Crash of a Swearingen SA227AT Expediter in Luqa: 5 killed

Date & Time: Oct 24, 2016 at 0720 LT
Type of aircraft:
Operator:
Registration:
N577MX
Flight Phase:
Survivors:
No
Schedule:
Luqa - Luqa
MSN:
AT-577
YOM:
1983
Flight number:
LXC77
Location:
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
3511
Captain / Total hours on type:
1229.00
Copilot / Total flying hours:
21806
Copilot / Total hours on type:
2304
Aircraft flight hours:
9261
Aircraft flight cycles:
3503
Circumstances:
The aircraft was involved in a maritime patrol flight over the Mediterranean Sea, carrying a crew of two and three members of the French Ministry of Defense. Shortly after takeoff from runway 13, while in initial climb, the twin engine aircraft banked to the right, hit a perimeter fence and crashed in a huge explosion on the Triq Carmelo Caruana Street. The aircraft was destroyed by impact forces and a post crash fire. All five occupants were killed. It was previously reported that the flight was performed on behalf of the EU Frontex Program but this was later denied by the Border Agency. The presence of all three French Officers was confirmed by the French Minister of Defense Jean-Yves Le Drian. It was also confirmed by the Government of Malta that this kind of flight was performed by the French Customs since five months, an official operation of surveillance to identify human traffic and narcotics routes in the Mediterranean Sea.
Probable cause:
Investigations show that a technical malfunction was the cause of the accident. This malfunction probably originated in the specific modifications of the aircraft and in the application of an inappropriate maintenance to these modifications.
Three scenarios can be envisaged:
- Rupture of the HF antenna, which then wrapped around the elevator control surface;
- Inadvertent activation of the SAS, countered by the pilot;
- Jamming of the elevator due to a technical failure in the flight control line.
Given the condition of the wreckage and the absence of witness reports from the crew, only a flight data recorder could have enabled the BEA-É to confirm one of these hypothesis. However, in consideration of the factors detailed in the analysis, the hypothesis of damage to a component of the elevator control line remains the most plausible explanation.
Final Report:

Crash of a De Havilland DHC-8-Q402 in Dire Dawa

Date & Time: Oct 24, 2016
Operator:
Registration:
ET-ANY
Flight Phase:
Survivors:
Yes
Schedule:
Dire Dawa – Addis Ababa
MSN:
4334
YOM:
2010
Flight number:
ET212
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
74
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
During the takeoff roll from runway 15/33 at Dire Dawa-Aba Tenna Dejazmach Yilma Airport, the aircraft collided with wild animals. The captaint abandoned the takeoff procedure and initiated an emergency braking manoeuvre when the aircraft veered off runway and came to rest. All 80 occupants evacuated safely and the aircraft was damaged beyond repair.
Probable cause:
Collision with wild animals during takeoff.

Crash of a Beechcraft D18S in Deming

Date & Time: Oct 23, 2016 at 1700 LT
Type of aircraft:
Operator:
Registration:
N644B
Flight Type:
Survivors:
Yes
Schedule:
Junction – Deming
MSN:
A-441
YOM:
1948
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
18600
Captain / Total hours on type:
300.00
Aircraft flight hours:
5545
Circumstances:
The pilot of the multi-engine tailwheel-equipped airplane reported that during the landing roll, after the tailwheel had touched down, the airplane veered sharply to the left. The pilot further reported that the airplane was close to the left runway edge, so he allowed the airplane to continue off the runway, in effort not to overcorrect to the right. During the runway excursion, the right main landing gear collapsed in soft terrain. The right wing sustained substantial damage. The pilot reported no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause:
The pilot's failure to maintain directional control during the landing roll, which resulted in a runway excursion.
Final Report:

Crash of an Airbus A300B4-230F in Recife

Date & Time: Oct 21, 2016 at 0630 LT
Type of aircraft:
Operator:
Registration:
PR-STN
Flight Type:
Survivors:
Yes
Schedule:
São Paulo – Recife
MSN:
236
YOM:
1983
Flight number:
STR9302
Country:
Crew on board:
3
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
11180
Captain / Total hours on type:
3000.00
Copilot / Total flying hours:
7300
Copilot / Total hours on type:
800
Circumstances:
Following an uneventful cargo service from São Paulo-Guarulhos Airport, the crew initiated the descent to Recife-Guararapes Airport. On final approach to runway 18, after the aircraft had been configured for landing, at an altitude of 500 feet, the crew was cleared to land. After touchdown, the thrust lever for the left engine was pushed to maximum takeoff power while the thrust lever for the right engine was simultaneously brang to the idle position then to reverse. This asymetric configuration caused the aircraft to veer to the right and control was lost. The airplane veered off runway to the right and, while contacting soft grounf, the nose gear collapsed. The airplane came to rest to the right of the runway and was damaged beyond repair. All four occupants evacuated safely.
Probable cause:
Contributing factors.
- Control skills - undetermined
Inadequate use of aircraft controls, particularly as regards the mode of operation of the Autothrottle in use and the non-reduction of the IDLE power levers at touch down, may have led to a conflict between pilots when performing the landing and the automation logic active during approach. In addition, the use of only one reverse (on the right engine) and placing the left throttle lever at maximum takeoff power resulted in an asymmetric thrust that contributed to the loss of control on the ground.
- Attitude - undetermined
The adoption of practices different from the aircraft manual denoted an attitude of noncompliance with the procedures provided, which contributed to put the equipment in an unexpected condition: non-automatic opening of ground spoilers and asymmetric thrust of the engines. These factors required additional pilot intervention (hand control), which may have made it difficult to manage the circumstances that followed the touch and led to the runway excursion.
- Crew Resource Management - a contributor
The involvement of the PM in commanding the aircraft during the events leading up to the runway excursion to the detriment of its primary responsibility, which would be to monitor systems and assist the PF in conducting the flight, characterized an inefficiency in harnessing the human resources available for the airplane operation. Thus, the improper management of the tasks assigned to each crewmember and the non-observance of the CRM principles delayed the identification of the root cause of the aircraft abnormal behavior.
- Organizational culture - a contributor
The reliance on the crew's technical capacity, based on their previous aviation experience, has fostered an informal organizational environment. This informality contributed to the adoption of practices that differed from the anticipated procedures regarding the management and operation of the aircraft. This not compliance with the procedures highlights a lack of safety culture, as lessons learnt from previous similar accidents (such as those in Irkutsk and Congonhas involving landing using only one reverse and pushing the thrust levers forward), have apparently not been taken into account at the airline level.
- Piloting judgment - undetermined
The habit of not reducing the throttle lever to the IDLE position when passing at 20ft diverged from the procedures contained in the aircraft-operating manual and prevented the automatic opening of ground spoilers. It is possible that the consequences of this adaptation of the procedure related to the operation of the airplane were not adequately evaluated, which made it difficult to understand and manage the condition experienced.
- Perception - a contributor
Failure to perceive the position of the left lever denoted a lowering of the crew's situational awareness, as it apparently only realized the real cause of the aircraft yaw when the runway excursion was already underway.
- Decision-making process - a contributor
An inaccurate assessment of the causes that would justify the behavior of the aircraft during the landing resulted in a delay in the application of the necessary power reduction procedure, that is, repositioning the left engine power lever.
Final Report:

Crash of a Piper PA-61P Aerostar (Ted Smith 601) in Karlsruhe

Date & Time: Oct 17, 2016 at 1243 LT
Operator:
Registration:
N20NR
Flight Type:
Survivors:
Yes
Schedule:
Bitburg - Karlsruhe
MSN:
61-0445-169
YOM:
1977
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
1446
Captain / Total hours on type:
362.00
Aircraft flight hours:
2635
Circumstances:
Following an uneventful flight from Bitburg, the pilot was cleared for an approach to Karlsruhe-Baden Baden Airport Runway 21. On final approach, while completing a sharp turn to the left to join the runway, the twin engine airplane stalled and crashed in an open field, bursting into flames. The pilot was seriously injured and the aircraft was destroyed by a post crash fire. The wreckage was found about 500 metres from the runway threshold and 350 metres to the left of the runway extended centerline.
Probable cause:
The aircraft stalled on final approach while completing a sharp turn to the left at an insufficient speed with an insufficient distance with the ground, following an unstabilized approach. The limited visibility was considered as a contributing factor.
Final Report:

Crash of a Socata TBM-900 in Fairoaks

Date & Time: Oct 15, 2016 at 0732 LT
Type of aircraft:
Registration:
M-VNTR
Flight Type:
Survivors:
Yes
Schedule:
Douglas - Fairoaks
MSN:
1097
YOM:
2016
Location:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
5272
Captain / Total hours on type:
1585.00
Circumstances:
The accident occurred as the aircraft was preparing to land at Fairoaks Airport at the end of a private flight from Ronaldsway Airport on the Isle of Man. On board were the aircraft commander and a passenger who occupied the front right seat. As the aircraft neared Fairoaks, the pilot listened to the Farnborough ATIS broadcast, which reported a visibility of 4,000 m in mist. He and the passenger discussed the visibility, and agreed that they would proceed to Fairoaks while retaining the option to divert to Farnborough Airport (9 nm to the south-west) if a landing was not possible. The visibility at Fairoaks was recorded as 4,500 m, with ‘few’ clouds at 4,000 ft and a surface wind of 3 kt from 240°. Runway 24 was in use with a left-hand circuit. The circuit height, based on the Fairoaks QNH was 1,100 ft (the elevation of Fairoaks Airport is 80 ft amsl). Runway 24 is a hard runway, 813 m long and 27 m wide. The pilot identified the airfield visually, although there was low lying mist in the area. In order to maintain visual contact with the landing area he joined the circuit and flew a downwind leg that was closer to the runway than usual. He recalled carrying out the pre-landing checks while downwind, including lowering the landing gear and extending the flaps to the takeoff position2 . Based on a final approach with flaps at the landing setting, the pilot planned for an initial approach speed of 90 kt, reducing to a final approach speed of 80 kt. The pilot recalled the aircraft being slightly low as it turned from the downwind leg onto its final approach track. He believed he had selected flaps to the landing position, and recalled seeing the airspeed just below 90 kt, which prompted him to increase power slightly. The aircraft flew through the extended runway centreline and the pilot increased the bank angle to regain it. The pilot’s next recollection was of being in a right bank and seeing only sky ahead. He pushed forward on the control column and attempted to correct the bank with aileron. The aircraft then rolled quickly in the opposite direction and he again applied a correction. He became aware of being in an approximately wings-level attitude and seeing the ground approaching rapidly. He responded by pulling back hard on the control column, but was unable to prevent the aircraft striking the ground. He did not recall hearing a stall warning, or any other audio warning, before the loss of control occurred. The aircraft struck flat ground and slid for about 85 m before coming to rest against a treeline, about 500 m from Runway 24 and approximately on the extended centreline. The propeller was destroyed in the accident sequence and the landing gear legs detached, causing damage to the wings which included a ruptured fuel tank. In the latter stages of the slide the aircraft yawed right, coming to rest heading approximately in the direction from which it had come. The pilot and passenger remained conscious but had both suffered injury. The passenger saw flames from the region of the engine and warned the pilot that they needed to evacuate. He went to the rear of the cabin, opened the main door and left the aircraft. The pilot initially attempted to open his side door, but his right arm was injured and he was unable to open the door with only his left. He therefore followed the passenger out of the rear door.
Probable cause:
There were no indications that the aircraft had been subject to any defects or malfunctions that may have contributed to the accident. Reports from the two occupants, eye witness accounts and radar data all confirm that the aircraft commenced its final turn from a position closer to the runway than usual. This would have required a sustained moderate angle of bank through about 180° of turn. The radar data indicates that the turn onto the final approach was initially flown with less angle of bank than required. The pilot therefore either lost visual contact with the runway or did not fully appreciate the turn requirements. An explanation for the latter might be that the low height on the downwind leg combined with the relatively poor visibility to produce a runway visual aspect that gave a false impression that the aircraft spacing was not abnormal. As the finals turn progressed, there was a need to increase the angle of bank to a relatively high value. With the flaps remaining at the takeoff setting, and maintaining level flight, this placed the aircraft close to its stalling speed. Any increase in angle of bank or ‘g’ loading (as may have occurred when it became evident that the aircraft would fly through the extended centreline) risked a stall. The available evidence indicates that the aircraft stalled during the turn onto the final approach. Recovery actions taken by the occupants appear to have been partially successful, but there was evidently insufficient height in which to effect a full recovery.
Final Report:

Crash of a Cessna 500 Citation I in Winfield: 4 killed

Date & Time: Oct 13, 2016 at 2136 LT
Type of aircraft:
Operator:
Registration:
C-GTNG
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Kelowna – Calgary
MSN:
500-0169
YOM:
1974
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
3912
Captain / Total hours on type:
525.00
Aircraft flight hours:
8649
Circumstances:
The pilot and 3 passengers boarded the aircraft. At 2126, the pilot obtained an IFR clearance from the CYLW ground controller for the KELOWNA SEVEN DEP standard instrument departure (SID) procedure for Runway 34. The instructions for the runway 34 KELOWNA SEVEN DEP SID were to climb to 9000 feet ASL, or to an altitude assigned by air traffic control (ATC), and to contact the Vancouver Area Control Centre (ACC) after passing through 4000 feet ASL. The aircraft was then to climb and track 330° magnetic (M) inbound to the Kelowna non-directional beacon (LW). From LW, the aircraft was to climb and track 330°M outbound for vectors to the filed or assigned route. At 2127, C-GTNG began to taxi toward Runway 34. At 2131, the CYLW tower controller cleared the aircraft to take off from the intersection of Runway 34 and Taxiway D. The pilot acknowledged the clearance and began the take-off roll on Runway 34 about 1 minute later. Radar data showed that, at 2133:41, the aircraft was 0.5 nautical miles (nm) beyond the departure end of the runway and was climbing at more than 4000 feet per minute (fpm) through 2800 feet ASL, at a climb angle of approximately 16°. In that time, it had deviated laterally by about 3° to the right of the 330°M track associated with the SID. At 2134:01, when the aircraft was 1.2 nm beyond the runway, it had climbed through 3800 feet ASL and deviated further to the right of the intended routing. The aircraft’s rate of climb decreased to about 1600 fpm, and its ground speed was 150 knots. A short time later, the aircraft’s rate of climb decreased to 600 fpm, its climb angle decreased to 2°, and its ground speed had increased to 160 knots. At 2134:22, the aircraft was 2.1 nm beyond the departure end of the runway, and it was climbing through approximately 4800 feet ASL. The aircraft had deviated about 13° to the right of the intended track, and its rate of climb reached its maximum value of approximately 000 fpm, 3 with a climb angle of about 22°. The ground speed was roughly 145 knots. At 2134:39, the aircraft was 2.7 nm beyond the departure end of the runway, passing through 5800 feet ASL, and had deviated about 20° to the right of the intended routing. The rate of climb was approximately 2000 fpm, with a climb angle of about 7°. According to the SID, the pilot was to make initial contact with the ACC after the aircraft had passed through 4000 feet ASL.Initial contact was made when the aircraft was passing through 6000 feet ASL, at 2134:42. At 2134:46, the ACC acknowledged the communication and indicated that the aircraft had been identified on radar. The aircraft was then cleared for a right turn direct to the MENBO waypoint once it was at a safe altitude, or once it was climbing through 8000 feet ASL. The aircraft was also cleared to follow the flight-planned route and climb to 10 000 feet ASL. At 2134:55, the pilot read back the clearance as the aircraft climbed through 6400 feet ASL, with a rate of climb of approximately 2400 fpm. The aircraft was tracking about 348°M at a ground speed of about 170 knots. At 2135:34, the aircraft began a turn to the right, which was consistent with the instruction from the ACC. Flying directly to the MENBO waypoint required the aircraft to be on a heading of 066°M, requiring a right turn of about 50°. At this point, the aircraft was still climbing and was passing through 8300 feet ASL. The rate of climb was about 3000 fpm. The aircraft continued the right turn and was tracking through 085°M. After reaching a peak altitude of approximately 8600 feet ASL, the aircraft entered a steep descending turn to the right, consistent with the characteristics of a spiral dive. At 2135:47, the ACC controller cleared C-GTNG to climb to FL 250. The lack of radar returns and radio communications from the aircraft prompted the controller to initiate search activities. At 2151, NAV CANADA notified first responders, who located the accident site in forested terrain at about midnight. The aircraft had been destroyed, and all of the occupants had been fatally injured.
Probable cause:
The aircraft departed controlled flight, for reasons that could not be determined, and collided with terrain.
Final Report:

Crash of an Antonov AN-26-100 in Belaya Gora

Date & Time: Oct 11, 2016 at 1638 LT
Type of aircraft:
Operator:
Registration:
RA-26660
Survivors:
Yes
Schedule:
Yakutsk - Belaya Gora
MSN:
8008
YOM:
1979
Flight number:
PI203
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
27
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
11439
Captain / Total hours on type:
2697.00
Copilot / Total flying hours:
11142
Copilot / Total hours on type:
122
Aircraft flight hours:
34490
Aircraft flight cycles:
16367
Circumstances:
On final approach to Belaya Gora Airport, the aircraft was too low and hit the ground. On impact, the right main gear and the nose gear collapsed. The aircraft slid for several yards before coming to rest in a snow covered field about 400 meters short of runway threshold and 300 meters to the left of the approach path. The propeller on the right engine was torn off and it appears that the fuselage was bent as well. All 33 occupants were evacuated safely. At the time of the accident, weather conditions were marginal with limited visibility caused by snow falls. It was reported the visibility was about 2,5 km at the time of the accident while the crew needed at least 4 km on an NDB approach.
Probable cause:
The accident was caused by the combination of the following factors:
- Absence of standard operating procedures issued by the operator of how to conduct NDB approaches,
- Violation of procedures by tower who only transmitted information about snow fall and recommended to perform a low pass over the runway but did not transmit the actual visibility was 1900 meters below required minimum
- Absence of information that the visibility was below required minimum, the last transmission indicated minimum visibility was present,
- Presence of numerous landmarks (abandoned ships, ship cranes, fuel transshipment complex, ...) covered by snow within 700-1000 meters from the unpaved runway which could be taken as runway markers by flight crew,
- Presence of a number of "bald spots" due to the transitional period of year where the underlying surface became visible making it difficult to visualize and recognize the unpaved runway covered with snow (it was the first flight into Belaya Gora for the crew in the winter season, they had operated into the aerodrome only in summer so far),
- Insufficient use of the available nav aid on final approach which led to lack of proper control of the aircraft position relative to the glide path,
- Lack of possibility for tower to watch the aircraft performing the NDB approach from his work place.
Final Report:

Crash of a Beechcraft 1900D in Beni

Date & Time: Sep 28, 2016 at 1230 LT
Type of aircraft:
Operator:
Registration:
ZS-PZE
Survivors:
Yes
Schedule:
Goma - Beni
MSN:
UE-32
YOM:
1992
Flight number:
UNO830
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
4728
Captain / Total hours on type:
921.00
Copilot / Total flying hours:
2258
Copilot / Total hours on type:
251
Aircraft flight hours:
21498
Aircraft flight cycles:
30564
Circumstances:
The twin engine aircraft departed Goma on a regular schedule flight (service UNO830) to Beni, carrying eight passengers and two pilots on behalf of the Monusco, the United Nations Organization Stabilization Mission in the Democratic Republic of Congo. On approach to Beni-Mavivi Airport, the crew completed the approach checklist and elected to configure the aircraft but realized that the undercarriage would not extend. After the circuit breaker was reset, the crew was able to lower the landing gear manually and continued the approach with no reporting to ATC. After touchdown on runway 11, the aircraft rolled for about 450 metres when the right main gear collapsed. Out of control the aircraft veered off runway to the right, slid in a grassy area, crossed a ditch and came to rest near the apron. All 10 occupants evacuated safely and the aircraft was damaged beyond repair.
Probable cause:
The following factors were identified:
- The ovality due to the wear of the junction point of the arm (270) with the actuator (15) over time to the point that it finally broke and released the actuator from the whole undercarriage system.
- Overheating of the time/delay relay caused the circuit breaker to trip.
- The ovality created by the job(65) at the junction of the arm(270) to the actuator(15) eventually thinned and broke off the actuator.
Final Report:

Crash of a Learjet 31A in Jakarta

Date & Time: Sep 25, 2016 at 1946 LT
Type of aircraft:
Operator:
Registration:
PK-JKI
Flight Type:
Survivors:
Yes
Schedule:
Yogyakarta – Jakarta
MSN:
31-213
YOM:
2001
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The crew was performing an ambulance flight from Yogyakarta-Adisujipto Airport to Jakarta-Halim Perdanakusuma Airport on behalf of the Indonesian Red Cross (Palang Merah Indonesia), carrying one patient, two doctors, two accompanists and three crew members. The approach was completed by night and marginal weather conditions. After touchdown on runway 24, the aircraft skidded on a wet runway. After a course of 1,300 metres, it veered to the right and departed the runway surface. While contacting soft ground, the right main gear was torn off while the left main gear partially collapsed. Then the aircraft bounced and impacted the ground several times, causing the left wing to be bent. Eventually, the right engine partially detached from the pylon. All eight occupants were rescued and the aircraft was damaged beyond repair. There was no fire.