Crash of a Piper PA-31-310 Navajo C near Colton: 1 killed

Date & Time: May 3, 2017 at 2030 LT
Type of aircraft:
Operator:
Registration:
C-GQAM
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Quebec - Montreal
MSN:
31-7912093
YOM:
1979
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
5250
Captain / Total hours on type:
1187.00
Circumstances:
The commercial pilot departed on a planned 1-hour cargo cross-country flight in the autopilot-equipped airplane. About 3 minutes after departure, the controller instructed the pilot to fly direct to the destination airport at 2,000 ft mean sea level (msl). The pilot acknowledged the clearance, and there were no further radio transmissions from the airplane. The airplane continued flying past the destination airport in straight-and-level flight at 2,100 ft msl, consistent with the airplane operating under autopilot control, until it was about 100 miles beyond the destination airport. A witness near the accident site watched the airplane fly over at a low altitude, heard three "pops" come from the airplane, and then saw it bank to the left and begin to descend. The airplane continued in the descending left turn until he lost sight of it as it dropped below the horizon. The airplane impacted trees in about a 45° left bank and a level pitch attitude and came to rest in a heavily wooded area. The airplane sustained extensive thermal damage from a postcrash fire; however, examination of the remaining portions of the airframe, flight controls, engines, and engine accessories revealed no evidence of preimpact failure or malfunction. The fuel selector valves were found on the outboard tanks, which was in accordance with the normal cruise procedures in the pilot's operating handbook. Calculations based on the airplane's flight records and the fuel consumption information in the engine manual indicated that, at departure, the outboard tanks of the airplane contained sufficient fuel for about 1 hour 10 minutes of flight. The airplane had been flying for about 1 hour 15 minutes when the accident occurred. Therefore, it is likely that the fuel in the outboard tanks was exhausted; without pilot action to switch fuel tanks, the engines lost power as a result of fuel starvation, and the airplane descended and impacted trees and terrain. The overflight of the intended destination and the subsequent loss of engine power due to fuel starvation are indicative of pilot incapacitation. The pilot's autopsy identified no significant natural disease:however, the examination was limited by the severity of damage to the body. Further, there are a number of conditions, including cardiac arrhythmias, seizures, or other causes of loss of consciousness, that could incapacitate a pilot and leave no evidence at autopsy. The pilot's toxicology results indicated that the pilot had used marijuana/tetrahydrocannabinol (THC) at some point before the accident. THC can impair judgment, but it does not cause incapacitation; therefore, the circumstances of this accident are not consistent with impairment from THC, and, the pilot's THC use likely did not contribute to this accident. The reason for the pilot's incapacitation could not be determined.
Probable cause:
The pilot's incapacitation for unknown reasons, which resulted in an overflight of his destination, a subsequent loss of engine power due to fuel starvation, and collision with terrain.
Final Report:

Crash of a Piper PA-31-310 Navajo in Schefferville: 2 killed

Date & Time: Apr 30, 2017 at 1756 LT
Type of aircraft:
Operator:
Registration:
C-FQQB
Survivors:
No
Schedule:
Schefferville - Schefferville
MSN:
31-310
YOM:
1968
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
461
Captain / Total hours on type:
110.00
Copilot / Total flying hours:
1693
Copilot / Total hours on type:
650
Aircraft flight hours:
20180
Circumstances:
The Piper PA-31 (registration C-FQQB, serial number 31-310) operated by Exact Air Inc., with 2 pilots on board, was conducting its 2nd magnetometric survey flight of the day, from Schefferville Airport, Quebec, under visual flight rules. At 1336 Eastern Daylight Time, the aircraft took off and began flying toward the survey area located 90 nautical miles northwest of the airport. After completing the magnetometric survey work at 300 feet above ground level, the aircraft began the return flight segment to Schefferville Airport. At that time, the aircraft descended and flew over the terrain at an altitude varying between 100 and 40 feet above ground level. At 1756, while the aircraft was flying over railway tracks, it struck power transmission line conductor cables and crashed on top of a mine tailings deposit about 3.5 nautical miles northwest of Schefferville Airport. Both occupants were fatally injured. The accident occurred during daylight hours. Following the impact, there was no fire, and no emergency locator transmitter signal was captured.
Probable cause:
Findings:
Findings as to causes and contributing factors:
- Sensation seeking, mental fatigue, and an altered risk perception very likely contributed to the fact that, immediately after completing the magnetometric survey work, the pilot flying descended to an altitude varying between 100 and 40 feet above ground level and maintained this altitude until the aircraft collided with the wires.
- It is highly likely that the pilots were unaware that there was a power transmission line in their path.
- The pilot flying did not detect the power transmission line in time to avoid it, and the aircraft collided with the wires, which were 70 feet above the ground.
- Despite the warning regarding low-altitude flying in the Transport Canada Aeronautical Information Manua, and in the absence of minimum-altitude restrictions imposed by the company, the pilot chose to descend to a very low altitude on the return flight; as a result, this flight segment carried an unacceptable level of risk.

Findings as to risk:
- If pilots fly at low altitude, there is a risk that they will collide with wires, given that these are extremely difficult to see in flight.
- If lightweight flight data recording systems are not used to closely monitor flight operations, there is a risk that pilots will deviate from established procedures and limits, thereby reducing safety margins.
- If Transport Canada does not take concrete measures to facilitate the use of lightweight flight data recording systems and flight data monitoring, there is a risk that operators will be unable to proactively identify safety deficiencies before they cause an accident.
- If safety management systems are not required, assessed, and monitored by Transport Canada in order to ensure continual improvement, there is an increased risk that companies will be unable to effectively identify and mitigate the hazards involved in their operations.
- Not wearing a safety belt increases the risk of injury or death in an accident.
- The current emergency locator transmitter system design standards do not include a requirement for a crashworthy antenna system. As a result, there is a risk that potentially life-saving search‑and‑rescue services will be delayed if an emergency locator transmitter antenna is damaged during an occurrence.
Final Report:

Crash of a Piper PA-31-325 near Purísima de la Concepción

Date & Time: Apr 9, 2017 at 1241 LT
Type of aircraft:
Operator:
Registration:
HP-1928
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Tolú - Montería
MSN:
31-7612020
YOM:
1976
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
14791
Captain / Total hours on type:
700.00
Aircraft flight hours:
6840
Circumstances:
The twin engine aircraft departed Cali-Alfonso Bonilla Aragón Airport in the morning on a flight to Tolú, carrying seven passengers and one pilot. After takeoff from Tolú, the pilot decided to position to Montería-Los Garzones Airport. Shortly after takeoff, the pilot encountered engine problems and elected to make an emergency landing in a pasture. Upon landing, the right wing collided with obstacles then the nose gear collapsed and the aircraft came to rest near Purísima de la Concepción, about 10 km east of Tolú. The pilot was uninjured and the aircraft was damaged beyond repair.
Probable cause:
Inadequate fuel management and incomplete execution of procedures by the Pilot, by not activating in time the fuel supply from the external tanks (OUTBD) to the internal tanks (INBD) for the feeding of both the engines, causing the fuel in the internal tanks to run out and causing both engines to stop due to fuel starvation.
Contributing Factors:
- Poor flight planning on part of the pilot by not considering the amount of minimum fuel needed and not complying with the minimum fuel amount required for domestic flights.
- Loss of situational awareness by the pilot by not following the standard operation procedures.
Final Report:

Crash of a Piper PA-31-310 Navajo C in Zielona Góra: 1 killed

Date & Time: Nov 24, 2016 at 1205 LT
Type of aircraft:
Operator:
Registration:
D-IFBU
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Zielona Góra - Nordhorn
MSN:
31T-8012050
YOM:
1980
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
9418
Captain / Total hours on type:
7371.00
Aircraft flight hours:
6641
Circumstances:
While taking off from a grassy runway at Zielona Góra-Przylep Airport, the airplane nosed down, impacted ground and crashed. Both engines were torn off and the aircraft was destroyed by impact forces. There was no fire. The pilot, sole on board, was killed. He was completing a ferry flight to Nordhorn, Lower Saxony.
Probable cause:
The pilot mistakenly retracted the undercarriage at liftoff. There was no immediate decision of the pilot to abandon the takeoff procedure when both propellers contacted the runway surface.
Final Report:

Crash of a Piper PA-31-325 Navajo C/R in Tuscaloosa: 6 killed

Date & Time: Aug 14, 2016 at 1115 LT
Type of aircraft:
Registration:
N447SA
Flight Type:
Survivors:
No
Schedule:
Kissimmee – Oxford
MSN:
31-8312016
YOM:
1983
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
6
Captain / Total flying hours:
749
Captain / Total hours on type:
48.00
Aircraft flight hours:
3447
Circumstances:
The private pilot and five passengers departed on a day instrument flight rules cross-country flight in the multiengine airplane. Before departure, the airplane was serviced to capacity with fuel, which corresponded to an endurance of about 5 hours. About 1 hour 45 minutes after reaching the flight's cruise altitude of 12,000 ft mean sea level, the pilot reported a failure of the right engine fuel pump and requested to divert to the nearest airport. About 7 minutes later, the pilot reported that he "lost both fuel pumps" and stated that the airplane had no engine power. The pilot continued toward the diversion airport and the airplane descended until it impacted trees about 1,650 ft short of the approach end of the runway; a postimpact fire ensued. Postaccident examination of the airframe and engines revealed no preimpact failures or malfunctions that would have precluded normal operation. The propellers of both engines were found in the unfeathered position. All six of the fuel pumps on the airplane were functionally tested or disassembled, and none exhibited any anomalies that would have precluded normal operation before the accident. Corrosion was noted in the right fuel boost pump, which was likely the result of water contamination during firefighting efforts by first responders. The airplane was equipped with 4 fuel tanks, comprising an outboard and an inboard fuel tank in each wing. The left and right engine fuel selector valves and corresponding fuel selector handles were found in the outboard tank positions. Given the airplane's fuel state upon departure and review of fuel consumption notes in the flight log from the day of the accident, the airplane's outboard tanks contained sufficient fuel for about 1 hour 45 minutes of flight, which corresponds to when the pilot first reported a fuel pump anomaly to air traffic control. The data downloaded from the engine data monitor was consistent with both engines losing fuel pressure due to fuel starvation. According to the pilot's operating handbook, after reaching cruise flight, fuel should be consumed from the outboard tanks before switching to the inboard tanks. Two fuel quantity gauges were located in the cockpit overhead switch panel to help identify when the pilot should return the fuel selectors from the outboard fuel tanks to the inboard fuel tanks. A flight instructor who previously flew with the pilot stated that this was their normal practice. He also stated that the pilot had not received any training in the accident airplane to include single engine operations and emergency procedures. It is likely that the pilot failed to return the fuel selectors from the outboard to the inboard tank positions once the outboard tanks were exhausted of fuel; however, the pilot misdiagnosed the situation as a fuel pump anomaly.
Probable cause:
A total loss of power in both engines due to fuel starvation as a result of the pilot's fuel mismanagement, and his subsequent failure to follow the emergency checklist. Contributing to the pilot's failure to follow the emergency checklist was his lack of emergency procedures training in the accident airplane.
Final Report:

Crash of a Piper PA-31-325 Navajo in State College: 2 killed

Date & Time: Jun 16, 2016 at 0830 LT
Type of aircraft:
Operator:
Registration:
N3591P
Flight Type:
Survivors:
No
Schedule:
Washington County – State College
MSN:
31-8012081
YOM:
1980
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
12493
Captain / Total hours on type:
718.00
Aircraft flight hours:
16040
Circumstances:
The commercial pilot was completing an instrument flight rules air taxi flight on a route that he had flown numerous times for the customer on board. Radar and voice communication data revealed that the airplane was vectored to the final approach course for the precision approach and was given a radio frequency change to the destination airport control tower frequency. The tower controller issued a landing clearance, which the pilot acknowledged; there were no further communications with the pilot. Weather conditions at the airport at the time of the accident included an overcast ceiling at 300 ft with 1 mile visibility in mist. The wreckage was located in densely-wooded terrain. Postaccident examination revealed no evidence of any mechanical malfunctions or anomalies that would have precluded normal operation. The wreckage path and evidence of engine power displayed by numerous cut tree branches was consistent with a controlled, wings-level descent with power. A radar performance study revealed that, as the airplane crossed the precision final approach fix 6.7 nautical miles (nm) from the runway threshold, the airplane was 800 ft above the glideslope. At the outer marker, 5.5 nm from the runway threshold, the airplane was 500 ft above the glideslope. When radar contact was lost 3.2 nm from the threshold, the airplane was about 250 ft above the glideslope. Although the airplane remained within the lateral limits of the approach localizer, its last two recorded radar returns would have correlated with a full downward deflection of the glideslope indicator in the cockpit, and therefore, an unstabilized approach. Further interpolation of radar data revealed that, during the last 2 minutes of the accident flight, the airplane's rate of descent increased from 400 ft per minute (fpm) to greater than 1,700 fpm, likely as a result of pilot inputs. During the final minute of the flight, the rate decreased briefly to 1,000 fpm before radar contact was lost. The company's standard operating procedures stated that, if a rate of descent greater than 1,000 fpm was encountered during an instrument approach, a missed approach should be performed. The airplane's relative position to the glideslope and its rapid changes in descent rate after crossing the outer marker suggest that the airplane never met the operator's stabilized approach criteria. Rather than executing a missed approach procedure as outlined in the company's operating procedures, the pilot chose to continue the unstabilized approach, which resulted in a descent into trees and terrain. It is unlikely that the pilot's well-controlled diabetes and effectively treated sleep apnea contributed to the circumstances of this accident. However, whether or not the pilot's multiple sclerosis contributed to this accident could not be determined.
Probable cause:
The pilot's decision to continue an unstabilized instrument approach in instrument meteorological conditions, which resulted in controlled flight into terrain.
Final Report: