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

Date & Time: Jun 9, 2009 at 1300 LT
Type of aircraft:
Operator:
Registration:
EX-156
Flight Phase:
Survivors:
Yes
MSN:
1G183-50
YOM:
1979
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The crew was completing a crop-spraying mission in Kadamdzhayskom when the engine failed in flight. The aircraft crashed in an open field and both pilots were injured.
Probable cause:
Engine failure for unknown reasons.

Crash of a Boeing 737-247 in Massamba: 7 killed

Date & Time: Apr 29, 2009 at 0600 LT
Type of aircraft:
Operator:
Registration:
TL-ADM
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Bangui – Brazzaville – Harare
MSN:
22264/753
YOM:
1981
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
7
Circumstances:
The aircraft departed Bangui on a ferry flight to Harare with an intermediate stop in Brazzaville, carrying five technicians and two pilots. After being parked at Bangui Airport for almost a year without flying, the aircraft should be transferred to Harare for maintenance purposes. While in cruising altitude over DRC, the aircraft entered an uncontrolled descent and crashed in a dense wooded area near Massamba, Bandundu Province. The aircraft disintegrated on impact and all 7 occupants were killed.

Crash of a NAL Saras near Bangalore: 3 killed

Date & Time: Mar 6, 2009 at 1534 LT
Type of aircraft:
Operator:
Registration:
VT-XRM
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Bangalore - Bangalore
MSN:
SP002
YOM:
2007
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
2414
Captain / Total hours on type:
310.00
Copilot / Total flying hours:
2080
Copilot / Total hours on type:
315
Aircraft flight hours:
50
Aircraft flight cycles:
49
Circumstances:
On 06.3.2009 Saras Prototype PT2 aircraft VT-XRM manufactured and owned by National Aerospace Laboratories, Bangalore was scheduled for carrying out its test flight n°49. Test flight programme includes general a ir tests/handling checks to ascertain the aircraft flying characteristics after the 50 hrs Scheduled servicing, dummy approach in simulated single engine configuration at 5000' AMSL, go around at 300' AGL in a simulated one engine inoperative condition, landing in a simulated one engine inoperative condition and to carry out in-flight engine shut down and relight procedure at 10000' AMSL within 130 - 150 kts speed. Tests are to be carried out as per existing SOP and test procedures and limitations and pre flight test briefing meeting. Aircraft was cleared by approved inspectors of NAL after carrying out daily inspection on 6.3.2009 for test flight n°49 and was duly accepted by the Chief test pilot. Preflight briefing was taken by the Wg Cdr (22917-S), F(P), chief test pilot was on commander seat , Wg Cdr (23165-H), F(P) - test pilot was on co-pilot seat and Sqn Ldr (24746-M), AE(M) was on Flight test engineer on board. The test team also accepted flight test schedule of flight n°49. Total duration of the tests was estimated to about 45 minutes. Engines were started at 0913 UTC at ASTE, dispersal area . All engine parameters were reported normal. After carrying out post startup and pre taxi checks, aircraft taxied out for Runway 09 at HAL airport. As pe r departure instructions after departure R/W 09 aircraft to climb on R/W heading 5000’, turn right set course to southwest -2 and in coordination with approach radar to operate upto 10 miles and level 100. Aircraft was cleared for takeoff from R/W 09 with surface wind 090º/06kts. Aircraft took-off at 0925 UTC and changed over to radar at 0926 UTC. There was no event. Aircraft was then cleared to level 100, operating up to 10 miles. After completing general handling checks at 9000’ AMSL without any events, Aircraft was stabilized with simulated single engine approach to the landing r/w 09. Single engine simulated approach was carried out. At about 0941 UTC aircraft was cleared for overshoot, wind 090/06 kts. Aircraft made overshoot at 300’ AGL. Aircraft was then changed over to radar again. At 0942 UTC aircraft was cleared to climb level 100 and proceed sector southwest 2. Aircraft right engine was throttled up to match left engine and aircraft climbed out to 9000’ AMSL in sector southwest. At about 0948 UTC aircraft reported 15 miles and FL90 and reported turning around. But HAL radar as well as BIAL radar showing level was 72 for which aircraft replied that it has descended and climbing back to 9000’ AMSL. At about 0955 UTC aircraft reported “OPS NORMAL” at 20 Nm in sector southwest 2. This was the last contact by aircraft with radar. After 0955 UTC Radar contact with the aircraft was completely lost. As per ASTE Telemetry, after turned round to point towards HAL airfield aircraft was observed about 20 miles at 9000’ AMSL with 140 kts speed. Telemetry link was good at this position Left engine was then shut down and secured following the test procedure at about 10:00:40 UTC. Pilot was in touch with Flight test director on R/T at telemetry desk. After about 47 secs, left engine relight procedure was initiated at around 9200’ AMSL. Pilot also reported to Telemetry the start of relight of the engine. Telemetry indications also showed the rise in Ng and ITT. At about 100 secs prior to crash aircraft went into sudden dive from 9200’ to 7300’ for about 13 secs. Meanwhile During the relighting of left engine, FTD desk also lost RT contact with aircraft about 37 secs prior to crash and telemetry link with the aircraft was also intermittent. At 37 secs prior to crash when Telemetry called aircraft “ can you call up. What is going on”, aircraft replied “Standby” this was the last contact of Telemetry with aircraft. After that there was no contact from the pilot. Just before 7 secs of crash when the telemetry data signal was restored aircraft already lost to the height of 4260’ AMSL(1900’AGL) and in continuous loss of height and Ng was about 31%. There was no response from pilots even after repeated calls from FTD desk. Aircraft was rapidly losing the height without any control. Cockpit voice recording clearly showed that on last moments just 10 secs prior to crash ,commander called out “ Aircraft has departed” indicating aircraft completely gone out of control. During the last moment of crash telemetry recorded Ng : about 54% (63% as per FDR), Engine oil pressure 88, fuel flow 94%,ITT 647 deg C, indicating engine relight was successful. But by the time aircraft was almost on ground. Aircraft crashed at about 1004 UTC (10:03:44). All possible communication means including through en -route traffic to contact the aircraft went in vain. Search operation by ALH helicopter (A67) ,Chetak(T45) and T55 was effected. At about 1033 UTC police control room reported that an aircraft had crashed near Bidadi. After extensive search efforts, at about 1100 UTC, A67 found out the crash site having bearing 251° and 17 Nm from HAL airport. Later it was affirmed that the aircraft crashed at a village called Sehsagirihalli (close to wonderland amusement park) near Bidadi and 37 km by road(off Mysore road) Southwest of HAL airport, Bangalore. The crash site was a wide -open residential plot area of uneven hard terrain surrounded by poles and wild plants. It was on a radial of 251° /17 NM from HAL, Bangalore airport having coordinates LAT : N12° 50’56”, LONG: E077° 23’46”). All the three persons on board were charred to death and were on their seats. There was post impact fire. Aircraft fuselage was broken from rear of the main plane and found in an inverted position. The vertical fin leading edge was facing the ground and the respective tail mounted engines by the side of it. The nose portion of the aircraft was facing East direction. Aircraft was completely destroyed due impact and fire.
Probable cause:
Incorrect relight procedure devised by the designer and adopted by the crew at insufficient height leading to rapid loss of altitude and abnormal behavior of aircraft resulted into accident.
Contributory factors:
a) Lack of crew coordination and cockpit procedures,
b) Handling of the controls,
c) Non-aborting of flight by the crew in coordination with the flight test Director after failure of first relight attempt,
d) Devising engine relight procedures by NAL without consulting the propeller manufacturer.
Final Report:

Crash of a De Havilland DHC-2 Beaver near Kenai

Date & Time: Feb 20, 2009 at 1515 LT
Type of aircraft:
Operator:
Registration:
N5342G
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Kenai - Kenai
MSN:
854
YOM:
1956
Location:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
14300
Captain / Total hours on type:
9000.00
Copilot / Total flying hours:
799
Copilot / Total hours on type:
30
Aircraft flight hours:
9483
Circumstances:
The certificated flight instructor was familiarizing the second pilot with ski operations in a ski-equipped airplane during an instructional flight. The flight instructor reported that he took the flight controls from the second pilot to demonstrate a touch-and-go landing on a frozen, snow-covered lake. After landing to the east, the instructor said that he kept the tail of the airplane up and the airspeed just below flying speed in order to make ski tracks on the lake to check the snow conditions. About midway along the lake the instructor added full engine power and the airplane became airborne but failed to climb sufficiently to avoid colliding with an area of rising, tree-covered terrain at the departure end of the lake. The airplane sustained substantial damage to the wings, fuselage, and empennage. Postaccident examination revealed no preaccident mechanical anomalies. The instructor noted that after the accident he noticed occasional strong gusts of wind from the west.
Probable cause:
The flight instructor’s decision to attempt a touch-and-go landing toward rising terrain and with a tailwind, resulting in an in-flight collision with terrain during takeoff.
Final Report:

Crash of a Cessna 650 Citation III in Trigoria: 2 killed

Date & Time: Feb 7, 2009 at 0602 LT
Type of aircraft:
Operator:
Registration:
I-FEEV
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Rome - Bologna
MSN:
650-0105
YOM:
1986
Flight number:
AOE301
Location:
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
6077
Captain / Total hours on type:
877.00
Copilot / Total flying hours:
3000
Copilot / Total hours on type:
58
Aircraft flight hours:
6977
Circumstances:
The crew was engaged in a positioning flight from Rome to Bologna to pick up a medical team for an ambulance mission. At 0554LT, the crew was cleared for takeoff. The aircraft departed Rome-Ciampino Airport runway 15 at 0600LT. During initial climb, after being cleared to Bolsena at FL240, the aircraft entered an uncontrolled descent and crashed near a cattle barn. The aircraft disintegrated on impact and both pilots were killed. At the time of the accident, weather conditions were as follow: wind from 140 at 18 knots, light rain, few at 1,800 feet, broken 3,000 feet and scattered at 7,000 feet with an OAT of 13° C.
Probable cause:
The cause of the accident was due to an impact with the ground resulting from the loss of control of the aircraft by the captain, who was also the PF. It appears very likely that during the initial phase inadequate attention was replaced by a phase of spatial disorientation, resulting in a loss of situational awareness, which prompted an inadequate intervention on the flight controls by the PF, resulting in total loss of control of the aircraft (having accentuated the tilt to the left wing, instead of leveling the aircraft). It is reasonable to assume that the PF, based on the conviction of being in a right turn for Bolsena in IMC night conditions, misinterpreted the unusual turn, using the controls in order to accentuate the bank angle to the left, drastically reducing the vertical component of lift. This turn has consequently caused the aircraft to assume an attitude of increasing bank, a condition that has been aggravated by the continued application on the controls of a positive load factor in order to stop the sudden loss of altitude, without first leveling the wings. Or the aircraft is stabilized in a pronounced downward spiral to the left. The first officer (PNF), engaged in the management of navigation equipment, has created the unusual turn of the aircraft in conjunction with the commander (PF). Nevertheless, the considerable gradient of experience on the airplane and hierarchy within the organization between the captain and the first officer has probably prevented him to intervene in a more directive or authoritative way in the recovery phase of the situation. Also contributing to the outcome of the event was the lack of detail in the definition of the duties of the crew procedures and inadequate adherence to the basic principles of CRM/MCC, with reference to the monitoring and statement of the navigation modes active, navigation procedures and in particular to the lack of requests for inclusion of turns and routes, the deficiency in the performance of controls and optimization of automation that can lighten the workload in a time unfavorable from the point of view of the circadian rhythm and IMC night. In this respect, it seems fitting to remember the problem of spatial disorientation, although known and studied for decades, is still relevant, and that the only way to counter it is the application of proper use of instruments in compliance with the basic principles of CRM/MCC, which should be part of the normal operating procedures of an operator. This is especially true when working outside of normal circadian rhythms, when it is most easily seen a slowing of cognitive processes.
Final Report:

Crash of a Piper PA-42-720 Cheyenne IIIA in Königstein im Taunus: 1 killed

Date & Time: Jan 19, 2009 at 1240 LT
Type of aircraft:
Operator:
Registration:
D-IDIA
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Frankfurt – Reichelsheim
MSN:
42-5501055
YOM:
1990
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
2900
Captain / Total hours on type:
449.00
Aircraft flight hours:
9332
Aircraft flight cycles:
21133
Circumstances:
The pilot, sole on board, was completing a positioning flight from Frankfurt-Main Airport to Reichelsheim where the airplane was based. At 1235LT, the twin engine aircraft departed Frankfurt-Main Airport runway 25L and the pilot was instructed to make a left turn and to climb and maintain 1,500 feet. The aircraft climbed to 1,800 feet then descended to 1,400 feet. In rain falls, the aircraft struck trees and crashed in a wooded area located in Königstein im Taunus, about 15 km north of Frankfurt Airport. The aircraft was totally destroyed and the pilot was killed.
Probable cause:
Controlled flight into terrain.
Final Report:

Crash of a Cessna 208 Caravan I in Intuto

Date & Time: Jan 9, 2009 at 1315 LT
Type of aircraft:
Operator:
Registration:
EP-858
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Intuto - Iquitos
MSN:
208-0246
YOM:
1996
Location:
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Shortly after takeoff from the Tigre River in Intuto, the single engine seaplane stalled and crashed. All 8 occupants were injured and the aircraft was destroyed.

Crash of a Beechcraft C90B King Air in Rocksprings: 1 killed

Date & Time: Dec 14, 2008 at 1500 LT
Type of aircraft:
Operator:
Registration:
N43KM
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Hondo – Goodyear
MSN:
LJ-1345
YOM:
1993
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
3500
Captain / Total hours on type:
250.00
Aircraft flight hours:
3725
Circumstances:
The pilot was cleared to 17,000 feet approximately 7 minutes after takeoff. After arriving at 17,000 feet, radar showed the airplane in a meandering flight path increasingly off course that continued through the end of the flight, even after several prompts from the controller. The pilot was cleared to flight level 240 (24,000 feet) after about 6 minutes at 17,000 feet, and about 2 minutes later, while passing through about 18,000 feet, he made his last radio transmission, acknowledging a corrected heading. About 6 minutes later, the airplane arrived at 24,000 feet and the pilot did not make any intelligible responses to controller inquiries for the remainder of the flight. At 1456, radar showed the airplane in a descent to 21,000 feet before beginning a rapid descent and continuing to impact. The airplane was substantially damaged by the impact forces and the pilot, who was the only occupant, was fatally injured. During the review of the air traffic control recordings, it was determined that none of the voice transmissions from N43KM sounded as if the pilot was speaking through an oxygen mask microphone. At the accident scene both bleed air switches were observed to be in the closed position and the airplane pressurization switch on the console was observed to be in the dump position. No other preimpact anomalies were observed that would have prevented the normal operation of the airplane.
Probable cause:
The pilot's failure to properly configure the pressurization controls, resulting in his impairment and subsequent incapacitation due to hypoxia.
Final Report:

Crash of a PAC Cresco 08-600 in Tarata: 1 killed

Date & Time: Dec 14, 2008 at 1155 LT
Type of aircraft:
Operator:
Registration:
ZK-LTC
Flight Phase:
Survivors:
No
Schedule:
Tarata - Tarata
MSN:
20
YOM:
1997
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
12100
Aircraft flight hours:
3272
Aircraft flight cycles:
33147
Circumstances:
On Sunday 14 December 2008, the aircraft departed from Stratford Aerodrome at 0630 hours for a transit flight to a farm airstrip near Tarata. Shortly after becoming airborne the pilot noticed the engine chip detector warning light on the instrument panel was illuminated. He diverted to the company maintenance base at Wanganui aerodrome for the defect to be rectified. The aircraft engineer found a light metallic fuzz on the engine magnetic (mag) plug. The fuzz was cleaned off and the mag plug refitted. The aircraft was released to service with a condition that a further inspection of the mag plug was to be performed after 10 hours flight time. The topdressing job, which involved the spreading of 450 tonnes of lime, had commenced on Thursday 11 December 2008 and continued on Friday 12 December 2008. No flying took place on Saturday 13 December 2008 due to a local horse-riding event being held on the farm property. The aircraft arrived at the farm airstrip at 0940 hours on the Sunday morning, and shortly thereafter commenced operations to complete the spreading of the lime. At the time of the accident, 423 tonnes of lime had been spread. The pilot flew a series of topdressing flights before needing to stop for the first refuel. When interviewed, the loader driver stated that the pilot informed him that he was having some difficulty with the lime product not flowing consistently from the aircraft hopper during the sowing runs. At approximately 1145 hours the pilot stopped again to refuel. On completion of the refuel, this gave the aircraft an estimated fuel load of 300 litres. The pilot completed a further two flights. On the third flight, the aircraft became airborne at the end of the airstrip and then descended 55 feet below the level of the airstrip where the aft fuselage struck a fence line. A concentration of lime along the aircraft’s take-off path indicated that the pilot had initiated an attempt to jettison his load at the end of the airstrip. Following the collision with the fence, the aircraft remained airborne for a further 450 metres before it impacted the side of a small hill in a slight nose down attitude. The aircraft then came to rest 12 metres to the left of the initial impact point. The accident occurred in daylight, at approximately 1155 hours NZDT, at Tarata, at an elevation of 410 feet amsl. Latitude: S39° 08.169', longitude: E174° 21.710'.
Probable cause:
Conclusions:
- The pilot was appropriately licensed, held the appropriate Medical Certificate, was experienced and fit to carry out aerial topdressing operations.
- The aircraft had been operating normally from the airstrip up to the time of the accident.
- The aircraft descended after take-off and struck a fence. The collision with the fence damaged the elevator control cable system which jammed the elevator control surface. This resulted in the pilot being unable to adequately control the aircraft in pitch, and the aircraft subsequently struck the ground.
- The aircraft was loaded with 1900 kg of lime product on the accident flight, this was in excess of the 1860 kg maximum structural hopper load. No variation above the maximum structural hopper load is allowed for in CAR Part 137. The aircraft’s all-up weight at the time of the accident was under the maximum allowed under the overload provisions of CAR Part 137 by 145 kg.
- The Aircraft Flight Manual does not provide take-off performance data for operation over the maximum certificated take-off weight and up to the maximum agricultural weight as allowed by CAR Part 137.
- A change in wind direction had occurred in the late morning which may have presented the pilot with a slight tail-wind or possible low level turbulence, including down draught conditions, during and after take-off.
- The windsock was not in the most suitable position to indicate the wind conditions to the pilot.
- Partial or full load jettisons had taken place on previous flights, indicating that the pilot was having difficulty achieving the required aircraft performance during or after take-off.
- On the accident flight, the aircraft was probably overloaded for the prevailing environmental conditions.
- The reported poor flowing qualities of the lime product being spread may have hampered the pilot’s efforts to jettison the load after take-off. The effectiveness of the jettison may have also been reduced by the downward flight path of the aircraft on leaving the end of the airstrip. It is unlikely that the pilot could comply with the CAR Part 137.103 requirement to jettison 80% of the load within five seconds.
- The possibility of a pre-existing airframe or engine defect that could have contributed to the accident was eliminated as far as practicable by the investigation.
- The ELT fitted to the aircraft was no longer an approved type, therefore the aircraft was not airworthy in accordance with CARs. The ELT was incapable of being detected by satellite and therefore would not automatically alert rescue services, however, this did not hamper rescue efforts in this accident.
- The accident was not survivable.
Final Report:

Crash of a Rockwell Shrike Commander 500S in Planeta Rica: 2 killed

Date & Time: Dec 3, 2008 at 1825 LT
Registration:
HK-1697
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Medellín – Montería
MSN:
500-3198
YOM:
1974
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
12153
Captain / Total hours on type:
2000.00
Copilot / Total hours on type:
18
Aircraft flight hours:
6179
Circumstances:
The twin engine aircraft departed Medellín-Enrique Olaya Herrera Airport at 1745LT on a cargo flight to Montería, carrying two pilots and a load of bovine embryos. The flight to Montería was completed at FL130 then the crew was cleared to start the descent to Montería-Los Garzones Airport. At an altitude of 7,500 feet on descent, the aircraft went out of control and crashed in an open field located in Verada Arroyo, near Planeta Rica. The aircraft disintegrated on impact and both pilots were killed.
Probable cause:
Loss of control in altitude for undetermined reasons.
Final Report: