Crash of a Casa 212 Aviocar in Saskatoon: 1 killed

Date & Time: Apr 1, 2011 at 1830 LT
Type of aircraft:
Operator:
Registration:
C-FDKM
Survivors:
Yes
Site:
Schedule:
Saskatoon - Saskatoon
MSN:
196
YOM:
1981
Country:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
7400
Captain / Total hours on type:
75.00
Copilot / Total flying hours:
7800
Copilot / Total hours on type:
1800
Aircraft flight hours:
21292
Circumstances:
At 1503 Central Standard Time, the Construcciones Aeronauticas SA (CASA) C-212-CC40 (registration C-FDKM, serial number 196) operated by Fugro Aviation Canada Ltd., departed from Saskatoon/Diefenbaker International Airport, Saskatchewan, under visual flight rules for a geophysical survey flight to the east of Saskatoon. On board were 2 pilots and a survey equipment operator. At about 1814, the right engine lost power. The crew shut it down, carried out checklist procedures, and commenced an approach for Runway 27. When the flight was 3.5 nautical miles from the runway on final approach, the left engine lost power. The crew carried out a forced landing adjacent to Wanuskewin Road in Saskatoon. The aircraft impacted a concrete roadway noise abatement wall and was destroyed. The survey equipment operator sustained fatal injuries, the first officer sustained serious injuries, and the captain sustained minor injuries. No ELT signal was received.
Probable cause:
Conclusions
Findings as to Causes and Contributing Factors:
1. The right engine lost power when the intermediate spur gear on the torque sensor shaft failed. This resulted in loss of drive to the high-pressure engine-driven pump, fuel starvation, and immediate engine stoppage.
2. The ability of the left-hand No. 2 ejector pump to deliver fuel to the collector tank was compromised by foreign object debris (FOD) in the ejector pump nozzle.
3. When the fuel level in the left collector tank decreased, the left fuel level warning light likely illuminated but was not noticed by the crew.
4. The pilots did not execute the fuel level warning checklist because they did not perceive the illumination of the fuel level left tank warning light. Consequently, the fuel crossfeed valve remained closed and fuel from only the left wing was being supplied to the left engine.
5. The left engine flamed out as a result of depletion of the collector tank and fuel starvation, and the crew had to make a forced landing resulting in an impact with a concrete noise abatement wall.
Findings as to Risk:
1. Depending on the combination of fuel level and bank angle in single-engine uncoordinated flight, the ejector pump system may not have the delivery capacity, when the No. 1 ejector inlet is exposed, to prevent eventual depletion of the collector tank when the engine is operated at full power. Depletion of the collector tank will result in engine power loss.
2. The master caution annunciator does not flash; this leads to a risk that the the crew may not notice the illumination of an annunciator panel segment, in turn increasing the risk of them not taking action to correct the condition which activated the master caution.
3. When cockpit voice and flight data recordings are not available to an investigation, this may preclude the identification and communication of safety deficiencies to advance transportation safety.
4. Because the inlets of the ejector pumps are unscreened, there is a risk that FOD in the fuel tank may become lodged in an ejector nozzle and result in a decrease in the fuel delivery rate to the collector tank.
Other Findings:
1. The crew’s decision not to recover or jettison the birds immediately resulted in operation for an extended period with minimal climb performance.
2. The composition and origin of the FOD, as well as how or when it had been introduced into the fuel tank, could not be determined.
3. The SkyTrac system provided timely position information that would have assisted search and rescue personnel if position data had been required.
4. Saskatoon police, firefighters, and paramedics responded rapidly to the accident and provided effective assistance to the survivors.
Final Report:

Crash of a De Havilland DHC-6 Twin Otter 300 near Alert

Date & Time: May 10, 2010 at 1719 LT
Operator:
Registration:
C-FSJB
Survivors:
Yes
MSN:
377
YOM:
1973
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The crew was performing a supply mission in the Nunavut with three scientists on board. Equipped with ski, the aircraft landed on the snow covered terrain some 168 km north of Alert Air Base. After landing, the aircraft came to a halt when the right ski punctured the ice and the aircraft partially sunk while both engines were still running. All five occupants escaped uninjured and were evacuated two hours later by the crew of a Bell 407 to Resolute Bay. Damaged beyond repair, the aircraft was abandoned on site and later cancelled from registry in November 2011.
Probable cause:
Landing gear went through the ice after landing on ice/snow terrain.

Crash of a Beechcraft 65-A90 King Air in Guyana: 3 killed

Date & Time: Nov 1, 2008 at 1254 LT
Type of aircraft:
Operator:
Registration:
N87V
Flight Phase:
Survivors:
No
Schedule:
Imbaimadai - Imbaimadai
MSN:
LM-130
YOM:
1971
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
3
Circumstances:
The twin engine aircraft departed Imbaimadai for a geophysical research mission on behalf of a Canadian company, carrying one passenger and two pilots. The accident occurred in unknown circumstances and the aircraft was missing. SAR operations did not find any trace of the aircraft nor the three occupants.

Crash of a Harbin Yunsunji Y-12-II near Chifeng: 3 killed

Date & Time: Jun 15, 2008
Type of aircraft:
Operator:
Registration:
B-3841
Flight Phase:
Survivors:
Yes
Site:
MSN:
0061
YOM:
1992
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Circumstances:
The twin engine aircraft was engaged in an aluminium prospecting flight. In unknown circumstances, it collided with the slope of a mountain and was destroyed. A pilot survived while three other occupants were killed.

Crash of a Cessna F406 Caravan II in Entebbe: 2 killed

Date & Time: Sep 26, 2007 at 0737 LT
Type of aircraft:
Operator:
Registration:
ZS-SSD
Flight Phase:
Survivors:
No
Schedule:
Entebbe - Masindi
MSN:
406-0027
YOM:
1988
Location:
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
The crew was scheduled to perform a geophysical survey flight for the government of Uganda between Entebbe and Masindi. Shortly after takeoff from Entebbe Airport runway 17, while climbing to a height of about 1,500 metres, the twin engine aircraft entered an uncontrolled descent and crashed in an open field. Both occupants were killed and the aircraft was destroyed.
Probable cause:
In-flight loss of control due to loss of airspeed and subsequent stall of the aircraft at low altitude. Investigations determined that the rudder trim was set to the full left at the time of the accident as opposed to the normal (central) takeoff setting.

Crash of a Piper PA-31-310 Navajo on Mt Yerbas Buenas: 2 killed

Date & Time: Aug 11, 2006 at 1135 LT
Type of aircraft:
Registration:
CC-CFK
Flight Phase:
Survivors:
No
Site:
Schedule:
La Serena - La Serena
MSN:
31-607
YOM:
1970
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
4519
Circumstances:
The twin engine aircraft departed La Serena-La Florida Airport at 1053LT on a geophysical mission over Domeyko, carrying one passenger and one pilot who were involved in a magnetic prospection mission on behalf of a mining program. Seven minutes after takeoff, the pilot informed ATC about his altitude at 6,500 feet and that he would descend to 500 feet once over the Domeyko area. About half an hour later, the aircraft crashed on the slope of Mt Yerbas Buenas, about 84 km north of La Serena Airport, bursting into flames. The wreckage was found four hours later at an altitude of 1,579 metres. The aircraft was destroyed by a post crash fire and both occupants were killed.
Probable cause:
The accident occurred after the pilot suffered a loss of situational awareness while flying at low altitude, which did not allow him to avoid the collision with the mountain. Such operation conducted in a single pilot configuration was considered as a contributing factor as the workload was high.
Final Report:

Crash of a Britten-Norman BN-2B-27 Islander near Vallecillos: 2 killed

Date & Time: May 5, 2004 at 1630 LT
Type of aircraft:
Operator:
Registration:
XC-FOE
Flight Phase:
Survivors:
No
Site:
MSN:
2031
YOM:
1981
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
The crew was completing a geophysical survey flight in the region of Vallecillos, Durango. While cruising at an altitude of 2,000 metres, the twin engine aircraft struck the slope of a mountain located in the Sierra del Rosario. Both occupants were killed.

Crash of a Cessna 404 Titan II in Nampula: 2 killed

Date & Time: Apr 20, 2004
Type of aircraft:
Operator:
Registration:
ZS-NVD
Flight Phase:
Survivors:
No
MSN:
404-0667
YOM:
1980
Location:
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
Shortly after takeoff from Nampula Airport, while in initial climb, the aircraft went out of control and crashed, killing both occupants. They were engaged in a geological mission on behalf of the Mozambican government in the north part of the country.

Crash of a Britten-Norman BN-2A-21 Islander near Cascalho: 3 killed

Date & Time: Jan 11, 2001 at 1440 LT
Type of aircraft:
Registration:
PT-KNE
Flight Phase:
Survivors:
No
Site:
Schedule:
Paramirim - Paramirim
MSN:
696
YOM:
1973
Location:
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
3886
Captain / Total hours on type:
3263.00
Copilot / Total flying hours:
6088
Copilot / Total hours on type:
23
Circumstances:
The twin engine aircraft departed Paramirim Airport at 1400LT on a 3-hours ore prospecting flight, carrying two pilots and one passenger. En route, weather conditions worsened and the crew apparently decided to return to Paramerim when he encountered atmospheric turbulences and windshear. The aircraft stalled and crashed in a mountainous area. After 17 hours without contact, the aircraft was declared as missing. Its wreckage was found the following day at 1800LT near the summit of Mt Serra Preta, near Cascalho, about 27 km east of Paramirim. The aircraft was destroyed and all three occupants were killed.
Probable cause:
Loss of control after the crew encountered adverse weather conditions with low level windshear. The following contributing factors were identified:
- Although the operations were carried out in accordance with the regulations in force, the pilots regularly exceeded the flight times and this type of prospecting mission is extremely tiring insofar as it is systematically operated at low altitude without the aid of the autopilot system in a high outside temperature environment, leading to greater than normal physical wear of the pilots,
- Poor flight preparation regarding the probable evolution of the weather conditions,
- The accident occurred in low visibility as the crew was presumably trying to return to his base,
- The accident occurred outside of the intended flight area,
- The flight, which was scheduled to take three hours, was started with an aircraft whose tanks were full (seven hours autonomy), unnecessarily increasing its weight,
- Poor flight planning,
- Non-compliance with standard operator procedures on part of the crew who positioned the flaps in an inappropriate angle to fly over obstacles,
- In the days preceding the accident, two incidents occurred at Paramirim Airport involving the captain, and neither of these two events had been reported to the management of the operator, indicating the absence of an effective control of operations,
- The supervision of crew schedules was poor,
- The operator wanted this type of flight to be carried out in the morning in order to avoid atmospheric turbulence specific to the region, but the crew decided to take off in the afternoon when the conditions were not favorable.
Final Report:

Crash of a De Havilland DHC-2 Turbo Beaver near Clearwater

Date & Time: Sep 22, 2000 at 1320 LT
Type of aircraft:
Operator:
Registration:
C-FOES
Flight Phase:
Survivors:
Yes
Schedule:
Clearwater - Clearwater
MSN:
1673
YOM:
1967
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
5000
Captain / Total hours on type:
900.00
Circumstances:
The de Havilland DHC-2T Beaver floatplane, serial number 1673TB43, was engaged in aerial application of fish fry to several lakes near Clearwater, British Columbia. The pilot and one other person were on board. The aircraft took off from Clearwater at about 1230 Pacific daylight time (PDT) to begin a planned series of drops to nearby lakes. The aircraft had dropped fish in four lakes before proceeding to Broken Hook Lake.When the aircraft was on approach to the northwestern end of Broken Hook Lake, the pilot reportedly advanced the power lever, but the engine did not respond. At this time, the aircraft was about 100 feet above ground level and struck several treetops. Within seconds, the aircraft descended, struck the terrain, and crashed into trees. The two occupants were seriously injured, and the aircraft was destroyed. There was no fire. The accident occurred at 1320 PDT.
Probable cause:
Findings as to Causes and Contributing Factors:
1. The pilot did not avoid the trees that obstructed his immediate flight path on descent to the lake.
2. The damage to the aircraft from the tree-strike seriously compromised the pilot's ability to control the aircraft, to the point where continued flight was impossible.
3. The pilot and the passenger suffered serious injuries. It is highly likely that proper use of a passenger restraint system would have lessened the injuries to both persons.
Findings as to Risk:
1. Canadian regulations regarding the use of seats and seat restraint systems are not sufficiently clear about high-risk, aerial work operations, such as aerial application.
2. Transport Canada was not advised of the fish-dropping operations and was unaware that the passenger in the cabin was unrestrained during high-risk operations.
3. Canadian regulations do not require specific training in aerial application techniques, such as fish-dropping.
4. The installation of the fish-hopper equipment constituted an aircraft modification, which had not been approved by Transport Canada.
Other Findings:
1. The operator did not maintain a proper logbook.
Final Report: