Crash of a Embraer EMB-500 Phenom 100 in São Pedro

Date & Time: Oct 30, 2020 at 1750 LT
Type of aircraft:
Operator:
Registration:
PR-LMP
Survivors:
Yes
Schedule:
São Paulo – São Pedro
MSN:
500-00094
YOM:
2009
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
7300
Captain / Total hours on type:
2350.00
Copilot / Total flying hours:
676
Copilot / Total hours on type:
409
Circumstances:
After touchdown on runway 29 at São Pedro Airport, the crew initiated the breaking procedure but the airplane failed to stop within the remaining distance. It overran, collided with various obstacles, went down an embankment of 10 metres and eventually came to rest 130 metres further, bursting into flames. All four occupants evacuated safely and the airplane was destroyed by a post crash fire.
Probable cause:
Studies and research showed that the low deceleration of the aircraft and the limitation of the hydraulic pressure provided by the brake system were compatible with a slippery runway scenario. Thus, one inferred that the runway was contaminated, a condition that would reduce its coefficient of friction and impair the aircraft's braking performance, making it impossible to stop within the runway limits. On account of the mirroring condition of the runway in SSDK, it is possible that the crew had some difficulty perceiving, analyzing, choosing alternatives, and acting appropriately, given a possible inadequate judgment of the aircraft's landing performance on contaminated runways.
Final Report:

Crash of a Piper PA-31T Cheyenne II in Lafayette: 5 killed

Date & Time: Dec 28, 2019 at 0921 LT
Type of aircraft:
Registration:
N42CV
Flight Phase:
Survivors:
Yes
Site:
Schedule:
Lafayette - Atlanta
MSN:
31T-8020067
YOM:
1980
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
1531
Captain / Total hours on type:
730.00
Aircraft flight hours:
5954
Circumstances:
The personal flight departed from Lafayette Regional Airport/Paul Fournet Field (LFT), Lafayette, Louisiana, and entered the clouds when the airplane was at an altitude of about 200 ft above ground level. Before takeoff, the controller issued an instrument flight rules clearance to the pilot, instructing him to turn right onto a heading of 240° and climb to and maintain an altitude of 2,000 ft mean sea level (msl) after takeoff. Automatic dependent surveillance-broadcast (ADS-B) data for the accident flight started at 0920:05, and aircraft performance calculations showed that the airplane was climbing through an altitude of 150 ft msl at that time. The calculations also showed that the airplane then turned slightly to the right toward the assigned heading of 240° and climbed at a rate that varied between 1,000 and 2,400 ft per minute and an airspeed that increased from about 151 to 165 knots. At 0920:13, the airplane started rolling back toward wings level and, 7 seconds later, rolled through wings level and toward the left. At that time, the airplane was tracking 232° at an altitude of 474 ft and an airspeed of 165 knots. The airplane’s airspeed remained at 165 knots for about 10 seconds before it started increasing again, and the airplane continued to roll steadily to the left at an average roll rate of about 2° per second. The aircraft performance calculations further showed that, at 0920:40, the airplane reached a peak altitude of 925 ft msl. At that time, the airplane was tracking 200°, its bank angle was about 35° to the left, and its airspeed was about 169 knots. The airplane then started to descend while the left roll continued. At 0920:55, the airplane reached a peak airspeed of about 197 knots, which then started decreasing. At 0920:57, the airplane descended through 320 ft at a rate of descent of about 2,500 ft per minute and reached a bank angle of 75° to the left. At 0920:58, the controller issued a low altitude alert, stating that the pilot should “check [the airplane’s] altitude immediately” because the airplane appeared to be at an altitude of 300 ft msl. The pilot did not respond, and no mayday or emergency transmission was received from the airplane. The last ADS-B data point was recorded at 0920:59; aircraft performance calculations showed that, at that time, the airplane was descending through an altitude of 230 ft msl at a flightpath angle of about -7°, an airspeed of 176 knots, and a rate of descent of about 2,300 ft per minute. (The flightpath angle is in the vertical plane—that is, relative to the ground. The ground track, as discussed previously, is in the horizontal plane—that is, relative to north.) The airplane struck trees and power lines before striking the ground, traveled across a parking lot, and struck a car. The car rolled several times and came to rest inverted at the edge of the parking lot, and a postcrash fire ensued. The airplane continued to travel, shedding parts before coming to rest at the far end of an adjacent field. At the accident site, the surviving passenger told a local police officer that “the plane went straight up and then straight down.”
Probable cause:
The pilot’s loss of airplane control due to spatial disorientation during the initial climb in instrument meteorological conditions.
Final Report:

Crash of a Pilatus PC-12/47E in Chamberlain: 9 killed

Date & Time: Nov 30, 2019 at 1233 LT
Type of aircraft:
Operator:
Registration:
N56KJ
Flight Phase:
Survivors:
Yes
Schedule:
Chamberlain – Idaho Falls
MSN:
1431
YOM:
2013
Crew on board:
1
Crew fatalities:
Pax on board:
11
Pax fatalities:
Other fatalities:
Total fatalities:
9
Captain / Total flying hours:
2314
Captain / Total hours on type:
1274.00
Aircraft flight hours:
1725
Circumstances:
The pilot and passengers flew in the day before the accident and the airplane remained parked outside on the airport ramp overnight. Light to moderate snow and freezing drizzle persisted during the 12 to 24-hour period preceding the accident. In addition, low instrument meteorological conditions existed at the time of the accident takeoff. Before the flight, the pilot removed snow and ice from the airplane wings. However, the horizontal stabilizer was not accessible to the pilot and was not cleared of accumulated snow. In addition, the airplane was loaded over the maximum certificated gross weight and beyond the aft center-of-gravity limit. A total of 12 occupants were on board the airplane, though only 10 seats were available. None of the occupants qualified as lap children under regulations. The takeoff rotation was initiated about 88 kts which was about 4 kts slower than specified with the airplane configured for icing conditions. After takeoff, the airplane entered a left turn. Airspeed varied between 89 and 97 kts during the initial climb; however, it decayed to about 80 kts as the airplane altitude and bank angle peaked. The airplane ultimately reached a left bank angle of 64° at the peak altitude of about 380 ft above ground level. The airplane then entered a descent that continued until impact. The stall warning and stick shaker activated about 1 second after liftoff. The stick pusher became active about 15 seconds after liftoff. All three continued intermittently for the duration of the flight. A witness located about 1/2-mile northwest of the airport reported hearing the airplane takeoff. It was cloudy and snowing at the time. He was not able to see the airplane but noted that it entered a left turn based on the sound. He heard the airplane for about 4 or 5 seconds and the engine seemed to be “running good” until the sound stopped. The airplane impacted a dormant corn field about 3/4-mile west of the airport. A postaccident airframe examination did not reveal any anomalies consistent with a preimpact failure or malfunction. On board recorder data indicated that the engine was operating normally at the time of the accident. An airplane performance analysis indicated that the accumulated snow and ice on the empennage did not significantly degrade the airplane performance after takeoff. However, the effect of the snow and ice on the airplane center-of-gravity and the pitch (elevator) control forces could not be determined. Simulations indicated that the pitch oscillations recorded on the flight could be duplicated with control inputs, and that the flight control authority available to the pilot would have been sufficient to maintain control until the airplane entered an aerodynamic stall about 22 seconds after lifting off (the maximum bank angle of 64° occurred after the critical angle-of-attack was exceeded). In addition, similar but less extreme pitch oscillations recorded on the previous flight (during which the airplane was not contaminated with snow but was loaded to a similar center-of-gravity position) suggest that the pitch oscillations on both flights were the result of the improper loading and not the effects of accumulated snow and ice. Flight recorder data revealed that the accident pilot tended to rotate more rapidly and to a higher pitch angle during takeoff than a second pilot who flew the airplane regularly. Piloted simulations suggested that the accident pilot’s rotation technique, which involved a relatively abrupt and heavy pull on the control column, when combined with the extreme aft CG, heavy weight, and early rotation on the accident takeoff, contributed to the airplane’s high angle-of attack immediately after rotation, the triggering of the stick shaker and stick pusher, and the pilot’s pitch control difficulties after liftoff. The resulting pitch oscillations eventually resulted in a deep penetration into the aerodynamic stall region and subsequent loss of control. Although conditions were conducive to the development of spatial disorientation, the circumstances of this accident are more consistent with the pilot’s efforts to respond to the activation of the airplane stall protection system upon takeoff. These efforts were hindered by the heightened airplane pitch sensitivity resulting from the aft-CG condition. As a result, spatial disorientation is not considered to be a factor in this accident.
Probable cause:
The pilot’s loss of control shortly after takeoff, which resulted in an inadvertent, low-altitude aerodynamic stall. Contributing to the accident was the pilot’s improper loading of the airplane, which resulted in reduced static longitudinal stability and his decision to depart into low instrument meteorological conditions.
Final Report:

Crash of an Embraer EMB-121A1 Xingu II in Campinas

Date & Time: Apr 2, 2019 at 2315 LT
Type of aircraft:
Registration:
PT-FEG
Survivors:
Yes
Schedule:
Sorocaba - Palmas
MSN:
121-057
YOM:
1982
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The twin engine airplane departed Sorocaba-Estadual Bertram Luiz Leupolz Airport at 2300LT on a flight to Palmas, Tocantins, carrying three passengers and a crew of two. Few minutes after takeoff, the crew encountered technical difficulties and was cleared to divert to Campinas-Viracopos Airport. On final, he realized he could not make it so he attempted an emergency landing in a prairie located about 6 km short of runway 15 threshold. The wreckage was found less than a km from the Jardim Bassoli condominium and all five occupants, slightly injured, were evacuated. The aircraft was damaged beyond repair.

Crash of an Epic LT in Egelsbach: 3 killed

Date & Time: Mar 31, 2019 at 1527 LT
Type of aircraft:
Operator:
Registration:
RA-2151G
Survivors:
No
Schedule:
Cannes - Egelsbach
MSN:
019
YOM:
2008
Location:
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
11425
Captain / Total hours on type:
676.00
Aircraft flight hours:
2221
Circumstances:
At 1357 hrs the airplane had taken off from Cannes-Mandelieu Airport, France, to a private flight to Egelsbach Airfield, Germany. On board were the pilot and two passengers. According to the flight plan cruise flight was planned for Flight Level (FL)260. At 1519:03 hrs the pilot established contact with Frankfurt Radar, and informed the controller that the airplane was in descent to FL60 towards reporting point UBENO. The radar recordings show that the airplane was flying towards 335° and transmitted the transponder code 4065. The radar controller issued the descent clearance to 4,000 ft AMSL and conveyed a QNH of 1,020 hPa. At 1519:25 hrs the controller addressed the pilot: “[…] proceed direct DELTA, runway zero eight in use.” The pilot acknowledged the clearance. At 1520:20 hrs the controller instructed the pilot to descend to 3,500 ft AMSL. After the pilot had acknowledged the controller’s question, the change of flight rules from IFR to VFR was conducted at 1521 hrs about 16 NM south of Egelsbach Airfield. At the time, the airplane was at about 5,000 ft AMSL with a ground speed of approximately 240 kt. At 1522:34 hrs, the airplane was at 3,500 ft AMSL and about 14 NM from the airfield, the pilot established radio contact with Egelsbach Information with the words: “[…] inbound DELTA, descending VFR.” The Flugleiter (A person required by German regulation at uncontrolled aerodromes to provide aerodrome information service to pilots) answered: “Hello […] runway zero eight, QNH one zero two zero, squawk four four four one.” The pilot acknowledged the landing direction and the QNH. The communicated transponder code was not acknowledged, and did not change during the remainder of the flight, according to the radar recording. At 1524:34 hrs the Flugleiter gave the pilot the hint: “[…] the maximum altitude in this area is one thousand five hundred feet.” The pilot answered: “Roger, continue descent […].” At this time, altitude was still about 2,000 ft AMSL. According to the radar recording, at 1524:45 hrs the airplane turned right in northern direction toward the DELTA approach path to runway 08 of Egelsbach Airfield. Altitude was about 1,900 ft AMSL, and ground speed 170 kt. At 1526:30 hrs, at about the Tank- und Rastanlage Gräfenhausen (resting facility) at the Bundesautobahn A5 (motorway), it began to turn right up to north-eastern direction. At 1526:44 hrs the Flugleiter addressed the pilot: “[…] do you have the field in sight?” The pilot responded: “Ah, not yet […].” At the time, the airplane was about 1,000 m south-west of threshold 08 at the western outskirts of Erzhausen flying a northeastern heading. The Flugleiter added: “I suggest to reduce, you are now in right base.” After the pilot had answered with “Roger”, the Flugleiter added: “You are number one to land. The wind is zero four zero, one zero knots.” At 1527:04 hrs, the airplane was about 300 m south of threshold 08 flying a northeastern heading, the radio message“[…] approach” of the pilot was recorded. From then on the airplane began to turn left. At 1527:11 hrs, the airplane crossed runway 08 with a ground speed of about 100 kt at very low altitude with northern heading. At 1527:24 hrs the pilot said: “[…] may I the […] make an orbit?” The Flugleiter answered: “Yes, do it to your left-hand side and do not overfly the highway westbound.” At 1527:31 hrs, the last radar target was recorded at approximately 600 m north-west of threshold 08 indicating an altitude of about 425 ft AMSL. About 100 m south-west of it the airplane crashed to the ground and caught fire. All three occupants suffered fatal injuries. At the time of the accident, three persons were in the Tower of the airfield. The Flugleiter, as tower controller, his replacement, and the apron controller. They observed that the airplane flew directly towards the tower coming from the DELTA approach in descent with north-eastern heading, i.e. diagonal to the landing direction. In this phase the landing gear extended. Two witnesses, who were at the airport close to the tower, stated that they had seen the airplane during the left-hand turn. They estimated the bank angle during the turn with 30-45°. The two occupants of a Piper PA-28, which had been on approach to runway 08, stated that they had become aware of the other airplane, before changing from downwind leg to final approach. They also stated that during the turn the airplane went into a dive and impacted the ground after about a half turn. Approximately 330 m north-east of the accident site, persons had been walking in a forest. One of them recorded a video. This recording was made available for investigation purposes. The video shows the shadow of the airplane moving west immediately prior to the accident. Consistent engine sounds and, 8 seconds after the shadow passed, the crash of the airplane can be heard. The aircraft was totally destroyed by a post crash fire and all three occupants were killed, among them Natalia Fileva, co-owner of the Russian Operator S7 Airlines.
Probable cause:
The accident was caused by the pilot steering the airplane during a turn in low altitude in an uncontrolled flight attitude, the airplane then banked over the wing and impacted the ground in a spinning motion.
Contributing factors:
- The decision of the pilot to conduct a non-standard approach to runway 08 without visual contact with the runway and contrary to the SOP and to continue the unstabilized approach,
- The complex airspace structure surrounding Frankfurt-Egelsbach Airfield,
- The late recognition of the airport and the pilot’s decision for an inappropriate manoeuvre close to the ground,
- The insufficient attention distribution of the pilot in combination with the missing stall warning of the airplane.
Final Report:

Crash of a Canadair CL-601 Challenger in Ox Ranch

Date & Time: Jan 13, 2019 at 1130 LT
Type of aircraft:
Registration:
N813WT
Survivors:
Yes
Schedule:
Fort Worth - Ox Ranch
MSN:
3016
YOM:
1983
Crew on board:
3
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
9000
Captain / Total hours on type:
3500.00
Copilot / Total flying hours:
1015
Copilot / Total hours on type:
25
Aircraft flight hours:
8408
Circumstances:
The pilot, copilot, flight attendant, and six passengers departed on a corporate flight to a private airstrip. After leveling off at flight level 280, the flight crew checked the weather conditions at nearby airports. Based on the weather information that they had, the pilot planned for a visual approach to the runway. As the airplane neared the destination, the pilot flew over the runway and entered a left downwind visual traffic pattern to check if any animals were on the runway and what the windsock on the airstrip indicated. The pilot stated that they did not see the windsock as they passed over the runway. The pilot reported that there were turbulence and wind gusts from the hills below and to the west. When the airplane was over the runway about 50 ft above ground level (agl), the pilot reduced the engine power to idle. The pilot reported the airplane then encountered wind shear; the airspeed dropped rapidly, and the airplane was "forced down" to the runway. A representative at the airstrip reported that the airplane hit hard on landing. The pilot unlocked the thrust reversers, applied brakes, and reached to deploy the ground spoilers. As he deployed the thrust reversers, the pilot said it felt like the right landing gear collapsed. He applied full left rudder and aileron, but the airplane continued to veer to the right. The pilot tried using the tiller to steer to the left but got no response. The airplane left the side of the runway and went into the grass, which resulted in substantial damage; the right main landing gear was broken aft and collapsed under the right wing. Postaccident examinations of the airplane revealed no preimpact mechanical malfunctions or failures that would have precluded normal operation. A review of weather conditions showed surface winds out of the north to northwest at 15 kts, with some gusts up to 20 kts. There was potential for turbulence and wind shear below 5,000 ft, but there were no direct observations. The area forecast about 30 minutes after the accident called for northwesterly winds at 10 to 17 kts with a few higher gusts in the afternoon for the general area. Data from an onboard enhanced ground proximity warning system (EGPWS) revealed that the crew received a terrain alert just before the airplane crossed the runway threshold. At the time the airplane was over the runway threshold, it was 48 ft agl and in a 1,391 ft per minute rate of descent. The airplane impacted the runway 3 seconds later. Given the pilot's account, the weather information for the area, and the data from the airplane's EGPWS, it is likely that the airplane encountered wind shear while transitioning from approach to landing.
Probable cause:
The airplane's encounter with wind shear on short final approach to the runway, which resulted in a hard landing and fracture of the right main landing gear.
Final Report:

Crash of a Cessna 525 CitationJet Cj2+ in Memphis: 3 killed

Date & Time: Nov 30, 2018 at 1028 LT
Type of aircraft:
Operator:
Registration:
N525EG
Flight Phase:
Survivors:
No
Schedule:
Jeffersonville – Chicago
MSN:
525-0449
YOM:
2009
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
3500
Aircraft flight hours:
3306
Circumstances:
On November 30, 2018, about 1028 central standard time, a Cessna 525A (Citation) airplane, N525EG, was destroyed when it was involved in an accident near Memphis, Indiana. The pilot and two passengers were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 business flight. The cross-country flight originated from Clark Regional Airport (JVY), Jeffersonville, Indiana, and was en route to Chicago Midway International Airport (MDW), Chicago, Illinois. The airplane was equipped with automatic dependent surveillance–broadcast (ADS-B), which recorded latitude and longitude from GPS, pressure and geometric altitude, and selected altitude and heading. The airplane was also equipped with a cockpit voice recorder (CVR), which recorded the accident flight and annunciations from the enhanced ground proximity warning system (EGPWS). It was not equipped with a flight data recorder (FDR) nor was it required to be. Review of the CVR transcript showed that the pilot operated as a single pilot but verbalized his actions as he configured the airplane before departure. He referenced items from the Before Taxi checklist and included in his crew briefing that in the event of a problem after takeoff decision speed, he would handle it as an in-flight emergency and “fly the airplane, address the problem, get the autopilot on, talk on the radios, divert over to Stanford.” The air traffic controller provided initial clearance for the pilot to fly direct to the STREP intersection and to climb and maintain 3,000 ft mean sea level. Before the departure from JVY, the pilot announced on the common traffic advisory frequency that he was departing runway 36 and verbalized in the cockpit “this is three six” before he advanced the throttles. The flight departed JVY about 1024:36 into instrument meteorological conditions. The CVR recorded the pilot state that he set power to maximum cruise thrust, switched the engine sync on, and turned on the yaw dampers. The pilot also verbalized his interaction with the autopilot, including navigation mode, direct STREP, and vertical speed climb up to 3,000 ft. According to the National Transportation Safety Board’s (NTSB) airplane performance study, the airplane climbed to about 1,400 ft msl before it turned left onto a course of 330° and continued to climb. The CVR recorded the pilot state he was turning on the autopilot at 1025:22. At 1025:39, the pilot was cleared up to 10,000 ft and asked to “ident,” and the airplane was subsequently identified on radar. The pilot verbalized setting the autopilot for 10,000 ft and read items on the After Takeoff/Climb checklist. The performance study indicated that the airplane passed 3,000 ft about 1026, with an airspeed between 230 and 240 kts, and continued to climb steadily. At 1026:29, while the pilot was conducting the checklist, the controller instructed him to contact the Indianapolis Air Route Traffic Control Center; the pilot acknowledged. At 1026:38, the pilot resumed the checklist and stated, “uhhh lets seeee. Pressurization pressurizing anti ice de-ice systems are not required at this time.” The performance study indicated that, at 1026:45, the airplane began to bank to the left at a rate of about 5° per second and that after the onset of the roll, the airplane maintained airspeed while it continued to climb for 12 seconds, consistent with engine power not being reduced in response to the roll onset. At 1026:48, the CVR recorded the airplane’s autopilot disconnect annunciation, “autopilot.” The performance study indicated that about this time, the airplane was in about a 30° left bank. About 1 second later, the pilot stated, “whooooaaaaah.” Over the next 8 seconds, the airplane’s EGPWS annunciated six “bank angle” alerts. At 1026:57, the airplane reached its maximum altitude of about 6,100 ft msl and then began to descend rapidly, in excess of 11,000 ft per minute. At 1026:58, the bank angle was about 70° left wing down, and by 1027:05, the airplane was near 90° left wing down. At 1027:04, the CVR recorded a sound similar to an overspeed warning alert, which continued to the end of the flight. The performance study indicated that about the time of the overspeed warning, the airplane passed about 250 kts calibrated airspeed at an altitude of about 5,600 ft. After the overspeed warning, the pilot shouted three expletives, and the bank angle alert sounded two more times. According to the performance study, at 1027:18, the final ADS-B data point, the airplane was about 1,000 ft msl, with the airspeed about 380 kts and in a 53° left bank. At 1027:11, the CVR recorded the pilot shouting a radio transmission, “mayday mayday mayday citation five two five echo golf is in an emergency descent unable to gain control of the aircraft.” At 1027:16, the CVR recorded the EGPWS annunciating “terrain terrain.” The sound of impact was recorded about 1027:20. The total time from the beginning of the left roll until ground impact was about 35 seconds. The accident site was located about 8.5 miles northwest of JVY.
Probable cause:
The asymmetric deployment of the left wing load alleviation system for undetermined reasons, which resulted in an in-flight upset from which the pilot was not able to recover.
Final Report:

Crash of a Cessna 525 CitationJet M2 in Fazenda Fortaleza de Santa Terezinha: 4 killed

Date & Time: Nov 26, 2018 at 0830 LT
Type of aircraft:
Operator:
Registration:
PP-OEG
Survivors:
No
Schedule:
Belo Horizonte - Fazenda Fortaleza de Santa Terezinha
MSN:
525-0849
YOM:
2014
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
11000
Captain / Total hours on type:
522.00
Circumstances:
The twin engine airplane was completing a flight from Belo Horizonte-Pampulha-Carlos Drummond de Andrade to the Fortaleza de Santa Terezinha Farm (Fazenda Fortaleza de Santa Terezinha) located in Várzea da Palma, Jequitaí, Minas Gerais. On board were three passengers and one pilot. On final approach to runway 20, during the last segment, the airplane collided with a metallic water irrigation system. The pilot initiated a go around procedure when he lost control of the airplane that veered to the left, impacted the ground and crashed in a field located to the left of the runway, about 600 metres from the initial impact, bursting into flames. The aircraft was totally destroyed by impact forces and a post crash fire and all four occupants were killed, among them Mr. Adolfo Geo, owner of the Brazilian group ARG Ltd active in food, oil and construction. He was accompanied by his wife Margarida Janete Geo.
Probable cause:
The following factors were identified:
- Airport infrastructure – a contributor.
It was found that the irrigation pivot, at the point where the collision took place, was impairing the gauge of the approach surface as described in Ordinance 957/GC3, of 09JUL2015, which provided for restrictions on objects projected into the airspace that could adversely affect the safety or regularity of air operations.
- Piloting judgment – a contributor.
The final approach was carried out below the ideal approach ramp, allowing the collision against the pivot, located in the alignment of the runway.
- Perception – undetermined.
It is possible that the PIC, when approaching for the landing, did not notice the irrigation pivot and, therefore, collided with the obstacle.
- Flight planning – a contributor.
There was no prior coordination with the farm employees, in a timely manner so that the irrigation pivot could be repositioned to a safe location in relation to the flight trajectory on the final landing approach.
Final Report:

Crash of a Honda HA-420 HondaJet in Foz do Iguaçu

Date & Time: Sep 24, 2018 at 1342 LT
Type of aircraft:
Operator:
Registration:
PR-TLZ
Survivors:
Yes
Schedule:
Curitiba – Foz do Iguaçu
MSN:
420-00068
YOM:
2017
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
5600
Captain / Total hours on type:
77.00
Copilot / Total flying hours:
660
Copilot / Total hours on type:
14
Circumstances:
The airplane departed Curitiba-Afonso Pena Airport at 1240LT on an executive flight to Foz do Iguaçu, carrying one passenger and two pilots. Following an uneventful flight, the crew started the descent to Foz do Iguaçu-Cataratas Airport. The aircraft was stabilized and landed on wet runway 32. After touchdown, the crew encountered difficulties to stop the aircraft that overran and came to rest into a ravine. All three occupants evacued safely and the aircraft was damaged beyond repair.
Probable cause:
The following findings were identified:
- The approach was considered stabilized;
- The required landing distance of 6,431t (1,960m) was compatible for the operation, since the LDA of runway 32 at SBFI was 7,201ft (2,195m);
- There was no evidence of malfunction of the aircraft brake system that could have caused the runway excursion;
- At the time of landing, the runway was wet with a significant amount of water on the pavement;
- The estimated deceleration corresponded to what would be expected on a very wet runway (> 3mm of water) with hydroplaning of the tires at higher speeds;
- The friction and macrotexture measurements had normal parameters and did not contribute to the aircraft's poor deceleration;
- The characteristics of the precipitation over threshold 14 associated with the large variations in wind direction and intensity were consistent with the windshear phenomenon, resulting from a microburst;
- The PR-TLZ sensors did not detect the occurrence of windshear during the landing approach;
- A sudden increase in the calibrated speed that peaked at 32kt altered the aircraft's lift and, consequently, reduced the tires' grip on the ground, resulting in poor braking in the parts where the ground speed was lower;
- The speedbrakes were not extended during the run after landing, contrary to what was prevised in the AFM;
- The aircraft ran the full length of the runway, overpassed its limits and crashed into a ravine;
- There was a windshear alert issued about 30 seconds after the landing of the PRTLZ by an aircraft that was at the threshold 32;
- The aircraft had substantial damage; and
- The crewmembers and the passenger left unharmed.
Contributing factors:
- Control skills – undetermined
Despite the low contribution of the speedbrakes to the reduction of the landing distance, this device represents a deceleration resource through aerodynamic drag that should not be neglected, especially during landing on wet runways, and could have contributed to avoiding runway excursion.
- Adverse meteorological conditions – a contributor
The large variation in wind intensity peaked at 32 kt. This variation lasted 13 seconds and raised the indicated speed from 76 kt to 108 kt. Considering that the speed of 108 kt was very close to the VREF (111 KCAS), it can be stated that this phenomenon altered the aircraft's lift and, consequently, reduced the tires' grip on the ground, leading to poor braking.
Final Report:

Crash of a Beechcraft C90B King Air in Ipumirim: 1 killed

Date & Time: Sep 15, 2018 at 1200 LT
Type of aircraft:
Operator:
Registration:
PR-RFB
Flight Phase:
Survivors:
No
Schedule:
Florianópolis – Chapecó
MSN:
LJ-1546
YOM:
1999
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
The pilot departed Florianópolis-Hercílio Luz Airport at 1100LT on a flight to Chapecó. Following an uneventful flight, the pilot initiated the descent to Chapecó-Serafim Enoss Bertasco Airport but encountered marginal weather conditions with limited visibility. While descending under VFR mode, the aircraft collided with trees and crashed in a dense wooded area located in Ipumirim, some 50 km east of Chapecó Airport, bursting into flames. The aircraft was destroyed by impact forces and a post crash fire and the pilot, sole occupant, was killed.
Probable cause:
Controlled flight into terrain.
Contributing factors.
- Attitude - contributed
The fact that the pilot continued the descent visually, not performing the instrument approach according to the IFR flight plan, denoted disregard of the real risks of this action. Thus, his attitude contributed to the inappropriate approach that culminated in the collision with the ground.
- Adverse weather conditions - contributed
Despite the aerodrome presenting ceiling and visibility conditions favorable for visual flight at the time of the accident, it was verified that there was dense fog covering the entire region near the impact site and, therefore, the IFR rules, which determined a minimum altitude of 5,000 ft, should have been observed.
- Emotional state - undetermined
Some events in the pilot's personal life were negatively affecting his emotional state. In addition, the pilot appeared to be more introspective in the period leading up to the accident.
Thus, it is possible that his performance was impaired due to his emotional state.
- External influences - undetermined
The pilot was possibly experiencing difficult events in his personal life. These events could have negatively affected his emotional state.
Thus, the pilot's way of thinking, reacting and performance at work may have been impacted by factors external to work.
- Motivation - undetermined
The pilot intended to return home because he would be celebrating his birthday and that of his stepdaughter.
The audio recording of the pilot's telephony with the GND-FL, shows that he insisted to accelerate his take-off, denoting a possible high motivation focused on fulfilling his eagerness to accomplish the flight. This condition may have influenced the flight performance.
- Decision making process - contributed
The choice to continue the descent without considering the IFR rules, based on an inadequate judgment of the meteorological conditions, revealed the pilot's difficulties to perceive, analyze, choose alternatives and act adequately in that situation.
Final Report: