Human factor

En route from Kedrovy to Tomsk, while cruising at an altitude of 12,000 feet in icing conditions, both engines failed simultaneously. The crew tried to restart both engines, without success. In such conditions, the crew reduced his altitude and attempted an emergency landing in the taiga. Upon impact, the flipped over and came to rest upside down. The wreckage was found around 1430LT some 52 km southeast of Kedrovy. All 17 occupants were found alive, among them few were injured. The captain broke one of his leg. The aircraft was damaged beyond repair.

Before taking off, the pilot canceled an instrument flight rules (IFR) flight plan that she had filed and requested a visual flight rules (VFR) on-top clearance, which the controller issued via the Monterey Five departure procedure. The departure procedure included a left turn after takeoff. The pilot took off and climbed to about 818 ft then entered a right turn. The air traffic controller noticed that the airplane was in a right-hand turn rather than a left-hand turn and issued a heading correction to continue a right-hand turn to 030o , which the pilot acknowledged. The airplane continued the climbing turn for another 925 ft then entered a descent. The controller issued two low altitude alerts with no response from the pilot. No further radio communication with the pilot was received. The airplane continued the descent until it contacted trees, terrain, and a residence about 1 mile from the departure airport. Review of weather information indicated prevailing instrument meteorological conditions (IMC) in the area due to a low ceiling, with ceilings near 800 ft above ground level and tops near 2,000 ft msl. Examination of the airframe and engines did not reveal any anomalies that would have precluded normal operation. The airplane’s climbing right turn occurred shortly after the airplane entered IMC while the pilot was acknowledging a frequency change, contacting the next controller, and acknowledging the heading instruction. Track data show that as the right-hand turn continued, the airplane began descending, which was not consistent with its clearance. Review of the pilot’s logbook showed that the pilot had not met the instrument currency requirements and was likely not proficient at controlling the airplane on instruments. The pilot’s lack of recent experience operating in IMC combined with a momentary diversion of attention to manage the radio may have contributed to the development of spatial disorientation, resulting in a loss of airplane control.

The intention of the flight was to drop eight parachutists from an altitude of 1,500 metres. It was the twelfth and planned to be the last flight of the day. The weather conditions were good. The parachutist bench to the right of the pilot had been replaced with a pilot's seat to distance the parachutists from the pilot as a Covid-19 precautionary measure. The pilot had no ability to perform a mass and balance calculation with the available information. After take-off, the aircraft climbed to an altitude of 400 to 500 feet above ground before changing course 180 degrees to the left. The aircraft turned around quickly in a descending turn with a high bank angle. During the final phase, the aircraft dived steeply and then slightly levelled off before impact. Upon impact, the landing gear was teared off, after which the aircraft skidded on its belly 48 metres straight ahead and caught fire. All nine persons on board sustained fatal injuries.

The twin engine airplane departed Villavicencio-La Vanguardia Airport Runway 05 at 0659LT on a training flight consisting with a proficiency check of the captain. On board were one instructor, one captain and one mechanic. About 10 minutes into the flight, while cruising at an altitude of 6,000 feet over mountainous terrain in Instrument Meteorological Conditions, the airplane impacted trees and crashed on the slope of a hilly terrain located in the region of Restrepo. The wreckage was found three days later. All three crew members were killed.

The aircraft departed Petropavlovsk-Kamchatsky Airport at 1257LT on a schedule service (flight PTK251) to Palana, carrying 22 passengers and a crew of six, among them Olga Mokhiriova, chief of the municipality of Palana. At 1439LT, the crew contacted Palana ATC and was cleared to start the descent. While completing an NDB approach to runway 29, the crew encountered marginal weather conditions with fog and ceiling at 300 metres. Too low, the aircraft impacted terrain about 4 km northwest of the airport. The wreckage was found in the evening on the top of a rocky wall. The aircraft disintegrated on impact and debris fall down on the sea bank. All 28 occupants were killed.

On the 5th July, 2021 at approximately 3:45PM, EDT (1945UTC), an Israeli Aircraft Industries, (IAI) Westwind 1124A aircraft, United States registration N790JR, crashed a short distance from the end of runway 32 at the Treasure Cay International Airport (MYAT), Treasure Cay, Abaco, Bahamas. The aircraft plowed through airport lighting equipment at the end of the runway, hitting and breaking several trees along its path. A trail of aviation fuel and pieces of the aircraft and avionics equipment from the flight deck, were left behind before the aircraft finally hit a small mound (hill), spinning, hitting several additional trees, breaking apart and bursting into flames. The aircraft came to rest at coordinates 26°45’21.50”N, 77°24’7.26”W, approximately 2,000 feet (.33 miles) from the end of runway 32. As this airport did not have a fire truck or crash and rescue personnel stationed on site, assistance with fire services were requested from the town. Two firetrucks from the township responded, however, due to the location of the crash, and no access road available, the trucks were unable to reach the crash site and assist in extinguishing the blaze. The fire continued unimpeded, dampened only by the intermittent downpour of rain, which did not aid in extinguishing the blaze, but rather, only limited the spread of the fire to surrounding bushes. The raging fire totally destroyed the aircraft and much of the control surfaces and components in the direct area of the blaze. On July 6, a team of investigators from the AAIA and CAA-B were dispatched to the scene. Upon arrival of the investigation team, surrounding brush and trees, as well as some parts and components of the aircraft were still burning. Initial assessments pointed to a possible failure of the aircraft to climb and perform as required. Runway 14/32 is 7,001 x 150 feet with an asphalt surface and based on the distance the aircraft traveled from the end of the runway to its final resting place, the signature marking on trees and airport lighting fixtures struck by the aircraft, in addition to the ground scars, along with pieces of the aircraft beyond the runway, up to the final resting place of the aircraft, it appears the aircraft was approximately 2 to 5 feet about the surface and not developing any lift or climb performance, while developing full power over the ground, striking trees and brush along its path. Investigations uncovered the private flight with a crew of two (2), proposed a flight time departure of 2:10PM EDT from the Treasure Cay International Airport (MYAT), with a planned destination of Nassau, Bahamas (MYNN) and an arrival time of 2:33PM EDT, according to flight plan retrieved from Flightaware.com. The flight plan did not specify whether the flight would be operated under Visual Flight Rules (VFR) or Instrument Flight Rules (IFR). According to witness statements taken at Treasure Cay, witnesses recalled two pilots entering the ramp after 3 pm. Witnesses also stated that one of the persons onboard advised customs that they will be departing for Marsh Harbor for fuel in the aircraft (N790JR).

Transair flight 810, a Title 14 Code of Federal Regulations Part 121 cargo flight, experienced a partial loss of power involving the right engine shortly after takeoff and a water ditching in the
Pacific Ocean about 11.5 minutes later. This analysis summarizes the accident and evaluates (1) the right engine partial loss of power, (2) the captain's communications with air traffic control (ATC) and the first officer's left and right engine thrust reductions, (3) the first officer's misidentification of the affected engine and the captain's failure to verify the information, (4) checklist performance, and (5) survival factors. Maintenance was not a factor in this accident. The flight data recorder (FDR) showed that, when the initial thrust was set for takeoff, the engine pressure ratios (EPR) for the left and right engines were 2.00 and 1.97, respectively. Shortly after rotation, the cockpit voice recorder (CVR) recorded a “thud” and the sound of a low-frequency vibration. The captain (the pilot monitoring at the time) and the first officer (the pilot flying) reported that they heard a “whoosh” and a “pop,” respectively, at that time. As the airplane climbed through an altitude of about 390 ft while at an airspeed of 155 knots, the right EPR decreased to 1.43 during a 2-second period. The airplane then yawed to the right; the first officer countered the yaw with appropriate left rudder pedal inputs. The CVR showed that the captain and the first officer correctly determined that the No. 2 (right) engine had lost thrust within 5 seconds of hearing the thud sound. After moving the flaps to the UP position, the captain reduced thrust to maximum continuous thrust, causing the left EPR to decrease from 1.96 to 1.91 while the airplane was in a climb. (The right EPR remained at 1.43). The captain reported that he did not move the thrust levers again until after he became the pilot flying. The first officer stated that, after the airplane leveled off at an altitude of about 2,000 ft, he reduced thrust on both engines. FDR data showed that thrust was incrementally reduced to near flight idle (1.05 EPR on the left engine and then 1.09 EPR on the right engine) and that airspeed decreased from about 250 to 210 knots. (A decrease in airspeed to 210 knots was consistent with the operator’s simulator guide procedures for a single-engine failure after the takeoff decision speed [V1]. The simulator guide, which supplemented information in the company’s flight crew training manual, contained the most recent operator guidance for single-engine failure training at the time of the accident.) The captain was unaware of the first officer’s thrust changes because he was busy contacting the controller about the emergency. The captain told the controller, “we’ve lost an engine,” but he had declared the emergency to the controller twice before this point, as discussed later in this analysis. The captain instructed the first officer to maintain a target speed of 220 knots (which the captain thought would be “easy on the running engine”), a target altitude of 2,000 ft, and a target heading of 240°. (About 52 seconds earlier, the controller had issued the 240° heading instruction to another airplane on the same radio frequency.) About 3 minutes 14 seconds after the right engine loss of thrust occurred, the captain assumed control of the airplane; at that time, the airplane’s airspeed was 224 knots and heading was 242°, but the airplane’s altitude had decreased from about 2,100 ft (the maximum altitude that the airplane reached during the flight) to 1,690 ft. The captain increased the airplane’s pitch to 9°; the airplane’s altitude then increased to 1,878 ft, but the airspeed decreased to 196 knots. The captain subsequently stated, “let’s see what is the problem...which one...what's going on with the gauges,” and “who has the E-G-T [exhaust gas temperature]?” The first officer stated that the left engine was “gone” and “so we have number two” (the right engine), thus misidentifying the affected engine. The captain accepted the first officer’s assessment and did not take action to verify the information. Afterward, the EPR level on the right engine began to increase in response to the captain advancing the right thrust lever so that the airplane could maintain airspeed and altitude. Right EPR increased and decreased several times during the rest of the flight (coinciding with crew comments regarding the EGT on the right engine and low airspeed) while the left EPR remained near flight idle. The first officer asked the captain if they “should head back toward the airport” before the airplane traveled “too far away,” and the captain responded that the airplane would stay within 15 miles of the airport. During a postaccident interview, the captain stated that, because there was no fire and an engine “was running,” he intended to have the airplane climb to 2,000 ft and stay within 15 miles of the airport to avoid traffic and have time to address the engine issue. The captain also stated that he had been criticized by the company chief pilot for returning to the airport without completing the required abnormal checklist for a previous in-flight emergency. Although the captain’s decision resulted in the accident airplane flying farther away from the airport and farther over the ocean at night, the captain’s decision was reasonable for a single-engine failure event. The captain directed the first officer to begin the Engine Failure or Shutdown checklist and stated that he would continue handling the radios. The first officer began to read aloud the conditions for executing the Engine Failure or Shutdown checklist but then stopped to tell the captain that the right EGT was at the “red line” and that thrust should be reduced on the right engine. The captain then decided that the airplane should return to the airport and contacted the controller to request vectors. The flight crew continued to express concern about the right engine. The first officer stated, “just have to watch this though…the number two.” The captain asked the first officer to check the EGT for the right engine, and the first officer responded that it was “beyond max.” Afterward, the captain told the first officer to continue with the Engine Failure or Shutdown checklist and finish as much as possible. The first officer resumed reading aloud the conditions for performing the checklist but then stopped to state, “we have to fly the airplane though,” because the airplane was continuing to lose altitude and airspeed. The captain replied “okay.” As a result, the flight crew did not perform key steps of the checklist, including identifying, confirming, and shutting down the affected (right) engine. The first officer told the captain that the airplane was losing altitude; at that time, the airplane’s altitude was 592 ft, and its airspeed was 160 knots. The captain agreed to select flaps 1 (which the first officer had previously suggested likely because the airplane was slowing). The CVR then recorded the first enhanced ground proximity warning system (EGPWS) annunciation (500 ft above ground level); various EGPWS callouts and alerts continued to be annunciated through the remainder of the flight. The captain then told the controller that “we’ve lost number one [left] engine…there’s a chance we’re gonna lose the other engine too it’s running very hot….we’re pretty low on the speed it doesn't look good out here.” Also, the captain mentioned that the controller should notify the US Coast Guard (USCG) because he was anticipating a water ditching in the Pacific Ocean. Because of the high temperature readings on the right engine, the flight crew thought, at this point in the flight, that a dual-engine failure was imminent. During a postaccident interview, the captain stated that his priority at that time was figuring out how the airplane could stay in the air and return safely to the airport. The captain also stated that he attempted to resolve the airplane’s deteriorating energy state by advancing the right engine thrust lever. However, with the left engine remaining near flight idle, the right engine was not producing sufficient thrust to enable the airplane to maintain altitude or climb. The captain’s communication with the controller continued, and the first officer stated, “fly the airplane please.” The controller asked if the airport was in sight, and the captain then asked the first officer whether he could see the airport. The first officer responded “pull up we’re low” to the captain and “negative” to the controller; the captain was likely unable to respond to the controller because he was trying to control the airplane. The captain asked the first officer about the EGT for the right engine; the first officer replied “hot…way over.” The captain then asked about, and the controller responded by providing, the location of the closest airport. Afterward, the CVR recorded a sound similar to the stick shaker, which continued intermittently through the rest of the flight. The CVR then recorded sounds consistent with water impact. The airplane came down into the Pacific Ocean about two miles offshore and sank. Both crew members were rescued, one was slightly injured and a second was seriously injured. The wreckage was later recovered for investigation purposes.

The pilot was conducting a cross-country flight when, about 8 miles north of his intended destination, he reduced engine power, pitched for level flight, and waited for indicated airspeed to drop below 174 kts to add 20° of flaps. As soon as the drag was introduced, the airplane began to “buck back and forward,” and the two engines were “throttling up and down on their own.” He noted that the right engine seemed to be “sputtering and popping” more than the left engine, so he decided to raise the flaps and to shut down and feather the right engine. He declared an emergency to air traffic control. The pilot then noticed that the left engine was “slowly spooling down” and the airplane was not able to maintain airspeed and altitude. The pilot performed a forced landing to a flat, muddy wheat field about 4 nautical miles from the airport. The airplane sustained substantial damage to the fuselage and to both wings. A Federal Aviation Administration inspector traveled to the accident site to examine the airplane. Flight control and engine control continuity were confirmed. The master switch was turned on and the fuel gauges showed a zero indication. There was no evidence of fuel at the accident site or in the airplane. During the recovery of the airplane from the field, no fuel was found in the three intact fuel tanks, nor in any of the engine fuel lines. The pilot later stated that he ran the airplane out of fuel during the accident flight. The pilot reported that, during the preflight checks and twice during the accident flight, he activated the low fuel warning light, and no anomalies were noted. Postaccident testing of the low fuel warning light in an exemplar Piper Aerostar 602P revealed no anomalies.

The instrument-rated pilot of the business jet airplane, pilot-rated passenger, and five passengers departed on a cross-country flight and entered the clouds while performing a climbing right turn. The airplane then began to descend, and air traffic control (ATC) asked the pilot to confirm altitude and heading. The pilot did not respond. After a second query from ATC, the pilot acknowledged the instructions. The airplane entered a climbing right turn followed by a left turn. After ATC made several attempts to contact the pilot, the airplane entered a rapid descending left turn and impacted a shallow reservoir at a high rate of speed. Postaccident examination of the recovered wreckage and both engines revealed no evidence of any preimpact mechanical malfunctions or failures that would have precluded normal operation. Flight track data revealed that after takeoff, the airplane entered the clouds and made a series of heading changes, along with several climbs and descents, before it entered a steep, descending left turn. This type of maneuvering was consistent with the onset of a type of spatial disorientation known as somatogravic illusion. According to a National Transportation Safety Board performance study, accelerations associated with the airplane’s increasing airspeed were likely perceived by the pilot as the airplane pitching up although it was in a continuous descent. This occurred because the pilot was experiencing spatial disorientation and he likely did not effectively use his instrumentation during takeoff and climb. As a result of the pilot experiencing spatial disorientation, he likely experienced a high workload managing the flight profile, which would have had a further adverse effect on his performance. As such, the airplane entered a high acceleration, unusual attitude, descending left turn from which the pilot was not able to recover. The pilot and the pilot-rated passenger did not report any medication use or medical conditions to the Federal Aviation Administration on their recent and only medical certification examinations. Postaccident specimens were insufficient to evaluate the presence of any natural disease during autopsy. However, given the circumstances of this accident, it is unlikely that the pilot’s or pilot-rated passenger’s medical condition were factors in this accident. Low levels of ethanol were detected in the pilot’s muscle tissue and the pilot-rated passenger’s muscle and kidney tissue; n-butanol was also detected in the pilot’s muscle tissue. Given the length of time to recover the airplane occupants from the water and the circumstances of this accident, it is reasonable that some or all of the identified ethanol in the pilot and the pilot-rated passenger were from sources other than ingestion. Thus, the identified ethanol in the pilot and the pilot-rated passenger did not contribute to this accident.

The airplane departed Myrtle Beach International Airport (MYR), Myrtle Beach, South Carolina, at 1812, with the intended destination of Grand Strand Airport (CRE), North Myrtle Beach, South Carolina. According to automatic dependent surveillance-broadcast and air traffic control (ATC) communications information, the pilot established contact with ATC and reported that he was ready for departure from runway 18. He was instructed to fly runway heading, climb to 1,700 ft mean sea level (msl), and was cleared for takeoff. Once airborne, the controller instructed the pilot to turn left; however, the pilot stated that he needed to return to runway 18. The controller instructed the pilot to enter a right closed traffic pattern at 1,500 ft msl. As the airplane continued to turn to the downwind leg of the traffic pattern, it reached an altitude of about 1,000 ft mean sea level (msl). While on the downwind leg of the traffic pattern, the airplane descended to 450 ft msl, climbed to 700 ft msl, and then again descended to 475 ft msl before radar contact was lost. About 1 minute after the pilot requested to return to the runway, the controller asked if any assistance was required, to which the pilot replied, “yes, we’re in trouble.” There were no further radio communications from the pilot. The airplane crashed in a field and was destroyed by impact forces and a post crash fire. The pilot, sole on board, was killed.