Crash of a Casa 212 Aviocar 200 in Larat

Date & Time: Dec 3, 2011 at 1308 LT
Type of aircraft:
Operator:
Registration:
PK-NCZ
Survivors:
Yes
Schedule:
Langur - Larat
MSN:
274/79N
YOM:
1986
Flight number:
MNA9933
Location:
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
19
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
7500
Captain / Total hours on type:
5500.00
Copilot / Total flying hours:
343
Copilot / Total hours on type:
72
Aircraft flight hours:
26935
Aircraft flight cycles:
30064
Circumstances:
The Casa 212-200 aircraft registered PK-NCZ operated by PT. Merpati Nusantara Airlines on a scheduled flight from Langur to Larat, touched down at 224 meters from runway 09, was bouncing twice to the left of runway centre line, out of the runway and stopped at 607 meters from runway 09 touch down area as final position, and 15 meters to the left of runway edge. The Pilot Flying was First Officer, and after second bouncing, PIC took over, and he tried to bring the aircraft to the centre line of the runway without success. The aircraft continued rolled to the shoulder away from the runway and stopped at the final position. This is the second landing at Larat runway on the same day. There were 15 passengers, 3 children, one baby, Pilot In Command, two First Officers, one First Officer was Pilot Flying from Langur to Larat, one engineer on board. One passenger was serious injured, another one passenger minor injured.
Final Report:

Crash of a Casa 212 Aviocar 200 near Bohorok: 18 killed

Date & Time: Sep 29, 2011 at 0750 LT
Type of aircraft:
Operator:
Registration:
PK-TLF
Flight Phase:
Survivors:
No
Site:
Schedule:
Medan - Kuta Cane
MSN:
88N/283
YOM:
1989
Flight number:
NBA823
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
16
Pax fatalities:
Other fatalities:
Total fatalities:
18
Captain / Total flying hours:
5935
Captain / Total hours on type:
3730.00
Copilot / Total flying hours:
2500
Copilot / Total hours on type:
1100
Aircraft flight hours:
11329
Aircraft flight cycles:
13626
Circumstances:
On 29 September 2011, a CASA 212-200 aircraft registered PK-TLF was being operated by Nusantara Buana Air as a non-scheduled passenger flight from Polonia International Airport (MES/WIMM), Medan - North Sumatera1 to Alas Leuser Airstrip Kuta Cane, South East Aceh. The flight was conducted under Visual Flight Rules (VFR) The aircraft departed from Medan at 0728 LT (0028 UTC) and scheduled to be arrived at Kuta Cane at 0058 UTC. There were 18 person on board consisted of two pilots and 16 passengers including two children and two infants. The aircraft radar target was last observed on the radar screen at about 0050 UTC, while at position on radial 262˚ and 35 NM from MDN VOR. The aircraft was found impacted to a of 70º slope terrain at 5,055 feet altitude in the Leuser Mountain National Park, direction of 109 and 16 Nm from Kuta Cane on coordinate N 030 24’ 00” E 0980 01’ 00”. All 18 occupants were fatally injured and the aircraft was severely damage.
Probable cause:
Factors:
1. The flight was in VFR however both pilots agreed to fly into the cloud, consequently, the flight crew had lack of situation awareness due to lost of visual references to the ground and no or late recovery action prior to impact due to low visibility.
2. There was lack of good crew coordination due to steep cockpit transition gradient.
3. There was no checklist reading and crew briefing.
Final Report:

Crash of a Casa 212 Aviocar 300DF off Robinson Crusoe Island: 21 killed

Date & Time: Sep 2, 2011 at 1748 LT
Type of aircraft:
Operator:
Registration:
966
Flight Type:
Survivors:
No
Schedule:
Santiago - Robinson Crusoe Island
MSN:
443
YOM:
1994
Country:
Crew on board:
4
Crew fatalities:
Pax on board:
17
Pax fatalities:
Other fatalities:
Total fatalities:
21
Circumstances:
The twin engine aircraft departed Santiago de Chile-Comodoro Arturo Merino Benítez (Pudahuel) Airport on a special flight to Robinson Crusoe Island, carrying 17 passengers and a crew of four. The flight was organized by NGO's in cooperation with the Chilean National Television to see the progress of the reconstruction on the island of Robinson Crusoe following the 2010 earthquake. Among the occupants were members of the National Television and also from the Council of Culture. The famous Chilean television icon Felipe Camiroaga Fernández was among the passengers. Following an almost 3-hour flight, the crew completed a low pass over the runway 14 then started the approach to runway 32 from the sea. At an altitude of about 650 feet, the aircraft entered an uncontrolled descent, rolled to the left to an angle of 90° and impacted the sea. Debris were found floating on water and the main wreckage was later found about one km southeast from the airport. All 21 occupants were killed.

Personnel from the Chilean Air Force:
Lt Carolina Fernández Quinteros,
Lt Juan Pablo Mallea Lagos,
1st Sgt Eduardo Jones San Martín,
1st Cpl Eduardo Estrada Muñoz,
2nd Cpl Flavio Oliva Pino,
2nd Cpl Erwin Núñez Rebolledo,
Cdt Rodrigo Fernández Apablaza,
José Cifuentes Juica.

Council of Culture:
Galia Diaz Riffo,
Romina Irarrázabal Faggiani.

Chilean National Television:
Felipe Camiroaga Fernández,
Roberto Bruce Pruzzo,
Sylvia Slier Munoz,
Caroline Gatica Aburto,
Rodrigo Cabezón de Amesti.

Members of the 'Desafío Levantemos Chile' NGO:
Felipe Cubillos Sigall,
Sebastián Correa Murillo,
Catalina Vela Montero,
Joel Lizama Nahuelhual,
Jorge Palma Calvo,
Joaquín Arnolds Reyes.
Probable cause:
The accident was caused by the loss of control of the airplane while performing the tailwind leg through the channel between the islands of Robinson Crusoe and Santa Clara to an estimated height of 650 feet or less, during the circuit approach to Runway 32 in a very low trajectory (with little height difference above the runway), where very adverse airflow conditions were found, including wind shear, which exposed the crew to extreme flight conditions.
Adverse airflow conditions were the results of a combination of different factors, including:
- Very unstable atmosphere, with strong turbulence and possibly eventually powerful down gusts arising from the presence of open cells after a front passed,
- The presence of the two counter-rotating vortexes in the Santa Clara Island downwind wake,
- The presence of strong and gusty crosswinds that were very variable in strength and direction in a very short time.

Crash of a Casa 212 Aviocar in Saskatoon: 1 killed

Date & Time: Apr 1, 2011 at 1830 LT
Type of aircraft:
Operator:
Registration:
C-FDKM
Survivors:
Yes
Site:
Schedule:
Saskatoon - Saskatoon
MSN:
196
YOM:
1981
Country:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
7400
Captain / Total hours on type:
75.00
Copilot / Total flying hours:
7800
Copilot / Total hours on type:
1800
Aircraft flight hours:
21292
Circumstances:
At 1503 Central Standard Time, the Construcciones Aeronauticas SA (CASA) C-212-CC40 (registration C-FDKM, serial number 196) operated by Fugro Aviation Canada Ltd., departed from Saskatoon/Diefenbaker International Airport, Saskatchewan, under visual flight rules for a geophysical survey flight to the east of Saskatoon. On board were 2 pilots and a survey equipment operator. At about 1814, the right engine lost power. The crew shut it down, carried out checklist procedures, and commenced an approach for Runway 27. When the flight was 3.5 nautical miles from the runway on final approach, the left engine lost power. The crew carried out a forced landing adjacent to Wanuskewin Road in Saskatoon. The aircraft impacted a concrete roadway noise abatement wall and was destroyed. The survey equipment operator sustained fatal injuries, the first officer sustained serious injuries, and the captain sustained minor injuries. No ELT signal was received.
Probable cause:
Conclusions
Findings as to Causes and Contributing Factors:
1. The right engine lost power when the intermediate spur gear on the torque sensor shaft failed. This resulted in loss of drive to the high-pressure engine-driven pump, fuel starvation, and immediate engine stoppage.
2. The ability of the left-hand No. 2 ejector pump to deliver fuel to the collector tank was compromised by foreign object debris (FOD) in the ejector pump nozzle.
3. When the fuel level in the left collector tank decreased, the left fuel level warning light likely illuminated but was not noticed by the crew.
4. The pilots did not execute the fuel level warning checklist because they did not perceive the illumination of the fuel level left tank warning light. Consequently, the fuel crossfeed valve remained closed and fuel from only the left wing was being supplied to the left engine.
5. The left engine flamed out as a result of depletion of the collector tank and fuel starvation, and the crew had to make a forced landing resulting in an impact with a concrete noise abatement wall.
Findings as to Risk:
1. Depending on the combination of fuel level and bank angle in single-engine uncoordinated flight, the ejector pump system may not have the delivery capacity, when the No. 1 ejector inlet is exposed, to prevent eventual depletion of the collector tank when the engine is operated at full power. Depletion of the collector tank will result in engine power loss.
2. The master caution annunciator does not flash; this leads to a risk that the the crew may not notice the illumination of an annunciator panel segment, in turn increasing the risk of them not taking action to correct the condition which activated the master caution.
3. When cockpit voice and flight data recordings are not available to an investigation, this may preclude the identification and communication of safety deficiencies to advance transportation safety.
4. Because the inlets of the ejector pumps are unscreened, there is a risk that FOD in the fuel tank may become lodged in an ejector nozzle and result in a decrease in the fuel delivery rate to the collector tank.
Other Findings:
1. The crew’s decision not to recover or jettison the birds immediately resulted in operation for an extended period with minimal climb performance.
2. The composition and origin of the FOD, as well as how or when it had been introduced into the fuel tank, could not be determined.
3. The SkyTrac system provided timely position information that would have assisted search and rescue personnel if position data had been required.
4. Saskatoon police, firefighters, and paramedics responded rapidly to the accident and provided effective assistance to the survivors.
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 Casa 212 Aviocar 100 near Mintom: 11 killed

Date & Time: Jun 19, 2010 at 1000 LT
Type of aircraft:
Operator:
Registration:
TN-AFA
Flight Phase:
Survivors:
No
Schedule:
Yaoundé - Yangadou
MSN:
151
YOM:
1979
Location:
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
11
Circumstances:
The aircraft departed Yaoundé-Nsimalen Airport at 0913LT on a charter flight to Yangadou, a small airstrip serving several iron mines in north Congo. At 0951LT, the crew made its last radio contact with ATC then the aircraft disappeared from radar screens. The wreckage was found around 1700LT on June 21 near Mintom. The aircraft was totally destroyed and all 11 occupants were killed, among them Ken Talbot, an Australian investor in iron business. The flight was conducted for the Cameroon company Cam Iron, a subcontractor of the Australian Sundance Resources Group.

Crash of a Casa 212 Aviocar 200 in Fonds-Verrettes: 11 killed

Date & Time: Oct 9, 2009
Type of aircraft:
Operator:
Registration:
FAU-531
Flight Phase:
Survivors:
No
Site:
Schedule:
Port-au-Prince - Port-au-Prince
MSN:
187
YOM:
1981
Flight number:
UN146
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
11
Circumstances:
The twin engine aircraft departed Port-au-Prince-Toussaint Louverture (ex François Duvalier) Airport on a border patrol mission on behalf of the MINUSTAH, the United Nations Mission for Stabilization in Haiti. On board were nine passengers and two pilots, among them Uruguayan and Jordan soldiers. In unknown circumstances, the aircraft struck the slope of a mountain located some 20 km west of Fonds-Verrettes. The aircraft was totally destroyed and all 11 occupants were killed.

Crash of a Casa 212 Aviocar 200M on Mt Salak: 18 killed

Date & Time: Jun 26, 2008 at 1100 LT
Type of aircraft:
Operator:
Registration:
A-2106
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Jakarta – Bogor
MSN:
228/N68
YOM:
1984
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
13
Pax fatalities:
Other fatalities:
Total fatalities:
18
Circumstances:
While flying in poor weather conditions, the twin engine aircraft struck the slope of Mt Salak located about 55 km south of Jakarta. All 18 occupants were killed.
Probable cause:
Controlled flight into terrain.

Crash of a Casa 212 Aviocar 200 in Long Apung: 3 killed

Date & Time: Jan 26, 2008 at 0936 LT
Type of aircraft:
Operator:
Registration:
PK-VSE
Flight Type:
Survivors:
No
Schedule:
Tarakan – Long Apung
MSN:
412/92N
YOM:
1993
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
21019
Captain / Total hours on type:
14234.00
Copilot / Total flying hours:
16849
Copilot / Total hours on type:
16849
Aircraft flight hours:
11750
Aircraft flight cycles:
13749
Circumstances:
On 26 January 2008, a Casa 212-200 aircraft, registered PK-VSE, was being operated by PT. Dirgantara Air Service as a cargo charter flight from Tarakan Airport to Long Apung Airport. There were 3 persons on board; two pilots and one aircraft maintenance engineer/load master. The aircraft was certified as being airworthy prior to departure. The aircraft departed from Tarakan at 0011 UTC (08:11 local time), and the estimated time arrival at Long Apung was 0136. At 0411 the pilot of another aircraft received a distress signal and informed air traffic services at Tarakan. Searchers subsequently found the aircraft wreckage at an elevation of 2,766 feet, about 3.4 NM from Long Apung Airport. The coordinates of the accident site were 01° 39.483′ S and 115° 00.265′ E near Lidung Payau Village, Malinau, East Kalimantan. The accident site was on the left downwind leg of the runway 35 circuit.
Probable cause:
The following findings were identified:
• The aircraft was certified as being airworthy prior to departure.
• All crew members held appropriate and valid flight crew licenses.
• The pilots continued flight into instrument meteorological conditions.
• The aircraft impacted terrain in controlled flight.
• The cargo was not adequately restrained.
Causes:
The crew did not appear to have awareness of the aircraft’s proximity with terrain until impact with terrain was imminent. The pilot attempted to continue the flight in instrument meteorological
conditions, below the lowest safe altitude.
Final Report:

Crash of a Casa 212 Aviocar 400 off Progreso

Date & Time: Nov 15, 2006
Type of aircraft:
Operator:
Registration:
AMP-114
Flight Phase:
Survivors:
Yes
Schedule:
Cancún - Cancún
Country:
Crew on board:
7
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The crew departed Cancún Airport for a routine maritime patrol flight over the Gulf of Mexico. After 5 hours of flight, while returning to his base and approaching the coast, the crew informed ATC that an engine failed. Few seconds later, the second engine stopped as well. The crew reduced his altitude and ditched the aircraft 3,5 km off Progreso, some 40 km north of Mérida. All 7 occupants were rescued while the aircraft was lost.
Probable cause:
Double engine failure for unknown reasons. Fuel exhaustion suspected.