Crash of an Antonov AN-2 in the Everglades National Park

Date & Time: Nov 14, 2022 at 1330 LT
Type of aircraft:
Operator:
Registration:
CU-A1885
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Dade-Collier - Miami-Opa Locka
MSN:
1G200-25
YOM:
1982
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
16000
Captain / Total hours on type:
0.00
Copilot / Total flying hours:
3000
Copilot / Total hours on type:
0
Aircraft flight hours:
7190
Circumstances:
The single engine airplane landed last October at Dade-Collier Airport, in the center of the Everglades National Park, following a flight from Sancti Spíritus, Cuba. The pilot defected Cuba and landed safely in the US. On November 14, the pilot and copilot were hired to relocate the radial engine-equipped biplane as a public flight from Dade-Collier Airport to Miami-Opa Locka. The pilot stated that, while enroute, the airplane began to smoke and the engine lost power. The pilot performed a forced landing to a levee; however, the airplane’s main landing gear were wider than the levee, and after touchdown, the airplane traveled off the left side,
nosed over, and came to rest inverted, resulting in substantial damage. Both crew members were highly experienced but none of them have any flight hours in the accident airplane make and model.
Probable cause:
The pilot's failure to properly configure the cowl flaps and oil cooler shutters, which resulted in a total loss of engine power due to overheating of the engine. Contributing to the accident was the pilot's decision to operate the airplane in with an inoperative cylinder head temperature gauge.
Final Report:

Crash of an Antonov AN-26B-100 in Mykhailivka: 1 killed

Date & Time: Apr 22, 2022 at 0900 LT
Type of aircraft:
Operator:
Registration:
UR-UZB
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Zaporozhye - Uzhgorod
MSN:
113 05
YOM:
1981
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
4225
Captain / Total hours on type:
2250.00
Copilot / Total flying hours:
1562
Copilot / Total hours on type:
412
Aircraft flight hours:
25168
Aircraft flight cycles:
14298
Circumstances:
Consequently to the recent invasion by the Russian Army of the east part of Ukraine, the decision was taken to transfer the airplane from Zaporozhye to Uzhgorod. The airplane departed Zaporozhye Airport shortly before 1000LT with a crew of three on board. Few minutes after takeoff, the crew encountered poor visibility due to fog. While cruising at a very low altitude, the airplane collided with a power line and crashed in an open field located in Mykhailivka, some 10 km northwest of Zaporozhye Airport. A crew member was killed and two others were injured. The aircraft was totally destroyed. It was reported that during the 90 days prior to the accident, the captain had just flown for 85 minutes while the copilot and the flight engineer had not made any flights.
Probable cause:
The cause of the aviation incident (collision of an airworthy aircraft with an obstacle) was the decision of the captain to carry out the flight under Visual Flight Rules (VFR) conditions in foggy weather at a critically low altitude, leading to the loss of visual contact with the ground, uncontrolled increase in speed, and the aircraft colliding with a power transmission line.
The following contributing factors were identified:
- The flight crew's failure to decide to switch to instrument flight and climb to a safe flight altitude when encountering weather conditions that did not meet the visual meteorological flight conditions.
- Likely use of altimeters by the flight crew to maintain flight altitude in meters when the altimeter mode was set to indicate altitude in feet.
- The decision of the flight crew to fly at critically low altitudes with the radio altimeter and GPWS turned off.
- The flight crew's failure to follow the departure procedure from the aerodrome area under VFR, which was discussed in detail by the flight crew during pre-flight briefings.
- Deterioration of weather conditions after takeoff.
- Low crew resource management (CRM) skills.
- Retraction of flaps in a turn at an altitude lower than recommended and at a speed higher than recommended for the An-26 aircraft.
- The complex emotional state of the crew during both preparation and execution of the flight due to combat actions conducted by the Russian Federation near the departure aerodrome.
- Conducting the flight without meteorological support, which contradicts aviation regulations.
- The absence of procedures for conducting flights under VFR at low and critically low altitudes for An-26 aircraft in the operator's manuals.
Final Report:

Crash of a Cessna 208 Caravan I on Mt Grüehorn: 1 killed

Date & Time: Mar 30, 2022 at 1223 LT
Type of aircraft:
Operator:
Registration:
D-FLIC
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Siegerland – Arezzo
MSN:
208-0274
YOM:
1998
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
6700
Captain / Total hours on type:
1800.00
Circumstances:
The pilot, sole on board, departed Siegerland Airport at 1100LT on a ferry flight to Arezzo, Tuscany. En route, while overflying Switzerland, he encountered marginal weather conditions. While cruising in IMC conditions, the single engine airplane impacted the slope of a rocky and snow covered face located west of Mt Grüehorn, in the south part of the canton of St Gallen. The wreckage was found later in the afternoon at an altitude of 1,700 metres. The aircraft was destroyed and the pilot was killed.
Probable cause:
The accident was the consequence of a controlled flight into terrain after the pilot continued under VFR mode in IMC conditions.
Final Report:

Crash of a Learjet 35A in Santee: 4 killed

Date & Time: Dec 27, 2021 at 1914 LT
Type of aircraft:
Operator:
Registration:
N880Z
Flight Type:
Survivors:
No
Site:
Schedule:
Santa Ana - Santee
MSN:
35A-591
YOM:
1985
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
2200
Copilot / Total flying hours:
1244
Aircraft flight hours:
13582
Circumstances:
Earlier on the day of the accident, the flight crew had conducted a patient transfer from a remote airport to another nearby airport. Following the patient transfer, the flight crew departed under night conditions to return to their home base. Review of air traffic control (ATC) communication, as well as cockpit voice recorder (CVR) recordings, showed that the flight crew initially was cleared on the RNAV (GPS) runway 17 instrument approach. The approach plate for the instrument approach stated that circling to runway 27R and 35 was not authorized at night. Following the approach clearance, the flight crew discussed their intent to cancel the approach and circle to land on runway 27R. Additionally, the flight crew discussed with each other if they could see the runway. Once the flight crew established visual contact with the runway, they requested to squawk VFR, then the controller cleared them to land on runway 17. The flight crew then requested to land on runway 27. The controller asked the pilot if they wanted to cancel their instrument flight rules (IFR) flight plan, to which the pilot replied, “yes sir.” The controller acknowledged that the IFR cancellation was received and instructed the pilot to overfly the field and enter left traffic for runway 27R and cleared them to land. Shortly after, the flight crew asked the controller if the runway lights for runway 27R could be increased; however, the controller informed them that the lights were already at 100 percent. Just before the controller’s response, the copilot, who was the pilot flying, then asked the captain “where is the runway.” As the flight crew maneuvered to a downwind leg, the captain told the copilot not to go any lower; the copilot requested that the captain tell him when to turn left. The captain told him to turn left about 10 seconds later. The copilot stated, “I see that little mountain, okay” followed by both the captain and co-pilot saying, “woah woah woah, speed, speed” 3 seconds later. During the following 5 seconds, the captain and copilot both stated, “go around the mountain” followed by the captain saying, “this is dicey” and the co-pilot responding, “yeah it’s very dicey.” Shortly after, the captain told the copilot “here let me take it on this turn” followed by the co-pilot saying, “yes, you fly.” The captain asked the copilot to watch his speed, and the copilot agreed. About 1 second later, the copilot stated, “speed speed speed, more more, more more, faster, faster… .” Soon after, the CVR indicated that the airplane impacted the terrain. Automatic dependent surveillance – broadcast (ADS-B) data showed that at the time the flight crew reported the runway in sight, they were about 360 ft below the instrument approach minimum descent altitude (MDA), and upon crossing the published missed approach point they were 660 ft below the MDA. The data showed that the flight overflew the destination airport at an altitude of about 775 ft mean sea level (msl), or 407 ft above ground level (agl), and entered a left downwind for runway 27R. While on the downwind leg, the airplane descended to an altitude of 700 ft msl, then ascended to an altitude of 950 ft msl while on the base leg. The last recorded ADS-B target was at an altitude of 875 ft msl, or about 295 ft agl.
Probable cause:
The flight crew’s decision to descend below the published MDA, cancel their IFR clearance to conduct an unauthorized circle-to-land approach to another runway while the airport was in nighttime IFR conditions, and the exceedance of the airplane’s critical angle of attack, and subsequently entering an aerodynamic stall at a low altitude. Contributing to the accident was the tower crew’s failure to monitor and augment the airport weather conditions as required, due in part to, the placement of the AWOS display in the tower cab and the lack of audible AWOS alerting.
Final Report:

Crash of a Pilatus PC-6/C-H2 Turbo Porter in Maturín

Date & Time: Aug 21, 2021 at 1638 LT
Operator:
Registration:
YV1912
Flight Phase:
Flight Type:
Survivors:
Yes
Site:
Schedule:
Maturín – Higuerote
MSN:
2048
YOM:
1971
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
5047
Aircraft flight hours:
5721
Circumstances:
Shortly after takeoff from Maturín-General José Tadeo Monagas Airport, while in initial climb, the engine failed. The pilot attempted an emergency when the airplane lost height, impacted trees and a concrete wall before coming to rest against a tree in a garden. The pilot was seriously injured.
Probable cause:
It was determined that the engine failed because the fuel was contaminated with a high amount of water. The malfunction of the engine regulator accessories was considered as a contributing factor.
Final Report:

Crash of a Hawker 800XP in Farmingdale

Date & Time: Dec 20, 2020 at 2035 LT
Type of aircraft:
Operator:
Registration:
N412JA
Flight Type:
Survivors:
Yes
Schedule:
Miami - Farmingdale
MSN:
258516
YOM:
2001
Flight number:
TFF941
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
4188
Captain / Total hours on type:
2060.00
Copilot / Total flying hours:
10000
Copilot / Total hours on type:
4100
Aircraft flight hours:
12731
Circumstances:
The flight crew were conducting an instrument landing system (ILS) approach in night instrument meteorological conditions when they were advised by the tower controller that the weather had deteriorated below minimums. The captain was the pilot monitoring, and the first officer was the pilot flying during the approach. Since the airplane was inside the final approach fix and stabilized, both pilots agreed to continue with the approach. Both pilots stated that they had visual contact with the runway approach lighting system at the 200 ft above ground level (agl) decision altitude, and they decided to continue the approach. The first officer said he then returned to flying the airplane via instruments. As the first officer continued the approach, the captain told him the airplane was drifting right of the runway centerline. The first officer said that he looked outside, saw that the weather had deteriorated, and was no longer comfortable with the approach. The first officer said he pressed the takeoff and go-around switch, while at the same time, the captain called for a go-around. The captain said that he called for the go-around because the airplane was not aligned with the runway. Although both pilots stated that the go-around was initiated when the airplane was about 50 to 100 ft agl, the cockpit voice recorder (CVR) recording revealed that the first officer flew an autopilot-coupled approach to 50 ft agl (per the approach procedure, a coupled approach was not authorized below 240 ft agl). As the airplane descended from 30 to 20 ft agl, the captain told the first officer three times to “flare” then informed him that the airplane was drifting to right and he needed to make a left correction to get realigned with the runway centerline. Three seconds passed before the first officer reacted by trying to initiate transfer control of the airplane to the captain. The captain did not take control of the airplane and called for a go-around. The first officer then added full power and called for the flaps to be retracted to 15º; however, the airplane impacted the ground about 5 seconds later, resulting in substantial damage to the fuselage. Data downloaded from both engines’ digital electronic engine control units revealed no anomalies. No mechanical issues with the airplane or engines were reported by either crew member or the operator. The sequence of events identified in the CVR recording revealed that the approach most likely became unstabilized after the autopilot was disconnected and when the first officer lost visual contact with the runway environment. The captain, who had the runway in sight, delayed calling for a go-around after the approach became unstabilized, and the airplane was too low to recover.
Probable cause:
The flight crew’s delayed decision to initiate a go-around after the approach had become unstabilized, which resulted in a hard landing.
Final Report:

Crash of a Beechcraft 60 Duke in Loveland: 1 killed

Date & Time: May 15, 2019 at 1248 LT
Type of aircraft:
Operator:
Registration:
N60RK
Flight Type:
Survivors:
No
Schedule:
Broomfield – Loveland
MSN:
P-79
YOM:
1969
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
7000
Captain / Total hours on type:
100.00
Aircraft flight hours:
3119
Circumstances:
The commercial pilot was relocating the multiengine airplane following the completion of an extensive avionics upgrade, which also included the installation of new fuel flow transducers. As the pilot neared the destination airport, he reported over the common traffic advisory frequency that he had "an engine out [and] smoke in the cockpit." Witnesses observed and airport surveillance video showed fire emanating from the airplane's right wing. As the airplane turned towards the runway, it entered a rightrolling descent and impacted the ground near the airport's perimeter fence. The right propeller was found feathered. Examination of the right engine revealed evidence of a fire aft of the engine-driven fuel pump. The fuel pump was discolored by the fire. The fire sleeves on both the fuel pump inlet and outlet hoses were burned away. The fuel outlet hose from the fuel pump to the flow transducer was found loose. The reason the hose was loose was not determined. It is likely that pressurized fuel sprayed from the fuel pump outlet hose and was ignited by the hot turbocharger, which resulted in the inflight fire.
Probable cause:
A loss of control due to an inflight right engine fire due to the loose fuel hose between the engine-driven fuel pump and the flow transducer.
Final Report:

Crash of a Piper PA-46-350P Malibu near Makkovik: 1 killed

Date & Time: May 1, 2019 at 0816 LT
Operator:
Registration:
N757NY
Flight Phase:
Flight Type:
Survivors:
Yes
Site:
Schedule:
Goose Bay - Narsarsuaq
MSN:
46-36657
YOM:
2015
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
3500
Captain / Total hours on type:
20.00
Copilot / Total flying hours:
1300
Copilot / Total hours on type:
0
Circumstances:
On 01 May 2019 at 0723, the aircraft departed CYYR on a VFR flight plan direct to BGBW. The ferry pilot, who was the pilot-in-command, occupied the left seat while the co-owner occupied the right seat. The aircraft climbed to 2000 feet ASL and proceeded on a direct track to destination. The altitude and heading did not change significantly along the route, therefore it is likely that the autopilot was engaged. At 0816, the aircraft collided with a snow-covered hill 2250 feet in elevation, located 35 nautical miles (NM) southeast of Makkovik Airport (CYFT), Newfoundland and Labrador. The impact happened approximately 200 feet below the top of the hill. The aircraft came to rest in deep snow on steep sloping terrain. The aircraft sustained significant damage to the propeller, nose gear, both wings, and fuselage. Although the cabin was crush-damaged, occupiable space remained. There was no post-impact fire. The ferry pilot was seriously injured and the co-owner was fatally injured. The Joint Rescue Coordination Centre (JRCC) in Halifax received an emergency locator transmitter (ELT) signal from the aircraft at 0823. The ferry pilot carried a personal satellite tracking device, a personal locator beacon (PLB) and a handheld very high frequency (VHF) radio, which allowed communication with search and rescue (SAR). Air SAR were dispatched to the area; however, by that time, the weather had deteriorated to blizzard conditions and aerial rescue was not possible. Ground SAR then deployed from the coastal community of Makkovik and arrived at the accident site approximately 4 hours later because of poor weather conditions and near zero visibility. The ferry pilot and the body of the co-owner were transported to Makkovik by snowmobile. The following day, they were airlifted to CYYR.
Probable cause:
Controlled flight into terrain.
Final Report:

Crash of a Beechcraft B200 Super King in Whatì: 2 killed

Date & Time: Jan 30, 2019 at 0915 LT
Operator:
Registration:
C-GTUC
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Yellowknife – Whatì – Wekweèti – Ekati
MSN:
BB-268
YOM:
1977
Flight number:
8T503
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
2762
Captain / Total hours on type:
1712.00
Copilot / Total flying hours:
566
Copilot / Total hours on type:
330
Aircraft flight hours:
20890
Aircraft flight cycles:
18863
Circumstances:
At 0851 Mountain Standard Time on 30 January 2019, the Air Tindi Ltd. Beechcraft King Air 200 aircraft (registration C-GTUC, serial number BB-268) departed Yellowknife Airport (CYZF), Northwest Territories, as flight TIN503, on an instrument flight rules flight itinerary to Whatì Airport (CEM3), Northwest Territories, with 2 crew members on board. At 0912, as the aircraft began the approach to CEM3, it departed controlled flight during its initial descent from 12 000 feet above sea level, and impacted terrain approximately 21 nautical miles east-southeast of CEM3, at an elevation of 544 feet above sea level. The Canadian Mission Control Centre received a signal from the aircraft’s 406 MHz emergency locator transmitter and notified the Joint Rescue Coordination Centre in Trenton, Ontario. Search and rescue technicians arrived on site approximately 6 hours after the accident. The 2 flight crew members received fatal injuries on impact. The aircraft was destroyed.
Probable cause:
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.
- For undetermined reasons, the left-side attitude indicator failed in flight.
- Although just before take off the crew acknowledged that the right-side attitude indicator was not operative, they expected it to become operative at some point in the flight. As a result, they did not refer to the minimum equipment list, and departed into instrument meteorological conditions with an inoperative attitude indicator.
- The crew’s threat and error management was not effective in mitigating the risk associated with the unserviceable right-side attitude indicator.
- The crew’s crew resource management was not effective, resulting in a breakdown in verbal communication, a loss of situation awareness, and the aircraft entering an unsafe condition.
- The captain did not have recent experience in flying partial panel. As a result, the remaining instruments were not used effectively and the aircraft departed controlled flight and entered a spiral dive.
- The captain and first officer likely experienced spatial disorientation.
- Once the aircraft emerged below the cloud layer at approximately 2000 feet above ground, the crew were unable to recover control of the aircraft in enough time and with enough altitude to avoid an impact with terrain.

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 flight crews do not use the guidance material provided in the minimum equipment list when aircraft systems are unserviceable, there is a risk that the aircraft will be operated without systems that are critical to safe aircraft operation.
- If flight crews do not use all available resources at their disposal, a loss in situation awareness can occur, which can increase the risk of an accident.

Other findings:
These items could enhance safety, resolve an issue of controversy, or provide a data point for future safety studies.
- A review of Air Tindi Ltd.'s pilot training program revealed that all regulatory requirements were being met or exceeded.
Final Report:

Crash of a Cessna 208B Supervan 900 in the Pacific Ocean: 1 killed

Date & Time: Sep 27, 2018 at 1528 LT
Type of aircraft:
Operator:
Registration:
VH-FAY
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Saipan - Sapporo
MSN:
208B-0884
YOM:
2001
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
13600
Aircraft flight hours:
9291
Circumstances:
The pilot of a Cessna 208B aircraft, registered VH-FAY (FAY), was contracted to ferry the aircraft from Jandakot Airport, Western Australia (WA), to Greenwood, Mississippi in the United States (US). The pilot planned to fly via the ‘North Pacific Route’. At 0146 Coordinated Universal Time (UTC) on 15 September 2018, the aircraft took off from Jandakot Airport, WA, and landed in Alice Springs, Northern Territory at 0743. After landing, the pilot advised the aircraft operator that the aircraft had a standby alternator fault indication. In response, two company licenced aircraft maintenance engineers went to Alice Springs and changed the alternator control unit, which fixed the problem. Late the next morning, the aircraft departed Alice Springs for Weipa, Queensland, where the pilot refuelled the aircraft and stayed overnight. On the morning of 17 September, the pilot conducted a 1-hour flight to Horn Island, Queensland. About an hour later, the aircraft departed Horn Island with the planned destination of Guam, Micronesia. While en route, the pilot sent a message to the aircraft operator advising that he would not land in Guam, but would continue another 218 km (118 NM) to Saipan, Northern Mariana Islands. At 1003, the aircraft landed at Saipan International Airport. The next morning, the pilot refuelled the aircraft and detected damage to the propeller anti-ice boot. The aircraft was delayed for more than a week while a company engineer travelled to Saipan and replaced the anti-ice boot. At 2300 UTC on 26 September, the aircraft departed Saipan, bound for New Chitose Airport, Hokkaido, Japan. Once airborne, the pilot sent a message from his Garmin device, indicating that the weather was clear and that he had an expected flight time of 9.5 hours. About an hour after departure, the aircraft levelled out at flight level (FL) 220. Once in the cruise, the pilot sent a message that he was at 22,000 feet, had a tailwind and the weather was clear. This was followed by a message at 0010 that he was at FL 220, with a true airspeed of 167 kt and fuel flow of 288 lb/hr (163 L/hr). At 0121, while overhead reporting point TEGOD, the pilot contacted Tokyo Radio flight information service on HF radio. The pilot was next due to report when the aircraft reached reporting point SAGOP, which the pilot estimated would occur at 0244. GPS recorded track showed that the aircraft passed SAGOP at 0241, but the pilot did not contact Tokyo Radio as expected. At 0249, Tokyo Radio made several attempts to communicate with the pilot on two different HF frequencies, but did not receive a response. Tokyo Radio made further attempts to contact the pilot between 0249 and 0251, and at 0341, 0351 and 0405. About 4.5 hours after the pilot’s last communication, two Japan Air Self-Defense Force (JASDF) aircraft intercepted FAY. The pilot did not respond to the intercept in accordance with international intercept protocols, either by rocking the aircraft wings or turning, and the aircraft continued to track at FL 220 on its planned flight route. The JASDF pilots were unable to see into the cockpit to determine whether the pilot was in his seat or whether there was any indication that he was incapacitated. The JASDF pilots flew around FAY for about 30 minutes, until the aircraft descended into cloud. At 0626 UTC, the aircraft’s GPS tracker stopped reporting, with the last recorded position at FL 220, about 100 km off the Japanese coast and 589 km (318 NM) short of the destination airport. Radar data showed that the aircraft descended rapidly from this point and collided with water approximately 2 minutes later. The Japanese authorities launched a search and rescue mission and, within 2 hours, searchers found the aircraft’s rear passenger door. The search continued until the next day, when a typhoon passed through the area and the search was suspended for two days. After resuming, the search continued until 27 October with no further parts of the aircraft found. The pilot was not located.
Probable cause:
From the evidence available, the following findings are made with respect to the uncontrolled flight into water involving a Cessna Aircraft Company 208B, registered VH-FAY, that occurred 260 km north-east of Narita International Airport, Japan, on 27 September 2018. These findings should not be read as apportioning blame or liability to any particular organisation or individual.
Contributing factors:
• During the cruise between Saipan and New Chitose, the pilot very likely became incapacitated and could no longer operate the aircraft.
• The aircraft’s engine most likely stopped due to fuel starvation from pilot inaction, which resulted in the aircraft entering an uncontrolled descent into the ocean.
Other factors that increased risk:
• The pilot was operating alone in the unpressurised aircraft at 22,000 ft and probably not using the oxygen system appropriately, which increased the risk of experiencing hypoxia and being unable to recover.
Final Report: