Human factor

On 23 December 2017, at 00:10 UTC (10:10 local), a Britten Norman BN-2A Islander aircraft, registered P2-ISM (ISM), owned and operated by North Coast Aviation, impacted a ridge, at about 9,500 ft (6°11'29"S, 146°46'11"E) that runs down towards the Sapmanga Valley from the Sarawaget Ranges, Morobe Province. The pilot elected to track across the Sarawaget ranges (See figure 1), from Derim Airstrip to Nadzab Airport, Morobe Province, not above 10,000 ft. The track flown from Derim was to the northwest 6.5 nm (12 km) to a point 0.8 nm (1.5 km) westsouthwest of Yalumet Airstrip where the aircraft turned southwest to track to the Saidor Gap. GPS recorded track data immediately prior to the last GPS fix showed that the aircraft was on a shallow descent towards the ridge. The aircraft impacted the ridge about 150 m beyond the last fix. There were no reports of a transmission of an ELT distress signal. During the search for the aircraft, what appeared to be the right aileron was found hanging from a tree near the top of the heavily-timbered, densely-vegetated ridge. The remainder of the wreckage was found about 130 m from the aileron along the projected track. The aircraft impacted the ground in a steep nose-down, right wing-low attitude. The majority of the aircraft wreckage was contained at the ground impact point. The aircraft was destroyed by impact forces. The pilot, the sole occupant, who initially survived, was reported deceased by the rescue team on 27 December 2017 at 22:10. The pilot had made contact with one of the operator’s pilots at 16:15 on 23 December. The pilot’s time of death, recorded on the Death Certificate, was 10:40 am local on 24 December. Rescuers felled trees on the steep heavily timbered, densely vegetated slope about 20 metres from the wreckage and constructed a helipad.

The twin engine aircraft was departing Bahía Solano-José Celestino Mutis Airport on a flight to Quibdó, carrying seven passengers and two pilots. During the takeoff roll on runway 36, the airplane deviated to the right and veered off runway. While contacting soft ground, the right main gear collapsed. The aircraft rotated and came to rest in a grassy area about 5 metres to the right of the runway. All 9 occupants evacuated safely and the aircraft was damaged beyond repair.

The single engine aircraft (an Antonov An-2TP that was converted in 2014 with a TPE331 turbine engine) departed Naryan-Mar Airport on a schedule service (flight NYA9280) to Kharuta, Republic of Komi, carrying 11 passengers and two pilots. Shortly after takeoff, while climbing to a height of 30-40 metres, the aircraft entered an excessive nose-up attitude then rolled to the right, stalled and crashed in a snow covered field. A passengers was killed and 12 other occupants were injured. In the evening, two other passengers died and a fourth passed away on 10 January 2018.

The flight instructor, commercial pilot receiving instruction, and commercial pilot-rated passenger were conducting an instructional flight in the multi-engine airplane during instrument meteorological conditions. After performing a practice instrument approach, the flight was cleared for a second approach; however, the landing runway changed, and the controller vectored the airplane for an approach to the new runway. The pilot was instructed to turn to a southwesterly heading and maintain 1,600 ft until established on the localizer. Radar information revealed that the airplane turned to a southwesterly heading on a course to intercept the localizer and remained at 1,600 ft for about 1 minute 39 seconds before beginning a descending right turn to 1,400 ft. The descent continued to 1,100 ft; at which time the air traffic control controller issued a low altitude alert. Over the following 10 seconds, the airplane continued to descend at a rate in excess of 4,800 ft per minute (fpm). The controller issued a second low altitude alert to the crew with instructions to climb to 1,600 ft immediately. The pilot responded about 5 seconds later, "yeah I am sir, I am, I am." The airplane then climbed 1,400 ft over 13 seconds, resulting in a climb rate in excess of 6,700 fpm, followed by a descent to 1,400 ft over 5 seconds, resulting in a 1,500-fpm descent before radar contact was lost in the vicinity of the accident site. Radar data following the initial instrument approach indicated that the airplane was flying a relatively smooth and consistent flightpath with altitude and heading changes that were indicative of autopilot use until the final turn to intercept the localizer course. Maneuvering the airplane in restricted visibility placed the pilot in conditions conducive to the development of spatial disorientation. The accident circumstances, including altitude and course deviations and the subsequent high-energy impact, are consistent with the known effects of spatial disorientation. Additionally, examination of the airframe, engines, and propellers revealed no evidence of any preexisting anomalies that would have precludednormal operation. Therefore, it is likely that the pilot receiving instruction was experiencing the effects of spatial disorientation when the accident occurred. Toxicology testing of the flight instructor identified significant amounts of oxycodone as well as its active metabolite, oxymorphone, in liver tissue; oxycodone was also found in muscle. Oxycodone is an opioid pain medication available by prescription that may impair mental and/or physical ability required for the performance of potentially hazardous tasks. The flight instructor's tissue levels of oxycodone suggest that his blood level at the time of the accident was high enough to have had psychoactive effects, and his failure to recognize and mitigate the pilot's spatial disorientation and impending loss of control further suggest that the flight instructor was impaired by the effects of oxycodone. Toxicology testing of all three pilots identified ethanol in body tissues; however, given the varying amounts and distribution, it is likely that the identified ethanol was from postmortem production rather than ingestion.

The private pilot departed on a cross-country flight in his high-performance, turbine-powered airplane with full tanks of fuel. He landed and had the airplane serviced with 150 gallons of fuel. He subsequently departed on the return flight. As the airplane approached the destination airport, the pilot asked for priority handling and reported that the airplane "lost a transfer pump and had a little less fuel than he thought," and he did not want to come in with a single engine. When asked if he needed assistance, he replied "negative." The pilot was cleared to perform a visual approach to runway 19 during night conditions. As the airplane approached the airport, the pilot requested the runway lights for runway 25 be turned on and reported that the airplane lost engine power in one engine. The controller advised that the lights on runway 25 were being turned on and issued a landing clearance. The airplane impacted terrain before the threshold for runway 25. During examination of the recovered wreckage, flight control continuity was established. No useable amount of fuel was found in any of the airplane's fuel tanks; however, fuel was observed in the fuel lines. All transfer pumps and boost pumps were operational. The engine-driven fuel pumps on both engines contained fuel in their respective fuel filter bowls. Both pumps were able to rotate when their input shafts were manipulated by hand. Disassembly of both pumps revealed that their inlet filters were free of obstructions. Bearing surfaces in both pumps exhibited pitting consistent with pump operation with inadequate fuel lubrication and fuel not reaching the pump. The examination revealed no evidence of airframe or engine preimpact malfunctions or failures that would have precluded normal operation of the airplane. Performance calculations using a flight planning method described in the airplane flight manual indicated that the airplane could have made the return flight with about 18 gallons (119 lbs) of fuel remaining. However, performance calculations using a fuel burn simulation method developed from the fuel burn and data from the airplane flight manual indicated that the airplane would have run out of fuel on approach. Regulations require that a flight depart with enough fuel to fly to the first point of intended landing and, assuming normal cruising speed, at night, to fly after that for at least 45 minutes. The calculated 45-minute night reserves required about 56 gallons (366 lbs) of fuel using a maximum recommended cruise power setting or about 37.8 gallons (246 lbs) of fuel using a maximum range power setting. Regardless of the flight planning method he could have used, the pilot did not depart on the accident flight with the required fuel reserves and exhausted all useable fuel while on approach to the destination. The airplane was owned by Edward B. Noakes III.

On 22 November 2017, the pilot-in-command (PIC) accompanied by the first officer (FO) took off from the Cape Town International Airport (FACT) on a private flight to the Rand Airport (FAGM). The flight was conducted under instrument flight rules (IFR) by day and the approach was conducted under visual flight rules (VFR). The PIC was the pilot flying (PF) and was seated on the left seat and the FO was occupying the right seat. The air traffic controller (ATC) on duty at FAGM tower stated that the FO reported in-bound for a fullstop landing at FAGM. The last wind direction data for Runway 29 was transmitted to the FO as 230°/11 knots (kts) and Query Nautical Height (QNH): 1021. The FO acknowledged the transmission and the crew elected to land on Runway 11. The PIC stated that the approach for landing was stable and that the touchdown was near the first taxiway exit point. According to the FO, the aircraft floated for a while before touchdown. This was confirmed during the investigation. During the landing rollout, the PIC applied the brakes and the brakes responded for a short while, however, the aircraft continued to roll without slowing down. At approximately 300 metres (m) beyond the intersection of Runway 35 and Runway 11, the PIC requested the FO to apply emergency brakes. The FO applied the emergency brakes gradually and the aircraft continued to roll before the brakes locked and the tyres burst. The aircraft skidded on the main wheels and continued for approximately 180m until it overshot the runway. The undercarriage went over a ditch of approximately 200 millimetres in depth at the end of the runway into the soft ground and the aircraft came to a stop approximately 10m from the threshold facing slightly left off the extended centre line Runway 11. The aircraft was substantially damaged during the impact sequence and none of the occupants sustained injuries. The crash alarm was activated by the tower and the fire services responded to the scene.

On 17 November, 2017, a Tropic Air Cessna 208B Grand Caravan with registration V3-HGX, departed from the Sir Barry Bowen Municipal Airport at approximately 7:15 a.m. local time with one aircraft captain, 11 passengers and 1 crew on board. The flight was a regular operated commercial passenger flight with scheduled stops in Dangriga, Placencia and with the final destination being Punta Gorda. The pilot reported that the portion of the flight from Belize City to Dangriga was uneventful and normal and so was the landing at Placencia. At approximately 8:40 a.m. local time the airplane taxied from the Tropic Air ramp and taxied towards the west on runway 25. The pilot did a turnaround using all the available runway at normal speed and started his takeoff run to the east on runway 07. The pilot proceeded down the runway in a normal takeoff roll with normal takeoff speed and prior to reaching the end of the runway, he rotated the aircraft and lifted the nose wheel to get airborne. At exactly 28 feet past the end of runway 07 and during the initial climb phase, a part of the aircraft landing gear made contact with the upper part of the front righthand passenger door frame of a vehicle that had breached the area in front of the runway which is normally protected by traffic barriers. The impact caused the aircraft to deviate from its initial climb profile, and the pilot reported that the engine was working for a couple seconds and it abruptly shut down shortly after. The pilot realized that he was unable to return to the airport. The pilot carried out emergency drills for engine loss after take-off over water and decided to ditch the aircraft in the sea, which was approximately 200-300 feet from the main shoreline in front of the Placencia airport. The flight crew and all passengers were safely evacuated from the fuselage with the assistance of witnesses and passing boats which provided an impromptu rescue for the passengers. All passengers received only minor injuries.

The single engine airplane departed Arusha Airport on a charter flight to the Serengeti National Park, carrying 10 tourists and one pilot. While flying in marginal weather conditions, the aircraft impacted hilly terrain near Empakaai Camp and was destroyed upon impact. All 11 occupants were killed.

The aircraft took off from the Bom Futuro Municipal Aerodrome (SILC), Lucas do Rio Verde - MT, to the Anápolis Aerodrome (SWNS) - GO, in order to carry out a transfer flight, with a pilot and three passengers on board. During the flight, the pilot identified conflicting information related to the amount of fuel remaining and chose to make an intermediate landing on an unapproved runway, located in the city of Goiás Velho - GO, in order to check the data visually. After the conference, the N154KQ took off from that location and, reaching approximately 300ft height, the aircraft lost power, colliding with vegetation 1.86 km from the runway used for takeoff. The aircraft was destroyed by the fire. The pilot suffered serious injuries and the three passengers suffered minor injuries.

The pilot of the turbine-powered airplane reported that, while landing in a gusting crosswind, it was "obvious" the wind had changed directions. He performed a go-around, but "the wind slammed [the airplane] to the ground extremely hard." Subsequently, the airplane veered to the right off the runway and then back to the left before coming to rest. The airplane sustained substantial damage to the fuselage. The pilot reported that there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation. The automated weather observation system located at the accident airport reported that, about the time of the accident, the wind was from 270° at 19 knots, gusting to 25 knots. The pilot landed on runway 20.