Crash of a Beechcraft A100 King Air in Timmins

Date & Time: Sep 26, 2014 at 1740 LT
Type of aircraft:
Operator:
Registration:
C-FEYT
Survivors:
Yes
Schedule:
Moosonee – Timmins
MSN:
B-210
YOM:
1975
Flight number:
CRQ140
Location:
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
2400
Captain / Total hours on type:
1000.00
Copilot / Total flying hours:
580
Copilot / Total hours on type:
300
Aircraft flight hours:
14985
Aircraft flight cycles:
15570
Circumstances:
The aircraft was operating as Air Creebec flight 140 on a scheduled flight from Moosonee, Ontario, to Timmins, Ontario, with 2 crew members and 7 passengers on board. While on approach to Timmins, the crew selected “landing gear down,” but did not get an indication in the handle that the landing gear was down and locked. A fly-by at the airport provided visual confirmation that the landing gear was not fully extended. The crew followed the Quick Reference Handbook procedures and selected the alternate landing-gear extension system, but they were unable to lower the landing gear manually. An emergency was declared, and the aircraft landed with only the nose gear partially extended. The aircraft came to rest beyond the end of Runway 28. All occupants evacuated the aircraft through the main entrance door. No fire occurred, and there were no injuries to the occupants. Emergency services were on scene for the evacuation. The accident occurred during daylight hours, at 1740 Eastern Daylight Time.
Probable cause:
Findings as to causes and contributing factors:
1. During the extension of the landing gear, a wire bundle became entangled around the landing-gear rotating torque shaft, preventing full extension of the landing gear.
2. The entanglement by the wire bundle also prevented the alternate landing-gear extension system from working. The crew was required to conduct a landing with only the nose gear partially extended.
Other findings:
1. The wire bundle consisted of wiring for the generator control circuits, and when damaged, disabled both generators. The battery became the only source of electrical power until the aircraft landed.
Final Report:

Crash of a Beechcraft B100 King Air in Pearland: 1 killed

Date & Time: Feb 19, 2014 at 0845 LT
Type of aircraft:
Operator:
Registration:
N811BL
Flight Type:
Survivors:
No
Schedule:
Austin – Galveston
MSN:
BE-15
YOM:
1976
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
1281
Captain / Total hours on type:
192.00
Circumstances:
The non-instrument-rated pilot departed on a cross-country flight in a twin-engine turboprop airplane on an instrument flight plan. As the pilot neared his destination airport, he received heading and altitude vectors from air traffic control. The controller cleared the flight for the approach to the airport; shortly afterward, the pilot radioed that he was executing a missed approach. The controller then issued missed approach instructions, which the pilot acknowledged. There was no further communication with the pilot. The airplane collided with terrain in a near-vertical angle. About the time of the accident, the automated weather reporting station recorded a 300-foot overcast ceiling, and 5 miles visibility in mist. Examination of the wreckage did not reveal any anomalies that would have precluded normal operation. Additionally, both engines displayed signatures consistent with the production of power at the time of impact. The pilot's logbook indicated that he had a total of 1,281.6 flight hours, with 512.4 in multi-engine airplanes and 192.9 in the accident airplane. The logbook also revealed that he had 29.7 total hours of actual instrument time, with 15.6 of those hours in the accident airplane. Of the total instrument time, he received 1 hour of instrument instruction by a flight instructor, recorded about 3 years before the accident. The accident is consistent with a loss of control in instrument conditions.
Probable cause:
The noninstrument-rated pilot's loss of airplane control during a missed instrument approach. Contributing to the accident was the pilot's decision to file an instrument flight rules flight plan and to fly into known instrument meteorological conditions.
Final Report:

Crash of a Beechcraft A100 King Air in Saint-Mathieu-de-Beloeil

Date & Time: Jun 10, 2013 at 1725 LT
Type of aircraft:
Operator:
Registration:
C-GJSU
Flight Type:
Survivors:
Yes
Schedule:
Montreal - Montreal
MSN:
B-88
YOM:
1971
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
4301
Captain / Total hours on type:
1500.00
Aircraft flight hours:
13616
Aircraft flight cycles:
10999
Circumstances:
The aircraft took off from the Montréal/St-Hubert Airport, Quebec, on a local flight under visual flight rules with 1 pilot and 3 passengers on board. The purpose of the flight was to check the rudder trim indicator and to confirm a potential synchronization problem between the autopilot and the global positioning system (GPS). As the aircraft approached Runway 24R at the Montréal/St-Hubert Airport, both engines (Pratt & Whitney Canada, PT6A-28) stopped due to fuel exhaustion. The pilot diverted to the St-Mathieu-de-Beloeil Airport, Quebec, and then attempted a forced landing in a field 0.5 nautical mile west of the St-Mathieu-de-Beloeil Airport. The aircraft struck the ground 30 feet short of the selected field, at 1725 Eastern Daylight Time. The aircraft was extensively damaged, and the 4 occupants sustained minor injuries. The emergency locator transmitter activated during the occurrence. The flight took place during daylight hours, and there was no fire.
Probable cause:
Findings as to causes and contributing factors:
- The pilot relied exclusively on the gauge readings to determine the quantity of fuel on board, without cross-checking the fuel consumption since the last fueling to validate those gauge readings.
- The pilot misread the fuel gauges and assumed that the aircraft had enough fuel on board to meet the minimum fuel requirements of the Canadian Aviation Regulations for this visual flight rules flight, rather than adding more fuel to meet the greater reserves required by the company operations manual.
- The pilot did not monitor the fuel gauges while in flight and decided to extend the flight to carry out a practice instrument approach with insufficient fuel to complete the approach.
- The right engine stopped due to fuel exhaustion.
- The pilot did not carry out the approved engine failure procedure when the first engine stopped, and the propeller was not feathered, resulting in significant drag which reduced the aircraft's gliding range after the second engine stopped.
- The pilot continued flying toward Montréal/St-Hubert Airport (CYHU), Quebec, despite having advised air traffic control of the intention to divert to the St-Mathieu-de-Beloeil Airport (CSB3), Quebec, and without communicating the emergency. The priority given to communications resulted in the aircraft moving farther away from the intended diversion airport.
- The left engine stopped due to fuel exhaustion 36 seconds after the right engine stopped, when the aircraft was 7.4 nautical miles from Runway 24R at Montréal/St-Hubert Airport (CYHU), Quebec, and 2400 feet above sea level.
- The pilot's decision to lower the landing gear while the aircraft was still at 1600 feet above sea level further increased the drag, reducing the aircraft's gliding range. As a result, the aircraft was not able to reach the runway at St-Mathieu-de-Beloeil Airport (CSB3), Quebec.
- The operations manager was unable to perform the duties and responsibilities of the position related to monitoring and supervision of flight operations. As a result, the safety of more than half of the flights was compromised.
Findings as to risk:
- If the total fuel quantity required for a flight is not calculated and clearly displayed on the operational flight plan, there is an increased risk that aircraft will depart without the fuel reserves required by the Canadian Aviation Regulations.
- If flights are planned and carried out without the fuel reserves required by the Canadian Aviation Regulations, there is an increased risk of fuel exhaustion resulting from unanticipated situations that extend the duration of the flight.
- If pilots elect to extend flight without first determining whether sufficient fuel reserves are available to do so, there is an increased risk of fuel exhaustion.
- If pilots do not regularly check the quantity of fuel on board, there is an increased risk of fuel exhaustion.
- If pilots do not rule out a fuel leak before opening the crossfeed valve, they risk losing all of the remaining fuel on board.
- If a pilot does not maintain control of an aircraft until landing, the force of an impact following an aerodynamic stall is likely to be far greater, increasing the risk of injury or death during a forced landing.
- If a pilot does not declare an emergency to air traffic control in a timely manner, the pilot may be deprived of assistance and resources that could help deal with the emergency, increasing the risk of an accident.
- If pilots do not receive training in dealing with complex emergencies that require prioritizing tasks, there is a risk that they will not react effectively to emergencies, increasing the risk of an accident.
- If companies do not establish a process to monitor the performance of their pilots during training and testing, there is a risk that those companies will inadvertently assign pilots to carry out flights for which they are not proficient.
- If a flight is planned and authorized solely by the pilot, with no cross-check for compliance with existing regulations, there is a risk that deviations will continue undetected, reducing the safety of the flight.
- If pilots operate without regular supervision to ensure compliance with regulations and company procedures, coupled with effective training, there is a risk of procedural adaptations that result in reduced safety margins.
- If companies assign inexperienced personnel to key flight operations management positions, there is a risk that deviations in performance or from regulations will not be detected, reducing the safety of flight operations.
- If the pilot proficiency check requirements for a chief pilot are not more stringent than those for other pilots, there is a risk that the chief pilot will be unable to perform the duties required to ensure the safety of company training and operations.
- If the approval process for appointment of operations management personnel by companies is reduced to a compliance checklist based on the minimum standards in the Commercial Air Service Standards and on pilot proficiency checks that may be repeated an unlimited number of times, there is a risk that candidates who are unfit to perform the duties and responsibilities of their positions will be appointed.
- If Transport Canada does not take into consideration the combined knowledge and experience of a new operator's management team, there is a risk that the operator will lack the skills necessary to ensure the safety of flight operations.
- If process inspections carried out by Transport Canada do not examine factors related to a recent occurrence, there is a risk that those hazardous conditions will go undetected and will persist.
If process inspections carried by TC on newly certificated operators do not closely examine the outcomes of company processes, there is a risk that hazardous conditions will not be identified and will persist.
- If the inability of appointed individuals to perform their duties and responsibilities does not constitute grounds for suspending or revoking the ministerial approval of such appointments, there is a risk that operations management personnel who are not competent will remain in their positions, increasing the risk to flight safety.
Other findings:
- The chief pilot did not meet the requirements of the Canadian Aviation Regulations at the time of appointment.
- There was no indication that the aircraft's fuel gauges were not functioning properly at the time of the occurrence flight, and it is unlikely that a deviation of the fuel gauge indicator was a factor in the pilot's decision to take off.
- C-GJSU had approximately 260 pounds of fuel on board when it took off from Montréal/St-Hubert Airport (CYHU), Quebec, and did not experience a fuel leak during the occurrence flight.
Final Report:

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-89
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 A100 King Air 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:
The twin engine aircraft was operating a taxi flight from Nassau-Lynden Pindling Airport to Deadmans Cay, and departed Nassau around 1 pm. On approach to Deadmans Cay, the crew encountered technical problems and was unable to lower the gear. The captain decided to perform a belly landing. The aircraft skidded on runway for several yards then veered off runway before coming to rest. There was no fire. While all occupants escaped uninjured, the aircraft was damaged beyond repair.

Crash of a Beechcraft A100 King Air 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, the crew initiated the approach in poor weather conditions (rain falls, strong crosswinds and turbulences). After touchdown, the twin engine aircraft skidded then veered off runway to the left. While contacting soft ground, the landing gear collapsed and the left engine was partially torn off. All 10 occupants escaped uninjured while the aircraft was damaged beyond repair. Wind shear conditions are suspected.

Crash of a Beechcraft A100 King Air 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-36
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 A100 King Air 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
Copilot / Total flying hours:
900
Copilot / Total hours on type:
2
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 100 King Air 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-42
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 B100 King Air 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:
The 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: