Crash of a Hawker 900XP in Maleo

Date & Time: May 11, 2023 at 1500 LT
Type of aircraft:
Operator:
Registration:
PK-LRU
Survivors:
Yes
Schedule:
Jakarta - Maleo
MSN:
HA-0212
YOM:
2012
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The airplane departed Jakarta-Halim Perdanakusuma Airport on a charter flight to Maleo, carrying four passengers and four crew members. Following an uneventful flight at FL390, the crew started the descent to Maleo-Morowali Airport Runway 23. After touchdown, the airplane was unable to stop within the remaining distance, overran, rolled for about 200 metres and came to rest against a wooded hill. All eight occupants evacuated safely, among them four Chinese passengers. The crew consisted of two pilots, one stewardess and one technician. Runway 05/23 at Maleo Airport is 1,000 metres long. It is believed that the airplane was operated by Lionair Charter Division.

Crash of a Pacific Aerospace PAC 750XL in Kudjip

Date & Time: Feb 9, 2023 at 1250 LT
Operator:
Registration:
P2-BJD
Flight Phase:
Survivors:
Yes
Schedule:
Giramben - Simbai
MSN:
124
YOM:
2005
Location:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3582
Captain / Total hours on type:
1885.00
Aircraft flight hours:
13811
Aircraft flight cycles:
17220
Circumstances:
The flight was planned to depart Giramben at 12:40, and track North for Simbai Airstrip, Madang Province at 9,000 ft AMSL. According to the pilot, the aircraft was loaded by NCA ground handlers following his instructions. The manifest was completed by one of the ground handler, who stated that the aircraft was loaded by the other ground handlers while he was completing the manifest in the vehicle, due to no proper shed for him to work from. The pilot also stated that at the time the loading was completed, and the passengers had boarded the aircraft, he observed that the winds were variable, blowing directly from the North and from the East as well. Recorded data showed that the aircraft commenced taxiing at 12:44. During the take-off roll, at the expected airborne point, about 500 m down the runway, as the aircraft accelerated with the airspeed approaching 60 knots, the right wheel hit a soft spot on the strip which dramatically reduced the momentum and speed of the aircraft, as described by the pilot. Eyewitnesses reported seeing the aircraft getting airborne briefly and got back on the ground again. The pilot recalled that by the time the aircraft got back on the ground he realized that he had passed the nominated committal point, which was identified during onsite activities to be about 540 m from the threshold of runway 16. The pilot opted to continue with the take-off roll, with full power hoping that the aircraft would regain speed on the remaining part of the strip to get airborne again. The pilot recalled reaching the end of the runway and getting airborne again with an airspeed of 50 kts airborne again, however, the right wheel got caught on the barbed wire of the perimeter fence that ran across to the runway, and subsequently impacted terrain. The pilot stated that he had lost consciousness at the time of the initial impact and therefore, had no recollection from thereon. The investigation found that the aircraft got airborne about 19 m past the end of runway 16. However, the aircraft’s main landing gears got caught on the perimeter fencing wire, subsequently impacting ground about 100 m from the end of the runway, then continued with the momentum and came to rest, in a local village garden about 160 m from the end of the runway. The aircraft was destroyed by impact forces. The pilot and passengers were rescued by the locals and taken to Nazarene General Hospital, Jiwaka Province, for treatment. The pilot, male adult and infant passengers sustained serious injuries, and the female passenger sustained minor injuries.
Probable cause:
The following factors were identified:
- The pilot did not complete a trim sheet for the flight.
- The manifest was completed by a ground handler who was not present at the time the cargo was being loaded by other ground handlers. The manifest was not signed by the ground handler who completed it, nor was it authorized by the pilot before departure.
- Pilot’s lack of supervision of the aircraft’s loading process to ensure cargo is loaded correctly and in accordance with the prescribed limitations and to prevent calculation errors. As a result, it was likely that the aircraft was overweight when it departed.
- Wet strip surface conditions that caused significant resistance during the take-off roll and impeded the aircraft’s ability to reach its required lift off airspeed.
- Pilot’s decision to continue the take-off roll after passing the committal.
- Training deficiencies of ground handlers and the pilot.
- The lack of adequate Quality Assurance systems oversight on the operator’s operating standard procedures.
Final Report:

Crash of a Cessna 208B Grand Caravan in Nasir: 1 killed

Date & Time: Feb 6, 2023
Type of aircraft:
Operator:
Registration:
5Y-BMZ
Flight Phase:
Survivors:
Yes
MSN:
208B-0367
YOM:
1994
Country:
Region:
Crew on board:
0
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
After liftoff from Nasir Airfield, the single engine airplane encountered difficulties to gain height. It rolled to the right, impacted terrain and crashed in an open field, bursting into flames. All occupants evacuated but an elderly passenger later died from injuries sustained. The airplane was totally destroyed by a post crash fire.

Crash of a Piper PA-31-350 Navajo Chieftain in Middlefield

Date & Time: Jan 18, 2023 at 0903 LT
Registration:
N101MA
Survivors:
Yes
Schedule:
Youngstown – Detroit – Minneapolis
MSN:
31-7752186
YOM:
1977
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
9275
Captain / Total hours on type:
750.00
Aircraft flight hours:
17154
Circumstances:
While enroute in instrument meteorological (IMC) conditions, the pilot of the twin-engine, piston-powered airplane declared an emergency following a loss of power to the right engine. The pilot secured the engine and was provided vectors by air traffic control for an instrument approach procedure at the nearest airport, which he successfully completed. The pilot reported that he flew the approach and landing with the wing flaps retracted and visually acquired the runway about 500 ft above the ground. The airplane touched down on the first third of the runway at 120 knots. The pilot knew he would not be able to stop the airplane on the 3,500-ft long runway but committed to the landing rather than risking a single-engine go-around in IMC. After landing, the airplane continued beyond the departure end of the runway and impacted a berm, collapsing the landing gear and resulting in substantial damage to the airplane. Examination of the engine revealed catastrophic damage consistent with detonation and oil starvation. The damage to the No. 5 cylinder was consistent with a subsequent over pressurization of the crankcase, which likely expelled the crankshaft nose seal and the oil supply. Detonation of the cylinder(s) can create excessive crankcase pressures capable of expelling the crankshaft nose seal. The crankshaft nose seal displacement likely created a rapid loss of oil and the resulting oil starvation of the engine. The fractured connecting rod and high-temperature signatures were consistent with oil starvation. No source or anomaly that would result in engine detonation was identified. According to the Pilot’s Operating Handbook (POH) for the accident airplane, during a single engine inoperative approach, the pilot should maintain an airspeed of 116 kts indicated (KIAS) or above until landing is assured. Once landing is assured, the pilot should extend the gear and flaps, slowly retard the power on the operative engine, and land normally. The airplane’s best single-engine rate of climb speed (blue line) was 106 KIAS, and its minimum controllable airspeed with one engine inoperative (Vmca) was 76 KIAS. The maximum speed for full flap extension (40°) was 132 KIAS. The POH also stated that a single-engine go-around should be avoided if at all possible. The pilot’s decision to commit to the landing was reasonable given the circumstances and the guidance provided by the POH; however, it is likely that his decision to conduct the landing without flaps and the airplane’s excessive airspeed at touchdown resulted in the runway overrun.
Probable cause:
A runway overrun during a precautionary landing following a total loss of right engine power due to detonation and subsequent oil starvation. Contributing was the pilot’s failure to lower the flaps and the excessive airspeed at touchdown.
Final Report:

Crash of a Beechcraft B200 Super King Air in Poplar

Date & Time: Jan 18, 2023 at 0818 LT
Operator:
Registration:
N200EJ
Survivors:
Yes
Schedule:
Billings - Poplar
MSN:
BB-1884
YOM:
2004
Location:
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
4242
Captain / Total hours on type:
2068.00
Copilot / Total flying hours:
10301
Copilot / Total hours on type:
4137
Aircraft flight hours:
4538
Circumstances:
The pilot reported that while on approach for landing, the airplane started to lose altitude quickly. After the co-pilot noticed the high decent rate and the slow airspeed, he advised the pilot to add power. However, the airplane continued to descend and impacted terrain in a right wing and nose low attitude, about 30 yards short of the runway approach threshold, which resulted in substantial damage to the right wing. The pilot reported that there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation.
Probable cause:
The pilot’s failure to maintain adequate airspeed and descent rate during the landing approach, which resulted in an impact with terrain short of the runway threshold.
Final Report:

Crash of a Cessna 208B Grand Caravan in Mweya

Date & Time: Dec 31, 2022 at 1315 LT
Type of aircraft:
Operator:
Registration:
5X-GBR
Survivors:
Yes
Location:
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
After landing at Mweya Airstrip located in the Queen Elizabeth National Park, the single engine airplane was unable to stop within the remaining distance. It overran and collided with a house. All five occupants escaped uninjured and the aircraft was damaged beyond repair. It just completed a charter flight with three European citizens and two pilots on board.

Crash of a Piper PA-42-1000 Cheyenne 400LS in Lewistown

Date & Time: Dec 13, 2022 at 1006 LT
Type of aircraft:
Operator:
Registration:
C-GZPU
Survivors:
Yes
Schedule:
Great Falls – Lewistown
MSN:
42-5527011
YOM:
1984
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The flight crew reported that, the instrument approach was flown on autopilot to about 700 ft above ground level until the runway was visually in sight. They were 300 ft off the runway centerline, and 1 nautical mile from the runway threshold. The visual glideslope indicator was inoperative, and the runway markings were obscured due to dry light snow. The airplane subsequently landed hard on the unusable portion of the runway, about 800 ft short of the landing threshold, and the left mail landing gear tire blew, causing the propeller to strike the runway. The airplane veered off the runway substantially damaging the left wing. The pilots reported that there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation.
Probable cause:
The pilot’s improper landing flare, which resulted in a hard landing. Contributing to the accident was the out of service visual glideslope indicator and snow obscuring the runway markings.
Final Report:

Crash of a Learjet 45 in Batesville

Date & Time: Nov 29, 2022 at 1910 LT
Type of aircraft:
Operator:
Registration:
N988MC
Survivors:
Yes
Schedule:
Waterloo – Batesville
MSN:
45-352
YOM:
2007
Flight number:
DHR003
Crew on board:
2
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3910
Captain / Total hours on type:
1560.00
Copilot / Total flying hours:
505
Copilot / Total hours on type:
263
Aircraft flight hours:
2490
Circumstances:
The two pilots were conducting a business flight with six passengers when the accident occurred. During the night arrival the captain flew a visual approach with excessive airspeed
and the airplane crossed the runway threshold more than 50 knots above approach speed (Vref). The before-landing checklist was not completed, and the flaps were at an incorrect 20° position instead of 40°. The airplane touched down near the midfield point of the 6,022 ft non grooved runway, which was wet due to earlier precipitation. The captain initially applied intermittent braking, then applied continuous braking starting about 2,069 ft from the end of the runway. The captain did not deploy the thrust reversers. The airplane exited the runway above 100 knots ground speed, then continued into a ditch and airport perimeter fence, which resulted in substantial damage to the forward fuselage. Examination of the airplane revealed no mechanical anomalies that would have precluded normal operation. The operator’s flight manual directed that all approaches were to be flown using the stabilized approach concept. For a visual approach, this included establishing and maintaining the proper approach speed and correct landing configuration at least 500 ft above the airport elevation. Neither pilot recognized the requirement to execute a go-around due to the excessive approach speed or the long landing on a wet runway, which resulted in the runway excursion.
Probable cause:
The crew’s failure to execute a go-around during the unstable approach and long landing, which resulted in a runway excursion.
Final Report:

Crash of a Piper PA-31-350 Navajo Chieftain in Medellín: 8 killed

Date & Time: Nov 21, 2022 at 1014 LT
Operator:
Registration:
HK-5121
Flight Phase:
Survivors:
No
Site:
Schedule:
Medellín – Pizarro
MSN:
31-7652004
YOM:
1976
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
8
Captain / Total flying hours:
3194
Captain / Total hours on type:
407.00
Copilot / Total flying hours:
535
Copilot / Total hours on type:
402
Aircraft flight hours:
19790
Circumstances:
The twin engine airplane was chartered by the Grupo San Germán Express to carry a team of six people from Medellín to Pizarro, Chocó. Shortly after takeoff from Medellín-Enrique Olaya Herrera Airport Runway 02, while in initial climb, the crew declared an emergency and informed ATC about an engine failure. The airplane entered a left turn then lost altitude and crashed onto a house located in the district of Belén Rosales, 523 metres west or runway 20 threshold and 2,325 metres from the departure point, bursting into flames. The house and the aircraft were destroyed and all 8 occupants were killed.
Crew:
Julián Aladino, pilot,
Sergio Guevara Delgado, copilot.
Passengers:
Jorge Cantillo Martínez,
Dubán Ovalle Quintero,
Anthony Mosquera Blanquiceth,
Pedro Pablo Serna,
Melissa Pérez Cuadros,
Nicolás Jiménez.
Probable cause:
The accident was the consequence of the combination of the following factors:
- A loss of control in flight as a result of a decrease in minimum control speed and drag, caused by a loss of power on the left engine (n°1);
- A failure of the propeller feathering system on engine n°1, caused by an excessive amount of grease accumulated in the blade coupling section, which prevented the propeller from being feathered quickly (or feathering at all) when the crew attempted to do so. The uncontrolled rotation of the propeller (spinning) created significant drag and made it more difficult to control the aircraft.
- The confirmed loss of power on the left engine, of undetermined origin, was probably caused by a turbocharger malfunction;
- An excess aircraft weight (approximately 770 lb or 349 kg above the MTOW), contributed to the aircraft's inability to accelerate and climb.
The following contributing factors were identified:
- Deficient operator processes in the preventive maintenance of the propellers, failing to detect and allowing the accumulation of grease in the blade coupling section, a circumstance that delayed or prevented the propeller from feathering in a critical phase of flight.
- Failure by the operator to comply with the requirements established by Supplement Type STC SA00192SE in order to operate aircraft HK-5121 with an increased MTOW of 7,352 lb, consisting of:
• Incorporating an FMS (flight manual supplement) into the operation to ensure that no more than four vortex-generating flaps (or blades) were missing.
• Not extending the length of the aircraft's wings or installing winglets.
- Failure by the Operator to comply with the procedures for preparing the Weight and Balance form, by not recording the exact weight of each of the occupants and, instead, using average weights that led to a Takeoff Weight (TOW) lower than the actual weight.
- The operator's lack of knowledge of the impact on the aircraft's MTOW, the altitude of the aerodrome, and the ambient temperature, which at Olaya Herrera aerodrome is lower than the operating MTOW of 7,000 lb corresponding to operation in standard atmosphere.
- The operator did not have a risk analysis for each of the company's operating aerodromes, establishing weight limits for takeoff, taking into account the aircraft's performance charts, the specific operating conditions, and the possible failure of an engine during takeoff or initial climb.
Final Report:

Crash of a De Havilland DHC-3 Otter in Pluto Lake

Date & Time: Oct 13, 2022 at 0929 LT
Type of aircraft:
Operator:
Registration:
C-FDDX
Survivors:
Yes
Schedule:
Mistissini - Pluto Lake
MSN:
165
YOM:
1956
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
1938
Captain / Total hours on type:
600.00
Aircraft flight hours:
17489
Circumstances:
On 12 October 2022, the True North Airways Inc. de Havilland DHC-3 Otter aircraft on floats (registration C-FDDX, serial number 165) was conducting a visual flight rules flight, with 1 pilot on board, from Mistissini Water Aerodrome (CSE6), Quebec, to Pluto Lake, Quebec, where it would deliver cargo and pick up passengers. At approximately 0929 Eastern Daylight Time, while manoeuvring for landing on Pluto Lake, the aircraft collided with the surface of the water. The pilot sustained serious injuries. The passengers, who had been waiting near the lake for the aircraft’s arrival, transported the pilot to a nearby cabin from where he was later taken to hospital by a search and rescue helicopter. The emergency locator transmitter activated. There was significant damage to the aircraft.
Probable cause:
3.1 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.
Due to the visual cues of the landing area that were visible to the pilot, the close proximity of the landing site where passengers were waiting, and the natural tendency to continue a plan under changing conditions, the pilot continued the approach despite visibility in the local area being below the minimum required for visual flight rules flight.
Owing to the reduced visibility, the pilot’s workload, while he was manoeuvring for landing, was high and his attention was focused predominantly outside the aircraft in order to keep the landing area in sight. As a result, a reduction in airspeed went unnoticed.
During the aircraft’s turn from base to final, the increased wing loading, combined with the reduced airspeed, resulted in a stall at an altitude too low to permit recovery.
The pilot was not wearing the shoulder harness while at the controls and operating the aircraft because he found it uncomfortable and other aircraft he flew were not equipped with one. As a result, during impact with the water, the pilot received serious injuries.

3.2 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.
If aircraft stall warning systems do not provide multiple types of alerts warning the pilot of an impending stall, there is an increased risk that a visual stall warning alone will not be salient enough and go undetected when the pilot’s attention is focused outside the aircraft or during periods of high workload.
If aircraft operators do not ensure that their contact information on file with the Canadian Beacon Registry is accurate, there is a risk that search and rescue operations may be delayed.
If companies do not employ robust flight-following procedures, there is a risk that, after an accident, potentially life-saving search and rescue services will be delayed.

3.3 Other findings
These items could enhance safety, resolve an issue of controversy, or provide a data point for future safety studies.
The occurrence aircraft was carrying dangerous goods on board, even though the operator was not authorized to do so on its DHC-3 Otter aircraft.
For unknown reasons, the pilot encountered difficulty inflating his personal flotation device, and because of his proximity to the shore, he removed it to make it easier to swim.
Final Report: