Crash of a Cessna 525 CitationJet CJ2+ in Saint-Tropez

Date & Time: Jun 6, 2018 at 1310 LT
Type of aircraft:
Operator:
Registration:
D-IULI
Flight Type:
Survivors:
Yes
Schedule:
Figari - Saint-Tropez
MSN:
525A-0514
YOM:
2013
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
2500
Captain / Total hours on type:
1234.00
Circumstances:
The aircraft departed Figari-Sud-Corse Airport on a positioning flight to Saint-Tropez-La Môle, carrying one passenger and one pilot. Weather conditions at destination were poor with ceiling at 1,800 feet and rain. The pilot contacted Nice Approach and was cleared to descend to 6,000 feet and to report over EM for an approach to La Môle Airport Runway 24. On final approach, the pilot was unable to establish a visual contact with the runway and initiated a go-around procedure. Few minutes later, he completed a second approach and landed the airplane 200 metres past the runway threshold at a speed of 136 knots. Spoilers were deployed but the airplane was unable to stop within the remaining distance. It veered slightly to the left, departed the end of the runway, crossed a river and came to rest against an embankment located about 100 metres past the runway end. The pilot escaped unhurt while the passenger was slighlty injured. The aircraft was damaged beyond repair.
Probable cause:
The landing distance of the airplane on a wet runway as defined in the Airplane Flight Manual (AFM) performance tables are not compatible with the length of runway available at La Môle Aaerodrome. When preparing the flight, the pilot used the flight record provided by the operator ProAir to determine landing performance. Landing distance on a wet runway presented in the file increased that on a dry runway by 15%. The 15% increase on a wet runway can only be used in conjunction with the increase of 60% imposed in commercial operation, otherwise it may be inappropriate. The value resulting from the calculation was, in this case, wrong and less than the value indicated in the aircraft flight manual. The pilot probably did not use the EFB application for the calculation of performance or the flight manual to verify this value. The pilot thus undertook the flight on the basis of erroneous performance values, without realizing that he could not land at this aerodrome if the runway was wet. In addition, during the final approach, the speed of the aircraft was greater than the speed approach reference and the approach slope was also greater than the nominal slope, which resulted in an increase in the landing distance. During the landing roll, the aircraft exited the runway longitudinally at a speed of 41 kt. The pilot failed to stop the aircraft until it does not violently collide with obstacles at the end of the track.
Contributing factors:
- The operator's use of the same operations manual for two different types of operations;
- The absence in the operations manual of a calculation method, coefficient and safety margin for the calculation of performance in non-commercial transport;
- Lack of knowledge by the pilot and the operator of the method of calculation of landing performance in non-commercial transport;
- The lack of indication in the operations manual that the landing performances at La Môle aerodrome are limiting in case of a wet or contaminated runway.
Final Report:

Crash of a Cessna 208B Grand Caravan in Manaus

Date & Time: May 22, 2018 at 0950 LT
Type of aircraft:
Operator:
Registration:
PT-FLW
Flight Type:
Survivors:
Yes
Schedule:
Manaus - Manaus
MSN:
208B-0451
YOM:
1995
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
10073
Captain / Total hours on type:
4637.00
Aircraft flight hours:
8776
Circumstances:
The pilot departed Manaus-Eduardo Gomes International Airport at 0940LT on a short positionning flight to Manaus-Aeroclub de Flores. On final approach to runway 11, the engine lost power and suffered power variations. The pilot attempted an emergency landing when the aircraft crashed 350 metres short of runway, bursting into flames. The pilot escaped with minor injuries and the aircraft was destroyed by a post crash fire.
Probable cause:
Contributing factors:
- Control skills - undetermined
The damage observed in the hot engine section components indicated the occurrence of an extrapolation of the ITT limits, which may have caused the melt observed in the blades of the compressor turbine. Thus, in view of the expected reactions of the engine during the use of the EPL, it is possible that there has been an inappropriate use of this resource and, consequently, an extrapolation of the engine limits, especially in relation to the temperature.
- Training - undetermined
The investigation of this accident identified issues related to the operation of the aircraft that could be related to the quality and/or frequency of emergency training with engine failure.
- Piloting judgment - undetermined
It is possible that the loss of lift produced by the flap retraction resulted in a sinking that prevented the plane from reaching the SWFN runway with the residual power that the engine still provided. In this case, an inadequate assessment of the effects of such action on the aircraft performance under those conditions would be characterized.
- Memory - undetermined
It is possible that the decisions made were the result of the pilot's difficulty in properly recalling the correct procedures for those circumstances, since these were actions to be memorized (memory items).
Final Report:

Crash of a PZL-Mielec AN-2TP in La Paragua

Date & Time: Jan 6, 2018
Type of aircraft:
Operator:
Registration:
YV1944
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
La Paragua - Canaima
MSN:
1G185-58
YOM:
1980
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Shortly after takeoff, while in initial climb, the single engine aircraft stalled and crashed in a prairie, bursting into flames. Both pilots were seriously injured and the aircraft was totally destroyed by a post crash fire.

Crash of a Cessna 525A CitationJet CJ2 in Michigan City

Date & Time: Dec 27, 2017 at 0650 LT
Type of aircraft:
Operator:
Registration:
N525KT
Flight Type:
Survivors:
Yes
Schedule:
DuPage - Michigan City
MSN:
525A-0058
YOM:
2002
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3200
Captain / Total hours on type:
300.00
Copilot / Total flying hours:
2020
Copilot / Total hours on type:
81
Aircraft flight hours:
2681
Circumstances:
The pilot reported that, during the approach following a positioning flight, he saw that the runway had a light dusting of snow on it and that the airplane touched down on speed in the first 1,000 ft of the 4,100- ft-long runway. The copilot, who was the pilot flying, applied heavy braking, but there appeared to be no braking effectiveness, and the airplane did not slow down as expected. The pilot added that, when the airplane reached about two-thirds of the way down the runway, he knew that it was going to overrun the runway due to the loss of only half of its airspeed. He thought that if he aborted the landing, there was a small chance the airplane could become airborne within the remaining runway. The copilot added engine power to abort the landing, and the nose landing gear lifted off, but insufficient runway was remaining to take off. The copilot reduced the engine power to idle, and the airplane overran the runway and went through the airport fence and a guardrail, across a highway, and into a field. Postaccident examination revealed no flat spots or evidence of skidding on the landing gear tires. The flaps were found in the “ground flaps” position, which is not allowed for takeoff. No evidence of any pre-accident mechanical malfunctions or failures were found with the airplane that would have precluded normal operation. Based on an airplane weight of 11,000 lbs, the airplane’s stopping distance would have been about 4,400
ft. The flight crew’s improper decision to land on a snow-covered runway that was too short to accommodate the landing in such conditions led to a runway overrun and impact with obstacles.
Probable cause:
The flight crew's improper decision to land on a snow-covered runway that had insufficient runway distance for the airplane to land with the contamination, which resulted in a runway overrun and impact with obstacles.
Final Report:

Crash of a Swearingen SA227AC Metro III in Thompson

Date & Time: Nov 2, 2017 at 1920 LT
Type of aircraft:
Operator:
Registration:
C-FLRY
Flight Type:
Survivors:
Yes
Schedule:
Gods River – Thompson
MSN:
AC-756
YOM:
1990
Flight number:
PAG959
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
1400
Captain / Total hours on type:
1000.00
Copilot / Total flying hours:
950
Copilot / Total hours on type:
700
Aircraft flight hours:
24672
Circumstances:
On 02 November 2017, a Perimeter Aviation LP Fairchild SA227-AC Metro III (serial number AC-756B, registration C-FLRY) was operating as flight 959 (PAG959) from Gods River Airport, Manitoba, to Thompson Airport, Manitoba, with 2 flight crew members on board. When the aircraft was approximately 40 nautical miles southeast of Thompson Airport, the crew informed air traffic control that they had received a low oil pressure indication on the left engine that might require the engine to be shut down. The crew did not declare an emergency, but aircraft rescue and firefighting services were put on standby. After touchdown on Runway 24 with both engines operating, the aircraft suddenly veered to the right and exited the runway. The aircraft came to rest in snow north of the runway. The captain and first officer exited the aircraft through the left side over-wing emergency exit and were taken to hospital with minor injuries. The aircraft was substantially damaged. The 406-MHz emergency locator transmitter did not activate. The occurrence took place during the hours of darkness, at 1920 Central Daylight Time.
Probable cause:
Findings as to causes and contributing factors:
1. The left engine low oil pressure indications during the previous and the occurrence flights were likely the result of a steady oil leak past the rear turbine air-oil seal assembly.
2. The loss of engine oil pressure resulted in a loss of propeller control authority on landing and the upset of the aircraft.
3. After consultation with maintenance, the crew considered the risks associated with landing single engine and without hydraulic pressure for the nose-wheel steering, and decided to continue the flight with both engines running, even though this was not consistent with the QRH procedures for low oil pressure indications.
4. Carbon deposits that accumulated within the inside diameter of the bellows convolutions interfered with the bellows’ ability to expand and to provide a positive seal against the rotor seal.

Findings as to risk:
1. If Canadian Aviation Regulations (CARs) subparts 703 and 704 operators do not provide initial or recurrent crew resource management training to pilots, these pilots may not be prepared to avoid, trap, or mitigate crew errors encountered during flight.
2. If operators of the SA227-AC Metro III aircraft rely solely on the emergency procedures listed in the aircraft flight manual, continued engine operation with low oil pressure may result in loss of control of the aircraft.
3. If an engine is not allowed to sufficiently cool down prior to shutdown, oil that remains trapped within hot areas of the engine may heat up to a point where the oil decomposes, creating a carbon deposit.
4. If flight data, voice, and video recordings are not available to an investigation, the identification and communication of safety deficiencies to advance transportation safety may be precluded.

Other findings:
1. The investigation was unable to determine the length of cooldown periods for the occurrence aircraft. However, a random sampling of engine shutdowns for similar company aircraft showed that 50% had not completed the full 3-minute cooldown period.
2. Despite having received limited crew resource management (CRM).
Final Report:

Crash of an Antonov AN-74TK-100 in São Tomé

Date & Time: Jul 29, 2017 at 0905 LT
Type of aircraft:
Operator:
Registration:
UR-CKC
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
São Tomé – Accra
MSN:
470 95 905
YOM:
1992
Flight number:
CVK7087
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
12847
Captain / Total hours on type:
986.00
Copilot / Total flying hours:
5389
Copilot / Total hours on type:
618
Aircraft flight hours:
5104
Circumstances:
On 29th July, 2017 at about 0905hrs, an Antonov aircraft Model AN-74TK-100, flight CVK7087, registration UR-CKC, owned by SWIFT SOLUTION FZC and operated by CAVOK Airlines LLC was departing Sao Tome International Airport to Kotoka International Airport, Accra, for positioning with six crew on board. The flight was on an Instrument Flight Rule (IFR) flight plan and Visual Meteorological Conditions prevailed. The aircraft exited runway 29 during a rejected take off. The Flight Navigator sustained an injury and the aircraft was destroyed. On 28th July, 2017 at 0225hrs the aircraft arrived Sao Tome International Airport from Stavanger (Norway), via Luxemburg and Ghardaia (Algeria) as a Cargo flight. On 29th July, 2017 at about 0800hrs, the crew of CVK 7087 comprising the Captain, the First Officer, the Flight Engineer, the Flight Navigator and 2 Maintenance Engineers arrived the airport and commenced the flight preparation; pre-flight inspection, determination of weight and balance, computation of performance and take-off speeds. The crew received flight briefing/weather information and refuelled the aircraft with an uplift of 5,700kg. At 0850hrs, the crew requested engine start-up clearance from Sao Tome Tower and it was approved. After completing the engine start procedures, engine parameter indications on both engines were normal. Appropriate checklist was completed and taxi clearance was requested by the crew. Sao Tome Tower initially cleared CVK 7087 to taxi on runway (RWY) 11 as favoured by the prevailing wind. However, the crew requested RWY 29 for departure. This request was approved by the Tower and the aircraft re-cleared to taxi to RWY 29 for departure. Sao Tome Tower did not provide the flight crew with the information about possible presence of birds at the aerodrome, in particular, on the runway. At 0905hrs, the aircraft began the take-off roll. The First Officer was the Pilot Flying (PF) while the Captain was the Pilot Monitoring (PM). The engines and systems parameters were reported to be normal. According to the Captain, "In the first half of the take-off run from the runway, from five to six eagles got off the ground of the runway and flew dangerously close to the aircraft". He then requested the Flight Engineer to check if the flood lights were ON and to monitor the engine parameters. The crew asserted that they observed a rising and narrowing runway as the aircarft accelerated to a speed of 180 km/hr. They stated further: "At a speed of 180 km/hr, ahead, a flock of eagles, which were not seen before this moment began to get off the ground from the runway." The Captain took control of the aircraft and decided, after assessing the situation within 4 seconds that the best option for the crew was to discontinue the take-off. At that moment, the crew heard a bang, which they suggested could be a bird strike. This was followed by aural and visual indications on the annunciator panel such as “Left Engine Failure”, “Dangerous Vibration”, and “Take-off is prohibited” and the Captain immediately initiated a rejected take-off and instructed the Flight Engineer to deploy thrust reversers. The rejected takeoff was initiated about 5 seconds after sighting the birds, at a speed of 220km/h. According to the Captain, his decision was necessitated by the consideration of losing multiple engines due to bird strike if the take-off continued. The Captain said he pressed the brake pedals completely immediately after initiating the rejected take-off, subsequently he assessed the braking action as not effective and he used the emergency braking at a speed of about 130 km/h. On realizing that the aircraft would not stop within the remaining available runway length (about 272.3m) coupled with the presence of a ravine at the end, the captain intentionally veered to the right in order to extend the runway stopping distance and also avoid the ravine. The aircraft exited the runway at a speed of approximately 76 km/h. As the aircraft’s speed decayed to 60 km/h and just before the aircraft exited the runway, the Captain instructed the Flight Engineer to close the fuel emergency shutoff cock. The aircraft travelled a distance of about 95m from the exit point before plunging into the ravine. In the process, the forward fuselage separated from the bulkhead located immediately after the cockpit section. The aircraft came to rest at a location with coordinates: N002° 2' 51'' and E006° 42' 07''. The accident occurred in daylight at about 0905hrs.
Probable cause:
The investigation determines that the cause of this accident as:
Due to the presence of birds on the runway, the take-off was rejected at a speed above decision speed V1, which is inconsistent with CAVOK’s Standard Operating Procedures (SOP).
Contributory factors:
The contributory factors to this accident include but are not limited to the following:
- Failure of the crew to deploy interceptors (speed brakes/spoilers).
- Inadequate flight crew training on details of rejected take-off procedure scenarios.
- The omission of the take-off briefing in CAVOK’s Normal Operations checklist.
- Poor Crew Resource Management (CRM), especially in a multi-crew flight operation.
Final Report:

Crash of a Dornier DO328Jet-310 in Mogadishu

Date & Time: May 30, 2017 at 1030 LT
Type of aircraft:
Operator:
Registration:
N330BG
Flight Type:
Survivors:
Yes
Schedule:
Entebbe – Mogadishu
MSN:
3184
YOM:
2001
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Following an unventful flight from Entebbe, the twin engine airplane made a belly landing at Mogadishu-Aden Abdulle Airport. After touchdown, it slid for few hundre metres before coming to rest. All four crew members evacuated safely and the aircraft was damaged beyond repair.

Crash of a Learjet 25B in Toluca: 2 killed

Date & Time: May 17, 2017 at 1525 LT
Type of aircraft:
Operator:
Registration:
XA-VMC
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Toluca - Durango
MSN:
25-114
YOM:
1973
Location:
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Aircraft flight hours:
14654
Aircraft flight cycles:
13449
Circumstances:
During the takeoff roll on runway 15 at Toluca-Licendiado Adolfo López Mateos, after the airplane passed the V1 speed, the warning light came on in the cockpit panel, informing the crew about the deployment of the reverse on the left engine. According to published procedures, the crew continued the takeoff and shortly after rotation, during initiale climb, the aircraft rolled to the left and crashed in an open field, bursting into flames. The wreckage was found about 200 metres past the runway end. The aircraft was destroyed and both pilots were killed.
Probable cause:
Probable Cause:
Loss of control of the aircraft during the emergency procedure of indication of the deployment of the reverse of the engine number one during the takeoff roll above V1, which was consistent with the training and standard operating procedures that call to continue the takeoff, causing the collapse of the aircraft, by low speed and the operation of abrupt maneuvers and turns towards the engine side in idle position and commanded opening of the Drag Shut due to poor CRM.
Contributing factors:
- False indication of reverse display of dwelling position number one.
- Failure of pilots of previous flights not to refer failures to indicate the deployment of reverses for maintenance actions.
Final Report:

Crash of a Learjet 35A in Teterboro: 2 killed

Date & Time: May 15, 2017 at 1529 LT
Type of aircraft:
Registration:
N452DA
Flight Type:
Survivors:
No
Schedule:
Philadelphia - Teterboro
MSN:
35A-452
YOM:
1981
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
6898
Captain / Total hours on type:
353.00
Copilot / Total flying hours:
1167
Copilot / Total hours on type:
407
Circumstances:
On May 15, 2017, about 1529 eastern daylight time, a Learjet 35A, N452DA, departed controlled flight while on a circling approach to runway 1 at Teterboro Airport (TEB), Teterboro, New Jersey, and impacted a commercial building and parking lot. The pilot-in-command (PIC) and the second-in-command (SIC) died; no one on the ground was injured. The airplane was destroyed by impact forces and postcrash fire. The airplane was registered to A&C Big Sky Aviation, LLC, and was operated by Trans-Pacific Air Charter, LLC, under the provisions of Title 14 Code of Federal Regulations (CFR) Part 91 as a positioning flight. Visual meteorological conditions prevailed, and an instrument flight rules flight plan was filed. The flight departed from Philadelphia International Airport (PHL), Philadelphia, Pennsylvania, about 1504 and was destined for TEB. The accident occurred on the flight crew’s third and final scheduled flight of the day; the crew had previously flown from TEB to Laurence G. Hanscom Field (BED), Bedford, Massachusetts, and then from BED to PHL. The PIC checked the weather before departing TEB about 0732; however, he did not check the weather again before the flight from PHL to TEB despite a company policy requiring that weather information be obtained within 3 hours of departure. Further, the crew filed a flight plan for the accident flight that included altitude (27,000 ft) and time en route (28 minutes) entries that were incompatible with each other, which suggests that the crew devoted little attention to preflight planning. The crew also had limited time in flight to plan and brief the approach, as required by company policy, and did not conduct an approach briefing before attempting to land at TEB. Cockpit voice recorder data indicated that the SIC was the pilot flying (PF) from PHL to TEB, despite a company policy prohibiting the SIC from acting as PF based on his level of experience. Although the accident flight waslikely not the first time that the SIC acted as PF (based on comments made during the flight), the PIC regularly coached the SIC (primarily on checklist initiation and airplane control) from before takeoff to the final seconds of the flight. The extensive coaching likely distracted the PIC from his duties as PIC and pilot monitoring, such as executing checklists and entering approach waypoints into the flight management system. Collectively, procedural deviations and errors resulted in the flight crew’s lack of situational awareness throughout the flight and approach to TEB. Because neither pilot realized that the airplane’s navigation equipment had not been properly set for the instrument approach clearance that the flight crew received, the crew improperly executed the vertical profile of the approach, crossing an intermediate fix and the final approach fix hundreds of feet above the altitudes specified by the approach procedure. The controller had vectored the flight for the instrument landing system runway 6 approach, circle to runway 1. When the crew initiated the circle-to-land maneuver, the airplane was 2.8 nautical miles (nm) beyond the final approach fix (about 1 mile from the runway 6 threshold) and could not be maneuvered to line up with the landing runway, which should have prompted the crew to execute a go-around because the flight did not meet the company’s stabilized approach criteria. However, neither pilot called for a go-around, and the PIC (who had assumed control of the airplane at this point in the flight) continued the approach by initiating a turn to align with the landing runway. Radar data indicated that the airplane’s airspeed was below the approach speed required by company standard operating procedures (SOPs). During the turn, the airplane stalled and crashed about 1/2 nm south of the runway 1 threshold.
Probable cause:
The National Transportation Safety Board determines that the probable cause of this accident was the pilot-in-command’s (PIC) attempt to salvage an unstabilized visual approach, which resulted in an aerodynamic stall at low altitude. Contributing to the accident was the PIC’s decision to allow an unapproved second-in-command to act as pilot flying, the PIC’s inadequate and incomplete preflight planning, and the flight crew’s lack of an approach briefing. Also contributing to the accident were Trans-Pacific Jets’ lack of safety programs that would have enabled the company to identify and correct patterns of poor performance and procedural noncompliance and the Federal Aviation Administration’s ineffective Safety assurance System procedures, which failed to identify these company oversight deficiencies.
Final Report:

Crash of a Piper PA-31-325 near Purísima de la Concepción

Date & Time: Apr 9, 2017 at 1241 LT
Type of aircraft:
Operator:
Registration:
HP-1928
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Tolú - Montería
MSN:
31-7612020
YOM:
1976
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
14791
Captain / Total hours on type:
700.00
Aircraft flight hours:
6840
Circumstances:
The twin engine aircraft departed Cali-Alfonso Bonilla Aragón Airport in the morning on a flight to Tolú, carrying seven passengers and one pilot. After takeoff from Tolú, the pilot decided to position to Montería-Los Garzones Airport. Shortly after takeoff, the pilot encountered engine problems and elected to make an emergency landing in a pasture. Upon landing, the right wing collided with obstacles then the nose gear collapsed and the aircraft came to rest near Purísima de la Concepción, about 10 km east of Tolú. The pilot was uninjured and the aircraft was damaged beyond repair.
Probable cause:
Inadequate fuel management and incomplete execution of procedures by the Pilot, by not activating in time the fuel supply from the external tanks (OUTBD) to the internal tanks (INBD) for the feeding of both the engines, causing the fuel in the internal tanks to run out and causing both engines to stop due to fuel starvation.
Contributing Factors:
- Poor flight planning on part of the pilot by not considering the amount of minimum fuel needed and not complying with the minimum fuel amount required for domestic flights.
- Loss of situational awareness by the pilot by not following the standard operation procedures.
Final Report: