Crash of an Antonov AN-148-100E in Garbuzovo: 6 killed

Date & Time: Mar 5, 2011 at 1040 LT
Type of aircraft:
Operator:
Registration:
61708
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Voronezh - Voronezh
MSN:
41-03
YOM:
2010
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
6
Circumstances:
The aircraft departed Voronezh-Pridacha Airport in the morning to conduct a test flight with six crew on board, two pilots from the manufacturer, two engineers and two pilots from the Myanmar Air Force to whom the aircraft should be delivered. In flight, the crew decided to perform an emergency descent. During this manoeuvre, the aircraft reached an excessive speed and lost part of its tail, stabilizers and elevators. It entered an uncontrolled descent and crashed in a snow covered field located near Garbuzovo, bursting into flames. The aircraft was totally destroyed and all six occupants were killed. Tail parts, stabilizers and elevators were later found about 3 km from the point of impact. The airplane was operated by the Voronezh Aircraft Production Association. (VASO - Voronezhskoye Aktsionernoye Samoletostroitelnoe Obshestvo). First accident involving an Antonov AN-148.
Probable cause:
The cause of the accident was the inadvertently permitted the aircraft to accelerate 110 km/h above the design limit speed during an emergency descent. This led to low-frequency vibrations on the aircraft in all axes, an increase of alternating accelerations exceeding the margin of safety. The result was the break up of the aircraft in the air, followed by its collision with the earth.
The main factors contributing to the accident were:
- Untimely and inadequate actions of the crew to control the emergency decent,
- Lack of proper coordination among the members of the crew,
- Deviations from recommendations in the flight manual in executing the emergency descent,
- Misleading indications on basic instruments when outside characteristic operating conditions.

Crash of a Cessna 411 in Carrasqueño: 3 killed

Date & Time: Mar 4, 2011
Type of aircraft:
Operator:
Registration:
XB-LWA
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Guadalajara – Mexico City
MSN:
411-0275
YOM:
1967
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
3
Circumstances:
Few minutes after takeoff from Guadalajara-Miguel Hidalgo y Costilla Airport, the crew informed ATC about technical problems and elected to make an emergency landing. While approaching a pasture, the twin engine airplane collided with a powerline and crashed, bursting into flames. Both pilots and two cows in the field were killed, and all four passengers were seriously injured (burns). Three days later, one of the survivor died from his injuries.

Crash of a Let L-410UVP-E20 near Tegucigalpa: 14 killed

Date & Time: Feb 14, 2011 at 0802 LT
Type of aircraft:
Operator:
Registration:
HR-AUQ
Flight Phase:
Survivors:
No
Schedule:
San Pedro Sula - Tegucigalpa
MSN:
91 26 03
YOM:
1991
Flight number:
CAA731
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
12
Pax fatalities:
Other fatalities:
Total fatalities:
14
Captain / Total flying hours:
15300
Copilot / Total flying hours:
4810
Aircraft flight hours:
5153
Circumstances:
The twin engine aircraft departed San Pedro Sula-Ramon Villeda Morales Airport at 0704LT on a 40-minute flight to Tegucigalpa, carrying 12 passengers and two pilots. After being cleared to descend to 9,000 feet for an approach to runway 20, the crew informed ATC he was initiating a go-around procedure for unknown reasons. Few minutes later, the aircraft was cleared for an approach to runway 02. On approach in marginal weather conditions in a full flaps down configuration, the aircraft stalled and crashed in a wooded area located 12 km from the airport. The aircraft was totally destroyed by impact forces and all 14 occupants were killed.
Probable cause:
The following findings were identified:
1) Weather conditions existing at the time of the event, during the approach to the runway the aircraft was operated slightly above the stall speed and a major change in wind speed could cause a stall. The altitude at which the windshear occurred, and the reaction time of the pilot and the responsiveness of the aircraft determined whether the descent could be arrested in time to avoid an accident.
2) No published descent procedures were performed, possibly misinterpretation of Flight Instruments (altimeter, airspeed indicator).
3) During the descent to the VOR/DME for runway 20 and 02, the pilot in command (PIC) did not check his approach chart, and did not continually consult the first officer on the altitude and course.
4) There was no adequate communication between crew; deficient CRM (No approach briefing was made for any of the two approaches).
5) The aircraft was configured for landing with flaps fully down (flap 42) at a very long distance from the track without having it in sight. It is noteworthy that the aircraft will not respond to an adverse condition windshear as it appeared at that time with such a configuration. It should be noted that in both approaches it is mandatory to perform a 'circling' procedure.
Final Report:

Crash of a Casa 212 Aviocar 100 near Tanjung Pinang: 5 killed

Date & Time: Feb 12, 2011 at 1342 LT
Type of aircraft:
Operator:
Registration:
PK-ZAI
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Batam - Tanjung Pinang
MSN:
120/18N
YOM:
1980
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
13027
Captain / Total hours on type:
3311.00
Copilot / Total flying hours:
2577
Copilot / Total hours on type:
152
Aircraft flight hours:
29990
Aircraft flight cycles:
35128
Circumstances:
On 12 February 2011, a CASA C212-100 aircraft, registered PK-ZAI, operated by Sabang Merauke Raya Air Charter (SMAC), departed from Hang Nadim Airport, Batam (BTH/WIDD) at 1318 LT (0618 UTC)1 for a test flight following an engine replacement to the engine number one. The test flight was conducted over Tanjung Pinang Island area. There were five persons on board consisted of two pilots, and three company engineers. At 0628 UTC the aircraft appeared on Tanjung Pinang Approach radar display and was flying toward Tanjung Pinang area. Tanjung Pinang Approach controller informed that the aircraft was identified flying over Tanjung Pinang at 2000 feet. At 0633 UTC the aircraft received clearance to climb to 4000 feet. At 0644 UTC the aircraft disappeared from Tanjung Pinang radar display. The last position of the aircraft identified on the radar display was on 16 miles radial 010º from Tanjung Pinang airport. Tanjung Pinang Approach controller could not communicate with the PK-ZAI. At 0705 UTC, the controller requested relay by another aircraft to search PK-ZAI. The other aircrafts could not communicate with PK-ZAI. At 0706 UTC Tanjung Pinang Approach controller received information from Indonesian Air Force Base at Gunung Bintan that an aircraft had crashed at Gunung Kijang forest, Bintan Island. After receiving the information, Tanjung Pinang Airport staff coordinated with SAR Bureau, local police, and Indonesian Army for search and rescue operation. The aircraft was found at Gunung Kijang forest, Bintan Island at coordinate 1° 10’ 45” N; 104° 34’ 22” E, about 30 km north of Tanjung Pinang Airport. All occupants were fatally injured in this accident. The aircraft was substantially damaged.
Probable cause:
Factors contributed to the accident are as follows:
• The flight test was not properly well prepared; there was no flight test plan.
• The current and applicable CMM is dissimilar the According to the CASA 212-100 and Garrett TPE331-5 Maintenance Manuals related to flight test requirement after the change of only one engine.
• The left engine was shut down using normal/ ground shut down procedure. It used the fuel shut off switches off followed by pulling the Power Lever rearward to reverse, as indicated by the propeller pitch.
• The right engine most likely shut down by wind milling prior the impact, it was indicated the propellers piston distance position to the cylinder was about normal flight range position and no indication of rotating impact on the blades.
• The Casa Service Bulletin No. 212-76-07 Revision 1 issued dated 23 December 1991 (Anti Reverse) that applicable for Casa 212 -100/200, was not incorporated to this aircraft.
• The PIC with pareses or paralysis vestibular organ or system could not response normally to the three dimensional motion or movement. This condition may the subject more sensitive to suffer Spatial Disorientation (SDO). The SDO is the pilot could not perceived rightly his position motion and attitude to the earth horizontal or to his aircraft or other aircraft and could as the dangerous precondition for unsafe action.
• The Director (DGCA) decree No 30/II/200 issued on 20 February 2009 stated that for issuing medical certificate for pilot after 60th birthday require several additional medical examination items. Point 1.b of this decree states the Video Nystagmography examination.(differed the ICAO Doc 8984).
Final Report:

Crash of a De Havilland DHC-6 Twin Otter 300 near Santa Clara: 6 killed

Date & Time: Jan 20, 2011 at 1545 LT
Operator:
Registration:
FAE449
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Shell – Tena
MSN:
834
YOM:
1986
Country:
Crew on board:
6
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
6
Circumstances:
The crew departed Shell Mera-Río Amazonas Airport at 1530LT on a flight to Tena on behalf of the ECORAE's Institute, a government supply and support program for isolated population in the center of Ecuador. Fifteen minutes after takeoff, the twin engine aircraft crashed in unknown circumstances near Santa Clara, about 30 km northeast of Shell Airport. A crew survived while five other occupants were killed. The only survivor died few hours later.

Crash of a Partenavia P.68C near Macapo: 5 killed

Date & Time: Jan 7, 2011 at 1600 LT
Type of aircraft:
Operator:
Registration:
YV1303
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Porlamar - Charallave
MSN:
353
YOM:
1973
Location:
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
5
Circumstances:
The twin engine aircraft departed Porlamar on a private flight to Charallave, carrying five passengers and one pilot, all from the same family. It is believed that the pilot changed his destination en route and elected to continue to the Cojedes Province. Due to fuel exhaustion, both engines lost power then failed, forcing the pilot to attempt an emergency landing. The aircraft crashed in a wooded area located near Macapo. A young girl aged 10 was seriously injured while five other occupants were killed.

Crash of a Piper PA-46-310P Malibu in Milaca: 2 killed

Date & Time: Dec 30, 2010 at 0958 LT
Operator:
Registration:
N9103N
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Aitkin - Beaumont
MSN:
46-08021
YOM:
1986
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
2078
Aircraft flight hours:
2466
Circumstances:
About 20 minutes after departing on a cross-country flight, the pilot acknowledged the air traffic controller’s clearance to climb to 17,000 feet mean sea level (msl). Radar data indicated that the airplane reached a maximum altitude of 16,800 feet msl. The airplane then entered a right descending turn followed by a left descending turn. While in the left turn, the pilot informed the controller, “I lost my autopilot; I’m in an unusual attitude.” The pilot stated this same information two more times in response to transmissions by the controller. The pilot’s last transmission was that he was busy trying to recover the airplane. Witnesses heard the airplane flying overhead for several minutes, but they could not see it due to the low ceiling. A postaccident examination of the airplane did not reveal any pre accident mechanical malfunctions or failures with the engine that would have precluded normal operation. Examination of the autopilot system revealed a loose screw inside the pitch servo housing. The screw was one of two that secured the high wattage resistor to the solenoid housing. Observed corrosion within the screw threads was consistent with the threads not being engaged in a nut or other internally threaded feature. No mechanical damage or arcing was visible on the screw. The operational impact of the loose screw is unknown. The pilot’s instrument flying proficiency could not be determined. According to log records, the pilot last flew 4.5 months before the accident. The airplane was in instrument meteorological conditions when the pilot stated that he was trying to recover from the unusual attitude. The pilot did not follow prescribed procedures for an autopilot malfunction. Weather data indicates that the airplane most likely encountered turbulence and icing conditions during the flight; however, the airplane was equipped with an ice protection system. Although ethanol was found during the toxicology tests, the levels varied greatly among the tissue/fluid samples. The investigation was unable to determine if the presence of ethanol was from ingestion or from postmortem production or contamination. The detected level of diphenhydramine, an over-the-counter sedating antihistamine used to treat allergies, was above therapeutic levels and likely contributed to the pilot’s inability to recover from the unusual attitude.
Probable cause:
The pilot did not recover from an unusual attitude while operating in instrument meteorological conditions following a disconnect of the autopilot system for undetermined reasons. Contributing to the accident were the pilot’s lack of recent flight experience and impairment due to diphenhydramine.
Final Report:

Crash of an Antonov AN-22A near Krasny Oktyabr: 12 killed

Date & Time: Dec 28, 2010 at 2130 LT
Type of aircraft:
Operator:
Registration:
RA-09343
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Voronezh - Tver
MSN:
043482272
YOM:
1974
Country:
Region:
Crew on board:
12
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
12
Circumstances:
The crew was returning to his base at Tver-Migalovo after he delivered a MiG-31 to the Voronezh Military Aviation Engineering University. While in cruising flight, the four engine aircraft entered an uncontrolled descent and crashed in a snow covered prairie located near Krasny Oktyabr. The aircraft was totally destroyed and all 12 occupants were killed.

Crash of a Fletcher FU-24A-954 in Wynella Station: 1 killed

Date & Time: Dec 20, 2010 at 1700 LT
Type of aircraft:
Registration:
VH-FNM
Survivors:
No
Schedule:
Wynella Station - Wynella Station
MSN:
263
YOM:
1979
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
5815
Circumstances:
On 20 December 2010, the owner/pilot of a Pacific Aerospace Corporation FU-24-954 Fletcher aircraft, registered VH-FNM, was conducting aerial spreading of urea fertilizer at Wynella Station; a property 40 km south-south-west of Dirranbandi, Queensland. At about 1650 Eastern Standard Time, the pilot was returning to the landing strip after the completion of an application run. The aircraft impacted the terrain, and the pilot was fatally injured.
Probable cause:
Examination of the accident site indicated that the aircraft’s engine was delivering power at the time of impact. Wreckage examination did not reveal evidence of any defect or mechanical failure that would have contributed to the event. Although the post-mortem report on the pilot noted that he had significant coronary atherosclerosis, there was insufficient information available to determine whether pilot incapacitation was involved in the accident. The investigation did not identify any organisational or systemic issues that might adversely affect the future safety of aviation
operations.
Final Report:

Crash of a Piper PA-46-350P Malibu Mirage in Gubin: 2 killed

Date & Time: Nov 2, 2010 at 1107 LT
Operator:
Registration:
D-EXTA
Flight Type:
Survivors:
No
Schedule:
Karlsruhe – Cottbus
MSN:
46-36168
YOM:
1998
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
1315
Captain / Total hours on type:
645.00
Aircraft flight hours:
1720
Circumstances:
At the day of the accident, the pilot, accompanied by his wife, planned to fly from Karlsruhe/Baden-Baden Airport to the Cottbus-Drewitz Special Airfield under Instrument Flight Rules (IFR) with a Piper PA 46-350P. Prior to the flight he refueled 400 liters and submitted a flight plan. According to the radar recording of the responsible air traffic control center, the airplane started at 0923 hrs1 and flew the planned route at Flight Level (FL) 190 to Cottbus-Drewitz, following the flight plan. The airplane started to descend at approx. 1044 hrs. The Initial Approach Fix (IAF) Cottbus-Drewitz NDB (DRW) was overflown in an altitude of approx. 3,900 ft AMSL with a Ground Speed (GS) of approx. 170 kt, at approx. 1104 hrs, and the descent was continued for the approach NDB-RWY-25. After flying over the intermediate approach fix in approx. 2,800 ft AMSL with a GS of approx. 190 kt, the airplane flew a turn to the left in order to intercept the final approach. The radar recording ended at 1107:34 hrs. At that time the airplane was turning into the final approach in an altitude of 2,400 ft AMSL with a GS of approx. 200 kt. According to radar recordings of the German Federal Armed Forces, the airplane was captured several more times within the turn radius: at 1107:50 hrs in an altitude of 1,200 ft AMSL, at 1108:01 hrs in an altitude of 2,700 ft AMSL, and finally in 1,700 ft AMSL and 1,000 ft AMSL. The recording ended at 1108:21 hrs in an altitude of 600 ft AMSL. The airplane crashed into a field south of the Polish city of Gubin and caught fire. Both occupants lost their lives.
Probable cause:
The accident is caused by a loss of control, when the aircraft changed from visual to instrument flight conditions during landing approach.
The following contributing factors were:
- the loss of visual reference in the turn,
- the change form automatic to manual flight control during a bank attitude,
- the permanently high speed during the landing approach.
Final Report: