Plain, Valley

On September 2, 2011, about 1335 Alaska daylight time, a Cessna 208B airplane, N207DR, and a Cessna 207 airplane, N73789, collided in midair about 9 miles north of Nightmute, Alaska. Both airplanes were being operated as charter flights under the provisions of 14 Code of Federal Regulations (CFR) Part 135 in visual meteorological conditions when the accident occurred. The Cessna 208B was operated by Grant Aviation Inc., Anchorage, Alaska, and the Cessna 207 was operated by Ryan Air, Anchorage, Alaska. Visual flight rules (VFR) company flight following procedures were in effect for each flight. The sole occupant of the Cessna 208B, an airline transport pilot, sustained fatal injuries. The sole occupant of the Cessna 207, a commercial pilot, was uninjured. The Cessna 208B was destroyed, and the Cessna 207 sustained substantial damage. After the collision, the Cessna 208B descended uncontrolled and impacted tundra-covered terrain, and a postcrash fire consumed most of the wreckage. The Cessna 207’s right wing was damaged during the collision and the subsequent forced landing on tundra-covered terrain. Both airplanes were based at the Bethel Airport, Bethel, Alaska, and were returning to Bethel at the time of the collision. The Cessna 208B departed from the Toksook Bay Airport, Toksook Bay, Alaska, about 1325, and the Cessna 207 departed from the Tununak Airport, Tununak, Alaska. During separate telephone conversations with the National Transportation Safety Board (NTSB) investigator-in-charge on September 2, the chief pilot for Ryan Air, as well as the director of operations for Grant Aviation, independently reported that both pilots had a close personal relationship. During an initial interview with the NTSB IIC on September 3, in Bethel, the pilot of the Cessna 207 reported that both airplanes departed from the neighboring Alaskan villages about the same time and that both airplanes were en route to Bethel along similar flight routes. She said that, just after takeoff from Tununak, she talked with the pilot of the Cessna 208B on a prearranged, discreet radio frequency, and the two agreed to meet up in-flight for the flight back to Bethel. She said that, while her airplane was in level cruise flight at 1,200 feet above mean sea level (msl), the pilot of the Cessna 208B flew his airplane along the left side of her airplane, and they continued to talk via radio. She said that the pilot of the Cessna 208B then unexpectedly and unannounced climbed his airplane above and over the top of her airplane. She said that she immediately told the pilot of the Cessna 208B that she could not see him and that she was concerned about where he was. She said that the Cessna 208B pilot then said, in part: "Whatever you do, don't pitch up." The next thing she recalled was moments later seeing the wings and cockpit of the descending Cessna 208B pass by the right the side of her airplane, which was instantaneously followed by an impact with her airplane’s right wing. The Cessna 207 pilot reported that, after the impact, while she struggled to maintain control of her airplane, she saw the Cessna 208B pass underneath her airplane from right-to-left, and it began a gradual descent, which steepened as the airplane continued to the left and away from her airplane. She said that she told the pilot of the Cessna 208B that she thought she was going to crash.She said that the pilot of the Cessna 208B simply stated, “Me too.” She said that she watched as the Cessna 208B continued to descend, and then it entered a steep, vertical, nose-down descent before it collided with the tundra-covered terrain below. She said that a postcrash fire started instantaneously upon impact. Unable to maintain level cruise flight and with limited roll control, the Cessna 207 pilot selected an area of rolling, tundra-covered terrain as a forced landing site. During touchdown, the airplane’s nosewheel collapsed, and the airplane nosed down. The Cessna 207’s forced landing site was about 2 miles east of the Cessna 208B’s accident site.

A Cessna 208B and a Cessna 207 collided in flight in daylight visual meteorological conditions. The Cessna 208B and the Cessna 207 were both traveling in an easterly direction. According to the Cessna 207 pilot, the airplanes departed from two neighboring remote Alaskan villages about the same time, and both airplanes were flying along similar flight routes. While en route, the Cessna 207 pilot talked with the Cessna 208B pilot on a prearranged, discreet radio frequency, and the two agreed to meet up in flight for the return to their home airport. The Cessna 207 pilot said that the pilot of the Cessna 208B flew his airplane along the left side of her airplane while she was in level cruise flight at 1,200 feet mean sea level and that they continued to talk via the radio. Then, unexpectedly and unannounced, the pilot of the Cessna 208B maneuvered his airplane above and over the top of her airplane. She said that she immediately told the Cessna 208B pilot that she could not see him and that she was concerned about where he was. She said that the Cessna 208B pilot then said, in part: "Whatever you do, don't pitch up." The next thing she recalled was seeing the wings and cockpit of the descending Cessna 208B pass by the right side of her airplane, which was instantly followed by an impact with her airplane's right wing. She said that after the collision, the Cessna 208B passed underneath her airplane from right-to-left before beginning a gradual descent that steepened as the airplane continued to the left. It then entered a steep, vertical, nose-down descent before colliding with the tundra-covered terrain below followed by a postcrash fire. Unable to maintain level cruise flight, the Cessna 207 pilot selected an area of rolling, tundra-covered terrain as a forced landing site. An examination of both airplanes revealed impact signatures consistent with the Cessna 208B's vertical stabilizer impacting the Cessna 207's right wing. A portion of crushed and distorted wreckage, identified as part of the Cessna 208B's vertical stabilizer assembly, was found embedded in the Cessna 207's right wing. The Cessna 208B's severed vertical stabilizer and rudder were found about 1,000 feet west of the Cessna 208B's crash site.

The single engine aircraft was dispatched in Baranikovskiy to perform a crop spraying mission on rice paddy field. Before flight, the tank was refueled with 250 litres of E95 fuel. The technician told the pilot the fuel was abnormally yellow but the pilot decided to proceed with the flight. Prior to take off, he asked the copilot to stay on ground and replaced him by the owner of the zone to be treated which is against the published procedures. During the takeoff roll, the aircraft did not accelerate as expected but the pilot continued. After liftoff, at a height of about 30 metres, the pilot initiated a 90° left turn when the engine lost power. He started to drop the load of chemicals then attempted an emergency landing when the aircraft impacted ground. It continued for about 134 metres then struck an irrigation drain, nosed over and came to rest, bursting into flames. The pilot was killed and the passenger was seriously injured.

The single engine aircraft was performing a taxi flight from Whitegrass Airport located on Tannu Island, to Port Vila, with six passengers and a pilot on board. While approaching Efate Island, the pilot encountered poor weather conditions with heavy rain falls and attempted an emergency landing in the garden of the Lagon Resort, south of Port Vila. On touchdown, the airplane lost its nose gear and left main gear, cartwheeled and came to rest, broken in two. All occupants were slightly injured and the aircraft was damaged beyond repair.

The twin engine aircraft departed Maracay on a cargo flight to Puerto Ordaz, carrying one pilot, one passenger and some bank documents. While in cruising altitude, the pilot informed ATC about smoke in the cockpit and elected to divert to the nearest airport. Eventually, he attempted an emergency landing in an open field located some 20 km east from Zaraza. After touchdown, the aircraft rolled for few dozen metres before coming to rest, bursting into flames. While both occupants escaped uninjured, the aircraft was totally destroyed by fire.

On 18 May 2011, the pilot in command (PIC) and the crew - composed of the copilot (COP) and cabin crew members (CCM) - initiated the flight OSL5428 from Rosario International Airport (ROS) in the province of Santa Fe at 20:35, the final destination being the Comodoro Rivadavia International Airport (CRD), in the province of Chubut. The flight had scheduled intermediate stopovers at Córdoba International Airport (COR), Mendoza (MDZ), and Neuquén (NQN), according to the company's plans. The company designated aircraft Saab 340A, with registration number LV-CEJ, for the flight. After having made the intermediate stopovers in Córdoba (COR) and Mendoza (MDZ), the pilot landed the aircraft at the airport in Neuquén at 22:20. After refuelling and carrying out the planned dispatch, the crew and 19 passengers (18 adults and one minor) on board, prepared to make the last leg of the flight OSL5428, from Neuquén Airport (NQN) to the final destination: Comodoro Rivadavia International Airport (CRD). The flight took off at 23:05. After the take-off, the aircraft started to climb AWY T 105, to reach FL190, in accordance with the flight plan. After flying for 24 minutes, the pilot levelled the aircraft at 17,800 feet, and remained at this level for approximately 9 minutes. Due to the fact that the meteorological conditions at this level caused icing, the technical crew descended to FL (flight level) 140. Shifting to FL140 took five minutes. During this stage of the flight the icing conditions steadily worsened. By the time the aircraft had reached FL140, the icing conditions were severe. The aircraft flew for approximately two minutes with a straight and level flight attitude, increasing the accumulation of ice. Then the aircraft completely lost lift, which resulted in a loss of control, and the subsequent entry into abnormal flight attitude. The aircraft plunged towards the earth and impacted the ground, which resulted in a fire. Everyone on board perished and the aircraft was destroyed. The accident happened at night under IMC conditions.

The pilot, sole on board, was performing a crop spraying flight when the engine lost power. He elected to make an emergency landing in a field 2 kilometers from Sofyevka, in the Stavropol krai. Upon touchdown, the aircraft rolled over and came to rest upside down, bursting into flames. The pilot escaped uninjured while the aircraft was partially destroyed by fire. The wreck was evacuated and disposed away before the arrival of the accident investigation commission. Therefore, it was not possible to the MAK to determine the cause of the engine failure. As the pilot did not have any valid licence for this kind of aircraft, this PZL-Mielec AN-2R built on 11FEB1982 did not have a valid Certificate of Airworthiness. It had a double registration: FLA-34906 and RA-68122 which was the official one present in the Russian Civil Aviation registry.

The pilot had worked a 10-hour shift the day of the accident and had been off duty about 2 hours when the chief pilot called him around midnight to transport a patient. The pilot accepted the flight and, about 2 hours later, was on an instrument approach to the airport to pick up the patient. While on the instrument approach, all of the anti-ice and deice systems were turned on. The pilot said that the deice boots seemed to be shedding the ice almost completely. He extended the flaps and lowered the landing gear to descend; he then added power, but the airspeed continued to decrease. The airplane continued to descend, and he raised the flaps and landing gear and applied full climb power. The airplane shuddered as it climbed, and the airspeed continued to decrease. The stall warning horn came on, and the pilot lowered the nose to increase the airspeed. The airplane descended until it impacted level, snow-covered terrain. The airplane was equipped with satellite tracking and engine and flight control monitoring. The minimum safe operating speed for the airplane in continuous icing conditions is 140 knots indicated airspeed. The airplane's IAS dropped below 140 knots 4 minutes prior to impact. During the last 1 minute of flight, the indicated airspeed varied from a high of 124.5 knots to a low of 64.6 knots, and the vertical speed varied from 1,965 feet per minute to -2,464 feet per minute. The last data recorded prior to the impact showed that the airplane was at an indicated airspeed of 68 knots, descending at 1,651 feet per minute, and the nose was pitched up at 20 degrees. The pilot did not indicate that there were any mechanical issues with the airplane. The chief pilot reported that pilots are on call for 14 consecutive 24-hour periods before receiving two weeks off. He said that the accident pilot had worked the previous day but that the pilot stated that he was rested enough to accept the mission. The chief pilot indicated he was aware that sleep cycles and circadian rhythms are disturbed by varied and prolonged activity. An NTSB study found that pilots with more than 12 hours of time since waking made significantly more procedural and tactical decision errors than pilots with less than 12 hours of time since waking. A 2000 FAA study found accidents to be more prevalent among pilots who had been on duty for more than 10 hours, and a study by the U.S. Naval Safety Center found that pilots who were on duty for more than 10 of the last 24 hours were more likely to be involved in pilot-at-fault accidents than pilots who had less duty time. The operator’s management stated that they do not prioritize patient transportation with regard to their medical condition but base their decision to transport on a request from medical staff and availability of a pilot and aircraft, and suitable weather. The morning of the accident, the patient subsequently took a commercial flight to another hospital to receive medical treatment for his non-critical injury/illness. Given the long duty day and the early morning departure time of the flight, it is likely the pilot experienced significant levels of fatigue that substantially degraded his ability to monitor the airplane during a dark night instrument flight in icing conditions. The NTSB has issued numerous recommendations to improve emergency medical services aviation operations. One safety recommendation (A-06-13) addresses the importance of conducting a thorough risk assessment before accepting a flight. The safety recommendation asked the Federal Aviation Administration to "require all emergency medical services (EMS) operators to develop and implement flight risk evaluation programs that include training all employees involved in the operation, procedures that support the systematic evaluation of flight risks, and consultation with others trained in EMS flight operations if the risks reach a predefined level." Had such a thorough risk assessment been performed, the decision to launch a fatigued pilot into icing conditions late at night may have been different or additional precautions may have been taken to alleviate the risk. The NTSB is also concerned that the pressure to conduct EMS operations safely and quickly in various environmental conditions (for example, in inclement weather and at night) increases the risk of accidents when compared to other types of patient transport methods, including ground ambulances or commercial flights. However, guidelines vary greatly for determining the mode of and need for transportation. Thus, the NTSB recommended, in safety recommendation A-09-103, that the Federal Interagency Committee on Emergency Medical Services (FICEMS) "develop national guidelines for the selection of appropriate emergency transportation modes for urgent care." The most recent correspondence from FICEMS indicated that the guidelines are close to being finalized and distributed to members. Such guidance will help hospitals and physicians assess the appropriate mode of transport for patients.

According to the pilot, during cruise flight the engine began to run rough and lose power. He heard a loud metallic sound; the engine vibrated violently and then lost power. He performed a forced landing to a farm field, and the airplane nosed over in the soft terrain, resulting in substantial damage to the wings. A postaccident inspection revealed that the crankshaft would not rotate. An internal inspection of the cylinders and spark plugs did not reveal a reason for the power loss. The oil system was examined and there were large amounts of metal particles in the oil. Due to a lack of suitable equipment and facilities, further disassembly of the engine was not attempted.

The crew was performing a crop spraying flight in Dibrova, some 60 km northwest from Zhytomyr. In flight, the engine caught fire and crew elected to make an emergency landing in an open field. Upon touchdown, the aircraft rolled for few metres then overturned and came to rest upside down. Both pilots escaped with minor injuries and the aircraft was damaged beyond repair.