Crash of a Beechcraft King Air 100 in Saint-Mathieu-de-Beloeil

Date & Time: Jun 10, 2013 at 1726 LT
Type of aircraft:
Operator:
Registration:
C-GJSU
Survivors:
Yes
Schedule:
Montreal - Saint-Mathieu-de-Beloeil
MSN:
B-088
YOM:
1971
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On final approach to Saint-Mathieu-de-Beloeil Airport, while on a taxi flight from Montreal-Saint-Hubert Airport, both engine failed simultaneously and aircraft stalled and crashed half a mile short of runway. All four occupants were injured, one of them seriously. Aircraft was damaged beyond repair. Double engine failure due to fuel exhaustion or fuel system management failure suspected.

Crash of a Beechcraft B100 King Air in Libby: 2 killed

Date & Time: Dec 19, 2012 at 0002 LT
Type of aircraft:
Operator:
Registration:
N499SW
Flight Type:
Survivors:
No
Schedule:
Coolidge - Libby
MSN:
BE-089
YOM:
1980
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
980
Circumstances:
When the flight was about 7 miles from the airport and approaching it from the south in dark night conditions, the noncertificated pilot canceled the instrument flight rules (IFR) flight plan. A police officer who was on patrol in the local area reported that he observed a twin-engine airplane come out of the clouds about 500 ft above ground level and then bank left over the town, which was north of the airport. The airplane then turned left and re-entered the clouds. The officer went to the airport to investigate, but he did not see the airplane. He reported that it was dark, but clear, at the airport and that he could see stars; there was snow on the ground. He also observed that the rotating beacon was illuminated but that the pilot-controlled runway lighting was not. The Federal Aviation Administration issued an alert notice, and the wreckage was located about 7 hours later 2 miles north of the airport. The airplane had collided with several trees on downsloping terrain; the debris path was about 290 ft long. Postaccident examination of the airframe and engine revealed no mechanical malfunctions or failures that would have precluded normal operation. The town and airport were located within a sparsely populated area that had limited lighting conditions, which, along with the clouds and 35 percent moon illumination, would have restricted the pilot’s visual references. These conditions likely led to his being geographically disoriented (lost) and his subsequent failure to maintain sufficient altitude to clear terrain. Although the pilot did not possess a valid pilot’s certificate, a review of his logbooks indicated that he had considerable experience flying the airplane, usually while accompanied by another pilot, and that he had flown in both visual and IFR conditions. A previous student pilot medical certificate indicated that the pilot was color blind and listed limitations for flying at night and for using color signals. The pilot had applied for another student pilot certificate 2 months before the accident, but this certificate was deferred pending a medical review.
Probable cause:
The noncertificated pilot’s failure to maintain clearance from terrain while maneuvering to land in dark night conditions likely due to his geographic disorientation (lost). Contributing to the accident was the pilot’s improper decision to fly at night with a known visual limitation.
Final Report:

Crash of a Beechcraft King Air A100 in Deadmans Cay

Date & Time: Mar 9, 2012 at 1410 LT
Type of aircraft:
Operator:
Registration:
N70JL
Survivors:
Yes
Schedule:
Nassau - Deadmans Cay
MSN:
B-87
YOM:
1971
Country:
Crew on board:
0
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Aircraft was operating a charter flight from Nassau-Lynden Pindling Airport to Deadmans Cay and left Nassau around 1 PM. On approach, crew encountered technical problems and was unable to lower the gear. Captain eventually decided to perform a belly landing. Aircraft skidded on runway for several yards and veered off runway before coming to rest. While all occupants escaped uninjured, aircraft was damaged beyond repair.

Crash of a Beechcraft King Air A100 in Pointe-Noire

Date & Time: Dec 4, 2011 at 1422 LT
Type of aircraft:
Operator:
Registration:
9Q-CEM
Survivors:
Yes
Schedule:
Moanda - Pointe-Noire
MSN:
B-105
YOM:
1972
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Following an uneventful flight from Moanda, Gabon, crew executed the approach in poor weather conditions (rain falls, winds and turbulence). On touch down, twin engine aircraft skidded and veered off runway to the left. While contacting a soft ground, landing gear collapsed while an engine was sheared off. Aircraft slid several yards and came to rest. All ten occupants were uninjured while the aircraft was damaged beyond repair. Windshear with microburst is suspected.

Crash of a Beechcraft King Air A100 in Vancouver: 2 killed

Date & Time: Oct 27, 2011 at 1612 LT
Type of aircraft:
Operator:
Registration:
C-GXRX
Survivors:
Yes
Schedule:
Vancouver - Kelowna
MSN:
B-036
YOM:
1970
Flight number:
NTA204
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
13876
Captain / Total hours on type:
978.00
Copilot / Total flying hours:
1316
Copilot / Total hours on type:
85
Aircraft flight hours:
26993
Circumstances:
The Northern Thunderbird Air Incorporated Beechcraft King Air 100 (serial number B-36, registration C‑GXRX) departed Vancouver International Airport for Kelowna, British Columbia, with 7 passengers and 2 pilots on board. About 15 minutes after take-off, the flight diverted back to Vancouver because of an oil leak. No emergency was declared. At 1611 Pacific Daylight Time, when the aircraft was about 300 feet above ground level and about 0.5 statute miles from the runway, it suddenly banked left and pitched nose-down. The aircraft collided with the ground and caught fire before coming to rest on a roadway just outside of the airport fence. Passersby helped to evacuate 6 passengers; fire and rescue personnel rescued the remaining passenger and the pilots. The aircraft was destroyed, and all of the passengers were seriously injured. Both pilots succumbed to their injuries in hospital. The aircraft’s emergency locator transmitter had been removed.
Probable cause:
Findings as to causes and contributing factors:
During routine aircraft maintenance, it is likely that the left-engine oil-reservoir cap was left unsecured.
There was no complete preflight inspection of the aircraft, resulting in the unsecured engine oil-reservoir cap not being detected, and the left engine venting significant oil during operation.
A non-mandatory modification, designed to limit oil loss when the engine oil cap is left unsecure, had not been made to the engines.
Oil that leaked from the left engine while the aircraft was repositioned was pointed out to the crew, who did not determine its source before the flight departure.
On final approach, the aircraft slowed to below VREF speed. When power was applied, likely only to the right engine, the aircraft speed was below that required to maintain directional control, and it yawed and rolled left, and pitched down.
A partially effective recovery was likely initiated by reducing the right engine’s power; however, there was insufficient altitude to complete the recovery, and the aircraft collided with the ground.
Impact damage compromised the fuel system. Ignition sources resulting from metal friction, and possibly from the aircraft’s electrical system, started fires.
The damaged electrical system remained powered by the battery, resulting in arcing that may have ignited fires, including in the cockpit area.
Impact-related injuries sustained by the pilots and most of the passengers limited their ability to extricate themselves from the aircraft.
Findings as to risk:
Multi-engine−aircraft flight manuals and training programs do not include cautions and minimum control speeds for use of asymmetrical thrust in situations when an engine is at low power or the propeller is not feathered. There is a risk that pilots will not anticipate aircraft behavior when using asymmetrical thrust near or below unpublished critical speeds, and will lose control of the aircraft.
The company’s standard operating procedures lacked clear directions for how the aircraft was to be configured for the last 500 feet, or what to do if an approach is still unstable when 500 feet is reached, specifically in an abnormal situation. There is a demonstrated risk of accidents occurring as a result of unstabilized approaches below 500 feet above ground level.
Without isolation of the aircraft batteries following aircraft damage, there is a risk that an energized battery may ignite fires by electrical arcing.
Erroneous data used for weight-and-balance calculations can cause crews to inadvertently fly aircraft outside of the allowable center-of-gravity envelope.
Final Report:

Mishap of a Beechcraft King Air A100 in Blountville

Date & Time: Jun 15, 2011 at 1405 LT
Type of aircraft:
Operator:
Registration:
N15L
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Bridgewater - Wichita
MSN:
B-212
YOM:
1974
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
4837
Captain / Total hours on type:
87.00
Aircraft flight hours:
16170
Circumstances:
The airplane was flying in instrument meteorological conditions at flight level 200 (about 20,000 feet), and a large area of thunderstorm activity was located to the northwest. About 20 miles from the thunderstorm activity, the airplane began to encounter moderate turbulence and severe icing conditions. The pilot deviated to the south; however, the turbulence increased, and the airplane entered an uncommanded left roll and dive. The autopilot disengaged, and the pilot's attitude indicator dropped. The pilot leveled the airplane at an altitude of 8,000 feet and landed without further incident. Subsequent examination revealed that one-third of the outboard left elevator separated in flight and that the empennage was substantially damaged. Meteorological and radar data revealed the airplane entered an area of rapidly intensifying convective activity, which developed along the airplane's flight path, and likely encountered convectively-induced turbulence with a high probability of significant icing. The effect of icing conditions on the initiation of the upset could not be determined; however, airframe structural icing adversely affects an airplane's performance and can result in a loss of control.
Probable cause:
An encounter with convectively-induced turbulence and icing, which resulted in an in-flight upset and a loss of airplane control.
Final Report:

Crash of a Beechcraft King Air A100 in Kirby Lake: 1 killed

Date & Time: Oct 25, 2010 at 1120 LT
Type of aircraft:
Operator:
Registration:
C-FAFD
Survivors:
Yes
Schedule:
Calgary - Edmonton - Kirby Lake
MSN:
B-042
YOM:
1970
Flight number:
KBA103
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
The aircraft was on an instrument flight rules flight from the Edmonton City Centre Airport to Kirby Lake, Alberta. At approximately 1114 Mountain Daylight Time, during the approach to Runway 08 at the Kirby Lake Airport, the aircraft struck the ground, 174 feet short of the threshold. The aircraft bounced and came to rest off the edge of the runway. There were 2 flight crew members and 8 passengers on board. The captain sustained fatal injuries. Four occupants, including the co-pilot, sustained serious injuries. The 5 remaining passengers received minor injuries. The aircraft was substantially damaged. A small, post-impact, electrical fire in the cockpit was extinguished by survivors and first responders. The emergency locator transmitter was activated on impact. All passengers were BP employees.
Probable cause:
Findings as to Causes and Contributing Factors:
1. The conduct of the flight crew members during the instrument approach prevented them from effectively monitoring the performance of the aircraft.
2. During the descent below the minimum descent altitude, the airspeed reduced to a point where the aircraft experienced an aerodynamic stall and loss of control. There was insufficient altitude to effect recovery prior to ground impact.
3. For unknown reasons, the stall warning horn did not activate; this may have provided the crew with an opportunity to avoid the impending stall.
Findings as to Risk:
1. The use of company standard weights and a non-current aircraft weight and balance report resulted in the flight departing at an inaccurate weight. This could result in a performance regime that may not be anticipated by the pilot.
2. Flying an instrument approach using a navigational display that is outside the normal scan of the pilot increases the workload during a critical phase of flight.
3. Flying an abbreviated approach profile without applying the proper transition altitudes increases the risk of controlled flight into obstacles or terrain.
4. Not applying cold temperature correction values to the approach altitudes decreases the built-in obstacle clearance parameters of an instrument approach.
Final Report:

Crash of a Beechcraft King Air B100 in Montmagny

Date & Time: Sep 22, 2010 at 1700 LT
Type of aircraft:
Operator:
Registration:
C-FSIK
Flight Phase:
Survivors:
Yes
Schedule:
Montmagny - Montreal
MSN:
BE-39
YOM:
1978
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
4500
Captain / Total hours on type:
2500.00
Copilot / Total flying hours:
7800
Copilot / Total hours on type:
675
Circumstances:
Aircraft was operating as flight MAX100 on an instrument flight rules flight from Montmagny to Montreal/St-Hubert, Quebec, with 2 pilots and 4 passengers on board. At approximately 1700 Eastern Daylight Time, the aircraft moved into position on the threshold of 3010-foot-long runway 26 and initiated the take-off. On the rotation, at approximately 100 knots, the flight crew saw numerous birds in the last quarter of the runway. While getting airborne, the aircraft struck the birds and the left engine lost power, causing the aircraft to yaw and roll to the left. The aircraft lost altitude and touched the runway to the left of the centre line and less than 100 feet from the runway end. The take-off was aborted and the aircraft overran the runway, coming to rest in a field 885 feet from the runway end. All occupants evacuated the aircraft via the main door. There were no injuries. The aircraft was substantially damaged.
Probable cause:
Findings As To Causes and Contributing Factors:
The bird strike occurred on take-off at an altitude of less than 50 feet. Gulls were ingested in the left engine, which then lost power.
After the loss of engine power, the flight crew had difficulty controlling the aircraft. The aircraft touched the ground, forcing the pilot flying to abort the take-off when the runway remaining was insufficient to stop the aircraft, resulting in the runway overrun.
Findings As To Risks:
Although a cannon was in place, it was not working on the day of the accident, which increased the risk of a bird strike.
The presence of a goose and duck farm outside the airport perimeter but near a runway increases the risk of attracting gulls.
Operators subject to Canadian Aviation Regulations Subpart 703 are not prohibited from having an aircraft take off from a runway that is shorter than the accelerate-stop distance of that aircraft as determined from the performance diagrams. Consequently, travellers carried by these operators are exposed to the risks associated with a runway overrun when a take-off is aborted.
The absence of a CVR makes it harder to ascertain material facts. Consequently, investigations can take more time, resulting in delays which compromise public safety.
Final Report:

Crash of a Beechcraft King Air 100 in Quebec City: 7 killed

Date & Time: Jun 23, 2010 at 0603 LT
Type of aircraft:
Operator:
Registration:
C-FGIN
Flight Phase:
Survivors:
No
Schedule:
Quebec City - Seven Islands - Natashquan
MSN:
B-164
YOM:
1973
Flight number:
APO201
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
7
Captain / Total flying hours:
3046
Captain / Total hours on type:
372.00
Copilot / Total flying hours:
2335
Copilot / Total hours on type:
455
Aircraft flight hours:
19665
Aircraft flight cycles:
16800
Circumstances:
Aircraft was making an instrument flight rules flight from Québec to Sept-Îles, Quebec. At 0557 Eastern Daylight Time, the crew started its take-off run on Runway 30 at the Québec/Jean Lesage International Airport; 68 seconds later, the co-pilot informed the airport controller that there was a problem with the right engine and that they would be returning to land on Runway 30. Shortly thereafter, the co-pilot requested aircraft rescue and fire-fighting (ARFF) services and informed the tower that the aircraft could no longer climb. A few seconds later, the aircraft struck the ground 1.5 nautical miles from the end of Runway 30. The aircraft continued its travel for 115 feet before striking a berm. The aircraft broke up and caught fire, coming to rest on its back 58 feet further on. The 2 crew members and 5 passengers died in the accident. No signal was received from the emergency locator transmitter (ELT).
Probable cause:
Findings as to Causes and Contributing Factors:
1. After the take-off at reduced power, the aircraft performance during the initial climb was lower than that established at certification.
2. The right engine experienced a problem in flight that led to a substantial loss of thrust.
3. The right propeller was not feathered; therefore, the rate of climb was compromised by excessive drag.
4. The absence of written directives specifying which pilot was to perform which tasks may have led to errors in execution, omissions, and confusion in the cockpit.
5. Although the crew had the training required by regulation, they were not prepared to manage the emergency in a coordinated, effective manner.
6. The priority given to ATC communications indicates that the crew did not fully understand the situation and were not coordinating their tasks effectively.
7. The impact with the berm caused worse damage to the aircraft.
8. The aircraft’s upside-down position and the damage it sustained prevented the occupants from evacuating, causing them to succumb to the smoke and the rapid, intense fire.
9. The poor safety culture at Aéropro contributed to the acceptance of unsafe practices.
10. The significant measures taken by TC did not have the expected results to ensure compliance with the regulations, and consequently unsafe practices persisted.
Findings as to Risk:
1. Deactivating the flight low pitch stop system warning light or any other warning system contravenes the regulations and poses significant risks to flight safety.
2. The maintenance procedures and operating practices did not permit the determination of whether the engines could produce the maximum power of 1628 ft-lb required at take-off and during emergency procedures, posing major risks to flight safety.
3. Besides being a breach of regulations, a lack of rigour in documenting maintenance work makes it impossible to determine the exact condition of the aircraft and poses major risks to flight safety.
4. The non-compliant practice of not recording all defects in the aircraft journey log poses a safety risk because crews are unable to determine the actual condition of the aircraft at all times, and as a result could be deprived of information that may be critical in an emergency.
5. The lack of an in-depth review by TC of SOPs and checklists of 703 operators poses a safety risk because deviations from aircraft manuals are not detected.
6. Conditions of employment, such as flight hours–based remuneration, can influence pilots’ decisions, creating a safety risk.
7. The absence of an effective non-punitive and confidential voluntary reporting system means that hazards in the transportation system may not be identified.
8. The lack of recorded information significantly impedes the TSB’s ability to investigate accidents in a timely manner, which may prevent or delay the identification and communication of safety deficiencies intended to advance transportation safety.
Final Report:

Crash of a Beechcraft King Air 100 in Chicoutimi: 2 killed

Date & Time: Dec 9, 2009 at 2250 LT
Type of aircraft:
Operator:
Registration:
C-GPBA
Survivors:
Yes
Schedule:
Val d'Or - Chicoutimi
MSN:
B-215
YOM:
1975
Flight number:
ET822
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
3500
Captain / Total hours on type:
1000.00
Copilot / Total flying hours:
1000
Copilot / Total hours on type:
150
Circumstances:
The Beechcraft was on an instrument flight rules flight between Val-d’Or and Chicoutimi/Saint-Honoré, Quebec, with 2 pilots and 2 passengers on board. At 2240 Eastern Standard Time, the aircraft was cleared for an RNAV (GNSS) Runway 12 approach and switched to the aerodrome traffic frequency. At 2250, the International satellite system for search and rescue detected the aircraft’s emergency locator transmitter signal. The aircraft was located at 0224 in a wooded area approximately 3 nautical miles from the threshold of Runway 12, on the approach centreline. Rescuers arrived on the scene at 0415. The 2 pilots were fatally injured, and the 2 passengers were seriously injured. The aircraft was destroyed on impact; there was no post-crash fire.
Probable cause:
For undetermined reasons, the crew continued its descent prematurely below the published approach minima, leading to a controlled flight into terrain (CFIT).
Findings as to Risk:
1. The use of the step-down descent technique rather than the stabilized constant descent angle (SCDA) technique for non-precision instrument approaches increases the risk of an approach and landing accident (ALA).
2. The depiction of the RNAV (GNSS) Runway 12 approach published in the Canada Air Pilot (CAP) does not incorporate recognized visual elements for reducing ALAs, as recommended in Annex 4 to the Convention, thereby reducing awareness of the terrain.
3. The installation of a terrain awareness warning system (TAWS) is not yet a requirement under the Canadian Aviation Regulations (CARs) for air taxi operators. Until the changes to regulations are put into effect, an important defense against ALAs is not available.
4. Most air taxi operators are unaware of and have not implemented the FSF ALAR task force recommendations, which increases the risk of a CFIT accident.
5. Approach design based primarily on obstacle clearance instead of the 3° optimum angle increases the risk of ALAs.
6. The lack of information on the SCDA technique in Transport Canada reference manuals means that crews are unfamiliar with this technique, thereby increasing the risk of ALAs.
7. Use of the step-down descent technique prolongs the time spent at minimum altitude, thereby increasing the risk of ALAs.
8. Pilots are not sufficiently educated on instrument approach procedure design criteria. Consequently, they tend to use the CAP published altitudes as targets, and place the aircraft at low altitude prematurely, thereby increasing the risk of an ALA.
9. Where pilots do not have up-to-date information on runway conditions needed to check runway contamination and landing distance performance, there is an increased risk of landing accidents.
10. Non-compliance with instrument flight rules (IFR) reporting procedures at uncontrolled airports increases the risk of collision with other aircraft or vehicles.
11. If altimeter corrections for low temperature and remote altimeter settings are not accurately applied, obstacle clearance will be reduced, thereby increasing the CFIT risk.
12. When cockpit recordings are not available to an investigation, this may preclude the identification and communication of safety deficiencies to advance transportation safety.
13. Task-induced fatigue has a negative effect on visual and cognitive performance which can diminish the ability to concentrate, operational memory, perception and visual acuity.
14. Where an emergency locator transmitter (ELT) is not registered with the Canadian Beacon Registry, the time needed to contact the owner or operator is increased which could affect occupant rescue and survival.
15. If the tracking of a call to 911 emergency services from a cell phone is not accurate, search and rescue efforts may be misdirected or delayed which could affect occupant rescue and survival.
Other Findings:
1. Weather conditions at the alternate airport did not meet CARs requirements, thereby reducing the probability of a successful approach and landing at the alternate airport if a diversion became necessary.
2. Following the accident, none of the aircraft exits were usable.
Final Report: