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Crash of a Piper PA-46-350P Malibu near Makkovik: 1 killed

Date & Time: May 1, 2019 at 0816 LT
Operator:
Registration:
N757NY
Flight Phase:
Flight Type:
Survivors:
Yes
Site:
Schedule:
Goose Bay - Narsarsuaq
MSN:
46-36657
YOM:
2015
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
3500
Captain / Total hours on type:
20.00
Copilot / Total flying hours:
1300
Copilot / Total hours on type:
0
Circumstances:
On 01 May 2019 at 0723, the aircraft departed CYYR on a VFR flight plan direct to BGBW. The ferry pilot, who was the pilot-in-command, occupied the left seat while the co-owner occupied the right seat. The aircraft climbed to 2000 feet ASL and proceeded on a direct track to destination. The altitude and heading did not change significantly along the route, therefore it is likely that the autopilot was engaged. At 0816, the aircraft collided with a snow-covered hill 2250 feet in elevation, located 35 nautical miles (NM) southeast of Makkovik Airport (CYFT), Newfoundland and Labrador. The impact happened approximately 200 feet below the top of the hill. The aircraft came to rest in deep snow on steep sloping terrain. The aircraft sustained significant damage to the propeller, nose gear, both wings, and fuselage. Although the cabin was crush-damaged, occupiable space remained. There was no post-impact fire. The ferry pilot was seriously injured and the co-owner was fatally injured. The Joint Rescue Coordination Centre (JRCC) in Halifax received an emergency locator transmitter (ELT) signal from the aircraft at 0823. The ferry pilot carried a personal satellite tracking device, a personal locator beacon (PLB) and a handheld very high frequency (VHF) radio, which allowed communication with search and rescue (SAR). Air SAR were dispatched to the area; however, by that time, the weather had deteriorated to blizzard conditions and aerial rescue was not possible. Ground SAR then deployed from the coastal community of Makkovik and arrived at the accident site approximately 4 hours later because of poor weather conditions and near zero visibility. The ferry pilot and the body of the co-owner were transported to Makkovik by snowmobile. The following day, they were airlifted to CYYR.
Probable cause:
Controlled flight into terrain.
Final Report:

Crash of a Piper PA-46-310P Malibu off Guernsey: 2 killed

Date & Time: Jan 21, 2019 at 2016 LT
Operator:
Registration:
N264DB
Flight Phase:
Survivors:
No
Schedule:
Nantes - Cardiff
MSN:
46-8408037
YOM:
1984
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
3500
Captain / Total hours on type:
30.00
Aircraft flight hours:
6636
Circumstances:
The pilot of N264DB flew the aircraft and the passenger from Cardiff Airport to Nantes Airport on 19 January 2019 with a return flight scheduled for 21 January 2019. The pilot arrived at the airport in Nantes at 1246 hrs on 21 January to refuel and prepare the aircraft for the flight. At 1836 hrs the passenger arrived at airport security, and the aircraft taxied out for departure at 1906 hrs with the passenger sitting in one of the rear, forward-facing passenger seats. Figure 1 shows the aircraft on the ground before departure. The pilot’s planned route would take the aircraft on an almost direct track from Nantes to Cardiff, flying overhead Guernsey en route (Figure 2). The Visual Flight Rules (VFR) flight plan indicated a planned cruise altitude of 6,000 ft amsl and distance of 265 nm. The aircraft took off from Runway 03 at Nantes Airport at 1915 hrs, and the pilot asked Air Traffic Control (ATC) for clearance to climb to 5,500 ft. The climb was approved by Nantes Approach Control and the flight plan was activated. The aircraft flew on its planned route towards Cardiff until it was approximately 13 nm south of Guernsey when the pilot requested and was given a descent clearance to remain in Visual Meteorological Conditions (VMC). Figure 3 shows the aircraft’s subsequent track. The last radio contact with the aircraft was with Jersey ATC at 2012 hrs, when the pilot asked for a further descent. The aircraft’s last recorded secondary radar point was at 2016:34 hrs, although two further primary returns were recorded after this. The pilot made no distress call that was recorded by ATC. On February 4, 2019, the wreckage (relatively intact) was found at a depth of 63 meters few km north of the island of Guernsey. On February 6, a dead body was found in the cabin and recovered. It was later confirmed this was the Argentine footballer Emiliano Sala. The pilot's body was not recovered.
Probable cause:
Causal factors
1. The pilot lost control of the aircraft during a manually-flown turn, which was probably initiated to remain in or regain VMC.
2. The aircraft subsequently suffered an in-flight break-up while manoeuvring at an airspeed significantly in excess of its design manoeuvring speed.
3. The pilot was probably affected by CO poisoning.
Contributory factors
1. A loss of control was made more likely because the flight was not conducted in accordance with safety standards applicable to commercial operations. This manifested itself in the flight being operated under VFR at night in poor weather conditions despite the pilot having no training in night flying and a lack of recent practice in instrument flying.
2. In-service inspections of exhaust systems do not eliminate the risk of CO poisoning.
3. There was no CO detector with an active warning in the aircraft which might have alerted the pilot to the presence of CO in time for him to take mitigating action.
Final Report:

Crash of a Cessna 414 Chancellor in Enstone

Date & Time: Jun 26, 2018 at 1320 LT
Type of aircraft:
Operator:
Registration:
N414FZ
Flight Phase:
Flight Type:
Survivors:
Yes
Site:
Schedule:
Enstone – Dunkeswell
MSN:
414-0175
YOM:
1971
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
1194
Captain / Total hours on type:
9.00
Circumstances:
The aircraft departed Dunkeswell Airfield on the morning of the accident for a flight to Retford (Gamston) Airfield with three passengers on board, two of whom held flying licences. The passengers all reported that the flight was uneventful and after spending an hour on the ground the aircraft departed with two passengers for Enstone Airfield. This flight was also flown without incident.The pilot reported that before departing Enstone he visually checked the level in the aircraft fuel tanks and there was 390 ltr (103 US gal) on board, approximately half of which was in the wingtip fuel tanks. After spending approximately one hour on the ground the pilot was heard to carry out his power checks before taxiing to the threshold of Runway 08 for a flight back to Dunkeswell with one passenger onboard). During the takeoff run the left engine was heard to stop and the aircraft veered to the left as it came to a halt. The pilot later recalled that he had seen birds in the climbout area and this was a factor in the abandoned takeoff. The aircraft was then seen to taxi to an area outside the Oxfordshire Sport Flying Club, where the pilot attempted to start the left engine, during which time the right engine also stopped. The right engine was restarted, and several attempts appeared to have been made to start the left engine, which spluttered into life before stopping again. Eventually the left engine started, blowing out clouds of white and black smoke. After the left engine was running smoothly the pilot was seen to taxi to the threshold for Runway 08. The takeoff run sounded normal and the landing gear was seen to retract at a height of approximately 200 ft agl. The climbout was captured on a video recording taken by an individual standing next to the disused runway, approximately 400 m to the south of Runway 08. The aircraft was initially captured while it was making a climbing turn to the right and after 10 seconds the wings levelled, the aircraft descended and disappeared behind a tree line. After a further 5 seconds the aircraft came into view flying west over buildings to the east of the disused runway at a low height, in a slightly nose-high attitude. The right propeller appeared to be rotating slowly, there was some left rudder applied and the aircraft was yawed to the right. The left engine could be heard running at a high rpm and the landing gear was in the extended position. The aircraft appeared to be in a gentle right turn and was last observed flying in a north-west direction. The video then cut away from the aircraft for a further 25 seconds and when it returned there was a plume of smoke coming from buildings to the north of the runway. The pilot reported that the engine had lost power during a right climbing turn during the departure. He recovered the aircraft to level flight and selected the ‘right fuel booster’ pump (auxiliary pump) and the engine recovered power. He decided to return to Enstone and when he was abeam the threshold for Runway 08 the right engine stopped. He feathered the propeller on the right engine and noted that the single-engine performance was insufficient to climb or manoeuvre and, therefore, he selected a ploughed field to the north of Enstone for a forced landing. During the approach the pilot noticed that the left engine would only produce “approximately 57%” of maximum power, with the result that he could not make the field and crashed into some farm buildings. There was an immediate fire following the accident and the pilot and passenger both escaped from the wreckage through the rear cabin door. The pilot sustained minor burns. The passenger, who was taken to the John Radcliffe Hospital in Oxford, sustained burns to his body, a fractured vertebra, impact injuries to his chest and lacerations to his head.
Probable cause:
The pilot and the passengers reported that both engines operated satisfactory on the two flights prior to the accident flight. No problems were identified with the engines during the maintenance activity carried out 25 and 5 flying hours prior to the accident and the engine power checks carried out at the start of the flight were also satisfactory. It is therefore unlikely that there was a fault on both engines which would have caused the left engine to stop during the aborted takeoff and the right engine to stop during the initial climb. The aircraft was last refuelled at Dunkeswell Airfield and had successfully undertaken two flights prior to the accident flight. There had been no reports to indicate that the fuel at Dunkeswell had been contaminated; therefore, fuel contamination was unlikely to have been the cause. The pilot reported that there was sufficient fuel onboard the aircraft to complete the flight, which was evident by the intense fire in the poultry farm, most probably caused by the fuel from the ruptured aircraft fuel tanks. With sufficient fuel onboard for the aircraft to complete the flight, the most likely cause of the left engine stopping during the aborted takeoff, and the right engine stopping during the accident flight, was a disruption in the fuel supply between the fuel tanks and engine fuel control units. The reason for this disruption could not be established but it is noted that the fuel system in this design is more complex than in many light twin-engine aircraft. The AAIB calculated the single-engine climb performance during the accident flight using the performance curves3 for engines not equipped with the RAM modification. It was a hot day and the aircraft was operating at 280 lb below its maximum takeoff weight. Assuming the landing gear and flaps were retracted, the engine cowls on the right engine were closed and the aircraft was flown at 101 kt, then the single-engine climb performance would have been 250 ft/min. However, the circumstances of the loss of power at low altitude would have been challenging and, shortly before the accident, the aircraft was seen flying with the landing gear extended and the right engine still windmilling. These factors would have adversely affected the single-engine performance and might explain why the pilot was no longer able to maintain height.
Final Report: