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Canada

Crash of a De Havilland DHC-6 Twin Otter 310 in the Maadhiggaru Falhu lagoon

Date & Time: Jul 11, 2011 at 0910 LT
Type of aircraft:
De Havilland DHC-6 Twin Otter
Operator:
Registration:
8Q-TMD
Flight Phase:
Landing (descent or approach)
Flight Type:
Training
Survivors:
Yes
Site:
Lake, Sea, Ocean, River
Schedule:
Male - Male
MSN:
530
YOM:
1977
Flight number:
TMW201A
Location:
Maadhiggaru Falhu
North Central Province
Country:
Maldivian Islands
Region:
Asia
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
5732
Captain / Total hours on type:
3387.00
Copilot / Total flying hours:
2650
Copilot / Total hours on type:
2650
Aircraft flight hours:
34746
Aircraft flight cycles:
62428
Circumstances:
The 8Q-TMD aircraft took-off from water runway of Male’ International Airport North Bound Left (NL) at 0820 hrs local time on 11 July 2011 for a routine training flight bound to Maadhiggaru Falhu (a lagoon located approximately 15 nautical miles south west of the Male’ International Airport). The sky was clear with good visibility and wind 8-10 knots from west and south west. During the training 5 landings and take-offs were made simulating different conditions of flight. Crew confirmed that all these landings and take-offs were made inside the lagoon except the last landing where the crew decided to land on open water outside the lagoon. Crew were simulating single engine landing with a tail wind. As per the crew, the aircraft initial touch down was smooth. However, they stroke a wave which made the aircraft bounce up for about 20 feet. With the low power the aircraft hit the water again, resulting in multiple float attachments to break. Both front and main spreader bars broke and floats rose up twisted, hitting the engine bottom cowlings. Propeller cut was found on top front of both floats.
Probable cause:
Impact with a high swell during landing followed by a high bounce and hard landing resulting in both float attachments being damaged and detached with a major structural damages. Major contributing factor was higher than normal touch down speed due to abnormal landing configuration.
Contributing factors:
- Selection of inappropriate landing site (channel) and landing direction (tail wind) based on surface conditions present at that time,
- Simulation of multiple emergencies,
- Abnormal landing configuration (flaps at zero) for single engine landing,
- Time pressure to complete the training and return to commercial operations.
Final Report:

Crash of a De Havilland DHC-6 Twin Otter 100 in Clayton: 2 killed

Date & Time: Mar 8, 2011 at 1140 LT
Type of aircraft:
De Havilland DHC-6 Twin Otter
Operator:
Registration:
N157KM
Flight Phase:
Landing (descent or approach)
Flight Type:
Test
Survivors:
No
Site:
Airport (less than 10 km from airport)
Schedule:
Clayton - Clayton
MSN:
57
YOM:
1967
Location:
Clayton
Georgia
Country:
United States of America
Region:
North America
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
1255
Captain / Total hours on type:
492.00
Aircraft flight hours:
16541
Aircraft flight cycles:
20927
Circumstances:
The airplane had not been flown for about 5 months and the purpose of the accident flight was a maintenance test flight after both engines had been replaced with higher horsepower models. Witnesses observed the airplane depart and complete two uneventful touch-and-go landings. The airplane was then observed to be struggling to gain altitude and airspeed while maneuvering in the traffic pattern. One witness, who was an aircraft mechanic, reported that he observed the airplane yawing to the left and heard noises associated with propeller pitch changes, which he believed were consistent with the "Beta" range. The airplane stalled and impacted trees in a wooded marsh area, about 1 mile from the airport. It came to rest about 80-degrees vertically. Examination of the wreckage did not reveal any preimpact malfunctions; however, the lack of flight recorders and the condition of the wreckage precluded the gathering of additional relevant information. Damage observed to both engines and both propellers revealed they were likely operating at symmetrical power settings and blade angles at the time of the impact, with any differences in scoring signatures likely the result of impact damage. The reason for the yawing and the noise associated with propeller pitch changes that were reported prior to the stall could not be determined.
Probable cause:
The pilot did not maintain airspeed while maneuvering, which resulted in an aerodynamic stall.
Final Report:

Crash of a De Havilland DHC-6 Twin Otter 300 near Santa Clara: 6 killed

Date & Time: Jan 20, 2011 at 1545 LT
Type of aircraft:
De Havilland DHC-6 Twin Otter
Operator:
Registration:
FAE449
Flight Phase:
Flight
Flight Type:
Military
Survivors:
No
Site:
Plain, Valley
Schedule:
Shell – Tena
MSN:
834
YOM:
1986
Location:
Santa Clara
Pastaza
Country:
Ecuador
Region:
South America
Crew on board:
6
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
6
Circumstances:
The crew departed Shell Mera-Río Amazonas Airport at 1530LT on a flight to Tena on behalf of the ECORAE's Institute, a government supply and support program for isolated population in the center of Ecuador. Fifteen minutes after takeoff, the twin engine aircraft crashed in unknown circumstances near Santa Clara, about 30 km northeast of Shell Airport. A crew survived while five other occupants were killed. The only survivor died few hours later.

Crash of a De Havilland DHC-6 Twin Otter 300 near Okhaldhunga: 22 killed

Date & Time: Dec 15, 2010 at 1530 LT
Type of aircraft:
De Havilland DHC-6 Twin Otter
Operator:
Registration:
9N-AFX
Flight Phase:
Flight
Flight Type:
Scheduled Revenue Flight
Survivors:
No
Site:
Mountains
Schedule:
Lamidanda - Kathmandou
MSN:
806
YOM:
1984
Location:
Okhaldhunga
Sagarmatha
Country:
Nepal
Region:
Asia
Crew on board:
3
Crew fatalities:
Pax on board:
19
Pax fatalities:
Other fatalities:
Total fatalities:
22
Captain / Total flying hours:
6700
Captain / Total hours on type:
5000.00
Copilot / Total flying hours:
1100
Copilot / Total hours on type:
341
Circumstances:
The twin engine aircraft departed Lamidanda Airport at 1508LT on a flight to Kathmandu. Shortly after departure, the crew was cleared to climb to 10,500 feet but ATC ask them to maintain 8,500 feet due to traffic. The captain disagreed with this ATC instruction and continued to climb. The copilot asked the captain to accept the ATC proposal so finally, the captain cleared the copilot (who was the pilot in command) to descend to 8,500 feet despite the fact it was risky due to the mountainous terrain. Few minutes later, the aircraft entered clouds when the right wing impacted ground. The aircraft crashed in a rocky area located on the Palunge Hill, near Okhaldhunga. The wreckage was found the following morning. The aircraft was destroyed by impact forces and all 22 occupants were killed. IMC conditions prevailed at the time of the accident due to low visibility (cloudy conditions).
Probable cause:
The cause of the accident was the unwise decision taken by the crew to descend without taking the harsh mountain terrain into consideration. Controlled flight into terrain.

Crash of a De Havilland DHC-6 Twin Otter 300 near Alert

Date & Time: May 10, 2010 at 1719 LT
Type of aircraft:
De Havilland DHC-6 Twin Otter
Operator:
Registration:
C-FSJB
Flight Phase:
Landing (descent or approach)
Flight Type:
Geographical / Geophysical / Scientific
Survivors:
Yes
Site:
Plain, Valley
MSN:
377
YOM:
1973
Location:
Alert AFB
Nunavut
Country:
Canada
Region:
North America
Crew on board:
2
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The crew was performing a supply mission in the Nunavut with three scientists on board. Equipped with ski, the aircraft landed on the snow covered terrain some 168 km north of Alert Air Base. After landing, the aircraft came to a halt when the right ski punctured the ice and the aircraft partially sunk while both engines were still running. All five occupants escaped uninjured and were evacuated two hours later by the crew of a Bell 407 to Resolute Bay. Damaged beyond repair, the aircraft was abandoned on site and later cancelled from registry in November 2011.
Probable cause:
Landing gear went through the ice after landing on ice/snow terrain.

Crash of a De Havilland DHC-6 Twin Otter 300 in Kokoda: 13 killed

Date & Time: Aug 11, 2009 at 1114 LT
Type of aircraft:
De Havilland DHC-6 Twin Otter
Operator:
Registration:
P2-MCB
Flight Phase:
Landing (descent or approach)
Flight Type:
Scheduled Revenue Flight
Survivors:
No
Site:
Mountains
Schedule:
Port Moresby - Kokoda
MSN:
441
YOM:
1975
Flight number:
CG4684
Location:
Kokoda
Central
Country:
Papua New Guinea
Region:
Oceania
Crew on board:
2
Crew fatalities:
Pax on board:
11
Pax fatalities:
Other fatalities:
Total fatalities:
13
Captain / Total flying hours:
2270
Captain / Total hours on type:
1970.00
Copilot / Total flying hours:
2150
Copilot / Total hours on type:
1940
Aircraft flight hours:
46700
Circumstances:
On 11 August 2009, a de Havilland Canada DHC-6 Twin Otter aircraft, registered P2-MCB, with two pilots and 11 passengers, was being operated on a scheduled regular public transport service from Port Moresby to Kokoda Airstrip, Papua New Guinea (PNG). At about 1113, the aircraft impacted terrain on the eastern slope of the Kokoda Gap at about 5,780 ft above mean sea level in heavily-timbered jungle about 11 km south-east of Kokoda Airstrip. The aircraft was destroyed by impact forces. There were no survivors. Prior to the accident the crew were manoeuvring the aircraft within the Kokoda Gap, probably in an attempt to maintain visual flight in reported cloudy conditions. The investigation concluded that the accident was probably the result of controlled flight into terrain: that is, an otherwise airworthy aircraft was unintentionally flown into terrain, with little or no awareness by the crew of the impending collision.
Probable cause:
From the evidence available, the following findings are made with respect to the collision with terrain, 11 km south-east of Kokoda Airstrip, Papua New Guinea, involving a de Havilland Canada DHC-6-300 Twin Otter aircraft, registered P2-MCB, and should not be read as apportioning blame or liability to any particular organisation or individual.
Contributing safety factors:
• Visual flight in the Kokoda Gap was made difficult by the extensive cloud coverage in the area.
• The crew attempted to continue the descent visually within the Kokoda Gap despite the weather conditions not being conducive to visual flight.
• It was probable that while manoeuvring at low level near the junction of the Kokoda Gap and Kokoda Valley, the aircraft entered instrument meteorological conditions.
• The aircraft collided with terrain in controlled flight.
Other safety factors:
• The copilot was assessed during normal proficiency checks for instrument approach procedures but was not qualified for flight in instrument meteorological conditions.
• The operator did not have a published emergency recovery procedure for application in the case of inadvertent flight into instrument meteorological conditions.
• The Civil Aviation Safety Authority Papua New Guinea surveillance of the operator did not identify the operations by the operator in contravention of Rule 91.112.
• The lack of a reliable mandatory occurrence reporting arrangement minimized the likelihood of an informed response to Papua New Guinea-specific safety risks.
• There was no qualified Director (or similar) of Aviation Medicine in Papua New Guinea (PNG).
• The lack of both flight data and cockpit voice recorders adversely affected a full understanding of the accident by the investigation.
Other key findings:
• The investigation was unable to discount the possible incapacitation of the copilot as a factor in the accident.
• Although not required by the aviation rules at the time of the accident, the adoption of threat and error management training for flight crews, and of the methodology by operators would provide a tool to identify and mitigate operational risk as follows:
– by flight crews, when flight planning and during flight; and
– by operators, when developing their operational procedures.
Final Report:

Crash of a De Havilland DHC-6 Twin Otter 300 near Oksibil: 15 killed

Date & Time: Aug 2, 2009 at 1100 LT
Type of aircraft:
De Havilland DHC-6 Twin Otter
Operator:
Registration:
PK-NVC
Flight Phase:
Flight
Flight Type:
Scheduled Revenue Flight
Survivors:
No
Site:
Mountains
Schedule:
Jayapura - Oksibil
MSN:
626
YOM:
1979
Flight number:
MZ9760D
Location:
Oksibil
Special Region of Papua
Country:
Indonesia
Region:
Asia
Crew on board:
3
Crew fatalities:
Pax on board:
12
Pax fatalities:
Other fatalities:
Total fatalities:
15
Captain / Total flying hours:
8387
Captain / Total hours on type:
8387.00
Copilot / Total flying hours:
1207
Copilot / Total hours on type:
1207
Aircraft flight hours:
27336
Circumstances:
On the morning of Sunday, 2 August 2009, a de Havilland DHC-6 Twin Otter aircraft, registered PK-NVC, operated by PT. Merpati Nusantara Airlines as flight number MZ-7960D, departed from Sentani Airport, Jayapura for Oksibil Airport. The flight was planned in accordance with the visual flight rules (VFR). There were 15 persons on board; two pilots, one engineer, 10 adult passengers and two infants. The estimated flight time was 50 minutes. The fuel on board was sufficient for 2 hours and 50 minutes flight time. About 15 minutes prior to the estimated time of arrival at Oksibil the crew of another aircraft informed the Twin Otter crew that the weather in the Oksibil area was partly cloudy. There were no further reports of radio transmissions from the Twin Otter, and it did not arrive at Oksibil. A search was initiated at the time the aircraft would have run out of fuel. On the morning of 4 August 2009, searchers located the wreckage of the Twin Otter at an elevation of about 9,300 feet about 6 Nm from Oksibil. The aircraft was destroyed by impact forces, and all of the occupants were fatally injured.
Probable cause:
The pilots did not maintain visual flight procedures when flying below lowest safe altitude, and the aircraft was flown into cloud in the vicinity of gap north west of Oksibil. In conclusion, the accident was consistent with controlled flight into terrain.
Final Report:

Crash of a De Havilland DHC-6 Twin Otter 300 near Wamena: 3 killed

Date & Time: Jun 29, 2009 at 1601 LT
Type of aircraft:
De Havilland DHC-6 Twin Otter
Operator:
Registration:
PK-BRO
Flight Phase:
Flight
Flight Type:
Cargo
Survivors:
No
Site:
Mountains
Schedule:
Dekai - Wamena
MSN:
756
YOM:
1981
Location:
Wamena
Special Region of Papua
Country:
Indonesia
Region:
Asia
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
3
Circumstances:
The twin engine aircraft departed Dekai Airport at 1530LT on a cargo flight to Wamena, carrying three crew members and a load of 1,600 kilos of various goods. Between 1554LT and 1600LT, the crew was in contact with Wamena. At 1601LT, while cruising at an altitude of 9,600 feet in limited visibility, the aircraft collided with a mountain slope. The wreckage was found a day later about 19 km southeast from Wamena. The aircraft disintegrated on impact and all three occupants were killed.
Probable cause:
Controlled flight into terrain after the crew was flying under VFR mode in IMC conditions. IFR approach to Wamena are not possible, VFR only.

Crash of a De Havilland DHC-6 Twin Otter 200 in Halaveli

Date & Time: Jun 2, 2009 at 1009 LT
Type of aircraft:
De Havilland DHC-6 Twin Otter
Operator:
Registration:
8Q-MAG
Flight Phase:
Landing (descent or approach)
Flight Type:
Aerial photography
Survivors:
Yes
Site:
Lake, Sea, Ocean, River
Schedule:
Male - Halaveli
MSN:
224
YOM:
1969
Location:
Halaveli (Alifu Alifu Atoll)
North Central Province
Country:
Maldivian Islands
Region:
Asia
Crew on board:
3
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3556
Captain / Total hours on type:
3240.00
Copilot / Total flying hours:
1974
Copilot / Total hours on type:
1688
Aircraft flight hours:
33685
Circumstances:
The 8Q-MAG aircraft departed at 0945hrs, with 3 crew and 4 passengers on board, for a Photo Flight around the Lagoon of Halaveli (North Ari Atoll) from the floating platform ( fixed to jetty) of Halaveli (North Ari Atoll). The sky was clear with good visibility and wind, 8-10 knots, from westerly direction. The estimated flight time for the flight was 40 minutes. The aircraft took off westbound. After levelling the aircraft the co-pilot gave his seat to the cameraman, one of the passengers. The co-pilot remained at third row left seat from thereon until the aircraft met the accident. According to the crew and passengers the aircraft made few orbits (right bank) around the island at the initial levelled height and, then descended lower heights and made few more orbits around the lagoon for photography. The passenger seated at the cabin wearing the headset informed the PIC that they got all the shots they wanted and now he could land. PIC started a descending turn (right bank) while keeping the passenger at the co-pilot seat in order to give a different view to him. Before the PIC could complete the turn, the right wing and/or float hit the water. The accident resulted in both wings being broken at the root. Left float was detached and right float got stuck, between the engine and the fuselage, blocking the co-pilot exit. Empennage was twisted upside down. The depth of the lagoon at the site of wreckage was about 1 meter. All the passengers and crew were able to escape the aircraft without any fatalities.
Probable cause:
It was observed by the investigation team that;
• The PIC was conducting flying activities (photographic activities) lower than that allowed in regulations and company operations manual and standard operating procedures.
• At the time of accident a passenger was occupying the co-pilot seat.
• PIC could not make a fair judgment of the aircraft altitude by looking outside since the aircraft was banking to the right for a turn and the co-pilot seat was occupied by a passenger.
• The crew of the aircraft acted swiftly to save lives, after the aircraft came to a halt.
• Investigation revealed that the right float forward and both wingtips were severely damaged. Since the aircraft was right banked at the impact it was evident that the right wing and/or float were the first to impact with the water.
Final Report:
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