Crash of a Casa 212 Aviocar in Bohorok: 18 killed

Date & Time: Sep 29, 2011 at 0735 LT
Type of aircraft:
Registration:
PK-TLF
Flight Phase:
Survivors:
No
Site:
Schedule:
Medan - Kuta Cane
MSN:
88N/283
YOM:
1989
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
14
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 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
Country:
Crew on board:
4
Crew fatalities:
Pax on board:
17
Pax fatalities:
Other fatalities:
Total fatalities:
21
Circumstances:
While approaching Robinson Crusoe island, aircraft crashed into the sea in unknown circumstances. All 21 occupants were killed. Flight was organised by NGO's in cooperation with the National Chilean Television to see the progress of reconstruction in the island of Robinson Crusoe following the 2010 earthquake. Among the occupants were members from the National Television and also from the Council of Culture. The famous Chilean television icon Felipe Camiroaga was among the passengers.

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 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 in Congo: 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 left Yaoundé-Nsimalen at 0913LT for Yangadou, a small airstrip serving several iron mines. At 0951LT, crew made its last radio contact with ATC and the aircraft crashed in a wooded area located in the region of Ouésso, north of Congo. Debris were found around 1700LT on Monday 21st of June and all eleven occupants were killed, among them Ken Talbot, Australian investors in iron mine. Flight was conducted for the Cameroon company Cam Iron, a subcontractor of the Australian Sundance Resources Group.

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

Date & Time: Oct 9, 2009 at 1200 LT
Type of aircraft:
Operator:
Registration:
FAU-531
Flight Phase:
Survivors:
No
Site:
Schedule:
Port-au-Prince - Port-au-Prince
MSN:
187
YOM:
1981
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
11
Circumstances:
The aircraft crashed in a mountainous area located 20 km west of Fonds-Verrettes, Haiti. All occupants, consisting of Uruguayan & Jordanian soldiers, were performing a border patrol flight on behalf of MINUSTAH, the United Nations Mission for Stabilization in Haiti. All occupants were killed in the accident.

Crash of a Casa 212 Aviocar in Jakarta: 18 killed

Date & Time: Jun 26, 2008 at 1200 LT
Type of aircraft:
Operator:
Registration:
A-2106
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Djakarta-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 bad weather conditions, the aircraft crashed near Mt Silak, south of Jakarta. All 18 occupants were killed.

Crash of a Casa 212 Aviocar 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 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

Crash of a Casa 212 Aviocar in Tanjung Bara

Date & Time: Jan 11, 2007 at 1200 LT
Type of aircraft:
Operator:
Registration:
PK-BRN
Survivors:
Yes
MSN:
411/91N
Country:
Region:
Crew fatalities:
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:

The aircraft landed hard, veered off runway into trees and was damaged beyond repair.

Crash of a Casa 212 Aviocar in Mérida, Mexico

Date & Time: Nov 15, 2006 at 1200 LT
Type of aircraft:
Operator:
Registration:
AMP-114
Flight Phase:
Survivors:
Yes
Country:
Crew on board:
7
Crew fatalities:
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:

The crew left Cancun for a routine maritime patrol flight over the Gulf of Mexico. After 5 hours of flight, while approaching mexican coast, the crew informed ATC that an engine stopped. Few seconds later, the second engine stopped also. Pilots decided to ditch the aircraft 3,5 km off Progreso, 40 km north of Mérida. All occupants escaped uninjured but the aircraft sunk.