Crash of a Socata TBM-850 near Calabogie: 1 killed

Date & Time: Oct 8, 2012 at 1219 LT
Type of aircraft:
Registration:
C-FBKK
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Carp - Goderich
MSN:
621
YOM:
2012
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
19200
Captain / Total hours on type:
700.00
Aircraft flight hours:
64
Circumstances:
The privately owned SOCATA TBM 700N (registration C-FBKK, serial number 621) departed from Ottawa/Carp Airport, Ontario, on an instrument flight rules flight plan to Goderich, Ontario. Shortly after takeoff, the pilot and sole occupant altered the destination to Wiarton, Ontario. Air traffic control cleared the aircraft to climb to flight level 260 (FL260). The aircraft continued climb through FL260 and entered a right hand turn, which quickly developed into a spiral dive. At approximately 1219 Eastern Daylight Time, the aircraft struck the ground and was destroyed. Small fires broke out and consumed some sections of the aircraft. The pilot was fatally injured. The 406 MHz emergency locator transmitter on board the aircraft was damaged and its signal was not sensed by the search and rescue satellite-aided tracking (SARSAT) system.
Probable cause:
Findings as to Causes and Contributing Factors:
1. The pilot lost control of the aircraft for undetermined reasons and the aircraft collided with terrain.
Findings as to Risk:
1. Operating an aircraft above 13 000 feet asl without an available emergency oxygen supply increases the risk of incapacitation due to hypoxia following depressurization.
Other Findings:
1. The avionics system had the capability to record data essential to the accident investigation but the recording medium was destroyed in the accident.
Final Report:

Crash of a De Havilland DH.84 Dragon near Borumba Dam: 6 killed

Date & Time: Oct 1, 2012 at 1413 LT
Type of aircraft:
Operator:
Registration:
VH-UXG
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Monto - Caboolture
MSN:
6077
YOM:
1934
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
6
Captain / Total flying hours:
1134
Captain / Total hours on type:
662.00
Circumstances:
At about 1107 Eastern Standard Time on 01OCT2012, a de Havilland Aircraft Pty Ltd DH-84 Dragon, registered VH-UXG (UXG), took off from Monto on a private flight to Caboolture, Queensland under the visual flight rules (VFR). On board the aircraft were the pilot/owner and five passengers. The weather conditions on departure were reported to include a light south-easterly wind with a high overcast and good visibility. Sometime after about 1230, the aircraft was seen near Tansey, about 150 km north-west of Caboolture on the direct track from Monto to Caboolture. The aircraft was reported flying in a south-easterly direction at the time, at an estimated height of 3,000 ft and in fine but overcast conditions. At 1315, the pilot contacted Brisbane Radar air traffic control (ATC) and advised that the aircraft’s position was about 37 NM (69 km) north of Caboolture and requested navigation assistance. At 1318, the pilot advised ATC that the aircraft was in ‘full cloud’. For most of the remainder of the flight, the pilot and ATC exchanged communications, at times relayed through a commercial flight and a rescue flight in the area due to the limited ATC radio coverage in the area at low altitude. At about 1320, a friend of one of the aircraft’s passengers received a telephone call from the passenger to say that she was in an aircraft and that they were ‘lost in a cloud’ and kept losing altitude. Witnesses in the Borumba Dam, Imbil and Kandanga areas 70 to 80 km north-north-west of Caboolture later reported that they heard and briefly saw the aircraft flying in and out of low cloud between about 1315 and 1415. At 1348, the pilot advised ATC that the aircraft had about an hour’s endurance remaining. The pilot’s last recorded transmission was at 1404. A search for the aircraft was coordinated by Australian Search and Rescue (AusSAR). The aircraft wreckage was located on 3 October 2012, about 87 km north-west of Caboolture on the northern side of a steep, densely wooded ridge about 500 m above mean sea level. The Australian Transport Safety Bureau (ATSB) later determined that the aircraft probably impacted terrain at about 1421 on 01OCT2012. Preliminary analysis indicated that the aircraft collided with trees and terrain at a moderate to high speed, with a left angle of bank. The aircraft’s direction of travel at impact was toward the south-south-west.
Probable cause:
From the evidence available, the following findings are made with respect to the visual flight rules into instrument meteorological conditions accident involving de Havilland Aircraft Pty Ltd DH-84 Dragon, registered VH-UXG, that occurred 36 km south-west of Gympie, Queensland, on 1 October 2012. These findings should not be read as apportioning blame or liability to any particular organisation or individual. Safety issues, or system problems, are highlighted in bold to emphasize their importance. A safety issue is an event or condition that increases safety risk and (a) can reasonably be regarded as having the potential to adversely affect the safety of future operations, and (b) is a characteristic of an organisation or a system, rather than a characteristic of a specific individual, or characteristic of an operating environment at a specific point in time.
Contributing factors:
- The pilot unintentionally entered instrument meteorological conditions and was unable to reattain and maintain visual conditions.
- It is likely that the pilot became spatially disoriented and lost control due to a combination of factors such as the absence of a visible horizon, cumulative workload, stress and/or distraction.
Other factors that increased risk:
- Though it probably did not have a significant bearing on the event, the aircraft was almost certainly above its maximum take-off weight (MTOW) on take-off, and around the MTOW at the time of the accident.
- Though airborne search and rescue service providers were regularly tasked to provide assistance to pilots in distress, there was limited specific guidance on the conduct of such assistance. Other findings:
- The aircraft wreckage was not located for 2 days as the search was hindered by difficult local weather conditions and terrain, and the cessation of the aircraft’s emergency beacon due to impact damage.
Final Report:

Crash of a De Havilland DHC-2 Beaver in Big River Lake

Date & Time: Aug 25, 2012 at 0800 LT
Type of aircraft:
Operator:
Registration:
N314HA
Survivors:
Yes
Schedule:
Soldotna - Big River Lake
MSN:
868
YOM:
1956
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
1500
Captain / Total hours on type:
725.00
Aircraft flight hours:
20174
Circumstances:
The pilot of a float-equipped airplane was landing at a remote lake. The pilot stated that he was on a left base leg turning onto a short final approach when the left float struck the ground. The airplane sustained substantial damage to the wings and fuselage. The pilot indicated there were no preaccident mechanical malfunctions or anomalies that would have precluded normal operation. Accident occurred in Big River Lake, in the Kenai region.
Probable cause:
The pilot’s failure to maintain adequate ground clearance during his landing approach, which resulted in a collision with terrain.
Final Report:

Crash of a Pilatus PC-12/47 in Solemont: 4 killed

Date & Time: Aug 24, 2012 at 1800 LT
Type of aircraft:
Operator:
Registration:
HB-FPZ
Flight Phase:
Survivors:
No
Schedule:
Antwerp - Saanen (Gstaad)
MSN:
702
YOM:
2006
Location:
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
5971
Captain / Total hours on type:
1785.00
Circumstances:
The pilot took off from Anvers (Belgium) at around 14 h 40 bound for Saanen (Switzerland) where he was supposed to drop off his three passengers. The flight was performed in IFR then VFR, at a cruise altitude of 26,000 ft. After about 1 h 15 min of flight, still under IFR, the Geneva controller cleared the pilot to descend towards FL 210 and to fly towards Saanen with a view to an approach. A short time later, the radar data showed that the aeroplane deviated from the planned trajectory. Following a question from the controller, the pilot said he had an autopilot problem. The controller then asked the pilot to follow heading 165°, which the pilot read back, then asked him ‘‘are you okay, okay for the safety, it’s good for you? ‘‘. The pilot answered that he had a ‘‘big problem’’. The radar data show tight turns on descent. During these manœuvres, in reply to a request from the controller, the pilot said that he was in ‘‘total IMC’’. During this communication, the aeroplane‘s overspeed warning could be heard. The aeroplane was then descending at 15,500 ft/min. About ten seconds later, it was climbing at 15,500 ft/min. The right wing broke off about twenty seconds later. The indicated airspeed was then 274 kt and the altitude was 12,750 ft. The wreckage was found in woods in the commune of Solemont (25). A piece of the right wing was found about 2.5 km from the main wreckage. Some debris, all from the right wing, was found on a south-west/north-east axis. The aeroplane part that was furthest away was found 10 km from the main site. The aircraft disintegrated on impact and all four occupants were killed.
Probable cause:
The in-flight failure of the right wing was due to exceeding the aeroplane’s structural limits (ultimate loads) during loss of control by the pilot. In the absence of any flight recorders, the investigation was not able to determine the causes of this loss of control. It is possible that it may have been induced by a loss of situational awareness by the pilot at the controls of an aeroplane affected by an icing phenomenon. This phenomenon may have affected the aeroplane’s wings or an area around the roll control.
Final Report:

Crash of a Piper PA-31-350 Navajo Chieftain near Bontang: 4 killed

Date & Time: Aug 24, 2012 at 0810 LT
Operator:
Registration:
PK-IWH
Flight Phase:
Survivors:
No
Schedule:
Samarinda - Bontang
MSN:
31-7852065
YOM:
1978
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
17547
Captain / Total hours on type:
4250.00
Aircraft flight hours:
16743
Aircraft flight cycles:
14830
Circumstances:
On 24 August 2012, a Piper Chieftain PA-31-350 aircraft, registered PK-IWH, was being operated by PT. Intan Angkasa Airservice to conduct an aerial survey (aero magnetic) flight at a survey area located north of Bontang, East Kalimantan. There were 4 persons on board; one pilot, one security officer and two surveyors. Based on the flight plan submitted by the Pilot in Command (PIC) to the Briefing Office, the flight was planned with an altitude of 3,000 feet AMSL en-route and 500 feet AGL while surveying the area. The fuel endurance was for 6 hours flight time and the aircraft equipped with an Emergency Locator Transmitter (ELT). The aircraft departed from Temindung Airport (WALS), Samarinda at 0751 local time (LT - 2351 UTC). At 0004 UTC, the pilot informed to the Temindung Control Tower controller (Temindung Tower) that the aircraft was abeam Tanjung Santan descending from 3,000 feet and established contact with Bontang Info officer (Bontang Info). At 0005 UTC, the pilot informed the Bontang Info that the aircraft altitude was 300 feet and estimated over Bontang at 0011 UTC. Bontang info acknowledged this transmission and advised the pilot to report when the flight left the Bontang Area. At 0010 UTC, the SureTrack (flight following system) stopped receiving data from the aircraft. The last recorded information was an aircraft speed of 138 knots, heading 352°, latitude 0°8’33” N and longitude 117°12’54” E. At 0600 UTC, the engineer of the PK-IWH aircraft asked the Temindung Tower about the flight as the fuel endurance had been exceeded. The Temindung Tower contacted Bontang Info to get information about the aircraft. After receiving the request, Bontang Info tried to contact the pilot twice and there was no reply. Bontang Info also contacted the Tanjung Bara Airstrip to request information about the aircraft but there was no information. The Temindung Tower reported that:
• at 0610 UTC declared INCERFA (Uncertainty phase);
• at 0630 UTC declared ALERFA (Alert phase);
• at 0700 UTC declared DETRESFA (Distress phase).
At 0730 UTC, the search and rescue team was assembled; the team consisted of the Temindung Airport Authority, National Search and Rescue, Indonesian Police, Army and Airforce. The search operation was conducted via ground and air using three helicopters. On 26 August 2012 at 0850 UTC, the aircraft wreckage was located by a ground search team on a ridge of Mayang Hill, Bontang at approximately 1,200 feet AMSL at coordinates 00°12’34.3”N, 117°16’57.3”E, 12 NM from Bontang Aerodrome on bearing of 294°. The accident site was within the planned aircraft survey area. All occupants were fatally injured and the aircraft was destroyed by impact force and post impact fire.
Probable cause:
The accident was typical of a Controlled Flight into Terrain (CFIT). Low altitude VFR flying in a low visibility environment limited the pilot’s visibility and increased the probability of impact with terrain.
Final Report:

Crash of a PZL-Mielec AN-2R in Padali

Date & Time: Jul 19, 2012
Type of aircraft:
Registration:
RA-40934
Flight Phase:
Survivors:
Yes
Schedule:
Pobeda - Pobeda
MSN:
1G216-14
YOM:
1985
Flight number:
9201
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The crew was engaged in a patrol flight (fire survey) from Pobeda when the engine failed in flight due to low oil pressure. The crew attempted an emergency landing on the road from Komsomolsk-on-Amur to Elban, near Padali (58 km from Komsomolsk). The aircraft suffered damage to the left main gear and the left lower wing and was damaged beyond repair. All three occupants escaped uninjured.
Probable cause:
Engine failure in flight following a loss of oil pressure.

Crash of a Beechcraft E90 King Air in Karnack: 1 killed

Date & Time: Jul 7, 2012 at 0404 LT
Type of aircraft:
Operator:
Registration:
N987GM
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
DeKalb - Brownsville
MSN:
LW-65
YOM:
1973
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
5300
Aircraft flight hours:
15082
Circumstances:
Before the flight, the pilot did not obtain a weather briefing and departed without approval from company personnel. The airplane departed the airport about 0230 and climbed to 14,500 feet mean sea level. The pilot obtained visual flight rules (VFR) flight following services from air traffic control (ATC) personnel during the flight. While the airplane was en route, ATC personnel advised the pilot that an area of moderate precipitation was located about 15 miles ahead along the airplane’s flight path. The pilot acknowledged the transmission and was then directed to contact another controller. About 3 minutes later, the new controller advised the pilot of an area of moderate to extreme precipitation about 2 miles ahead of the airplane. The pilot responded that he could see the weather and asked the controller for a recommendation for a reroute. The controller indicated he didn’t have a recommendation, but finished by saying a turn to the west (a right turn) away from the weather would probably be better. The pilot responded that he would make a right turn. There was no further radio contact with the pilot. Flight track data indicated the airplane was in a right turn when radar contact was lost. A review of the radar data, available weather information, and airplane wreckage indicated the airplane flew through a heavy to extreme weather radar echo containing a thunderstorm and subsequently broke up in flight. Postaccident examination revealed no mechanical malfunctions or anomalies with the airframe and engines that would have precluded normal operation. During the VFR flight, the pilot was responsible for remaining in VFR conditions and staying clear of clouds. However, Federal Aviation Administration directives instruct ATC personnel to issue pertinent weather information to pilots, provide guidance to pilots to avoid weather (when requested), and plan ahead and be prepared to suggest alternate routes or altitudes when there are areas of significant weather. The weather advisories and warnings issued to the pilot by ATC were not in compliance with these directives. The delay in providing information to the pilot about the heavy and extreme weather made avoiding the thunderstorm more difficult and contributed to the accident.
Probable cause:
The pilot's inadvertent flight into thunderstorm activity, which resulted in the loss of airplane control and the subsequent exceedance of the airplane’s design limits and in-flight breakup. Contributing to the accident was the failure of air traffic control personnel to use available radar information to provide the pilot with a timely warning that he was about to encounter extreme precipitation and weather along his route of flight or to provide alternative routing to the pilot.
Final Report:

Crash of an Embraer EMB-820C Navajo near Espinosa: 1 killed

Date & Time: Jul 6, 2012 at 1050 LT
Operator:
Registration:
PT-ENG
Flight Phase:
Survivors:
Yes
Schedule:
Gunanmbi - Guanambi
MSN:
820-066
YOM:
1982
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
3876
Captain / Total hours on type:
238.00
Circumstances:
The twin aircraft departed Guanambi Airport to perform a low level survey flight in the region of Espinosa, carrying two observers and one pilot. About two hours into the flight, while cruising at an altitude of 330 feet, the right engine lost power then failed. While executing the emergency checklist, the left engine failed as well. The pilot attempted an emergency landing when the aircraft crashed in a wooded area, bursting into flames. Both passengers evacuated with minor injuries and the pilot was killed. The aircraft was totally destroyed by a post crash fire.
Probable cause:
There was sufficient fuel in the tanks at the time of the accident as the aircraft was refueled prior to departure for a 5-hour flight. The exact cause of the double engine failure remains unknown. When the right engine failed, the pilot was flying at an altitude of 330 feet which was below the minimum safe altitude fixed at 500 feet. Also, he was apparently using his cell phone.
Final Report:

Crash of a Piper PA-31T Cheyenne II near Catacamas: 1 killed

Date & Time: Jul 3, 2012
Type of aircraft:
Operator:
Registration:
PT-OFH
Flight Phase:
Flight Type:
Survivors:
Yes
MSN:
31-7920034
YOM:
1979
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
The twin engine aircraft was engaged in an illegal flight, carrying two pilots and a load consisting of 600 kilos of cocaine. After being tracked by the Honduran Police, the crew apparently attempted an emergency landing when the aircraft crashed. While the copilot was injured, the captain was killed.

Crash of a Lockheed C-130H Hercules near Edgemont: 4 killed

Date & Time: Jul 1, 2012 at 1738 LT
Type of aircraft:
Operator:
Registration:
93-1458
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Colorado Springs - Colorado Springs
MSN:
5363
YOM:
1994
Crew on board:
6
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total hours on type:
1966.00
Copilot / Total hours on type:
3647
Circumstances:
On 1 July 2012, at approximately 1738 Local time, a C-130H3, Tail Number 93-1458, assigned to the 145th Airlift Wing, North Carolina Air National Guard, Charlotte Douglas International Airport (KCLT), Charlotte, North Carolina, crashed on public land managed by the United States Forest Service (USFS), while conducting wildland firefighting operations near Edgemont, South Dakota. At the time of the mishap all members of the Mishap Crew (MC) were assigned or attached to the 156th Airlift Squadron, based at KCLT. The Mishap Crew (MC) consisted of Mishap Pilot 1 (MP1), Mishap Pilot 2 (MP2), Mishap Navigator (MN), Mishap Flight Engineer (ME), Mishap Loadmaster 1 (ML1) and Mishap Loadmaster 2 (ML2). For the mishap sortie, MP1 was the aircraft commander and pilot flying in the left seat. MP2 was in the right seat as the instructor pilot. MN occupied the navigator station on the right side of the flight deck behind MP2. ME was seated in the flight engineer seat located between MP1 and MP2, immediately aft of the center flight console. ML1 and ML2 were seated on the Modular Airborne Fire Fighting System (MAFFS) unit, near the right paratroop door. ML1 occupied the aft MAFFS control station seat and ML2 occupied the forward MAFFS observer station seat. MP1, MP2, MN and ME died in the mishap. ML1 and ML2 survived the mishap, but suffered significant injuries. The mishap aircraft (MA) and a USFS-owned MAFFS unit were destroyed. The monetary loss is valued at $43,453,295, which includes an estimated $150,000 in post aircraft removal and site environmental cleanup costs. There were no additional fatalities, injuries or damage to other government or civilian property.
Probable cause:
The accident investigation report released by the Air Force Air Mobility Command said:
I developed my opinion by inspecting the mishap site and wreckage, as well as analyzing factual data from the following: historical records, Air Force directives and guidance, USFS and Interagency guidance, reconstructing the mishap sortie in a C-130H3 simulator, engineering analysis, witness testimony, flight data, weather radar data, computer animated reconstruction, consulting with subject matter experts and information provided by technical experts. The failure of the Digital Flight Data Recorder severely complicated the recreation of the mishap, and impacted my ability to determine facts in this investigation. I find by clear and convincing evidence the cause of the mishap was MPl, MP2, MN and ME's inadequate assessment of operational conditions, resulting in the MA impacting the ground after flying into a microburst. Additionally, I find by the preponderance of evidence, the failure of the White Draw Fire Lead Plane aircrew and Air Attack aircrew to communicate critical operational information; and conflicting operational guidance concerning thunderstorm avoidance, substantially contributed to the mishap.
Final Report: