Crash of a Beechcraft C90B King Air in Rattan

Date & Time: Feb 14, 2017 at 1145 LT
Type of aircraft:
Operator:
Registration:
N1551C
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
McAlester – Idabel
MSN:
LJ-1365
YOM:
1994
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
22000
Captain / Total hours on type:
400.00
Aircraft flight hours:
7862
Circumstances:
The pilot stated that the engine start and airplane power-up were normal for the air medical flight with two medical crewmembers. The engine ice vanes were lowered (as required for ground operations) and then were subsequently raised before takeoff. Takeoff and climbout were routine, and the pilot leveled off the airplane at the assigned cruise altitude. The air traffic controller informed the pilot of heavy showers near the destination airport, and the pilot "put the ice vanes down." The pilot indicated that, shortly afterward, the airplane experienced two "quick" electrical power fluctuations in which "everything went away and then came back," and "[s]econds later the entire [electrical] system failed." Due to the associated loss of navigation capability while operating in instrument meteorological conditions (IMC), the pilot set a general course for better weather conditions based on information from his preflight weather briefing. While the pilot attempted to find a suitable hole in the clouds to descend through under visual conditions, the left engine lost power. The pilot ultimately located a field through the cloud cover and executed a single-engine off-airport landing, which resulted in substantial damage to the right engine mount and firewall. A postaccident examination of the airplane and systems did not reveal any anomalies consistent with an in-flight electrical system malfunction. The three-position ignition and engine start/starter-only switches were in the ON position, and the engine anti-ice switches were in the ON position. When the airplane battery was initially checked during the examination, the voltmeter indicated 10.7 volts (normal voltage is 12 volts); the battery was charged and appeared to function normally thereafter. The loss of electrical power was likely initiated by the pilot inadvertently selecting the engine start switches instead of the engine anti-ice (ice vane) switches. This resulted in the starter/generators changing to starter operation and taking the generator function offline. Airplane electrical power was then being supplied solely by the battery, which caused it to deplete and led to a subsequent loss of electrical power to the airplane. A postaccident examination revealed that neither wing fuel tank contained any visible fuel. The left nacelle fuel tank did not contain any visible fuel, and the right nacelle fuel tank appeared to contain about 1 quart of fuel. The lack of fuel onboard at the time of the accident is consistent with a loss of engine power due to fuel exhaustion. This was a result of the extended flight time as the pilot attempted to exit instrument conditions after the loss of electrical power to locate a suitable airport. Further, the operator reported that 253 gallons (1,720 lbs) of fuel were on board at takeoff, and the accident flight duration was 3.65 hours. At maximum range power, the expected fuel consumption was about 406 lbs/hour, resulting in an endurance of about 4.2 hours. Thus, the pilot did not have the adequate fuel reserves required for flying in IMC. Both the pilot and medical crewmembers described a lack of communication and coordination among crewmembers as the emergency transpired. This resulted in multiple course adjustments that hindered the pilot's ability to locate visual meteorological conditions before the left engine fuel supply was exhausted.
Probable cause:
The loss of electrical power due to the pilot's inadvertent selection of the engine start switches and the subsequent fuel exhaustion to the left engine as the pilot attempted to locate visual meteorological conditions. Contributing to the accident were the pilot's failure to ensure adequate fuel reserves on board for the flight in instrument meteorological conditions and the miscommunication between the pilot and medical crewmembers.
Final Report:

Crash of a Beechcraft B200 Super King Air in Moomba

Date & Time: Dec 13, 2016 at 1251 LT
Operator:
Registration:
VH-MVL
Flight Type:
Survivors:
Yes
Schedule:
Innamincka – Moomba
MSN:
BB-1333
YOM:
1989
Flight number:
FD209
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On 13 December 2016, a Beech Aircraft Corporation B200, registered VH-MVL, conducted a medical services flight from Innamincka, South Australia (SA) to Moomba, SA. On board the aircraft were the pilot and two passengers. On arrival at Moomba at about 1250 Central Daylight-saving Time (CDT), the pilot configured the aircraft to join the circuit with flaps set to the approach setting and the propeller speed set at 1900 RPM. They positioned the aircraft at 150–160 kt airspeed to join the downwind leg of the circuit for runway 30, which is a right circuit. The pilot lowered the landing gear on the downwind circuit leg. They reduced power (set 600-700 foot-pounds torque on both engines) to start the final descent on late downwind abeam the runway 30 threshold, in accordance with their standard operating procedures. At about the turn point for the base leg of the circuit, the pilot observed the left engine fire warning activate. The pilot held the aircraft in the right base turn, but paused before conducting the engine fire checklist immediate actions in consideration of the fact that they were only a few minutes from landing and there were no secondary indications of an engine fire. After a momentary pause, the pilot decided to conduct the immediate actions. They retarded the left engine condition lever to the fuel shut-off position, paused again to consider if there was any other evidence of fire, then closed the firewall shutoff valve, activated the fire extinguisher and doubled the right engine power (about 1,400 foot-pounds torque). The pilot continued to fly the aircraft in a continuous turn for the base leg towards the final approach path, but noticed it was getting increasingly difficult to maintain the right turn. They checked the engine instruments and confirmed the left engine was shut down. They adjusted the aileron and rudder trim to assist controlling the aircraft in the right turn. The aircraft became more difficult to control as the right turn and descent continued and the pilot focused on maintaining bank angle, airspeed (fluctuating 100–115 kt) and rate of descent. Due to the pilot’s position in the left seat, they were initially unable to sight the runway when they started the right turn. The aircraft had flown through the extended runway centreline when the pilot sighted the runway to the right of the aircraft. The aircraft was low on the approach and the pilot realised that a sand dune between the aircraft and the runway was a potential obstacle. They increased the right engine power to climb power (2,230 foot-pounds torque) raised the landing gear and retracted the flap to reduce the rate of descent. The aircraft cleared the sand dune and the pilot lowered the landing gear and continued the approach to the runway from a position to the left of the runway centreline. The aircraft landed in the sand to the left of the runway threshold and after a short ground roll spun to the left and came to rest. There were no injuries and the aircraft was substantially damaged.
Probable cause:
From the evidence available, the following findings are made with respect to the collision with terrain involving Beech Aircraft Corporation B200, registered VH-MVL that occurred at Moomba Airport, South Australia on 13 December 2016. These findings should not be read as apportioning blame or liability to any particular organisation or individual.
Contributing factors:
- The operator did not modify the aircraft to include a more reliable engine fire detection system in accordance with the manufacturer’s service bulletin, and as subsequently recommended by the Civil Aviation Safety Authority’s airworthiness bulletin. The incorporation of the manufacturer’s modification would have reduced the risk of a false engine fire warning.
- During the approach phase of flight, the pilot shutdown the left engine in response to observing a fire warning, but omitted to feather the propeller. The additional drag caused by the windmilling propeller, combined with the aircraft configuration set for landing while in a right turn, required more thrust than available for the approach.

Other factors that increased risk:
- The advice from the Civil Aviation Safety Authority to the operator, that differences training was acceptable, resulted in the pilot not receiving the operator’s published B200 syllabus of training. The omission of basic handling training on a new aircraft type could result in a pilot not developing the required skilled behaviour to handle the aircraft either near to or in a loss of control situation.

Other findings:
- The pilot met the standard required by the operator in their cyclic training and proficiency program and no knowledge deficiencies associated with handling engine fire warnings were identified.
Final Report:

Crash of a Piper PA-31T Cheyenne in Elko: 4 killed

Date & Time: Nov 18, 2016 at 1920 LT
Type of aircraft:
Operator:
Registration:
N779MF
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Elko - Salt Lake City
MSN:
31-7920093
YOM:
1979
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
7050
Aircraft flight hours:
6600
Circumstances:
The airline transport pilot departed in the twin-engine, turbine-powered airplane on an air ambulance flight with two medical crew members and a patient on board in night visual meteorological conditions. According to a witness, during the initial climb, the airplane made a left turn of about 30° from the runway heading, then stopped climbing, made an abrupt left bank, and began to descend. The airplane impacted a parking lot and erupted into flames. In the 2 months before the accident, pilots had notified maintenance personnel three times that the left engine was not producing the same power as the right engine. In response, mechanics had replaced the left engine's bleed valve three times with the final replacement taking place three days before the accident. In addition, about 1 month before the accident, the left engine's fuel control unit was replaced during trouble shooting of an oil leak. Post accident examination revealed that the right engine and propeller displayed more pronounced rotational signatures than the left engine and propeller. This is consistent with the left engine not producing power or being at a low power setting at impact. Further, the abrupt left bank and descent observed by the witness are consistent with a loss of left engine power during initial climb. The extensive fire and impact damage to the airplane precluded determination of the reason for the loss of left engine power.
Probable cause:
A loss of engine power to the left engine for reasons that could not be determined due to the extensive fire and impact damage to the airplane.
Final Report:

Crash of a Learjet 31A in Jakarta

Date & Time: Sep 25, 2016 at 1946 LT
Type of aircraft:
Operator:
Registration:
PK-JKI
Flight Type:
Survivors:
Yes
Schedule:
Yogyakarta – Jakarta
MSN:
31-213
YOM:
2001
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The crew was performing an ambulance flight from Yogyakarta-Adisujipto Airport to Jakarta-Halim Perdanakusuma Airport on behalf of the Indonesian Red Cross (Palang Merah Indonesia), carrying one patient, two doctors, two accompanists and three crew members. The approach was completed by night and marginal weather conditions. After touchdown on runway 24, the aircraft skidded on a wet runway. After a course of 1,300 metres, it veered to the right and departed the runway surface. While contacting soft ground, the right main gear was torn off while the left main gear partially collapsed. Then the aircraft bounced and impacted the ground several times, causing the left wing to be bent. Eventually, the right engine partially detached from the pylon. All eight occupants were rescued and the aircraft was damaged beyond repair. There was no fire.

Crash of a Piper PA-31T Cheyenne II near McKinleyville: 4 killed

Date & Time: Jul 29, 2016 at 0105 LT
Type of aircraft:
Operator:
Registration:
N661TC
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Crescent City – Oakland
MSN:
31-8120022
YOM:
1981
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
7300
Captain / Total hours on type:
125.00
Aircraft flight hours:
7309
Circumstances:
About 13 minutes after takeoff for a medical transport flight, while climbing through about 14,900 ft mean sea level (msl), the pilot reported to air traffic control (ATC) that he was smelling smoke in the cockpit and would be returning to the originating airport. The flight was cleared to return with a descent at pilot's discretion to 9,000 ft msl. The pilot replied, "okay," and said that it looked like he was going to lose some power shortly. The pilot then stated that he had smoke in the cockpit, declared an emergency, and requested that ATC contact the fire department. About 1 minute 15 seconds after the initial report of smelling smoke, the pilot made the last radio transmission of the flight stating that he had three people on board. The wreckage was located about 9 hours later in an area of brush and heavily forested terrain. Portions of the burned and fragmented wreckage were scattered along a debris path that measured about 2,400 ft in length, which is consistent with an inflight breakup. The center fuselage and cockpit areas were largely intact and displayed no evidence of fire; however, there was an area of thermal damage to the forward fuselage consistent with an inflight fire. The thermal damage was primarily limited to the floor area between the two forward seats near the main bus tie circuit breaker panel and extended to the forward edge of the wing spar. All exposed surfaces were heavily sooted. Some localized melting and thermal-related tearing of the aluminum structure was present. The primer paint on the floor panels under the right aft corner of the pilot seat and the left aft corner of the co-pilot seat was discolored dark brown. An aluminum stringer in this location exhibited broomstrawing indicating that the stringer material was heated to near its melting point prior to impact. A single wire located in the area exhibited notching consistent with mechanical rubbing. The main bus tie circuit breakers were partially missing. The remaining breakers were heavily sooted on their aft ends, and one breaker was thermally discolored. Areas of charring were on the backside of the panel. Examination of the wiring in this area showed evidence of electrical arcing damage. Four hydraulic lines servicing the landing gear system were located in this area, and all the lines exhibited signs of thermal exposure with melting and missing sections of material. Six exemplar airplanes of the same make and model as the accident airplane were examined, and instances of unsafe conditions in which electrical lines and hydraulic lines in the area of the main bus tie circuit breaker panel were in direct contact were found on all six airplanes. Some of the wires in the exemplar airplanes showed chafing between hydraulic lines and the electrical wires, which, if left uncorrected, could have led to electrical arcing and subsequent fire. Based on the unsafe conditions found during examination of the exemplar airplanes and the thermal damage to the area near the main bus tie circuit breaker panel on the accident airplane, including broomstrawing of the aluminum structure, electrical arcing damage to the wiring, and melting of the hydraulic lines, it is likely that an electrical wire near the tie bus circuit breakers chafed on a hydraulic line and/or airplane structure, which resulted in arcing and a subsequent in-flight fire that was fed by the hydraulic fluid.
Probable cause:
An inflight fire in the floor area near the main bus tie circuit breaker panel that resulted from chafing between an electrical wire and a hydraulic line and/or airplane structure.
Final Report:

Crash of a Piper PA-31-325 Navajo in State College: 2 killed

Date & Time: Jun 16, 2016 at 0830 LT
Type of aircraft:
Operator:
Registration:
N3591P
Flight Type:
Survivors:
No
Schedule:
Washington County – State College
MSN:
31-8012081
YOM:
1980
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
12493
Captain / Total hours on type:
718.00
Aircraft flight hours:
16040
Circumstances:
The commercial pilot was completing an instrument flight rules air taxi flight on a route that he had flown numerous times for the customer on board. Radar and voice communication data revealed that the airplane was vectored to the final approach course for the precision approach and was given a radio frequency change to the destination airport control tower frequency. The tower controller issued a landing clearance, which the pilot acknowledged; there were no further communications with the pilot. Weather conditions at the airport at the time of the accident included an overcast ceiling at 300 ft with 1 mile visibility in mist. The wreckage was located in densely-wooded terrain. Postaccident examination revealed no evidence of any mechanical malfunctions or anomalies that would have precluded normal operation. The wreckage path and evidence of engine power displayed by numerous cut tree branches was consistent with a controlled, wings-level descent with power. A radar performance study revealed that, as the airplane crossed the precision final approach fix 6.7 nautical miles (nm) from the runway threshold, the airplane was 800 ft above the glideslope. At the outer marker, 5.5 nm from the runway threshold, the airplane was 500 ft above the glideslope. When radar contact was lost 3.2 nm from the threshold, the airplane was about 250 ft above the glideslope. Although the airplane remained within the lateral limits of the approach localizer, its last two recorded radar returns would have correlated with a full downward deflection of the glideslope indicator in the cockpit, and therefore, an unstabilized approach. Further interpolation of radar data revealed that, during the last 2 minutes of the accident flight, the airplane's rate of descent increased from 400 ft per minute (fpm) to greater than 1,700 fpm, likely as a result of pilot inputs. During the final minute of the flight, the rate decreased briefly to 1,000 fpm before radar contact was lost. The company's standard operating procedures stated that, if a rate of descent greater than 1,000 fpm was encountered during an instrument approach, a missed approach should be performed. The airplane's relative position to the glideslope and its rapid changes in descent rate after crossing the outer marker suggest that the airplane never met the operator's stabilized approach criteria. Rather than executing a missed approach procedure as outlined in the company's operating procedures, the pilot chose to continue the unstabilized approach, which resulted in a descent into trees and terrain. It is unlikely that the pilot's well-controlled diabetes and effectively treated sleep apnea contributed to the circumstances of this accident. However, whether or not the pilot's multiple sclerosis contributed to this accident could not be determined.
Probable cause:
The pilot's decision to continue an unstabilized instrument approach in instrument meteorological conditions, which resulted in controlled flight into terrain.
Final Report:

Crash of a BAe 125-700B off Dakar: 7 killed

Date & Time: Sep 5, 2015 at 1812 LT
Type of aircraft:
Operator:
Registration:
6V-AIM
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Ouagadougou - Dakar
MSN:
257062
YOM:
1979
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
7
Captain / Total flying hours:
7658
Captain / Total hours on type:
2158.00
Copilot / Total flying hours:
3339
Aircraft flight hours:
13279
Aircraft flight cycles:
11877
Circumstances:
The airplane departed Ouagadougou Airport at the end of the afternoon on an ambulance flight to Dakar-Léopold Sédar Senghor Airport with one patient, one doctor, two nurses and three crew members on board. After entering in contact with Dakar Control, the crew was cleared to FL340, an altitude that was confirmed by the crew at 1801LT. But the airplane continued and climbed to FL350. At 1812LT, the aircraft collided with a Boeing 737-8FB operated by Ceiba Intercontinental. Registered 3C-LLY, the B737 was operating the flight CEL071 Dakar - Cotonou - Malabo with 104 passengers and 8 crew members on board. Immediately after the collision, the BAe 125 entered an uncontrolled descent and crashed in the Atlantic Ocean about 111 km off Dakar. The pilot of the Boeing 737 informed ATC about a possible collision and continued to Malabo without further problem. Nevertheless, the top of the right winglet of the Boeing 737 was missing. SAR operations were suspended after a week and no trace of the BAe 125 nor the 7 occupants was ever found.
Probable cause:
The collision was the consequence of an error on part of the crew of the BAe 125 who failed to follow his assigned altitude at FL340 and continued to FL350 which was the assigned altitude for the Boeing 737. The captain of the B737 confirmed that he have seen the aircraft descending to him. Only the flight recorders could have helped to determine how such a situation could have occurred; Unfortunately they disappeared with the plane. There was a difference of 1,000 feet in the indications of both captain/copilot altimeters.
Final Report:

Crash of a Cessna 441 Conquest II in Cape Town: 5 killed

Date & Time: Aug 16, 2015 at 0629 LT
Type of aircraft:
Operator:
Registration:
V5-NRS
Flight Type:
Survivors:
No
Site:
Schedule:
Oranjemund - Cape Town
MSN:
441-0288
YOM:
1983
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
6353
Captain / Total hours on type:
1357.00
Copilot / Total flying hours:
1394
Copilot / Total hours on type:
1
Aircraft flight hours:
7605
Circumstances:
On 15 August 2015 at 2351Z a Cessna 441 aeroplane, with two crew and a paramedic on board took off from Eros Airport (FYWE) on a medical evacuation flight with their intended final destination Cape Town International Airport (FACT). The aircraft landed at Oranjemund (FYOG) to pick up a male patient and his daughter. At 0206Z the aircraft departed from FYOG on a mercy flight to FACT. At 0343Z the aircraft made the first contact with FACT area and the aircraft was put under radar control. At 0355Z, area control advised the crew that there was a complete radar failure. The aircraft was on a descent to 6500 ft when approach advised them to prepare for a VOR approach for runway 19. At 0429Z, while on approach for landing at FACT, all contact was lost with the aircraft. At approximately 0556Z the aircraft’s wreckage was located approximately 8 nm to the north of FACT. All five occupants on board were fatally injured and the aircraft was destroyed by impact and post impact fire. The investigation revealed the aircraft collided with terrain during instrument meteorological condition (IMC) conditions while on the VOR approach for Runway 19 at FACT. At the time the ILS was working, however the approach controller offered a VOR approach for separation with an outbound aircraft as the radar was unserviceable.
Probable cause:
The aircraft collided with terrain during instrument meteorological flight conditions while on the VOR approach Runway 19.
Final Report:

Crash of a Learjet 35A in Tamanrasset

Date & Time: Oct 25, 2014 at 1513 LT
Type of aircraft:
Operator:
Registration:
D-CFAX
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Tamanrasset – Bata
MSN:
35-135
YOM:
1977
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The airplane was completing an ambulance flight (positioning) from Europe to Bata, Equatorial Guinea, with an intermediate stop in Tamanrasset, carrying a medical team of two doctors and two pilots. During the takeoff roll from Tamanrasset-Aguenar Airport, the crew heard a loud noise and decided to abort. Unable to stop within the remaining distance, the aircraft overran and came to rest. All four occupants escaped uninjured and the aircraft was damaged beyond repair.

Crash of a Beechcraft 200C Super King Air in Nouméa

Date & Time: Sep 9, 2014 at 1150 LT
Operator:
Registration:
F-GRSO
Flight Type:
Survivors:
Yes
Schedule:
Lifou – Nouméa
MSN:
BL-11
YOM:
1980
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The twin engine airplane departed Lifou Airport on an ambulance flight to Nouméa-Magenta Airport, carrying two passengers and two pilots. On approach to Magenta Airport, the crew followed the checklist and lower the landing gears. As all three green light failed to came on the cockpit panel, the crew elected to lower the gears manually without success. The crew completed two low passes in front of the control tower and it was confirmed that the left main gear seems to be down but not locked. After a 45-minute flight to burn fuel, the crew completed the landing. Upon touchdown, both main landing gear collapsed while the nose gear remained extended. The aircraft slid for few dozen metres before coming to rest. All four occupants evacuated safely and the aircraft was damaged beyond repair.
Probable cause:
The rupture of two teeth of the sprocket of the control cylinder of the left main landing gear caused the cylinder to be locked and thus caused the mechanical system to extend the landing gear. This blockage prevented the complete extension and locking of the landing gear. This rupture and other damage to the two main landing gear actuators was probably the result of improper installation of the toothed gear and / or improper adjustment of the assembly.
Final Report: