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Crash of a Piper PA-60-602P Super 700 Aerostar on Gabriola Island: 3 killed

Date & Time: Dec 10, 2019 at 1805 LT
Operator:
Registration:
C-FQYW
Flight Type:
Survivors:
No
Schedule:
Cabo San Lucas – Chino – Bishop – Nanaimo
MSN:
60-8265-020
YOM:
1982
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
320
Aircraft flight hours:
5752
Circumstances:
On 09 December 2019, a private Piper Aerostar PA-60-602P aircraft (registration C-FQYW, serial number 60-8265020), departed Cabo San Lucas International Airport (MMSL), Baja California Sur, Mexico, with 3 people on board, for a 2-day trip to Nanaimo Airport (CYCD), British Columbia (BC). As planned the aircraft stopped for an overnight rest at Chino Airport (KCNO), California, U.S. At 1142, on 10 December 2019, the aircraft departed KCNO on a visual flight rules (VFR) flight plan to Bishop Airport (KBIH), California, U.S., for a planned fuel stop. The aircraft departed KBIH at approximately 1425 on an instrument flight rules (IFR) flight plan to CYCD. On 10 December 2019, night started at 1654. At 1741, the Vancouver area control centre air traffic controller advised the pilot that an aerodrome special meteorological report (SPECI) had been issued for CYCD at 1731. The SPECI reported visibility as 2 ½ statute miles (SM) in light drizzle and mist, with an overcast ceiling of 400 feet above ground level (AGL). The pilot informed the controller that he would be conducting an instrument landing system (ILS) approach for Runway 16. At 1749, when the aircraft was approximately 32 nautical miles (NM) south of CYCD, the pilot contacted the controller to inquire about the weather conditions at Victoria International Airport (CYYJ), BC. The controller informed the pilot that a SPECI was issued for CYYJ at 1709 and it reported the visibility as 5 SM in mist, a broken ceiling at 600 feet AGL, and an overcast layer at 1200 feet AGL. The controller provided the occurrence flight with pilot observations from another aircraft that had landed at CYCD approximately 15 minutes before. That crew had reported being able to see the Runway 16 approach lights at minimums, i.e., at 373 feet AGL. Between 1753 and 1802, the controller provided vectors to the pilot in order to intercept the ILS localizer. At 1803, the controller observed that the aircraft had not intercepted the localizer for Runway 16. The aircraft had continued to the southwest, past the localizer, at an altitude of 2100 feet above sea level (ASL) and a ground speed of 140 knots. The controller queried the pilot to confirm that he was still planning to intercept the ILS for Runway 16. The pilot confirmed that he would be intercepting the ILS as planned. The aircraft made a heading correction and momentarily lined up with the localizer before beginning a turn to the west. At 1804:03, the pilot requested vectors from the controller and informed him that he “just had a fail.” The controller responded with instructions to “turn left heading zero nine zero, tight left turn.” The pilot asked the controller to repeat the heading. The controller responded with instructions to “…turn right heading three six zero.” The pilot acknowledged the heading; however, the aircraft continued turning right beyond the assigned heading while climbing to 2500 feet ASL and slowing to a ground speed of 80 knots. The aircraft then began to descend, picking up speed as it was losing altitude. At 1804:33, the aircraft descended to 1800 feet ASL and reached a ground speed of 160 knots. At 1804:40, the pilot informed the air traffic controller that the aircraft had lost its attitude indicator.Footnote6 At the same time, the aircraft was climbing into a 2nd right turn. At 1804:44, the air traffic controller asked the pilot what he needed from him; the pilot replied he needed a heading. The controller provided the pilot with a heading of three six zero. At 1804:47, the aircraft reached an altitude of 2700 feet ASL and a ground speed of 60 knots. The aircraft continued its right turn and began to lose altitude. The controller instructed the pilot to gain altitude if he was able to; however, the pilot did not acknowledge the instruction. The last encoded radar return for the aircraft was at 1805:26, when the aircraft was at 300 feet ASL and travelling at a ground speed of 120 knotsControl of the aircraft was lost. The aircraft collided with a power pole and trees in a wooded park area on Gabriola Island, BC, and then impacted the ground. The aircraft broke into pieces and caught fire. The 3 occupants on board received fatal injuries. As a result of being damaged in the accident, the emergency locator transmitter (Artex ME406, serial number 188-00293) did not activate.
Probable cause:
The occurrence aircraft was equipped with a BendixKing KI 825 electronic horizontal situation indicator (HSI) that was interfaced to the flight control system and GPS (global positioning system) Garmin GNS530W/430W. The HSI also supplies the autopilot system with heading information. The investigation determined that the HSI had failed briefly during operation on 22 November 2019 and a 2nd time, 3 days later, on 26 November 2019. The KI 825 HSI is electrically driven and therefore is either on and working, or off and dark with no display. The aircraft owner was in contact with an aircraft maintenance organization located at Boundary Bay Airport (CZBB), BC, and an appointment to bring the occurrence aircraft in for troubleshooting of the 2 brief HSI malfunctions had been made for 11 December 2019, i.e., the day after the accident. In total, 13 flights had been conducted after the 1st failure of the HSI. There were no journey log entries for defects with the HSI or evidence of maintenance completed. RegulationsFootnote9 require that defects that become apparent during flight operations be entered in the aircraft journey logbook, and advisory guidance in the regulatory standardsFootnote10 states that all equipment required for a particular flight or type of operation, such as the HSI in this case, be functioning correctly before flight. The HSI was destroyed in the accident and the investigation was unable to determine if it was operational on impact. Similarly, it could not be determined if the HSI was supplying the autopilot with heading information, or if the autopilot was engaged during the approach.
Final Report:

Crash of a Pilatus PC-6/C-H2 Turbo Porter in Vigo Park

Date & Time: Aug 28, 2003 at 1700 LT
Operator:
Registration:
N394R
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Bishop - Dalhart
MSN:
599
YOM:
1966
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
33000
Captain / Total hours on type:
10004.00
Aircraft flight hours:
15120
Circumstances:
During cruise flight, the 33,000-hour pilot stated that the airplane encountered "extreme clear air turbulence followed by three jolts in rapid succession." He "heard a loud pop as he jerked the throttle to the flight idle position." As the airspeed was slowing, the pilot attempted to add power. The "throttle would not move from the flight idle position and the propeller went into BETA." The airplane pitched downward as the pilot continued to try and "push the throttle lever forward." The airplane established "a rate of descent in excess of 10,000 feet per minute at a near vertical attitude." The pilot initiated an evacuation of the airplane and deployed his parachute (the pilot was wearing a sport parachute during the flight). Subsequently, the airplane impacted terrain. During a post accident examination, no mechanical anomalies were noted on the airframe, propeller, or engine that could have caused the accident. The reason for the loss of propeller pitch control could not be determined.
Probable cause:
The loss of propeller pitch control for undetermined reasons.
Final Report:

Crash of a Cessna 340A in Bishop: 1 killed

Date & Time: Aug 8, 2003 at 2132 LT
Type of aircraft:
Operator:
Registration:
N340DC
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Bishop - Upland
MSN:
340A-0968
YOM:
1980
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
1302
Captain / Total hours on type:
1.00
Aircraft flight hours:
1123
Circumstances:
During a nighttime takeoff initial climb, the airplane collided with terrain near the airport. Witnesses reported watching the airplane accelerate on runway 12, rotate, and climb to 200 to 300 feet above ground level. The climb rate decreased and the airplane appeared to initiate a left turn, with the roll continuing to a wings vertical attitude. At this point the airplane descended into the terrain. One witness north of the accident site described the landing lights going from horizontal to vertical followed by a decrease in engine sound just before impact. According to the airplane owner, the pilot had never flown the accident airplane before the first leg to the accident location to drop off the owner and another passenger. Examination of the pilot records failed to locate any previous flight time in Cessna 300 or 400 series airplanes. In the last 30 days he had given instruction in a smaller light twin engine airplane. Post accident examination of the wreckage revealed the landing gear to be in the down position at the time of impact. The retractable landing lights were extended and the nose gear taxi light was destroyed. Both propellers exhibited symmetrical power signatures. No preimpact mechanical malfunctions or failures were identified. The impact site was east of the airport about 0.68 nautical miles. The departure direction is towards a mountain range with sparse population and few ground reference lights. The moon's disk was 25 degrees above the southeastern horizon and was 89 percent illuminated. The FAA AC61-23C Pilot's Handbook of Aeronautical Knowledge addresses the environmental factors and potential in-flight visual illusions, which could affect pilot performance. The reference material describes Somatogravic Illusion as, "a rapid acceleration during takeoff can create the illusion of being in a nose up attitude. The disoriented pilot will push the airplane into a nose low, or dive attitude. A rapid deceleration by a quick reduction of the throttles can have the opposite effect, with the disoriented pilot pulling the airplane into a nose up, or stall attitude."
Probable cause:
The pilot's in-flight loss of control due to a Somatogravic illusion and/or spatial disorientation. Factors in the accident were the dark lighting conditions and the pilot's lack of familiarity with the airplane.
Final Report:

Crash of a Rockwell Grand Commander 690A in Bishop: 4 killed

Date & Time: Aug 11, 2002 at 0123 LT
Operator:
Registration:
N690TB
Flight Type:
Survivors:
No
Schedule:
Oakland - Bishop
MSN:
690-11109
YOM:
1973
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
3802
Captain / Total hours on type:
52.00
Aircraft flight hours:
3782
Circumstances:
The pilot entered the left-hand traffic pattern at an uncontrolled airport on a dark moonless night. Witnesses reported observing the airplane in a left descending turn. As the airplane turned onto the base leg, its left bank angle suddenly became steep. The airplane rapidly descended until colliding with level desert terrain 1.63 nm from runway 30's threshold. There were no ground reference lights in the accident site area. An examination of the airplane structure, control systems, engines, and propellers did not reveal any evidence of preimpact malfunctions or failures. Signatures consistent with engine power were found in both the engines and the propellers. The wreckage examination revealed that the airplane descended into the terrain in a left wing and nose low attitude. Fragmentation evidence, consisting of the left navigation light lens and left propeller spinner, was found near the initial point of impact. The wreckage was found principally distributed along a 307- to 310-degree bearing, over a 617- foot-long path. The bearing between the initial point of impact and the runway threshold was 319 degrees. The pilot's total logged experience in the accident airplane was 52 hours, of which only 1.6 hours were at night. The pilot was familiar with the area, but he had made only two nighttime landings within the preceding 90 days. Review of the recorded ATC communications tapes did not reveal any evidence of pilot impairment during voice communications with the pilot.
Probable cause:
The pilot's failure to maintain an appropriate terrain clearance altitude while maneuvering in the traffic pattern due to the sensory and visual illusions created by a lack of ground reference lights and/or terrain conspicuity, and the dark nighttime conditions.
Final Report:

Crash of a Beechcraft C99 Airliner near Bishop: 1 killed

Date & Time: Feb 12, 1999 at 1030 LT
Type of aircraft:
Operator:
Registration:
N205RA
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Tonopah - Bishop
MSN:
U-205
YOM:
1983
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
2958
Captain / Total hours on type:
692.00
Aircraft flight hours:
20522
Circumstances:
The airline transport pilot was repositioning the Beech C99 turboprop cargo hauler on a 73-mile trip without cargo. The pilot had been flying this route for some time and this was his last trip before upgrading to a larger aircraft and route. He told friends that he would take pictures of the scenic parts of the route on his last trip. Three witnesses reported seeing the airplane flying west at low altitude. Two of the witnesses were local ranchers who saw the airplane enter the White Mountains near Trace Plumas Canyon about 7,000 to 8,000 feet msl. White Mountain is 14,246 feet, tapering off north to 13,559 feet and south to 11,285 feet msl. The airplane was reported missing and 2 days later located on White Mountain about 9,400 feet msl. The company flight planned route is 15 miles south of the accident site through Westgard Pass, about 7,291 feet msl. Examination of the low energy impact and the subsequent recovery inspection failed to reveal any mechanical issues.
Probable cause:
The pilot's failure to follow procedures and directives and his failure to maintain clearance from mountainous terrain.
Final Report:

Crash of a Cessna 414A Chancellor near Big Pine: 1 killed

Date & Time: Jul 31, 1988 at 1217 LT
Type of aircraft:
Registration:
N414YV
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Bishop - San Diego
MSN:
414A-0529
YOM:
1980
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
3500
Circumstances:
The pilot-owner decided to overfly a glacier which was located in the Sierra Nevada Mountains. The glacier was located near the 12,000 foot msl base of a 14,000 foot msl mountain near the head of a box canyon. Witnesses reported clearly observing the aircraft enter the canyon area. When the aircraft was nearly over the glacier the aircraft was observed to commence a course reversal. During the turn the aircraft stalled, descended rapidly and crashed into rocky 40° upsloping terrain whereupon it burned. The pilot, sole on board, was killed.
Probable cause:
The pilot intentionally flew over an area of high terrain in which he failed to maintain the proper altitude and he delayed his decision to reverse course. A contributing factor was the pilot's improper inflight decision.
Findings:
Occurrence #1: loss of control - in flight
Phase of operation: maneuvering - turn to reverse direction
Findings
1. Terrain condition - blind/box canyon
2. Terrain condition - high terrain
3. (c) remedial action - delayed - pilot in command
4. (f) in-flight planning/decision - improper - pilot in command
----------
Occurrence #2: in flight collision with terrain/water
Phase of operation: descent - uncontrolled
Findings
5. (c) proper altitude - not maintained - pilot in command
6. (c) stall - inadvertent - pilot in command
Final Report:

Crash of a Piper PA-61P Aerostar (Ted Smith 601P) in Bishop: 1 killed

Date & Time: Dec 9, 1979 at 1330 LT
Registration:
N600WW
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Bishop - Bishop
MSN:
61P-0269-056
YOM:
1976
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
1765
Captain / Total hours on type:
500.00
Circumstances:
The pilot, sole on board, was completing a solo practice flight in the vicinity of Bishop Airport. While flying at low height, he lost control of the airplane that stalled and crashed in a field. The aircraft was destroyed and the pilot was killed.
Probable cause:
Stall during a low pass after the pilot failed to maintain flying speed.
Final Report:

Crash of a Convair CV-440 Metropolitan in Bishop: 36 killed

Date & Time: Mar 13, 1974 at 2028 LT
Operator:
Registration:
N4819C
Flight Phase:
Survivors:
No
Site:
Schedule:
Bishop - Burbank
MSN:
138
YOM:
1953
Flight number:
SZ802
Crew on board:
4
Crew fatalities:
Pax on board:
32
Pax fatalities:
Other fatalities:
Total fatalities:
36
Captain / Total flying hours:
9902
Captain / Total hours on type:
1742.00
Copilot / Total flying hours:
2845
Copilot / Total hours on type:
2500
Aircraft flight hours:
41112
Circumstances:
The aircraft was chartered by Wolper Productions Inc. to fly a movie production crew from Bishop (BIH) to Burbank (BUR). The cast and crew of the television series 'Primal Man' was returning from shooting a prehistoric hunting sequence in the snow-covered Sierra. Amongst the crew were director-writer Dennis Azzarella and actor Janos Prohaska. Flight 802 departed Hollywood-Burbank Airport at 18:14 to pick up the passengers at Bishop. The flight from Burbank to Bishop was conducted under VFR conditions and at 19:10 the crew contacted the Tonopah Flight Service Station (FSS) and cancelled their VFR flight plan. The crew then "air filed" an IFR flight plan for the return trip from Bishop to Burbank. The aircraft landed at Bishop at 19:20. Baggage and equipment were loaded and 32 passengers boarded the flight. The Convair CV-440 departed the gate at about 20:20. The crew then contacted the Tonopah FSS and advised that they were taxiing for departure and requested that their IFR clearance be activated. After takeoff from runway 12 the flight made a climbing right turn, circled back over, or near, the BIH VOR and then proceeded outbound in an east-southeasterly direction. At 20:24 Flight 802 again contacted the Tonopah FSS and reported that they were off Bishop at 20:20 and were, "climbing VFR over Bishop, awaiting clearance." About four minutes later the aircraft struck a foothill in the White Mountain range at an elevation of 6,100 feet. The aircraft was on a heading of about 175° magnetic and in an approximate 25° bank to the right at impact. All 36 occupants were killed.
Probable cause:
It was not possible to determine the probable cause of this accident. The reason why the flight crew did not maintain a safe distance from hazardous terrain during night visual flight conditions could not be established.
Final Report: