Ambulance

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.

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.

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.

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.

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.

Following an uneventful flight, the crew configured the aircraft for landing when he realized that the right main landing gear was stuck in its wheel well. The crew continued the approach and landed on runway 15. The airplane fell on its belly, causing the right wing to struck the ground. The airplane slid for few hundred metres then veered off runway to the left and came to rest in a grassy area. All nine occupants were rescued and the aircraft was damaged beyond repair.

The pilot of the medical transport flight had been cleared by the air traffic controller for the instrument approach and told by ATC to change to the advisory frequency, which the pilot acknowledged. After crossing the initial approach fix on the RNAV approach, the airplane began a gradual descent and continued northeast towards the intermediate fix. Before reaching the intermediate fix, the airplane entered a right turn and began a rapid descent, losing about 2,575 ft of altitude in 14 seconds; radar returns were then lost. A witness at the destination airport, who was scheduled to meet the accident airplane, observed the pilot-controlled runway lights illuminate. When the airplane failed to arrive, she contacted the company to inquire about the overdue airplane. The following day, debris was found floating on the surface of the ocean. About 48 days later, after an extensive underwater search, the heavily fragmented wreckage was located on the ocean floor at a depth of about 500 ft. A postaccident examination of the engines revealed contact signatures consistent with the engines developing power at the time of impact and no evidence of mechanical malfunctions or failures that would have precluded normal operation. A postaccident examination of the airframe revealed about a 10° asymmetric flap condition; however, significant impact damage was present to the flap actuator flex drive cables and flap actuators, indicating the flap actuator measurements were likely not a reliable source of preimpact flap settings. In addition, it is unlikely that a 10° asymmetric flap condition would result in a loss of control. The airplane was equipped with a total of 5 seats and 5 restraints. Of the three restraints recovered, none were buckled. The unbuckled restraints could suggest an emergency that required crewmembers to be up and moving about the cabin; however, the reason for the unbuckled restraints could not be confirmed. While the known circumstances of the accident are consistent with a loss of control event, the factual information available was limited because the wreckage in its entirety was not recovered, the CVR recording did not contain the accident flight, no non-volatile memory was recovered from the accident airplane, and no autopsy or toxicology of the pilot could be performed; therefore, the reason for the loss of control could not be determined. Due to the limited factual information that was available, without a working CVR there is little we know about this accident.

The pilot and two medical crewmembers were repositioning the airplane to pick up a patient for aeromedical transport. Dark night instrument meteorological conditions prevailed for the flight. Radar data showed the airplane climb to 14,000 ft mean sea level after departure and proceed direct toward the destination airport before beginning a right descending turn. The airplane subsequently broke up inflight and impacted terrain. No distress calls were received from the pilot before the accident. Although weather conditions were conducive for inflight icing, no evidence of structural icing was identified at the scene. The debris field was 2,500 ft long and the disbursement of the wreckage confirmed that both wings, the horizontal stabilizer, both elevators, and both engines separated from the airplane before impacting the ground. Examination of the wreckage revealed that the initiating failure was the failure of the wing where it passed through the center of the airplane. The three wing spars exhibited S-bending deformation, indicative of positive overload producing compressive buckling and fracture. Further, impact signatures as black paint transfers and gouged aluminum, were consistent with the left outboard wing separating when it was struck by the right engine after the wing spars failed. There was no evidence of any pre-exiting conditions that would have degraded the strength of the airplane structure at the fracture locations. Flight control continuity was confirmed. An examination of the engines, propellers, and available systems showed no mechanical malfunctions or failure that could have contributed to the accident. The descending right turn was inconsistent with the intended flight track and ATC-provided clearance. However, there was insufficient information to determine how it was initiated and when the pilot became aware of the airplane's state in the dark night IMC conditions. Yet, the
absence of a distress call or communication with ATC about the airplane's deviation suggests that the pilot was not initially aware of the change in state. The structural failure signatures on the airplane were indicative of the wings failing in positive overload, which was consistent with the pilot initiating a pullup maneuver that exceeded the airplane spars' structural integrity during an attempted recovery from the spiral dive.

After takeoff, the commercial pilot saw flames coming from the left engine nacelle area. He retarded the throttle and turned off the fuel boost pump; however, the fire continued. He then feathered the propeller, shut down the engine, and maneuvered the airplane below the clouds to remain in the local traffic pattern. He attempted to keep the runway environment in sight while drifting in and out of clouds. He was unable to align the airplane for landing on the departure runway, so he attempted to land on another runway. When he realized that the airspeed was decreasing and that the airplane would not reach the runway, he landed it on an adjacent grass field. After touchdown, the landing gear separated, and the airplane came to a stop. The airframe sustained substantial damage to the wings and lower fuselage. Examination of the left engine revealed evidence of a fuel leak where the fuel mixture control shaft inserted into the fuel injector body, which likely resulted in fuel leaking onto the hot turbocharger in flight and the in-flight fire. A review of recent maintenance records did not reveal any entries regarding maintenance or repair of the fuel injection system. The pilot reported clouds as low as 500 ft with rain, snow, and reduced visibility at the time of the accident, which likely reduced his ability to see the runway and maneuver the airplane to land on it.

The twin engine aircraft departed Dundo Airport at 1658LT on an ambulance flight to Luanda, carrying three doctors, one patient from South Africa and three crew members. About 15 minutes into the flight, the crew reported engine problems when one of them caught fire shortly later. The airplane went out of control and crashed in an open field located near Cuilo, about 170 km southwest of Dundo. All seven occupants were killed.