Crash of a PZL-Mielec AN-2T in Azov

Date & Time: May 10, 2015 at 1433 LT
Type of aircraft:
Operator:
Registration:
RF-01159
Flight Phase:
Survivors:
Yes
Schedule:
Azov - Azov
MSN:
1G108-24
YOM:
1969
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
12
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The aircraft departed Azov-Almaz Airfield on a skydiving mission, carrying 12 skydivers and one pilot on behalf of the Azov Flying Club. Shortly after takeoff, while climbing, the engine lost power. The pilot attempted to return for an emergency landing when the aircraft lost height and crashed in an open field located near the airport, bursting into flames. All 13 occupants were rescued, among them one passenger suffered minor injuries. The aircraft was totally destroyed by fire.
Probable cause:
Loss of engine power for unknown reasons.

Crash of a Pacific Aerospace PAC 750XL in Taupo Lake

Date & Time: Jan 7, 2015 at 1216 LT
Operator:
Registration:
ZK-SDT
Flight Phase:
Survivors:
Yes
Schedule:
Taupo - Taupo
MSN:
122
YOM:
2005
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
12
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
588
Captain / Total hours on type:
14.00
Circumstances:
On 7 January 2015 a Pacific Aerospace Limited 750XL aeroplane was being used for tandem parachuting (or ‘skydiving’) operations at Taupō aerodrome. During the climb on the fourth flight of the day, the Pratt & Whitney Canada PT6A-34 engine failed suddenly. The 12 parachutists and the pilot baled out of the aeroplane and landed without serious injury. The aeroplane crashed into Lake Taupō and was destroyed.
Probable cause:
The following findings were identified:
- The first compressor turbine blade failed after a fatigue crack, which had begun at the trailing edge, propagated towards the leading edge. The blade finally fractured in tensile overload. The separated blade fragment caused other blades to fracture and the engine to stop.
- The fatigue crack in the trailing edge of the blade was likely initiated by the trailing edge radius having been below the specification for a new blade.
- The P&WC Repair Requirement Document 725009-SRR-001, at the time the blades were overhauled, had generic requirements for trailing edge thickness inspections but did not specify a minimum measurement for the trailing edge radius.
- The higher engine power settings used by the operator since August 2014 were within the flight manual limits. Therefore it was unlikely that the operator’s engine handling policy contributed to the engine failure.
- The operator had maintained the engine in accordance with an approved, alternative maintenance programme, but the registration of the engine into that programme had not been completed. The administrative oversight did not affect the reliability of the engine or contribute to the blade failure.
- It was likely that the maintenance provider had not followed fully the engine manufacturer’s recommended procedure for inspecting the compressor turbine blades. It could not be determined whether the crack might have been present, and potentially detectable, at the most recent borescope inspection.
- The operator had not equipped its pilots with flotation devices to cover the possibility of a ditching or an emergency bale-out over or near water.
- The pilot had demonstrated that he was competent and he had the required ratings. However, it was likely that the operator’s training of the pilot in emergency procedures was inadequate. This contributed to the pilot making a hasty exit from the aeroplane that jeopardized others.
Final Report:

Crash of a Piper PA-31P Pressurized Navajo in Częstochowa: 11 killed

Date & Time: Jul 5, 2014 at 1611 LT
Type of aircraft:
Registration:
N11WB
Flight Phase:
Survivors:
Yes
Schedule:
Częstochowa - Częstochowa
MSN:
31P-7630005
YOM:
1976
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
11
Pax fatalities:
Other fatalities:
Total fatalities:
11
Captain / Total flying hours:
996
Captain / Total hours on type:
40.00
Circumstances:
The twin engine aircraft was engaged in a series of skydiving flights at Częstochowa-Rudniki Airport, Silesia. It took off from runway 26C with 11 skydivers and one pilot on board. During initial climb, at an altitude of 100 metres, the pilot encountered technical problems with the engines and elected to make an emergency landing. He informed the passengers about the emergency situation and reduced his altitude when the aircraft rolled to the left to an angle of 70° then stalled and crashed in a wooded area, bursting into flames. The wreckage was found 4,200 metres past the runway end. Three skydivers were seriously injured while 9 other occupants were killed. Few minutes later, two of the survivors died from their injuries.
Probable cause:
The following findings were identified:
- The aircraft was operated without a valid CofA,
- Failure of the left engine during initial climb after the crankshaft failed, causing the malfunction of the propeller that could not be feathered, resulting in an asymmetry that caused the aircraft to enter a stall condition. Damages to the pin clutch connecting the crankshaft to the drive shaft of the right engine transmission could be due to the following causes: an earlier impact of a propeller's blade with an obstacle, in circumstances and time which could not be determined and/or a long-term fatigue process caused by uneven engine operation (one of the cylinders was replaced on the right engine),
- Improper maintenance of the aircraft,
- The left engine was producing low power due to improper operation,
- The fuel in the tanks did not meet the engine manufacturer's requirements,
- The aircraft was modified in violation of its Type Certificate,
- A high ambiant temperature.
Final Report:

Crash of a PZL-Mielec AN-2T in Olsztyn

Date & Time: Jun 8, 2014 at 1115 LT
Type of aircraft:
Operator:
Registration:
SP-FDZ
Survivors:
Yes
Schedule:
Olsztyn - Olsztyn
MSN:
1G74-73
YOM:
1967
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3460
Captain / Total hours on type:
490.00
Copilot / Total flying hours:
875
Copilot / Total hours on type:
205
Circumstances:
The single engine aircraft was completing local skydiving missions from Olsztyn Airport. Following a successful flight, the crew was returning to the airfield. On short final, the engine lost power. The aircraft lost height, collided with trees and crashed in a wooded area, coming to rest about 200 metres short of runway. Both pilots were injured and the aircraft was destroyed.
Probable cause:
The following findings were identified:
- Engine malfunction due to fuel shortage,
- Lack of fuel gauge monitoring on part of the crew,
- Poor crew coordination,
- Failure of the crew to respond with appropriate action when the warning light showing a lack of fuel came on.
Final Report:

Crash of a Comp Air CA-8 in Jämijärvi: 8 killed

Date & Time: Apr 20, 2014 at 1540 LT
Type of aircraft:
Registration:
OH-XDZ
Flight Phase:
Survivors:
Yes
Schedule:
Jämijärvi - Jämijärvi
MSN:
01
YOM:
2008
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
10
Pax fatalities:
Other fatalities:
Total fatalities:
8
Captain / Total flying hours:
1029
Captain / Total hours on type:
43.00
Aircraft flight hours:
809
Aircraft flight cycles:
3015
Circumstances:
The Tampere Skydiving Club (TamLK) organized the skydiving event “Easter Boogie” at Jämijärvi aerodrome, in the Satakunta region, on Sunday 20 Apr 2014. The event started on Maundy Thursday, 17 Apr 2014 and was planned to end on Easter Monday, 21 Apr 2014. The aircraft reserved for the event were Finland’s Sport Aviators’ Comp Air 8 airplane (CA8, OH-XDZ), which was intended to be used to take skydivers up to 4 000 m, and the Tampere Skydiving Club’s own Cessna U206F (OH-CMT), to be used for jumps from lower altitudes. On Sunday morning the cloud base hampered skydiving operations, which is why the activity started with student jumps from the Cessna. The pilot of the accident flight flew two flights on the Cessna. Once the weather improved he began to fly on the OH-XDZ. He flew two flights on it before he took a lunch break. Another pilot flew four flights on the airplane, following which it was topped up with 240 l of fuel. After refuelling the pilots changed duties again and the pilot of the accident flight flew yet another skydiving flight, landing at 15:25. Ten skydivers boarded the airplane for the accident flight. Takeoff occurred at 15:28 from northern runway 27 of Jämijärvi aerodrome. The airplane climbed to 4 230 m AGL by making a wide, left turn. The pilot steered the aircraft to the jump run, which was over the southern runway. Some of the skydivers sitting at the rear rose to their knees, and two of them cracked the jump door open so as to check the jump run. The skydivers then gave instructions to the pilot as regards correcting the jump run. The pilot adjusted the heading following which he reduced engine power to idle, reducing airspeed to approximately 70-75 kt. Nonetheless, the skydivers noted that they had overshot the jump line and requested that the pilot take them to a new run. The skydivers closed the door. The pilot increased engine power and, according to his account, simultaneously began to turn to the left at a 20-30 degree bank angle. He did not order the skydivers to return to their seats as he was homing in on the new jump run. At the end of the turn the occupants of the aircraft felt a downward acceleration which the skydivers experienced as a force pushing them towards the cabin ceiling. Approximately three seconds later the situation returned to normal. According to the pilot the airspeed was approximately 100 kt when they encountered the vertical acceleration. A moment later the pilot noticed that the airplane was in a descent and that the airspeed had suddenly risen to over 180 kt IAS. According to the pilot the airspeed peaked at 185 kt. He attempted to end the descent by pulling on the control stick. The aircraft levelled out or went into a shallow climb. He reduced engine power to idle to decrease the airspeed. The pilot said that the pitch control stick forces were relatively high. The aircraft returned to level flight, or to a gentle climb. The longitudinal control force suddenly decreased and the airplane suddenly flipped forward past the vertical axis. One of the surviving skydivers said that he heard a crushing sound roughly at the same time; how-ever, he was unsure of the precise point in time of the sound. The aircraft became uncontrollable and began to rotate around its vertical axis, akin to an inverted spin. According to eyewitness videos the aircraft was turning to the left. The videos show that the right wing was buckled against the fuselage and that a vapour trail of fuel was streaming from the damaged wing. While the aircraft was spinning its left wing, which was intact, was pointing upwards and the airplane was falling with its right side forward. Shouts of “open the jump door, bail out immediately” were heard inside the airplane. The pilot concluded that the aircraft was so badly damaged that it was no longer possible to recover from the dive. He unbuckled his seat belts and opened the pilot’s door on his left at approximately 2 000 m. The pilot jumped out at approximately 1 800 m and opened his emergency parachute. Even though twists had developed in the parachute’s lines, the pilot managed to untangle them. The skydiver sitting at the rear of the seat positioned next to the pilot (skydiver 3) noted that it would be impossible for him to make it to the jump door. Therefore, he chose the pilot’s door as a point of exit. It was extremely difficult to get to the door because the airplane was spinning. The skydiver sitting at the front of the seat positioned next to the pilot (skydiver 2) followed skydiver 3 on his way to the cockpit door and pushed skydiver 3 out of the door. Following egress, skydiver 3 immediately hit his head on airplane structures. The blow momentarily blurred his field of vision but he remained conscious. The Automatic Activation Device (AAD) opened the reserve parachute almost immediately after egress, at approximately 250 m. While skydiver 2 was still behind skydiver 3 he grabbed the control stick, intending to reduce the g-forces caused by the spinning and make it easier to bail out of the airplane. He soon realized that the airplane did not respond to stick movements and exited through the pilot’s door immediately behind skydiver 3. The skydiver who had occupied the furthest forward position (skydiver 1) assisted skydiver 2 in exiting through the door. The AAD of skydiver 2 opened his reserve parachute at approximately 200 m. After skydiver 2 had bailed out neither skydiver 1, situated closest to the pilot’s door, nor the remaining seven skydivers in the rear of the cabin managed to bail out. The airplane collided with the ground at 15:40 and caught fire immediately. The pilot landed approximately 300 m downwind from the wreckage. Skydiver 3 landed on a dirt road, some 60 m from the wreckage and skydiver 2 in the woods, approximately 40 m from the wreckage.
Probable cause:
The cause of the accident was that the stress resistance of the right wing’s wing strut was exceeded as a result of the force which was generated by a negative g-force. The force which resulted in the buckling of the wing strut was the direct result of a negative (nose-down) change in pitching moment, in conjunction with an engine power reduction intended to decrease the high airspeed. The buckling was followed by the right wing folding against the fuselage and the jump door. The aircraft entered into a flight condition resembling an inverted spin, which was unrecoverable. It was impossible to exit through the jump door.
The contributing factors were the following:
1. There was a fatigue crack on the wing strut. Because of the damage to the aircraft it was not possible to investigate the mechanism of the fatigue crack formation. It is possible that, in addition to the stress caused to the aircraft by short flights and high takeoff weights, the temperature changes caused by the exhaust gas stream as well as vibration contributed to the fatigue cracking.
2. The nature of skydiving operations generated many takeoffs and landings in relation to flight hours. A significant part of the operations was flown close to the maximum takeoff weight. These factors increased the structural stress.
3. The pilot’s limited flight experience on a powerful turboprop aircraft, his inadequate training as regards aircraft loading and its effects on the centre of gravity and airplane behavior, the high weight of the aircraft and the aft position of the CG in the beginning of a new jump line and, possibly, the pilot’s incorrect observation of the actual visual horizon contributed to the onset of the occurrence. During the turn to a new jump run the aircraft began to descend and very rapidly accelerated close to its maximum permissible airspeed. The pilot did not immediately realize this.
4. The structural modifications on the wing increased the loads on the aircraft and the wing struts. Their effects had not been established beforehand. The kit manufacturer was aware of the modifications. No changes to the Permit to build were applied for in writing regarding the modifications. Neither the build supervisor nor the aircraft inspectors were aware of the origin or the effects of the modifications.
Final Report:

Crash of a Pilatus PC-6/B2-H4 Turbo Porter near Namur: 11 killed

Date & Time: Oct 19, 2013 at 1535 LT
Operator:
Registration:
OO-NAC
Flight Phase:
Survivors:
No
Schedule:
Namur - Namur
MSN:
710
YOM:
1969
Location:
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
10
Pax fatalities:
Other fatalities:
Total fatalities:
11
Captain / Total flying hours:
2919
Captain / Total hours on type:
332.00
Aircraft flight hours:
16159
Aircraft flight cycles:
34903
Circumstances:
On 19 October 2013, the Pilatus Porter was being used for parachute drops. The day started normally with the first take-off at 07:21. Each flight transported 9 or 10 passengers. Except for the first two, all the flights of that day were conducted by the same pilot. The aircraft’s last landing in EBNM was at 13:20 to board the next group of 10 parachutists. After the take-off, the aircraft appeared again on the radar at 13:28 at an altitude of 1200 ft. At 13:28:52, the EBCI Air Traffic Control Officer (ATCO) instructed the aircraft to remain at 2000 ft AMSL to allow for crossing traffic, a B737 landing at EBCI, and to proceed further to the east. After the crossing, the Pilatus was authorized to climb to 5000 ft. At 13:33:32, when the aeroplane was flying at 4400 ft, the pilot was authorized to turn back to the drop zone and turned towards its target, the EBNM airfield. Shortly after, a witness observed the aeroplane making a wide turn to the left. This witness monitored the aeroplane for about 40 seconds. He indicated the engine was making an abnormal noise which he compared with the explosions made by the exhaust of a rally car when decelerating. Finally, the witness heard a loud explosion ending by the dive of the aeroplane. He believed that the sound of an explosion was caused by the “engine turbine disintegration”. Another witness driving on the E42 highway saw the aeroplane performing what he perceived as being some aerobatic manoeuvers. The aeroplane was diving and was spinning. A moment later, he saw the wing break-up, including the separation and falling of smaller parts. A sailplane pilot was standing in his garden not far from the crash site. He first heard the sound of the Pilatus which he described as being typical, smooth and constant. He looked at the aeroplane and noticed it was flying at a lower altitude than usual. He stopped observing after a few seconds. 30 to 40 seconds later, he heard an abnormal noise change which he thought was a propeller pitch change or an engine power change. He looked for the aeroplane in the sky and saw the aeroplane diving with an angle of more than 45° immediately followed by a sharp pull-out angle of over 70°, followed by the upwards breaking of a wing. The aeroplane went down “as in a stall”. The witness still heard “the sound of propeller angle moving” after the wing separation. Another witness standing approximately at an horizontal distance of 600 m from the aeroplane described having heard a sound change. He looked at the aeroplane and saw the aeroplane flying horizontally, making several significant left and right roll movements of the wings before it disappearing from his view. The aeroplane crashed on a field in the territory of Gelbressée, killing all occupants. The aeroplane caught fire shortly after the impact. A big part of the left wing, elements thereof and the right sliding door of the cabin were found at 2 km from the main wreckage. Of the aircraft’s occupants, 4 parachutists were ejected from the aircraft just prior to impact.
Probable cause:
The cause of the accident is a structural failure of the left wing due to a significant negative g aerodynamic overload, leading to an uncontrollable aeroplane and subsequent crash. The most probable cause of the wing failure is the result of a manoeuvre intended by the pilot, not properly conducted and ending with an involuntary negative g manoeuvre, exceeding the operating limitations of the aeroplane.
Contributing safety factors:
• The weakness of the monitoring of the aeroplane operations by the operator.
• The lack of organizational structure between the operator and the parachute club [safety issue].
Other safety factors identified during the investigation:
• The performance of aerobatics manoeuvre with an aircraft not certified to perform such manoeuvres.
• The performance of aerobatics manoeuvre by a pilot not adequately qualified and/or trained to perform such manoeuvres.
• Transportation of unrestrained passengers, not sitting on seat during dangerous phase of the flight.
• The weakness of the legal framework and guidance for aerial work [safety issue].
• The lack of effective oversight of aerial work operations by the BCAA [safety issue].
• The lack of mandatory requirement to install devices recording flight data on board aeroplane used for parachuting [safety issue].
• Insufficient back protection for the pilot [safety issue].
• No easy determination of the weight and balance of the aeroplane due to the passengers not sitting in predetermined positions [safety issue].
• The issuing by BCAA of two distinct authorizations to the aeroplane operator and the parachute club incorporating some overlaps, which does not encourage the awareness of responsibility of the stakeholders involved [safety issue].
• Possible erroneous interpretation of the maintenance manual [safety issue].
• Violations and/or safety occurrences not reported as required by the Circular GDF-04, preventing the BCAA from taking appropriate action.
• Peer pressure of parachutists sometimes encouraging pilots to perform manoeuvres not approved for normal category aeroplanes.
• Flying at high altitude without oxygen breathing system although required by regulation.
Final Report:

Crash of a PZL-Mielec AN-2T in Rybinsk

Date & Time: Mar 2, 2013 at 1344 LT
Type of aircraft:
Operator:
Registration:
RF-01024
Flight Phase:
Survivors:
Yes
Schedule:
Rybinsk - Rybinsk
MSN:
1G194-39
YOM:
1981
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
12
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Shortly after takeoff from Rybinsk-Yuzhny Airport, the crew encountered engine problems and elected to make an emergency landing. The aircraft impacted trees and crashed in a snowy wooded area located 2 km from the airport. All 14 occupants evacuated safely. Nevertheless, one skydiver was slightly injured but refused to go to hospital. The aircraft was damaged beyond repair.
Probable cause:
Engine failure for unknown reasons.

Crash of a Casa 212 Aviocar 300 in Bloemfontein

Date & Time: Jan 17, 2013 at 1030 LT
Type of aircraft:
Operator:
Registration:
8020
Survivors:
Yes
Schedule:
Bloemfontein - Bloemfontein
MSN:
371
YOM:
1988
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The twin engine aircraft was engaged in a local paratroopers/skydiving mission at Bloemspruit AFB that shares a runway with Bloemfontein-Bram Fischer International Airport. For unknown reasons, the aircraft landed hard on its nose, veered off runway and came to rest with its left wing on the ground. All five crew members escaped uninjured while the aircraft was damaged beyond repair.

Crash of a PZL-Mielec AN-2R in Yugorsk: 1 killed

Date & Time: Nov 25, 2012 at 1120 LT
Type of aircraft:
Registration:
RA-33589
Flight Phase:
Survivors:
Yes
Schedule:
Yugorsk - Yugorsk
MSN:
1G230-31
YOM:
1988
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
12116
Captain / Total hours on type:
3068.00
Aircraft flight hours:
1250
Circumstances:
The single engine aircraft was engaged in a local skydiving mission, carrying one pilot and 9 skydivers. Shortly after take off from runway 31, while climbing to a height of about 80 meters, the engine suffered a power loss. The pilot initiated a left turn to reach the airport when the aircraft rolled to an angle of 60° then stalled and crashed in a snow covered field near a forest, bursting into flames. The aircraft was destroyed by a post impact fire. Nine occupants escaped injured and a passenger was killed.
Probable cause:
Most probably the accident with and An-2 RA-33589 aircraft was caused by aircraft beyond stall angle of attack entry during dynamic turn for emergency landing with reverse runway heading due to engine failure after take-off at low-altitude followed by shaking and its power loss resulted in aircraft ground impact with bank angle more than 60°. Engine failure was caused by high-temperature damage and destruction of cylinder-piston group details due to it inadequate technical operation and using motor gasoline in aircraft fuel flow system which quality didn't comply with requirements for preferred AI-95 gasoline in accordance with aeronautical equipment flight service evaluation program, Order of Ministry of Transport of the Russian Federation № НА-131-р from April 11, 2001 and engineering solution № АБ-1236-2003 from May 22, 2003. Most probably the contributing factor was partial skill loss of An-2 aircraft control by aircraft pilot in command (PIC). Flight operation was performed by PIC, meteorological minimas and which authorizations written in Private-Pilot License and the fact of medical flight-expert commission procedure were not documented. PIC's decision to perform straight-ahead landing most probably didn't allow to reduce the severity of accident consequences.
Final Report:

Crash of a Pilatus PC-6/B2-H2 Turbo Porter off Granville

Date & Time: Aug 18, 2012 at 1855 LT
Operator:
Registration:
F-GMJG
Survivors:
Yes
Schedule:
Granville - Granville
MSN:
659
YOM:
1967
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Aircraft flight hours:
13300
Circumstances:
The single engine aircraft departed Granville-Bréville Aerodrome on a local skydiving mission. After all skydivers left the aircraft, the pilot reduced his altitude to return to his base. On final approach to runway 07, the aircraft went out of control and crashed in the sea, few dozen metres offshore. A sailor went quickly to the scene and evacuated the pilot who was slightly injured while the aircraft sank by a depth of 5-6 metres. The wreckage was recovered and pulled on the beach a day later. The aircraft was damaged beyond repair.