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Crash of a De Havilland DHC-3T Turbo Otter near Kodiak: 1 killed

Date & Time: Sep 23, 2011 at 1930 LT
Type of aircraft:
Operator:
Registration:
N361TT
Flight Phase:
Survivors:
Yes
Site:
Schedule:
Old Harbor - Kodiak
MSN:
361
YOM:
1960
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
3000
Captain / Total hours on type:
280.00
Aircraft flight hours:
14634
Circumstances:
According to a passenger who was seated in the front, right seat, as the flight progressed toward the destination, the pilot decided to make an unscheduled landing at a lake that was surrounded by rising terrain. The passenger said that after making an easterly approach to the lake, before touching down, the pilot initiated a go-around. The passenger said they flew low over the surface of the lake toward a “V” shaped notch formed by a creek with hills on either side at the east end of the lake. He said that while flying through the notch, he thought the left wing of the airplane had hit the hillside. He said the pilot reacted by pulling back hard on the control yoke and rolling the airplane to the right. The airplane entered a steep climb, it began to shake, and stall warning horn sounded. The airplane then rolled left into a steep descent and impacted the ground in a nose-down attitude. The airplane’s left wing had impacted a tree on the creek bank prior to the crash. A postaccident examination of the airframe and engine revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation. Toxicological tests detected the pilot’s recent use of over-the-counter medications used for relief of cold and flu symptoms. Two of these medications are sedating. The use of these sedating medications on the day of the accident or the underlying illness may have affected the pilot’s performance. Given the lack of mechanical deficiencies with the airplane, and the passenger's account of the accident, it is likely the pilot failed to maintain adequate clearance with a tree while performing a low altitude maneuver following a go-around.
Probable cause:
The pilot’s failure to maintain clearance from a tree during a low altitude maneuver and his failure to maintain control of the airplane. Contributing to the accident was the pilot’s use of over-the-counter sedating medications.
Final Report:

Crash of a Britten-Norman BN-2A-21 Islander in Kodiak

Date & Time: Mar 15, 2010 at 1243 LT
Type of aircraft:
Operator:
Registration:
N663SA
Flight Phase:
Survivors:
Yes
Schedule:
Kodiak - Old Harbor
MSN:
4
YOM:
1967
Flight number:
8D501
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
7370
Captain / Total hours on type:
106.00
Aircraft flight hours:
11348
Circumstances:
The airline transport pilot was taking off on a passenger flight under Title 14, CFR Part 135, when the accident occurred. He reported that during takeoff the wind was reported from 290-300 degrees, at 15 knots, gusting to 27 knots. He chose to make an intersection takeoff on runway 25 at its intersection with runway 29, rather than use the full length of runway 29. He said his airspeed did not develop as quickly as he had anticipated, and that with his airspeed lagging and poor climb performance, he realized the airplane was not going to clear the ridge at the end of the runway. He said he initiated a right descending turn to maintain his airspeed, but impacted trees alongside the runway. He reported that the airplane sustained substantial damage to the wings and fuselage when it impacted trees. He said there were no mechanical problems with the airplane prior to the accident.
Probable cause:
The pilot's failure to maintain clearance from rising terrain during takeoff resulting in collision with trees.
Final Report:

Crash of a Piper PA-31-350 Navajo Chieftain off Kodiak: 6 killed

Date & Time: Jan 5, 2008 at 1343 LT
Operator:
Registration:
N509FN
Flight Phase:
Survivors:
Yes
Schedule:
Kodiak - Homer
MSN:
31-7952162
YOM:
1979
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
6
Captain / Total flying hours:
9437
Captain / Total hours on type:
400.00
Aircraft flight hours:
13130
Circumstances:
The airline transport pilot and nine passengers were departing in a twin-engine airplane on a 14 Code of Federal Regulations Part 135 air taxi flight from a runway adjacent to an ocean bay. According to the air traffic control tower specialist on duty, the airplane became airborne about midway down the runway. As it approached the end of the runway, the pilot said he needed to return to the airport, but gave no reason. The specialist cleared the airplane to land on any runway. As the airplane began a right turn, it rolled sharply to the right and began a rapid, nose- and right-wing-low descent. The airplane crashed about 200 yards offshore and the fragmented wreckage sank in the 10-foot-deep water. Survivors were rescued by a private float plane. A passenger reported that the airplane's nose baggage door partially opened just after takeoff, and fully opened into a locked position when the pilot initiated a right turn towards the airport. The nose baggage door is mounted on the left side of the nose, just forward of the pilot's windscreen. When the door is opened, it swings upward, and is held open by a latching device. To lock the baggage door, the handle is placed in the closed position and the handle is then locked by rotating a key lock, engaging a locking cam. With the locking cam in the locked position, removal of the key prevents the locking cam from moving. The original equipment key lock is designed so the key can only be removed when the locking cam is engaged. Investigation revealed that the original key lock on the airplane's forward baggage door had been replaced with an unapproved thumb-latch device. A Safety Board materials engineer's examination revealed evidence that a plastic guard inside the baggage compartment, which is designed to protect the door's locking mechanism from baggage/cargo, appeared not to be installed at the time of the accident. The airplane manufacturer's only required inspection of the latching system was a visual inspection every 100 hours of service. Additionally, the mechanical components of the forward baggage door latch mechanism were considered "on condition" items, with no predetermined life-limit. On May 29, 2008, the Federal Aviation Administration issued a safety alert for operators (SAFO 08013), recommending a visual inspection of the baggage door latches and locks, additional training of flight and ground crews, and the removal of unapproved lock devices. In July 2008, Piper Aircraft issued a mandatory service bulletin (SB 1194, later 1194A), requiring the installation of a key lock device, mandatory recurring inspection intervals, life-limits on safety-critical parts of forward baggage door components, and the installation of a placard on the forward baggage door with instructions for closing and locking the door to preclude an in-flight opening. Post accident inspection discovered no mechanical discrepancies with the airplane other than the baggage door latch. The airplane manufacturer's pilot operating handbook did not contain emergency procedures for an in-flight opening of the nose baggage door, nor did the operator's pilot training program include instruction on the proper operation of the nose baggage door or procedures to follow in case of an in-flight opening of the door. Absent findings of any other mechanical issues, it is likely the door locking mechanism was not fully engaged and/or the baggage shifted during takeoff, and contacted the exposed internal latching mechanism, allowing the cargo door to open. With the airplane operating at a low airspeed and altitude, the open baggage door would have incurred additional aerodynamic drag and further reduced the airspeed. The pilot's immediate turn towards the airport, with the now fully open baggage door, likely resulted in a sudden increase in drag, with a substantive decrease in airspeed, and an aerodynamic stall.
Probable cause:
The failure of company maintenance personnel to ensure that the airplane's nose baggage door latching mechanism was properly configured and maintained, resulting in an inadvertent opening of the nose baggage door in flight. Contributing to the accident were the lack of information and guidance available to the operator and pilot regarding procedures to follow should a baggage door open in flight and an inadvertent aerodynamic stall.
Final Report: