Crash of a Piper PA-31-350 Navajo Chieftain in Salitre: 6 killed

Date & Time: Apr 7, 2021 at 1200 LT
Operator:
Registration:
HC-CVC
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Nueva Loja – Guayaquil
Location:
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
6
Circumstances:
The twin engine airplane (a PA-31 Panther II variant) departed Nueva Loja-Lago Agrio Airport at 1023LT on an ambulance flight to Guayaquil, carrying one patient, one nurse, two doctors and two pilots. The descent to Guayaquil-José Joaquín de Olmedo Airport was started when the aircraft crashed in unknown circumstances in the Río Salitre, near Salitre, about 35 km north of Guayaquil Airport. The aircraft was destroyed and all six occupants were killed.

Crash of a PZL-Mielec AN-2T in Boralday

Date & Time: Feb 26, 2021 at 1226 LT
Type of aircraft:
Operator:
Registration:
UP-A0351
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Boralday - Kegen
MSN:
1G194-19
YOM:
1981
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The single engine aircraft departed Boralday Airport in the suburb of Almaty on an ambulance flight to Kegen with five people on board. Shortly after takeoff, while climbing, the engine suffered a loss of power. The crew attempted an emergency landing when the aircraft lost height and crashed in hilly terrain. All five occupants escaped uninjured while the aircraft was damaged beyond repair. Operator reported as Asia Continental Airlines.

Crash of a Learjet 31A in Diamantina

Date & Time: Jan 2, 2021 at 0851 LT
Type of aircraft:
Operator:
Registration:
PP-BBV
Flight Type:
Survivors:
Yes
Schedule:
São Paulo – Diamantina
MSN:
31-113
YOM:
1995
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
4606
Captain / Total hours on type:
1138.00
Copilot / Total flying hours:
1475
Copilot / Total hours on type:
680
Circumstances:
The airplane departed São Paulo-Congonhas Airport on an ambulance flight to Diamantina-Juscelino Kubitschek Airport, carrying two doctors and two pilots. Following an unstabilized approach, the airplane landed too far down the runway 03 and was unable to stop within the remaining distance. It overran, went down a ravine and came to rest. All four occupants evacuated with minor injuries while the aircraft was damaged beyond repair.
Probable cause:
Following a wrong approach configuration on part of the crew, it was determined that the airplane landed about 600 metres from the runway end. In such conditions, the airplane could not be stopped within the remaining distance.
The following contributing factors were identified:
- Both pilots knew each other well and often flew together, thus it is possible that they over-relied on each other during the final phase of the flight,
- This over-confidence led the crew to neglect certain parameters related to the approach manoeuvre,
- Lack of crew coordination,
- Post-accident medical examinations revealed that the pilot-in-commands' (PF) lack of reaction to the pilot monitoring's (PM) warnings, and his impaired alertness, could indicate that he was suffering from the effects of alcohol and fatigue, reducing his performances,
- The pilots' decision to continue with the landing procedure despite an unstabilized approach characterized by inadequate situational awareness,
- Poor judgment on the part of the crew who failed to take the correct decision to initiate a go-around procedure.
Final Report:

Crash of a Learjet 35A in Esquel: 3 killed

Date & Time: May 5, 2020 at 2238 LT
Type of aircraft:
Operator:
Registration:
LV-BXU
Flight Type:
Survivors:
Yes
Schedule:
San Fernando – Esquel
MSN:
35-462
YOM:
1982
Location:
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
1498
Copilot / Total flying hours:
2612
Aircraft flight hours:
11711
Aircraft flight cycles:
10473
Circumstances:
The airplane departed San Fernando Airport on an ambulance flight to Esquel, carrying a doctor, a nurse and two pilots. On approach to Esquel-Brigadier General Antonio Parodi Airport at night, the crew encountered poor visibility (200 metres) and the visual contact with the runway was lost intermittently. Nevertheless, the crew continued the approach and at decision height, the captain decided to continue the descent. After crossing Runway 23 threshold at a height of 78 feet, the pilot-in-command initiated a go-around procedure and turned to the left. The airplane continued in a left hand turn, causing the left wing tip fuel tank to struck the ground. Out of control, the airplane crashed on a small embankment located about 400 metres to the left of the runway centerline, coming to rest upside down and bursting into flames. Both passengers were killed and both pilots were seriously injured. Two days later, the copilot died from injuries sustained.
Probable cause:
It was determined that the accident was the consequence of a controlled flight into terrain (CFIT) and the airplane did not suffer any technical anomalies.
The following contributing factors were identified:
- The crew failed to check the approach charts according to SOP's,
- The approach was initiated and continued in conditions that were below weather minimums,
- Visibility data transmitted by Tower to the crew were inaccurate, leading to confusion on the part of the pilots and their decision-making,
- Both engines were at full power upon impact as the crew was initiating a go-around procedure.
Final Report:

Crash of an IAI 1124A Westwind II in Manila: 8 killed

Date & Time: Mar 29, 2020 at 2000 LT
Type of aircraft:
Operator:
Registration:
RP-C5880
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Manila - Tokyo
MSN:
353
YOM:
1981
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
8
Circumstances:
An IAI Westwind II 1124A type of aircraft with registry number RP-C5880, was destroyed following a runway excursion while taking-off at RWY 06, Ninoy Aquino International Airport (NAIA), Manila Philippines. All eight (8) occupants (six (6) Filipino, one (1) Canadian and one (1) American citizen are fatally injured. The aircraft is being operated by Lionair Inc. and was bound for Haneda, Japan on a medical evacuation flight. While the aircraft was on take-off roll before reaching taxiway R2, sparks were noted at the runway, it continued until the aircraft came to complete stop and engulfed by fire. Chunks of rubber and metal debris were present on the runway. Scrape marks coming from the right hand (RH) wheel hub were also visible. Tire marks followed by scrape marks on the runway coming from the LH tire and wheel hub were also seen after taxiway H1 intersection. Large portion of the remaining LH tire was recovered from the grassy portion near taxiway H1. After exiting from the asphalted portion of runway safety area, the aircraft initially run over two (2) runway edge lights then impacted into a concrete electric junction box and came to a complete stop at the runway secondary fence. The aircraft settled almost 172 meters away from the end of RWY 06, in an upright position at 14°30'53.50"N; 121°1'48.48"E and heading of 170 degrees. The flight was on Instrument Flight Rules (IFR) condition. A Notice to Airmen (NOTAM) of NAIA RWY 06/24 closure for aircraft operation was declared at 2000H and opened for operation at 0420H, March 30, 2020.
Probable cause:
The accident was the caused by the combination of the decision of the PF to abort the take-off after VR that resulted to runway excursion and incorrect pilot techniques or procedures in the high-speed rejected take-off.
The following contributing factors were identified:
- Operational pressures related to the delay of schedule due to late filing of the flight plan compelling the crew to rush and meet the schedule demand.
- The crew's complacency by skipping required briefing item in the before take-off checklist, in this case, the considerations in the event of a malfunction before/after V1.
Final Report:

Crash of a PZL-Mielec AN-2P in Ust-Kamenogorsk

Date & Time: Feb 26, 2020 at 1226 LT
Type of aircraft:
Operator:
Registration:
UP-A0001
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Ust-Kamenogorsk - Aksuat
MSN:
1G140-49
YOM:
1972
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The single engine airplane departed Ust-Kamenogorsk Airport on an ambulance flight to Aksuat. After takeoff, while in initial climb, the crew encountered engine problems. They elected to make an emergency in a snow covered field. The airplane came to rest upside down, bursting into flames. All five occupants escaped with minor injuries while the aircraft was destroyed.

Crash of a Beechcraft B200 King Air off Dutch Harbor

Date & Time: Jan 16, 2020 at 0806 LT
Operator:
Registration:
N547LM
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Dutch Harbor - Adak
MSN:
BB-1642
YOM:
1998
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
6470
Captain / Total hours on type:
756.00
Aircraft flight hours:
7058
Circumstances:
According to the pilot, when the airplane’s airspeed reached about 90 knots during the takeoff roll, he applied back pressure to the control yoke to initiate the takeoff and noted a brief positive rate of climb followed by a sinking sensation. The airspeed rapidly decayed, and the stall warning horn sounded. To correct for the decaying airspeed, he lowered the nose then pulled back on the airplane’s control yoke and leveled the wings just before impacting the ocean. The pilot stated there were no pre accident mechanical malfunctions or anomalies that would have precluded normal operation. Wind about the time of the accident was recorded as 110º downwind of the airplane at 15 knots gusting to 28 knots. The passengers recalled that the pilot’s preflight briefing mentioned the downwind takeoff but included no discussion of the potential effect of the wind conditions on the takeoff. The airplane’s estimated gross weight at the time of the accident was about 769.6 pounds over its approved maximum gross weight, and the airplane’s estimated center of gravity was about 8.24 inches beyond the approved aft limit at its maximum gross weight. It is likely that the pilot’s decision to takeoff downwind and operate the airplane over the maximum gross weight with an aft center of gravity led to the aerodynamic stall during takeoff and loss of control. Downwind takeoffs result in higher groundspeeds and increase takeoff distance. While excessive aircraft weight increases the takeoff distance and stability, and an aft center of gravity decreases controllability. Several instances of the operator’s noncompliance with its operational procedures and risk mitigations were discovered during the investigation, including two overweight flights, inaccurate and missing information on aircraft flight logs, and the accident pilot’s failure to complete a flight risk assessment for the accident flight. The operator had a safety management system (SMS) in place at the time of the accident that required active monitoring of its systems and processes to ensure compliance with internal and external requirements. However, the discrepancies noted with several flights, including the accident flight, indicate that the operator’s SMS program was inadequate to actively monitor, identify, and mitigate hazards and deficiencies.
Probable cause:
The pilot’s improper decision to takeoff downwind and to load the airplane beyond its allowable gross weight and center of gravity limits, which resulted in an aerodynamic stall and loss of control. Contributing to the accident was the inadequacy of the operator’s safety management system to actively monitor, identify, and mitigate hazards and deficiencies.
Final Report:

Crash of a Piper PA-31-350 Navajo Chieftain near Cooper Landing: 3 killed

Date & Time: Nov 29, 2019 at 1911 LT
Operator:
Registration:
N4087G
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Anchorage – Seward
MSN:
31-8152127
YOM:
1981
Flight number:
SVX36
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
35000
Captain / Total hours on type:
1200.00
Aircraft flight hours:
5502
Circumstances:
On November 29, 2019, about 1911 Alaska standard time, a Piper PA-31-350 airplane, N4087G, was destroyed by impact and postcrash fire when it collided with mountainous terrain about 15 miles west of Cooper Landing, Alaska. The three occupants; the airline transport pilot, a flight nurse, and the flight paramedic were fatally injured. The airplane was operated by Fly 4 You Inc., doing business as Security Aviation, as a Title 14 Code of Federal Regulations Part 135 visual flight rules air ambulance flight. Dark night visual meteorological conditions existed at the departure and destination locations and company flight following procedures were in effect. The flight departed Ted Stevens International Airport (PANC), Anchorage, Alaska, about 1848, destined for Seward Airport (PAWD), Seward, Alaska. Dispatch records indicated that, on November 29, Providence Seward Medical Center emergency clinic personnel contacted multiple air ambulance companies with a "weather check" for possible air ambulance transportation of a patient from Seward to Anchorage. The first company contacted was Guardian Flight, who declined the flight at 1624 due to limited daylight hours. The second company, LifeMed Alaska, declined the flight at 1637 due to weather. The third and final company contacted for the flight was Medevac Alaska. Their dispatch officer was not notified of the previous declined flight requests and forwarded the request to Security Aviation, who is their sole air charter provider. At 1731 Security Aviation accepted the flight, and Medevac Alaska flight SVX36 was staffed with a nurse and paramedic. A preliminary review of archived Federal Aviation Administration (FAA) radar and automatic dependent surveillance (ADS-B) data revealed that the accident airplane departed PANC and flew south about 3,000 ft mean sea level (msl) toward the Sterling Highway. The airplane was then observed descending to 2,200 ft msl while flying a right racetrack pattern before flying into the valley toward Cooper Landing. The last data point indicated that at 1911:14 the airplane was over the west end of Jean Lake at 2,100 ft msl, on a 127° course, and 122 kts groundspeed. Ground witnesses who were in vehicles on the Sterling Highway near milepost 63, reported that they saw the lights of the airplane flying over the highway that night. One witness stated that he saw the airplane west of the mountains turn in a circle as it descended and then entered the valley. He observed the wings rocking back and forth and while he was looking elsewhere, he heard an explosion and observed a large fire on the mountainside. Another witness reported seeing the airplane flying low and explode when it impacted the mountain. Witnesses to the fire called 911 and observed the wreckage high on the mountainside burning for a long time after impact. The airplane was reported overdue by the chief pilot for Security Aviation and the FAA issued an alert notice (ALNOT) at 2031. The Alaska Rescue Coordination Center dispatched an MH-60 helicopter to the last known position and located the burning wreckage that was inaccessible due to high winds in the area. On December 1, 2019, the Alaska State Troopers coordinated a mountain recovery mission with Alaska Mountain Rescue Group. The wreckage was observed on the mountain at an elevation of about 1,425 ft msl in an area of steep, heavily tree-covered terrain near the southeast end of Jean Lake in the Kenai National Wildlife Refuge. The airplane was highly fragmented and burned, however all major airplane components were accounted for. Multiple large trees around the wreckage were fractured and indicated an easterly heading prior to the initial impact.

Crash of a Beechcraft 350 Super King Air in Pansol: 9 killed

Date & Time: Sep 1, 2019 at 1510 LT
Operator:
Registration:
RP-C2296
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Dipolog - Manila
MSN:
FL-196
YOM:
1998
Location:
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
9
Circumstances:
The airplane encountered a loss of control in flight while approaching Manila and crashed into a private resort located in Barangay Pansol, Calamba, Laguna, Philippines. It lost radar contact with Manila Approach after being cleared to descent from 9,000 feet for 5,000 feet tracking-in radial 170, 25 DME to Ninoy Aquino International Airport (RPLL). The aircraft wreckage was found in a private resort with coordinates of 14°10’33.62” N and 121°11’34” E and heading approximately 228° with most its fuselage totally burned. All the nine (9) occupants were fatally injured and two (2) other persons on the ground sustained serious injuries. The aircraft took off from Dipolog Principal Airport (RPMG), Dipolog City, Zamboanga del Norte bound for Manila (RPLL) on a MEDEVAC flight. Instrument Metrological Condition (lMC) prevailed at the time of the accident.
Probable cause:
The aircraft experienced a loss of control in flight (LOC-I) after encountering adverse and hazardous atmospheric turbulent weather conditions which led to an inflight breakup.
The following contributing factors were identified:
- The presence of adverse and potentially hazardous atmospheric conditions on route of the flight.
- Failure of the flight crew to maintain situational awareness.
- Break-down of CRM to apply appropriate emergency procedures to recover the aircraft from the unusual situation they encountered.
Final Report:

Crash of a Beechcraft B200 Super King Air in Gillam

Date & Time: Apr 24, 2019 at 1823 LT
Operator:
Registration:
C-FRMV
Flight Type:
Survivors:
Yes
Schedule:
Winnipeg – Churchill – Rankin Inlet
MSN:
BB-979
YOM:
1982
Flight number:
KEW202
Location:
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
1350
Captain / Total hours on type:
1100.00
Copilot / Total flying hours:
3500
Copilot / Total hours on type:
1350
Circumstances:
On 24 April 2019, the Keewatin Air LP Beechcraft B200 aircraft (registration C‑FRMV, serial number BB979), equipped to perform medical evacuation flights, was conducting an instrument flight rules positioning flight (flight KEW202), with 2 flight crew members and 2 flight nurses on board, from Winnipeg/James Armstrong Richardson International Airport, Manitoba, to Rankin Inlet Airport, Nunavut, with a stop at Churchill Airport, Manitoba. At 1814 Central Daylight Time, when the aircraft was cruising at flight level 250, the flight crew declared an emergency due to a fuel issue. The flight crew diverted to Gillam Airport, Manitoba, and initiated an emergency descent. During the descent, both engines flamed out. The flight crew attempted a forced landing on Runway 23, but the aircraft touched down on the frozen surface of Stephens Lake, 750 feet before the threshold of Runway 23. The landing gear was fully extended. The aircraft struck the rocky lake shore and travelled up the bank toward the runway area. It came to rest 190 feet before the threshold of Runway 23 at 1823:45 Central Daylight Time. None of the occupants was injured. The aircraft sustained substantial damage. The 406 MHz emergency locator transmitter activated. Emergency services responded. There was no fire.
Probable cause:
Findings as to causes and contributing factors:
These are conditions, acts or safety deficiencies that were found to have caused or contributed to this occurrence.
1. When the captain asked if the aircraft was ready for the flight, the first officer replied that it was, not recalling that the aircraft required fuel.
2. While performing the FUEL QUANTITY item on the AFTER START checklist, the captain responded to the first officer’s prompt with the rote response that the fuel was sufficient, without looking at the fuel gauges.
3. The aircraft departed Winnipeg/James Armstrong Richardson International Airport with insufficient fuel on board to complete the planned flight.
4. The flight crew did not detect that there was insufficient fuel because the gauges had not been included in the periodic cockpit scans.
5. When the flight crew performed the progressive fuel calculation, they did not confirm the results against the fuel gauges, and therefore their attention was not drawn to the low-fuel state at a point that would have allowed for a safe landing.
6. Still feeling the effect of the startle response to the fuel emergency, the captain quickly became task saturated, which led to an uncoordinated response by the flight crew, delaying the turn toward Gillam Airport, and extending the approach.
7. The right engine lost power due to fuel exhaustion when the aircraft was 1 nautical mile from Runway 23. From that position, a successful forced landing on the intended runway was no longer possible and, as a result, the aircraft touched down on the ice surface of Stephens Lake, short of the runway.

Findings as to risk:
These are conditions, unsafe acts or safety deficiencies that were found not to be a factor in this occurrence but could have adverse consequences in future occurrences.
1. If procedures are not developed to instruct pilots on their roles and responsibilities during line indoctrination flights, there is a risk that flight crew members may not participate when expected, or may work independently towards different goals.

Other findings:
These items could enhance safety, resolve an issue of controversy, or provide a data point for future safety studies.
1. Because emergency medical services and the fire department were not notified immediately about the declared emergency, they were not on site before the aircraft arrived at Gillam Airport.
Final Report: