Crash of a Piper PA-31-310 Navajo C in Zielona Góra: 1 killed

Date & Time: Nov 24, 2016 at 1205 LT
Type of aircraft:
Operator:
Registration:
D-IFBU
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Zielona Góra - Nordhorn
MSN:
31T-8012050
YOM:
1980
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
9418
Captain / Total hours on type:
7371.00
Aircraft flight hours:
6641
Circumstances:
While taking off from a grassy runway at Zielona Góra-Przylep Airport, the airplane nosed down, impacted ground and crashed. Both engines were torn off and the aircraft was destroyed by impact forces. There was no fire. The pilot, sole on board, was killed. He was completing a ferry flight to Nordhorn, Lower Saxony.
Probable cause:
The pilot mistakenly retracted the undercarriage at liftoff. There was no immediate decision of the pilot to abandon the takeoff procedure when both propellers contacted the runway surface.
Final Report:

Crash of a Beechcraft B100 King Air in Jackson

Date & Time: Sep 21, 2016 at 1620 LT
Type of aircraft:
Registration:
N66804
Flight Type:
Survivors:
Yes
Schedule:
Memphis – Jackson
MSN:
BE-82
YOM:
1980
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
11295
Captain / Total hours on type:
570.00
Aircraft flight hours:
4013
Circumstances:
The commercial pilot reported that he had completed several uneventful flights in the multiengine airplane earlier on the day of the accident. He subsequently took off for a return flight to his home airport. He reported that the en route portion of the flight was uneventful, and on final approach for the traffic pattern for landing, all instruments were indicating normal. He stated that the airplane landed "firmly," that the right wing dropped, and that the right engine propeller blades contacted the runway. He pulled back on the yoke, and the airplane became airborne again momentarily before settling back on the runway. The right main landing gear (MLG) collapsed, and the airplane then veered off the right side of the runway and struck a runway sign and weather antenna. Witness reports corroborated the pilot's report. Postaccident examination revealed that the right MLG actuator was fractured and that the landing gear was inside the wheel well, which likely resulted from the hard landing. The pilot reported that there were no preimpact mechanical failures or malfunctions with the airframe or engine that would have precluded normal operation. Based on the pilot and witness statements and the wreckage examination, it is likely that the pilot improperly flared the airplane, which resulted in the hard landing and the collapse of the MLG.
Probable cause:
The pilot's improper landing flare, which resulted in a hard landing.
Final Report:

Crash of a De Havilland DHC-2 Beaver I in Elwyn Creek: 1 killed

Date & Time: Jul 15, 2016 at 2220 LT
Type of aircraft:
Operator:
Registration:
C-GWDW
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Telegraph Creek – Mowdade Lake
MSN:
306
YOM:
1952
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
The Beaver floatplane departed Telegraph Creek Water Aerodrome, BC (CAH9) destined for Mowdade Lake, BC, at approximately 2040 PDT on 15 July 2016 on a VFR flight itinerary round-trip with one pilot on board. When the aircraft did not arrive at Mowdade Lake and did not return to CAH9, a search was initiated. The aircraft's wreckage was located at approximately 2000 PDT the following day in a ravine at an elevation of about 5,000 feet near the headwaters of Elwyn Creek, BC. The aircraft was consumed by fire and the pilot was fatally injured.

Crash of a De Havilland DHC-2 Beaver near Barkárdal: 1 killed

Date & Time: Aug 9, 2015 at 1445 LT
Type of aircraft:
Operator:
Registration:
N610LC
Flight Phase:
Flight Type:
Survivors:
Yes
Site:
Schedule:
Akureyri – Keflavik
MSN:
1446
YOM:
1960
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
22000
Captain / Total hours on type:
250.00
Circumstances:
At 14:01 on August 9th, 2015, a pilot along with a friend, a contracted ferry flight pilot, planned to fly airplane N610LC, which is of the type De Havilland DHC-2 Beaver, under Visual Flight Rules (VFR) from Akureyri Airport to Keflavik Airport in Iceland. The purpose of the flight was to ferry the airplane from Akureyri to Minneapolis/St. Paul in the United States, where the airplane was to be sold. The airplane was initially flown in Eyjafjörður in a northernly direction from Akureyri, over Þelamörk and then towards and into the valley of Öxnadalur. The cloud ceiling was low and it was not possible to fly VFR flight over the heath/ridge of Öxnadalsheiði. The airplane was turned around in the head of the valley of Öxnadalur and flown towards the ridge of Staðartunguháls, where it was then flown towards the heath/ridge of Hörgárdalsheiði at the head of the valley of Hörgárdalur. In the valley of Hörgárdalur it became apparent that the cloud base was blocking off the heath/ridge of Hörgárdalsheiði, so the airplane was turned around again. The pilots then decided to fly around the peninsula of Tröllaskagi per their original backup plan, but when they reached the ridge of Staðartunguháls again the pilots noticed what looked like a break in the cloud cover over the head of the valley of Barkárdalur. A spontaneous decision was made by the pilots to fly into the valley of Barkárdalur. The valley of Barkárdalur is a long narrow valley with 3000 – 4500 feet high mountain ranges extending on either side. At the head of the valley of Barkárdalur there is a mountain passage at an elevation of approximately 3900 ft. About 45 minutes after takeoff the airplane crashed in the head of the valley of Barkárdalur at an elevation of 2260 feet. The pilot was severely injured and the ferry flight pilot was fatally injured in a post crash fire.
Probable cause:
Causes:
- According to the ITSB calculations the airplane was well over the maximum gross weight and the airplane’s performance was considerably degraded due to its overweight condition.
Weather
- VFR flight was executed, with the knowledge of IMC at the planned flight route across Tröllaskagi. The airplane was turned around before it entered IMC on two occasions and it crashed when the PF attempted to turn it around for the third time.
- Favorable weather on for the subsequent flight between Keflavik Airport and Greenland on August 10th may have motivated the pilots to fly the first leg of the flight in poor weather conditions on August 9th.
Terrain
- The pilots failed to take into account the geometry of the valley of Barkárdalur, namely its narrow width and the fast rising floor in the back of the valley.
Contributing factors:
CRM - Inadequate planning
- The W&B calculations performed by the PF prior to the flight were insufficient, as the airplane’s weight was well over the maximum gross weight of the airplane.
- The plan was to look for an opening (in the weather), first in the head of the valley of Öxnadalur, then the head of Hörgárdalur and finally in the head of Barkárdalur.
- The decision to fly into the valley of Barkárdalur was taken spontaneously, when flying out of the valley of Hörgárdalur and the pilots noticed what looked like a break in the cloud cover over the head of the valley of Barkárdalur.
CRM – Failed to conduct adequate briefing
- A failure of CRM occurred when the PNF did not inform the PF of the amount of fuel he added to the airplane prior to the flight.
Overconfidence
- The special ferry flight permit the pilots received for the ferry flight to Iceland in 2008 may have provided the pilots with a misleading assumption that such loading of the airplane in 2015 was also satisfactory.
Continuation bias
- The pilots were determined to continue with their plan to fly to Keflavik Airport, over the peninsula of Tröllaskagi, in spite of bad weather condition.
Loss of situational awareness
- The pilots were not actively managing the flight or staying ahead of the aircraft, taking into account various necessary factors including performance, weather and terrain.
- The airplane most likely incurred severe carburetor icing in Barkárdalur.
Final Report:

Crash of a Cessna 340 in Riyadh

Date & Time: Dec 3, 2014 at 1757 LT
Type of aircraft:
Registration:
N340JC
Flight Type:
Survivors:
Yes
Schedule:
Heraklion – Hurghada – Riyadh
MSN:
340-0162
YOM:
1972
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The crew was completing a ferry flight from Heraklion to Riyadh with an intermediate stop in Hurghada, Egypt. On final approach to Riyadh-King Khaled Airport, at an altitude of about 600 feet, the left engine lost power and failed, followed 10 seconds later by the right engine. The crew reported his situation to ATC when the aircraft lost height, impacted ground and slid for few dozen metres before coming to rest against a pile of rocks. One of the pilot suffered a broken wrist while the second pilot escaped uninjured. The aircraft was damaged beyond repair.
Probable cause:
Double engine failure on approach due to fuel exhaustion. It was determined that the crew miscalculated the fuel consumption for the flight from Hurghada to Riyadh.

Crash of a Beechcraft B200 Super King Air in Wichita: 4 killed

Date & Time: Oct 30, 2014 at 0948 LT
Registration:
N52SZ
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Wichita – Mena
MSN:
BB-1686
YOM:
1999
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
3139
Aircraft flight hours:
6314
Aircraft flight cycles:
7257
Circumstances:
The airline transport pilot was departing for a repositioning flight. During the initial climb, the pilot declared an emergency and stated that the airplane "lost the left engine." The airplane climbed to about 120 ft above ground level, and witnesses reported seeing it in a left turn with the landing gear extended. The airplane continued turning left and descended into a building on the airfield. A postimpact fired ensued and consumed a majority of the airplane. Postaccident examinations of the airplane, engines, and propellers did not reveal any anomalies that would have precluded normal operation. Neither propeller was feathered before impact. Both engines exhibited multiple internal damage signatures consistent with engine operation at impact. Engine performance calculations using the preimpact propeller blade angles (derived from witness marks on the preload plates) and sound spectrum analysis revealed that the left engine was likely producing low to moderate power and that the right engine was likely producing moderate to high power when the airplane struck the building. A sudden, uncommanded engine power loss without flameout can result from a fuel control unit failure or a loose compressor discharge pressure (P3) line; thermal damage prevented a full assessment of the fuel control units and P3 lines. Although the left engine was producing some power at the time of the accident, the investigation could not rule out the possibility that a sudden left engine power loss, consistent with the pilot's report, occurred. A sideslip thrust and rudder study determined that, during the last second of the flight, the airplane had a nose-left sideslip angle of 29°. It is likely that the pilot applied substantial left rudder input at the end of the flight. Because the airplane's rudder boost system was destroyed, the investigation could not determine if the system was on or working properly during the accident flight. Based on the available evidence, it is likely that the pilot failed to maintain lateral control of the airplane after he reported a problem with the left engine. The evidence also indicates that the pilot did not follow the emergency procedures for an engine failure during takeoff, which included retracting the landing gear and feathering the propeller. Although the pilot had a history of anxiety and depression, which he was treating with medication that he had not reported to the Federal Aviation Administration, analysis of the pilot's autopsy and medical records found no evidence suggesting that either his medical conditions or the drugs he was taking to treat them contributed to his inability to safely control the airplane in an emergency situation.
Probable cause:
The pilot's failure to maintain lateral control of the airplane after a reduction in left engine power and his application of inappropriate rudder input. Contributing to the accident was the pilot's failure to follow the emergency procedures for an engine failure during takeoff. Also contributing to the accident was the left engine power reduction for reasons that could not be determined because a postaccident examination did not reveal any anomalies that would have precluded normal operation and thermal damage precluded a complete examination.
Final Report:

Crash of a Fokker 100 in Ganla

Date & Time: May 10, 2014 at 2000 LT
Type of aircraft:
Operator:
Registration:
5N-SIK
Flight Phase:
Flight Type:
Survivors:
Yes
Site:
Schedule:
Bratislava – Ghardaïa – Kano
MSN:
11286
YOM:
1989
Location:
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Following a C-Check at Bratislava Airport, the aircraft was returning to its base in Kano, Nigeria, with an intermediate stop in Ghardaïa. While flying over the Niger airspace, the crew was in contact with Niamey ATC when he apparently encountered poor weather conditions (sand storm) and lost all communications. The exact circumstances of the accident are unclear, but it is believed that the crew was forced to attempt an emergency landing due to fuel shortage. The aircraft landed in a desert area located in the region of the Ganla beacon, south of Niger. Upon landing, the aircraft lost its undercarriage and slid for few dozen metres before coming to rest. Both pilots evacuated safely and the aircraft was damaged beyond repair. The wreckage was found about 190 km north of Kano.

Crash of a PZL-Mielec AN-28 near Addis Ababa

Date & Time: Jan 20, 2014 at 0935 LT
Type of aircraft:
Operator:
Registration:
UP-A2805
Flight Type:
Survivors:
Yes
Schedule:
Entebbe - Sana'a
MSN:
1AJ008-22
YOM:
1990
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
When flying in the Ethiopian Airspace, the crew informed ATC about engine problems and was cleared to divert to Addis Ababa-Bole Airport for an emergency landing. On approach, the twin engine aircraft crashed in an open field located in Legedadi, about 20 km northeast of the airport. Both pilots were seriously injured and the aircraft was destroyed.

Crash of a Piper PA-31-350 Navajo Chieftain in Langgur: 4 killed

Date & Time: Jan 19, 2014 at 1225 LT
Operator:
Registration:
PK-IWT
Flight Type:
Survivors:
No
Schedule:
Jayapura – Langgur – Kendari – Surabaya
MSN:
31-7752090
YOM:
1977
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
2860
Captain / Total hours on type:
1045.00
Aircraft flight hours:
5859
Circumstances:
On 19 January 2014, a PA-31-350 Piper Chieftain, registered PK-IWT, was being operated by PT. Intan Angkasa Air Service, on positioning flight from Sentani Airport, Jayapura with intended destination of Juanda Airport, Surabaya for aircraft maintenance. The positioning flight was planned to transit at Dumatubun Airport Langgur of Tual, Maluku and Haluoleo Airport, Kendari at South East Sulawesi for refuelling. On the first sector, the aircraft departed Sentani Airport at 2351 UTC (0851 WIT) and estimated arrival at Langgur was 0320 UTC. On board on this flight was one pilot, two company engineers and one ground staff. At 0240 UTC the pilot contacted to the Langgur FISO, reported that the aircraft position was 85 Nm to Langgur Airport at altitude 10,000 feet and requested weather information. Langgur FISO acknowledged and informed that the weather was rain and thunderstorm and the runway in used was 09. When the aircraft passing 5,000 feet, the pilot contacted the Langgur FISO and reported that the aircraft position was 50 Nm from langgur and informed the estimated time of arrival was 0320 UTC. The Langgur FISO acknowledged and advised the pilot to contact when the aircraft was at long final runway 09. At 0318 UTC, the pilot contacted Langgur FISO, reported the position was 25 Nm to Langgur at altitude of 2,500 feet and requested to use runway 27. The Langgur FISO advised the pilot to contact on final runway 27. At 0325 UTC, Langgur FISO contacted the pilot with no reply. At 0340 UTC, Langgur FISO received information from local people that the aircraft had crashed. The aircraft was found at approximately 1.6 Nm north east of Langgur Airport at coordinate 5° 38’ 30.40” S; 132° 45’ 21.57” E. All occupants fatally injured and the aircraft destroyed by impact force and post impact fire. The aircraft was destroyed by impact forces and post impact fire, several parts of the remaining wreckage such as cockpit could not be examined due to the level of damage. The aircraft was not equipped with flight recorders and the communication between ATC and the pilot was not recorded. No eye witness saw the aircraft prior to impact. Information available for the investigation was limited. The analysis utilizes available information mainly on the wreckage information including the information of the wings, engines and propellers.
Probable cause:
The investigation concluded that the left engine most likely failed during approach and the propeller did not set to feather resulted in significant asymmetric forces. The asymmetric forces created yaw and roll tendency and the aircraft became uncontrolled, subsequently led the aircraft to impact to the terrain.
Final Report:

Crash of a Beechcraft B200 Super King Air in Akureyri: 2 killed

Date & Time: Aug 5, 2013 at 1329 LT
Operator:
Registration:
TF-MYX
Flight Type:
Survivors:
Yes
Schedule:
Reykjavik - Akureyri
MSN:
BB-1136
YOM:
1983
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
2600
Captain / Total hours on type:
1700.00
Copilot / Total flying hours:
2200
Copilot / Total hours on type:
1100
Aircraft flight hours:
15247
Aircraft flight cycles:
18574
Circumstances:
On 4th of August 2013 the air ambulance operator Mýflug, received a request for an ambulance flight from Höfn (BIHN) to Reykjavík Airport (BIRK). This was a F4 priority request and the operator, in co-operation with the emergency services, planned the flight the next morning. The plan was for the flight crew and the paramedic to meet at the airport at 09:30 AM on the 5th of August. A flight plan was filed from Akureyri (BIAR) to BIHN (positioning flight), then from BIHN to BIRK (ambulance flight) and from BIRK back to BIAR (positioning flight). The planned departure from BIAR was at 10:20. The flight crew consisted of a commander and a co-pilot. In addition to the flight crew was a paramedic, who was listed as a passenger. Around 09:50 on the 5th of August, the flight crew and the paramedic met at the operator’s home base at BIAR. The flight crew prepared the flight and performed a standard pre-flight inspection. There were no findings to the aircraft during the pre-flight inspection. The pre-flight inspection was finished at approximately 10:10. The departure from BIAR was at 10:21 and the flight to BIHN was uneventful. The aircraft landed at BIHN at 11:01. The commander was the pilot flying from BIAR to BIHN. The operator’s common procedure is that the commander and the co-pilot switch every other flight, as the pilot flying. The co-pilot was the pilot flying from BIHN to BIRK and the commander was the pilot flying from BIRK to BIAR, i.e. during the accident flight. The aircraft departed BIHN at 11:18, for the ambulance flight and landed at BIRK at 12:12. At BIRK the aircraft was refueled and departed at 12:44. According to flight radar, the flight from BIRK to BIAR was flown at FL 170. Figure 4 shows the radar track of the aircraft as recorded by Reykjavík Control. There is no radar coverage by Reykjavík Control below 5000 feet, in the area around BIAR. During cruise, the flight crew discussed the commander’s wish to deviate from the planned route to BIAR, in order to fly over a racetrack area near the airport. At the racetrack, a race was about to start at that time. The commander had planned to visit the racetrack area after landing. The aircraft approached BIAR from the south and at 10.5 DME the flight crew cancelled IFR. When passing KN locator (KRISTNES), see Figure 6, the flight crew made a request to BIAR tower to overfly the town of Akureyri, before landing. The request was approved by the tower and the flight crew was informed that a Fokker 50 was ready for departure on RWY 01. The flight crew of TF-MYX responded and informed that they would keep west of the airfield. After passing KN, the altitude was approximately 800’ (MSL), according to the co-pilot’s statement. The co-pilot mentioned to the commander that they were a bit low and recommended a higher altitude. The altitude was then momentarily increased to 1000’. When approaching the racetrack area, the aircraft entered a steep left turn. During the turn, the altitude dropped until the aircraft hit the racetrack.
Probable cause:
The commander was familiar with the racetrack where a race event was going on and he wanted to perform a flyby over the area. The flyby was made at a low altitude. When approaching the racetrack area, the aircraft’s calculated track indicated that the commander’s intention of the flyby was to line up with the racetrack. In order to do that, the commander turned the aircraft to such a bank angle that it was not possible for the aircraft to maintain altitude. The ITSB believes that during the turn, the commander most probably pulled back on the controls instead of levelling the wings. This caused the aircraft to enter a spiral down and increased the loss of altitude. The investigation revealed that the manoeuvre was insufficiently planned and outside the scope of the operator manuals and handbooks. The low-pass was made at such a low altitude and steep bank that a correction was not possible in due time and the aircraft collided with the racetrack. The ITSB believes that human factor played a major role in this accident. Inadequate collaboration and planning of the flyover amongst the flight crew indicates a failure of CRM. This made the flight crew less able to make timely corrections. The commander’s focus was most likely on lining up with the racetrack, resulting in misjudging the approach for the low pass and performing an overly steep turn. The overly steep turn caused the aircraft to lose altitude and collide with the ground. The co-pilot was unable to effectively monitor the flyover/low-pass and react because of failure in CRM i.e. insufficient planning and communication. A contributing factor is considered to be that the flight path of the aircraft was made further west of the airfield, due to traffic, resulting in a steeper turn. The investigation revealed that flight crews were known to deviate occasionally from flight plans.
Causal factors:
- A breakdown in CRM occurred.
- A steep bank angle was needed to line up with the racetrack.
- The discussed flyby was executed as a low pass.
- The maximum calculated bank angle during last phase of flight was 72.9°, which is outside the aircraft manoeuvring limit.
- ITSB believes that the commander’s focus on a flyby that he had not planned thoroughly resulted in a low-pass with a steep bank, causing the aircraft to lose altitude and collide with the ground.
Contributory factors:
- The commander’s attention to the activity at the race club area, and his association with the club was most probably a source of distraction for him and most likely motivated him to execute an unsafe maneuver.
- Deviations from normal procedures were seen to be acceptable by some flight crews.
- A flyby was discussed between the pilots but not planned in details.
- The flight crew reacted to the departing traffic from BIAR by bringing their flight path further west of the airport.
- The approach to the low pass was misjudged.
- The steep turn was most probably made due to the commander’s intention to line up with the race track.
Final Report: