Crash of a Cessna 402C in Nassau

Date & Time: Feb 17, 2024 at 1637 LT
Type of aircraft:
Operator:
Registration:
C6-JTJ
Flight Phase:
Flight Type:
Survivors:
Yes
MSN:
402C-0648
YOM:
1982
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Shortly after takeoff from Nassau-Lynden Pindling Airport Runway 14, while in initial climb, the twin engine airplane went out of control and crashed in a pond, bursting into flames. The pilot, sole on board, escaped uninjured while the airplane was destroyed.

Crash of a Piper PA-31-310 in Deadmans Cay: 1 killed

Date & Time: Jun 5, 2022 at 0905 LT
Type of aircraft:
Operator:
Registration:
N711JW
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Deadmans Cay - Nassau
MSN:
31-7712084
YOM:
1977
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
1
Aircraft flight hours:
7102
Circumstances:
Shortly after takeoff from Deadmans Cay Airport Runway 09, while climbing, both engines lost power simultaneously. The airplane went out of control, impacted trees and crashed some 3 km northwest of the airfield. The airplane came to rest in bushes and was destroyed by impact forces. There was no fire. Among the seven people on board, a woman passenger was killed and six other occupants were injured.
Probable cause:
The AAIA has determined the probable cause of this accident to be Loss of Power (Dual) resulting in a loss of control inflight (LOC-I), and subsequent uncontrolled flight into terrain.
Final Report:

Crash of a IAI 1124A Westwind II in Treasure Cay: 2 killed

Date & Time: Jul 5, 2021 at 1545 LT
Type of aircraft:
Operator:
Registration:
N790JR
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Treasure Cay – Nassau
MSN:
424
YOM:
1984
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
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).
Probable cause:
The AAIA has classified the accident as a controlled flight into terrain (CFIT) and determined the probable cause of the CFIT accident is due to the failure of the aircraft to climb (perform) as required.
Contributing factors which resulted in the failure of the aircraft to perform as required includes:
- Failure of the crew to configure the aircraft for the proper takeoff segment,
- Crew unfamiliarity with the aircraft systems.
Final Report:

Crash of a Douglas DC-3C off Nassau

Date & Time: Oct 18, 2019 at 1630 LT
Type of aircraft:
Operator:
Registration:
N437GB
Flight Type:
Survivors:
Yes
Schedule:
Miami - Nassau
MSN:
19999
YOM:
1944
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On the 18th October 2019, at approximately 4:30 PM local time, a Douglas DC-3C aircraft, registration N437GB crashed in the ocean; at coordinates 25°05.55N 077°30.29W, approximately 2.87miles from Runway 14 at the Lynden Pindling International Airport (MYNN) Nassau, Bahamas. There were 2 souls on board. The pilot reported that the left engine failed approximately 25-30 nautical miles from MYNN. The pilot further stated that during single engine operation, the aircraft performance was not optimal so the decision was made to land the aircraft in the ocean. The Air Traffic Control tower was notified by the crew of N437GB, that they will be performing a control water landing. The Royal Bahamas Defense Force was notified. Rescue efforts were then put into place. No injuries were received by the occupants of the aircraft. Aircraft could not be located for physical analysis to be carried out. The weather at the time of the accident was visual meteorological conditions and not a factor in this accident. A limited scope investigation was conducted, no safety message or recommendations were issued.
Probable cause:
Failure of the left engine on approach for unknown reasons.
Final Report:

Crash of a Convair C-131B Samaritan off Miami: 1 killed

Date & Time: Feb 8, 2019 at 1216 LT
Type of aircraft:
Operator:
Registration:
N145GT
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Nassau - Miami
MSN:
256
YOM:
1955
Flight number:
QAI504
Location:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
23000
Captain / Total hours on type:
725.00
Copilot / Total flying hours:
650
Copilot / Total hours on type:
305
Aircraft flight hours:
12701
Circumstances:
According to the first officer, during the first cargo flight of the day, the left engine propeller control was not working properly and the captain indicated that they would shut down the airplane and contact maintenance if the left engine propeller control could not be reset before the return flight. For the return flight, the engines started normally, and both propellers were cycled. The captain and the first officer were able to reset the left propeller control, so the airplane departed with the first officer as the pilot flying. The takeoff and initial climb were normal; however, as the airplane climbed through 4,000 ft, the left engine propeller control stopped working and the power was stuck at 2,400 rpm. The captain tried to adjust the propeller control and inadvertently increased power to 2,700 rpm. The captain then took control of the airplane and tried to stabilize the power on both engines. He leveled the airplane at 4,500 ft, canceled the instrument flight rules flight plan, and flew via visual flight rules direct toward the destination airport. The first officer suggested that they return to the departure airport, but the captain elected to continue as planned (The destination airport was located about 160 nautical miles from the departure airport). The first officer's postaccident statements indicated that he did not challenge the captain's decision. When the flight began the descent to 1,500 ft, the right engine began to surge and lose power. The captain and the first officer performed the engine failure checklist, and the captain feathered the propeller and shut down the engine. Shortly afterward, the left engine began to surge and lose power. The captain told the first officer to declare an emergency. The airplane continued to descend, and the airplane impacted the water "violently," about 32 miles east of the destination airport. The captain was unresponsive after the impact and the first officer was unable to lift the captain from his seat. Because the cockpit was filling rapidly with water, the first officer grabbed the life raft and exited the airplane from where the tail section had separated from the empennage. The first officer did not know what caused both engines to lose power. The airplane was not recovered from the ocean, so examination and testing to determine the cause of the engine failures could not be performed. According to the operator, the flight crew should have landed as soon as practical after the first sign of a mechanical issue. Thus, the crew should have diverted to the closest airport when the left engine propeller control stopped working and not continued the flight toward the destination airport.
Probable cause:
The captain's decision to continue with the flight with a malfunctioning left engine propeller control and the subsequent loss of engine power on both engines for undetermined reasons, which resulted in ditching into the ocean. Contributing to the accident was the first officer's failure to challenge the captain's decision to continue with the flight.
Final Report:

Crash of a Piper PA-31-350 Navajo Chieftain off Nassau: 1 killed

Date & Time: Dec 2, 2014 at 0845 LT
Operator:
Registration:
C6-REV
Flight Phase:
Survivors:
Yes
Schedule:
Governor’s Harbour – Nassau
MSN:
31-7652062
YOM:
1976
Flight number:
302
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
10
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
7650
Aircraft flight hours:
11744
Circumstances:
On Tuesday December 2nd, 2014 at approximately 8:45 am (1345Z) a Ferg’s Air Limited, Piper PA-31-350 Navajo aircraft, registration C6-REV, operated as Southern Air Limited Flight 302, ditched in waters approximately 6nm from shore in the southwestern district of New Providence. The flight originated at Governor’s Harbour, Eleuthera (MYEM) with 10+1 persons on board at approximately 8:15 am in Visual Meteorological Conditions (VMC). At around 8:30am, the aircraft 15 nautical miles east of Lynden Pindling International Airport at 4,500 feet contacted Nassau Air Traffic Control Tower. The aircraft was instructed that runway 09 was in use and they can expect a landing on that runway. Upon final approach to runway 09, with the landing gears selected to the “EXTEND” position, only the nose and right main landing gear lights indicated the “down and locked” position. The left main landing gear light did not illuminate to indicate the “down and locked” position, so the landing was aborted and the pilot requested to go around so he could recycle and troubleshoot the landing gear issue. The pilot made a left turn, flew over the north western shoreline and recycled the landing gears a few times and also tried the emergency hand pump in an attempt to extend the gear. Despite all efforts, the left main landing gear light still did not illuminate to indicated the gear was in the safe “down and locked” position. At this time the aircraft was allowed to fly by the tower so that the controller may make a visual check of the landing gears to see if they were in the extended position. The controller advised the pilot that all gears “appeared to be extended”. Once again the pilot proceeded outbound to make another attempt for landing. For this approach the pilot made a right turn over the southwestern shoreline and proceeded downwind to runway 09. While on the downwind to runway 09 the pilot stated he began to experience problems with the right engine. The engine eventually stopped and all attempts to restart were unsuccessful. As a result of single engine operation, level flight could not be maintained even after retracting the gears and cleaning up the airplane. The decision was made by the pilot to ditch in the water vs. attempting to make the airport where numerous trees and obstacles would make the landing more difficult if the runway could not be made. After touching down on the water the most of the occupants were able to evacuate the aircraft through the normal and emergency exits before the aircraft sank into the ocean. One passenger died during the process. Witness stated that “the plane skipped across the water three times before rotating and hitting with a severe impact. The port (left) tail section received the bulk of the impact as did the port side of the plane.” Eye witness further stated that the passenger that died and “luggage from the baggage compartment were ejected from the rear of the plane on the port side.” “Multiple passengers could not swim or were extremely limited in their ability to swim.” Despite the plane having the full complement of survival equipment (life vests), only two were taken out of the aircraft. Passengers were holding on to bags and other debris that floated out of the aircraft as it submerged. Passengers helped each other until rescuers arrived to assist. Estimates from eye witness were that “the entire plane disappeared under water from 30 to 60 seconds after impact.” The depth where the aircraft came to rest on the water was reported as in excess of 6,500 feet. Once the aircraft settled, it submerged and was not able to be recovered. Safety concerns raised by eye witness could not be confirmed as the plane was never recovered.
Probable cause:
The AAIPU determines that the probable causes of this accident as:
- Engine failure and the inability of the aircraft to maintain a safe altitude.
Contributing Factors includes:
- Failure of the left main landing gear.
The following findings were identified:
1. Weather was not a factor in the accident.
2. Air Traffic Services were proper and did not contribute to the cause of the accident.
3. The pilot was properly certified, trained and qualified for the flight.
4. The loss of power on the right engine resulted in the aircraft inability to maintain a safe altitude.
5. The Police and other emergency services response were timely and effective.
6. The depth of the water where the aircraft came to rest made it impossible for the aircraft to be recovered.
7. The aircraft was properly maintained in accordance with Bahamas and United States regulations and maintenance practices.
Final Report:

Crash of a Cessna 402C II in Mayaguana: 3 killed

Date & Time: Apr 4, 2013 at 0100 LT
Type of aircraft:
Operator:
Registration:
C6-BGJ
Flight Type:
Survivors:
Yes
Schedule:
Nassau - Mayaguana
MSN:
402C-0106
YOM:
1979
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
3
Circumstances:
On Thursday April 4, 2013 at approximately1:00AM DST (0500 UTC) a fixed wing, twin-engine, Cessna 402C aircraft Bahamas registration C6-BGJ, serial number 402C0106, crashed into obstacles (vehicles) while landing on Runway 06 at Mayaguana International Airport (MYMM), Abraham’s Bay, Mayaguana, Bahamas. The pilot in command stated that on April 3, 2013, he received a call at approximately 9:30PM from the Princess Margaret Hospital requesting emergency air ambulance services out of Mayaguana. The local police on the island was contacted to confirm lighting approval and availability in order to conduct the emergency flight. After confirming lighting arrangements with Nassau Air Traffic Control Services, and obtaining the necessary clearance, the pilot in command, along with a copilot and one passenger, (a nurse), proceeded with the flight to Mayaguana. The flight departed Lynden Pindling International Airport at approximately 1:30PM DST (0330UTC). The destination was Abraham’s Bay, Mayaguana, Bahamas. The pilot in command also reported “about 1 hour and 40 minutes later we arrived at Mayaguana Airport, leveled off at 1500 feet and about 4 miles left base Runway 06, we had the runway in sight via lighting from vehicles.” The crew continued with the landing procedures. The aircraft touch down approximately 300 feet from the threshold on runway 06, the pilot in command reported that prior to the nose gear making contact with the runway “the right wing hit an object (vehicle), causing the aircraft to veer out of control to the right eventually colliding with a second vehicle approximately 300 to 400 feet on the right side (southern) of Runway 06.” The impact of the right wing of the aircraft with the second vehicle, caused the right wing (outboard of the engine nacelle) and right fuel sealed wet wing tank to rupture releasing the aircraft fuel in that wing, which caused an explosion engulfing the vehicle in flames. The force of the impact with the second vehicle caused the right main gear to break away from the aircraft and it was flung ahead and to the left side of the runway approximately 200 feet from the point of impact with the truck. As the right main gear of the aircraft was no longer attached, the aircraft collapsed on its right side, slid onto the gravel south (right) of the runway and somewhere during this process, the nose gear also collapsed. The pilot immediately shut off the fuel valve of the aircraft and once the engines and the aircraft came to a stop, the three occupants evacuated the aircraft. The occupants of the aircraft did not sustain any visible injuries requiring medical attention or hospitalization. However, three (3) occupants of the second vehicle that was struck, were fatally injured. The airplane sustained substantial damages as a result of the impact and post impact crash sequence. The impact with the first vehicle occurred at approximately 427 feet from the threshold of runway 06 and at coordinates 28˚ 22’30”N and 073˚ 01’15’W. The flight was operated on an Instrument Flight Rules flight plan. Instrument Meteorological Conditions (night) prevailed at the time of the accident.
Probable cause:
Breakdown in communication during the planning and execution of an unapproved procedure has been determined to be the probable cause of this accident.
Other contributing factors:
- Use of an unapproved procedure to aid in a maneuver that was critical,
- Too many persons were planning the maneuver and not coordinating their actions,
- Failure of planners of the maneuver to verify whether participants were in the right position,
- Inexperienced persons used in the execution of a maneuver that was not approved,
- Vehicle parked to close to the side of the runway,
- Vehicle left with engine running while parked near the runway.
Final Report:

Crash of a Beechcraft A100 King Air in Deadmans Cay

Date & Time: Mar 9, 2012 at 1410 LT
Type of aircraft:
Operator:
Registration:
N70JL
Survivors:
Yes
Schedule:
Nassau - Deadmans Cay
MSN:
B-87
YOM:
1971
Country:
Crew on board:
0
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The twin engine aircraft was operating a taxi flight from Nassau-Lynden Pindling Airport to Deadmans Cay, and departed Nassau around 1 pm. On approach to Deadmans Cay, the crew encountered technical problems and was unable to lower the gear. The captain decided to perform a belly landing. The aircraft skidded on runway for several yards then veered off runway before coming to rest. There was no fire. While all occupants escaped uninjured, the aircraft was damaged beyond repair.

Crash of a Beechcraft C-45 Expeditor off Nassau: 2 killed

Date & Time: Dec 14, 2010 at 1510 LT
Type of aircraft:
Operator:
Registration:
N38L
Flight Type:
Survivors:
No
Schedule:
Fort Lauderdale – Nassau
MSN:
6323
YOM:
1944
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
While approaching Nassau-Lynden Pindling Airport runway 27 in poor weather conditions (cold front), the twin engine aircraft crashed into the sea few km offshore. Some debris were found floating on water north of Nassau. Both pilots were killed.

Crash of a Cessna 402C in Nassau: 9 killed

Date & Time: Oct 5, 2010 at 1236 LT
Type of aircraft:
Operator:
Registration:
C6-NLH
Flight Phase:
Survivors:
No
Schedule:
Nassau – Cockburn Town
MSN:
402C-0458
YOM:
1981
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
9
Captain / Total flying hours:
12000
Captain / Total hours on type:
10000.00
Circumstances:
On October 5, 2010 about 1636 UTC / 12:36pm Eastern Daylight Time (EDT), C6-NLH a Cessna 402C aircraft registered to Lebocruise Air Limited and operated by Acklins Blue Air Charter/Nelson Hanna crashed into lake Killarney shortly after becoming airborne from runway 14 at Lynden Pindling International Airport, Nassau, New Providence, Bahamas. The airplane sustained substantial damages by impact forces. The pilot, copilot and seven (7) passengers aboard the airplane received fatal injuries. The aircraft was on a passenger carrying flight from Lynden Pindling Intl Airport (MYNN) to Cockburn Town, San Salvador, Bahamas (MYSM). The aircraft was on a visual flight rules flight plan. Visual meteorological conditions prevailed at the time of the accident. The official notification of the accident was made to the Manager of the Flight Standards Inspectorate at Lynden Pindling Intl Airport, Nassau, N. P., Bahamas shortly thereafter. The investigation began the same day at approximately 1655 UTC upon notification of the IIC. The investigation was conducted by the Bahamas Civil Aviation Department [BCAD], Inspector Delvin R. Major (Investigator-in-Charge) of the Air Accident Investigation and Prevention Unit (AAIPU), Management of BCAD and Flight Standards Inspectorate (FSI), Airworthiness Inspectors, Operations Inspectors, Human Factors and other administrative staff. Valuable assistance was also received from the National Transportation Safety Board (NTSB), the Federal Aviation Administration (FAA) and Manufacturers of the aircraft and engine components. Three (3) Air Operator Certificate (AOC) holders at the Domestic Section of Lynden Pindling Intl Airport stated that on the day of the accident flight; one of the victims of the accident aircraft approached each of them individually at different times, requesting a quote and their availability to conduct a charter flight to Cockburn Town, San Salvador, Bahamas. Each AOC holder reported that they declined to conduct the charter because by looking at the amount of luggage and other equipment that accompanied the passengers and the size of the passengers that wanted to travel, in their estimation the combined weight appeared to be in excess of the weight that their respective aircraft (Cessna 402C and Hawker Beechcraft B100) can accommodate. After the AOC holders declined to conduct the charter, sometime thereafter, the same individual that was arranging the flight with the previous AOC holders made contact with Nelson Hanna / Acklins Blue Air Charter where arrangements were made to conduct the charter flight. The aircraft type certificate allowed for the aircraft to be operated by one (1) pilot, but the fatal flight was operated by a crew of two (2) pilots (according to eyewitness reports). The aircraft actual weight and center of gravity was unknown. As far as could be determined, the takeoff weight exceeded the maximum weight allowed of 6,850 pounds by more than 500 pounds. This excess in weight also placed the center of gravity of the aircraft outside of the safe envelope / limits for flight allowed by the manufacturer. The flight crew was given instructions by ATC to taxi from the business aviation apron (Executive Flight Support) for a takeoff on Runway 14 at intersection Foxtrot. (Intersection Foxtrot is 2,000 feet beyond the threshold of Runway 14, with a take-off run available of 9,353 feet. (Runway 14 - 11,353 feet long by 150 feet wide, see Appendix 5.15). According to eyewitness reports, from the initiation of takeoff power up to the point when the aircraft lost control white smoke was observed trailing behind the left engine of the aircraft. Eyewitnesses also reported that the take off appeared normal with gear being retracted shortly after takeoff and the aircraft seemed to be struggling to climb. The aircraft was seen at a low height, turning in a left direction over the lake as if trying to return for a landing at the airport. The bank of the aircraft changed from shallow to very steep to almost perpendicular to the ground, gears were extended and almost immediately the aircraft lost control and nose dived into the lake inverted. It cart wheeled, coming to rest upright, approximately ¼ mile from the approach end of runway 27. The aircraft came to rest on an approximate heading of 210 degrees. Eyewitness also reported hearing the engine run for a few seconds after the aircraft made contact with the water of the lake. There were no reports from the pilot to ATC of an emergency or any abnormalities with the aircraft or its systems after takeoff. The flight plan form filed for this flight listed one (1) soul on board; however, there were 7 additional occupants including a “second pilot” discovered onboard the accident flight the day of the accident. The aircraft's recovery and search for luggage, equipment and additional victims commenced shortly after the accident. This effort however, was hampered by inclement weather, rough lake conditions and darkness. On October 6th, the day after the crash, aircraft recovery continued. Family members of an additional person believed to be on board, advised the authorities that there was a ninth (9th) person on board. Search to recover any additional bodies continued but search and recovery efforts proved fruitless. On October 7th, the second day after the crash, the body of the ninth (9th) victim was found in the marshes and recovered from the southwestern end of the lake in the vicinity of where the fatal crash occurred.
Probable cause:
The following findings were identified:
1. Acklins Blue Air Charter was advertising and operating as a Bahamas air taxi operator without having undergone the certification process in contravention of Bahamas Civil Aviation (Safety) Regulations Schedule 12.
2. The airplane was issued a Certificate of Airworthiness on May 19, 2010, by the Bahamas Flight Standards Inspectorate, and was being operated by Acklins Blue Air Charter.
3. The Cessna 402C aircraft is classified in the performance Group C. This requires rapid feathering of the propeller of a failed engine and the raising of flap and the landing gear in order to achieve maximum climb performance.
4. The airplane maintenance records were not located; therefore, no determination could be made whether the airplane was being maintained in accordance with Bahamas Civil Aviation Regulations.
5. The 12,000 hour pilot and second pilot were not qualified to operate in Bahamas commercial air taxi operations.
6. No determination could be made whether the pilot or second pilot had completed required training and had accomplished a satisfactory recurrent flight check of their flying ability as required by CASR Schedule 12 and 14 for aircraft operating in commercial air transportation as well as the stipulation by the insurance policy.
7. Post-accident weight and balance calculations indicate the airplane was being operated approximately 523 pounds over maximum certificated takeoff weight (6,850 lb)
8. The pilot was advised by an air traffic controller that white smoke was trailing the left engine during takeoff; the pilot did not declare an emergency or advise the controller of any engine failure or mechanical abnormality.
9. The airplane's left engine could not produce rated shaft horsepower during takeoff.
10. Several factors contributing to the degradation of the airplane's performance and its inability to maintain flight include the wind-milling propeller, the pilot's intentional initiation of a steep turn to return to the departure airport, and his intentional lowering of the landing gear during the turn to return.
11. While turning to return, the airplane stalled, pitched nose down, and impacted in a lake.
12. The search and rescue efforts were timely and appropriate; however, the lack of accurate information on the pilot submitted flight plan delayed recovery of all victims.
13. The left propeller was not feathered.
14. The No. 2 cylinder of the left engine failed due to fatigue that originated in the root of the cylinder head thread that was engaged with the first thread on the barrel.
15. Post-accident inspection of the cockpit revealed several switches for the right engine were secured; however, no determination could be made when the switches were placed / moved in those positions.
16. No evidence of failure of the airplane's structures or flight control system contributed to the accident.
17. Existing regulations did not require the aircraft to be fitted with flight recorders. The lack of any recorded data about the aircraft's performance or the flight crew conversations deprived the investigation team of essential factual information.
18. Current Civil Aviation Department personnel and budget resources may not be sufficient to ensure that the quality of surveillance for certified as well as uncertified air carrier operations will improve.
19. Airside access procedures are inadequate at Fixed Base Operators. Access to the secure airside occurring without any check of individuals to challenge whether they have a legitimate reason for accessing the secure airside. FBO door to access airside is not secured or locked continuously; persons observed walking in and out without being challenged.
20. Flight Plan Forms are being accepted and transmitted to ATC with incomplete information. This information is vital for search and rescue purposes.
21. Weather was not a factor in the accident.
22. ATC was not a factor in the accident.
23. Currently flight plans for private flights are only required for international operations.
24. The pilot was aware of discrepancy associated with the manifold pressure reading of the left engine prior to takeoff. This discrepancy was brought to his attention by a client from the flight immediately preceding the accident flight.
25. The exact center of gravity of the accident airplane could not be calculated accurately as no indication of what seat each passenger occupied in the airplane and no indication of where luggage or equipment were placed on the aircraft could be determined. However, due to the exceedance of weight limits the aircraft was already outside the allowable center of gravity envelope developed by the manufacturer.
26. The pilot had insufficient time to prepare for the approach to runway 27 before beginning the approach. The airplane pitched up quickly into a stall, after extension of gear, recovery before ground impact was unlikely once the stall began.
27. Post accident inspection did not reveal any mechanical evidence or problems with the right hand engine.
28. The pilot's decision to return to the airfield was reasonable. Once the aircraft began to lose height a return to the airfield became impractical and a forced landing in the direction of flight should have been attempted.
29. The right propeller was never recovered from the lake.
The following causal factors were identified:
1. The left engine suffered a mechanical failure of the #2 cylinder, and therefore could not produce rated shaft horsepower. No indication of total loss of power with the left engine reported.
2. Right Engine electrical and engine control switches were found in the “OFF” position, therefore the aircraft was incapable of climbing on the power of one engine alone.
3. The excess weight above the maximum weight allowed for takeoff may have been an important factor in the aircraft's inability to gain adequate altitude after takeoff.
4. The pilot secured the right engine which was mechanically capable of producing power resulting in a total loss of thrust. He then sometime thereafter initiated a steep turn with gear down and the left engine already not developing sufficient shaft horsepower to sustain lift.
5. The pilot attempted to return to the departure airfield but lost control of the aircraft during a turn to the left.
Final Report: