident were the pilot's failure to ensure adequate fuel reserves on board for the flight in instrument meteorological conditions and the miscommunication between the pilot and medical crewmembers.
Final Report:

Crash of an Ilyushin II-18V near Tiksi

Date & Time: Dec 19, 2016 at 0445 LT
Type of aircraft:
Operator:
Registration:
RF-91821
Flight Type:
Survivors:
Yes
Schedule:
Yekaterinburg - Kansk - Tiksi
MSN:
185 0080 03
YOM:
1965
Country:
Region:
Crew on board:
7
Crew fatalities:
Pax on board:
31
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The four engine airplane departed Yekaterinburg on a flight to Tiksi with an intermediate stop in Kansk, carrying 32 passengers and seven crew members. During a polar night approach, the aircraft deviated from the approach pattern and dropped below the glide path relying on a flawed approach scheme. This caused the belly to touch the summit of a snow-covered hill (392 metres high) located 31 km northwest of Tiksi Airport. The aircraft bounced and touched the ground again on the rear slope of the hill some 1,250 metres further on. The fuselage broke into three parts. There was no fire. All 7 crew and 31 passengers were injured, 16 seriously.

Crash of a Swearingen SA227AC Metro III in Camilla: 1 killed

Date & Time: Dec 5, 2016 at 2222 LT
Type of aircraft:
Operator:
Registration:
N765FA
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Panama City – Albany
MSN:
AC-765
YOM:
1990
Flight number:
LYM308
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
8451
Captain / Total hours on type:
4670.00
Aircraft flight hours:
24233
Circumstances:
The airline transport pilot delayed his scheduled departure for the night cargo flight due to thunderstorms along the route. Before departing, the pilot explained to the flight follower assigned to the flight that if he could not get though the thunderstorms along the planned route, he would divert to the alternate airport. While en route, the pilot was advised by the air traffic controller in contact with the flight of a "ragged line of moderate, heavy, and extreme" precipitation along his planned route. The controller also stated that he did not see any breaks in the weather. The controller cleared the pilot to descend at his discretion from 7,000 ft mean sea level (msl) to 3,000 ft msl, and subsequently, the controller suggested a diversion to the northeast for about 70 nautical miles that would avoid the most severe weather. The pilot responded that he had enough fuel for such a diversion but concluded that he would "see what the radar is painting" after descending to 3,000 ft msl. About 1 minute 30 seconds later, as the airplane was descending through 7,000 ft msl, the controller stated, "I just lost you on radar, I don't show a transponder, it might have to do with the weather." About 40 seconds later, the pilot advised the controller that he intended to deviate to the right of course, and the controller told the pilot that he could turn left and right as needed. Shortly thereafter, the pilot stated that he was going to turn around and proceed to his alternate airport. The controller cleared the pilot direct to his alternate and instructed him to maintain 3,000 ft msl. The pilot acknowledged the instruction, and the controller then stated, "do you want to climb back up? I can offer you any altitude." The pilot responded that he would try to climb back to 3,000 ft msl. The controller then recommended a heading of 180° to "get you clear of the weather quicker," and the pilot responded, "alright 180." There were no further communications from the pilot. Shortly thereafter, radar data showed the airplane enter a right turn that continued through about 540°. During the turn its airspeed varied between 198 and 130 knots, while its estimated bank angles were between 40 and 50°. Examination of the wreckage indicated that airplane experienced an in-flight breakup at relatively low altitude, consistent with radar data that showed the airplane's last recorded altitudes to be around 3,500 ft msl. The symmetrical nature of the breakup, damage to the outboard wings, and damage to the upper fuselage were all signatures indicative that the left and right wings failed in positive overload almost simultaneously. All of the fracture surfaces examined had a dull, grainy appearance consistent with overstress separation. There was no evidence of pre-existing cracking noted at any of the separation points, nor was there evidence of any mechanical anomalies that would have prevented normal operation. Review of base reflectivity weather radar data showed that, while the pilot was maneuvering to divert to the alternate airport, the airplane was operating in an area of light precipitation that rapidly intensified to heavy precipitation, as shown by radar scans completed shortly after the accident. During this time, the flight was likely operating in clouds along the leading edge of the convective line, where the pilot most likely would have encountered updrafts and severe or greater turbulence. The low visibility conditions that existed during the flight, which was conducted at night and in instrument meteorological conditions, coupled with the turbulence the flight likely encountered, were conducive to the development of spatial disorientation. Additionally, the airplane's maneuvering during the final moments of the flight was consistent with a loss of control due to spatial disorientation. The pilot's continued flight into known convective weather conditions and his delayed decision to divert the flight directly contributed to the accident. Although the operator had a system safety-based program, the responsibility for the safe outcome of the flight was left solely to the pilot. Written company policy required completion of a flight risk assessment tool (FRAT) before each flight by the assigned flight follower; however, a FRAT was not completed for the accident flight. The flight followers responsible for completing the FRATs were not trained to complete them for night cargo flights, and the operator's management was not aware that the FRATs were not being completed for night cargo flights. Further, if a FRAT had been completed for the accident flight, the resultant score would have allowed the flight to commence into known hazardous weather conditions without any further review. If greater oversight had been provided by the operator, it is possible that the flight may have been cancelled or re-routed due to the severity of the convective weather conditions present along the planned route of flight.
Probable cause:
The pilot's decision to initiate and continue the flight into known adverse weather conditions, which resulted spatial disorientation, a loss of airplane control, and a subsequent in-flight breakup.
Final Report:

Crash of a Beechcraft E90 King Air in Sotillo de las Palomas: 4 killed

Date & Time: Dec 4, 2016 at 1617 LT
Type of aircraft:
Registration:
N79CT
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Madrid – Cascais
MSN:
LW-303
YOM:
1979
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
4
Circumstances:
The twin engine aircraft departed Madrid-Cuatro Vientos Airport on a private flight to Cascais, Portugal, carrying three passengers and one pilot. One of the reasons for the flight was to repair the weather radar at a Portuguese maintenance center that specialized in this equipment. The pilot had to delay the takeoff until 1557LT due to bad weather conditions. The aerodrome of Cuatros Vietnos was in instrument conditions (IMC), which forced its closing from 0900LT until 1444LT. At 1615LT, the aircraft was en route, climbing from flight level 190 to its authorized cruise level of 210. Moments later, according to a detailed analysis of the data taken from the radar, there was a yaw to the left, and the aircraft started to turn in this direction and suddenly lose altitude. After this event, the airspeed fell quickly and gradually until the aircraft stalled. The aircraft went into a spin, which after some time turned into a flat spin. As the airplane descended out of control, and with the spin fully developped, loads were placed on the horizontal tail that exceeded the design loads, causing the tail to break up in flight into five parts before the aircraft impacted the ground. The aircraft was completely destroyed by the impact and sibsequent fire, and its four occupants were killed in the accident.
Probable cause:
The investigation has concluded that this accident was caused by the loss of control of the aircraft in flight due to a stall and subsequent spin. Due to the high degree of destruction of the aircraft's wreckage after the ground impact and subsequent fire, and the lack of other pertinent data to do so, it has not been possible to determine with precision the sequence of the process leading to the aircraft stall/spin.
The investigation identified the following contributing factors:
- The decision to make the flight with adverse meteorological conditions (IMC) along the planned route, considering the fact that the weather radar was not operational.
- The forecast of moderate to strong icing conditions in areas of the route (presence of cumulonimbus with caps of up to 35,000 feet and with temperatures between -17°C and -19°C at flight level FL180) suggests that the formation of ice or its accumulation on the aircraft has been a significant contributory factor in this accident
- The use of the autopilot and the failure to disengage it when the emergency situation arose, as it is concluded from the detailed analysis of the radar data, could have contributed significantly to the process that resulted in the loss of control of the aircraft.
- The inadequate training of the pilot (who lacked the type rating for the accident aircraft) in abnormal or emergency situations on the accident aircraft.
Final Report:

Crash of a Piper PA-31-350 Navajo Chieftain in El Sacrificio

Date & Time: Nov 29, 2016
Operator:
Registration:
N633D
Flight Type:
Survivors:
Yes
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The twin engine airplane was involved in a smuggling flight within Mexico and was carrying three people. In unclear circumstances, the pilot attempted a belly landing in a swampy area located in El Sacrificio, State of Campeche. The wreckage was found by local authorities few hours later and no trace of the occupant was found or the load was found. The registration N633D is attributed to a Piper PA-31 with MSN 31-7852098 which was not involved in this accident. Thus, it was confirmed by Mexican and US Authorities that the registration was false.

Crash of a Piper PA-61P Aerostar (Ted Smith 601) near Carrollton

Date & Time: Oct 20, 2016 at 1110 LT
Operator:
Registration:
N601UK
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Hampton – Carrollton
MSN:
61-0183-012
YOM:
1974
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
1338
Captain / Total hours on type:
36.00
Aircraft flight hours:
2236
Circumstances:
The pilot reported that the purpose of the flight was to reposition the airplane to another airport for refuel. During preflight, he reported that the airplane's two fuel gauges read "low," but the supplemental electronic fuel totalizer displayed 55 total gallons. He further reported that it is not feasible to visual check the fuel quantity, because the fueling ports are located near the wingtips and the fuel quantity cannot be measured with any "external measuring device." According to the pilot, his planned flight was 20 minutes and the fuel quantity, as indicated by the fuel totalizer, was sufficient. The pilot reported that about 12 nautical miles from the destination airport, both engines began to "surge" and subsequently lost power. During the forced landing, the pilot deviated to land in grass between a highway, the airplane touched down hard, and the landing gear collapsed. The fuselage and both wings sustained substantial damage. The pilot reported no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation. The pilot reported in the National Transportation Safety Board Pilot/ Operator Aircraft Accident Report that there was a "disparity" between the actual fuel quantity and the fuel quantity set in the electronic fuel totalizer. He further reported that a few days before the accident, he set the total fuel totalizer quantity to full after refueling, but in hindsight, he did not believe the fuel tanks were actually full because the wings may not have been level during the fueling. The "Preflight" chapter within the operating manual for the fuel totalizer in part states: "Digiflo-L is a fuel flow measuring system and NOT a quantity-sensing device. A visual inspection and positive determination of the usable fuel in the fuel tanks is a necessity. Therefore, it is imperative that the determined available usable fuel be manually entered into the system."
Probable cause:
The pilot's failure to verify the usable fuel in the fuel tanks, which resulted in an inaccurate fuel totalizer setting during preflight, fuel exhaustion, and a total loss of engine power.
Final Report:

Crash of a De Havilland DHC-2 Beaver I near Laidman Lake: 1 killed

Date & Time: Oct 10, 2016 at 0844 LT
Type of aircraft:
Registration:
C-GEWG
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Vanderhoof - Laidman Lake
MSN:
842
YOM:
1955
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
280
Captain / Total hours on type:
23.00
Circumstances:
On 10 October 2016, at approximately 0820 Pacific Daylight Time, a privately operated de Havilland DHC-2 Beaver aircraft on amphibious floats (registration C-GEWG, serial number 842), departed from Vanderhoof Airport, British Columbia, for a day visual flight rules flight to Laidman Lake, British Columbia. The pilot and 4 passengers were on board. Approximately 24 minutes into the flight, the aircraft struck terrain about 11 nautical miles east of Laidman Lake. The 406 MHz emergency locator transmitter (ELT) activated on impact. The ELT's distress signal was detected by the Cospas-Sarsat satellite system, and a search-and-rescue operation was initiated by the Joint Rescue Coordination Centre Victoria. One of the passengers was able to call 911 using a cell phone. The pilot was fatally injured, and 2 passengers were seriously injured. The other 2 passengers sustained minor injuries. The aircraft was substantially damaged. There was no post-impact fire.
Probable cause:
Findings as to causes and contributing factors:
1. As the aircraft approached the mountain ridge, the high overcast ceiling and uniform snow-covered vegetation were conducive to optical illusions associated with flight in mountainous terrain. These illusions likely contributed to the pilot’s misjudgment of the proximity of the terrain, inadvertent adoption of an increasingly nose-up attitude, and non-detection of the declining airspeed before banking the aircraft to turn away from the hillside.
2. As the angle of bank increased during the turn, the stall speed also increased and the aircraft entered an accelerated stall.
3. The aircraft’s out-of-limit weight-and-balance condition increased its stall speed and degraded its climb performance, stability, and slow-flight characteristics. As a result, its condition, combined with the aircraft’s low altitude, likely prevented the pilot from regaining control of the aircraft before the collision with the terrain.
4. The absence of a stall warning system deprived the pilot of the last line of defence against an aerodynamic stall and the subsequent loss of control of the aircraft.
5. The forward shifting of the unsecured cargo and the partial detachment of the rear seats during the impact resulted in injuries to the passengers.
6. During the impact sequence, the load imposed on the pilot’s lap-belt attachment points was transferred to the seat-attachment points, which then failed in overload. As a result, the seat moved forward during the impact and the pilot was fatally injured.

Findings as to risk:
1. If pilots do not obtain quality sleep during the rest period prior to flying, there is a risk that they will operate an aircraft while fatigued, which could degrade pilot performance.
2. If cargo is not secured, there is a risk that it will shift forward during an impact or turbulence and injure passengers or crew.

Other findings:
1. Because the aircraft was equipped with a 406 MHz emergency locator transmitter that transmitted an alert message to the Cospas-Sarsat satellites system in combination with the homing signal transmitted on 121.5 MHz, the Joint Rescue Coordination Centre aircraft was able to locate the wreckage and occupants in a timely manner.
Final Report:

Crash of a Piper PA-46-310P Malibu in Chariton: 1 killed

Date & Time: Sep 7, 2016 at 1219 LT
Registration:
N465JM
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Olathe - Ankeny
MSN:
46-8408042
YOM:
1984
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
242
Captain / Total hours on type:
118.00
Circumstances:
The noninstrument-rated private pilot was conducting a visual flight rules (VFR) cross-country flight while receiving VFR flight following services from air traffic control. Radar data and voice
communication information indicated that the airplane was in cruise flight as the pilot deviated around convective weather near his destination. The controller issued a weather advisory to the pilot concerning areas of moderate to extreme precipitation along his route; the pilot responded that he saw the weather on the airplane's NEXRAD weather display system and planned to deviate around it before resuming course. About 3 minutes later, the pilot stated that he was around the weather and requested to start his descent direct toward his destination. The controller advised the pilot to descend at his discretion. Radar showed the airplane in a descending right turn before radar contact was lost at 2,900 ft mean sea level. There were no eyewitnesses, and search personnel reported rain and thunderstorms in the area about the time of the accident. The distribution of the wreckage was consistent with an in-flight breakup. Examination of the airframe revealed overload failures of the empennage and wings. No pre-impact airframe structural anomalies were found, and the propeller showed evidence of rotation at the time of impact. Further, there was no evidence of pilot impairment or incapacitation. Review of weather information indicated that the pilot most likely encountered instrument meteorological conditions as the airplane descended during the last several minutes of flight. During this time, it is likely that the pilot became disoriented while attempting to maneuver in convective, restricted visibility conditions, and lost control of the airplane. The transition from visual to instrument flight conditions would have been conducive to the development of spatial disorientation; the turning descent before the loss of radar contact and the in-flight breakup are also consistent with a loss of control due to spatial disorientation.
Probable cause:
The non-instrument-rated pilot's loss of control due to spatial disorientation in instrument meteorological conditions, which resulted in an exceedance of the airplane's design stress limitations and a subsequent in-flight breakup. Contributing to the accident was the pilot's decision to continue visual flight into convective instrument meteorological conditions.
Final Report:

Crash of a Beechcraft B60 Duke in Loma Plata

Date & Time: Sep 1, 2016 at 1655 LT
Type of aircraft:
Operator:
Registration:
ZP-BID
Flight Phase:
Flight Type:
Survivors:
Yes
MSN:
P-326
YOM:
1975
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The twin engine airplane was completing a flight to Asunción, carrying one passenger and one pilot. En route, the pilot encountered an unexpected situation and was forced to attempt an emergency landing. Upon landing on a dirt road, the aircraft lost its undercarriage and slid for few dozen metres before coming to rest with its right wing torn off. Both occupants were injured and the aircraft was destroyed.