Airport (less than 10 km from airport)

**This report was modified on April 2, 2020. Please see the public docket for this accident to view the original report.**
After the airplane touched down on the 4,422-ft-long runway, the airline transport pilot applied the brakes to decelerate; however, he did not think that the brakes were operating. He continued "pumping the brakes" and considered conducting a go-around; however, there was insufficient remaining runway to do so. The airplane subsequently continued off the end of the runway, impacted a berm, and came to rest upright, which resulted in substantial damage to the right wing. During postaccident examination of the airplane, brake pressure was obtained on both sets of brake pedals when they were depressed, and there was no bleed down or reduction in pedal firmness when the brakes were pumped several times. Examination revealed no evidence off any preimpact anomalies with the brake system that would have precluded normal operation. In addition, the pilot indicated that he was not aware of and was not trained on the use of the ALL INTERRUPT button, which is listed as a step in the Emergency Procedures section of the airplane flight manual and is used to disable the anti-skid brake system functions and restore normal braking when the brakes are ineffective; thus, the pilot did not follow proper checklist procedures. According to data downloaded from the airplane's diagnostic storage unit (DSU), the airplane touched down 1,280 ft beyond the runway threshold, which resulted in 2,408 ft of runway remaining (the runway had a displaced threshold of 734 ft) and that it traveled 2,600 ft before coming to rest about 200 ft past the runway. The airplane's touchdown speed was about 91 knots. Comparing DSU data from previous downloaded flights revealed that the airplane's calculated deceleration rate during the accident landing was indicative of braking performance as well as or better than the previous landings. Estimated landing distance calculations revealed that the airplane required about 3,063 ft when crossing the threshold at 50 ft above ground level. The target touchdown speed was 76 knots. However, the airplane touched down with only 2,408 ft of remaining runway faster than the target touchdown speed, which resulted in the runway overrun.

On 16 August 2015, a Maritime Air Charter Limited Beechcraft King Air A100 (registration C-FDOR, serial number B-103) was on a charter flight from Halifax Stanfield International Airport, Nova Scotia, to Margaree Aerodrome, Nova Scotia, with 2 pilots and 2 passengers on board. At approximately 1616 Atlantic Daylight Time, while conducting a visual approach to Runway 01, the aircraft touched down hard about 263 feet beyond the threshold. Almost immediately, the right main landing gear collapsed, then the right propeller and wing contacted the runway. The aircraft slid along the runway for about 1350 feet, then veered right and departed off the side of the runway. It came to rest about 1850 feet beyond the threshold and 22 feet from the runway edge. There were no injuries and there was no post-impact fire. The aircraft was substantially damaged. The occurrence took place during daylight hours. The 406-megahertz emergency locator transmitter did not activate.

The Cessna 172 (N1285U) was conducting touch-and-go landings at Brown Field Municipal Airport (SDM), San Diego, California, and the experimental North American Rockwell NA265-60SC Sabreliner (N442RM, call sign Eagle1) was returning to SDM from a mission flight. SDM has two parallel runways, 8R/26L and 8L/26R; it is common in west operations for controllers to use a right traffic pattern for both runways 26R and 26L due to the proximity of Tijuana Airport, Tijuana, Mexico, to the south of SDM. On the morning of the accident, the air traffic control tower (ATCT) at SDM had both control positions (local and ground control) in the tower combined at the local control position, which was staffed by a local controller (LC)/controller-in-charge, who was conducting on-the-job training with a developmental controller (LC trainee). The LC trainee was transmitting control instructions for all operations; however, the LC was monitoring the LC trainee's actions and was responsible for all activity at that position. About 13 minutes before the accident, the N1285U pilot contacted the ATCT and requested touch-andgo landings in the visual flight rules (VFR) traffic pattern. About that time, another Cessna 172 (N6ZP) and a helicopter (N8360R) were conducting operations in the VFR traffic pattern, and a Cessna 206 Stationair (N5058U) was inbound for landing. Over the next 5 minutes, traffic increased, with two additional aircraft inbound for landing. (Figure 1 in the factual report for this accident shows the aircraft in the SDM traffic pattern about 8 minutes before the accident.) The LC trainee cleared the N1285U pilot for a touch-and-go on runway 26R; the pilot acknowledged the clearance and then advised the LC trainee that he was going to go around. The LC trainee advised the N1285U pilot to expect runway 26L on the next approach. At that time, three aircraft were using runway 26R (Global Express [N18WZ] was inbound for landing, N6ZP was on a right base for a touch-and-go, and a Cessna Citation [XALVV] was on short final) and three aircraft were using runway 26L (N1285U was turning right downwind for the touch-and-go, a Skybolt [N81962] was on a left downwind for landing, and N8360R was conducting a touch-and-go landing). After N1285U completed the touch-andgo on runway 26L, the pilot entered a right downwind for runway 26R. Meanwhile, Eagle1 was 9 miles west of the airport and requested a full-stop landing; the LC trainee instructed the Eagle1 flight crew to enter a right downwind for runway 26R at or above an altitude of 2,000 ft mean sea level. At this time, about 3 minutes before the accident, the qualified LC terminated the LC trainee's training and took over control of radio communications. From this time until the collision occurred, the LC was controlling nine aircraft. (Figure 2 and Figure 4 in the factual report for this accident show the total number of aircraft under ATCT control shortly before the accident.) During the next 2 minutes, the LC made several errors. For example, after N6ZP completed a touch-andgo on runway 26R, the pilot requested a right downwind departure from the area, which the LC initially failed to acknowledge. The LC also instructed the N5058U pilot, who had been holding short of runway 26L, that he was cleared for takeoff from runway 26R. Both errors were corrected. In addition, the LC instructed the helicopter pilot to "listen up. turn crosswind" before correcting the instruction 4 seconds later to "turn base." (Figure 2 in the factual report for this accident shows the aircraft in the traffic pattern about 2 minutes before the accident.) About 1 minute before the collision, the Eagle1 flight crew reported on downwind midfield and stated that they had traffic to the left and right in sight. At that time, N1285U was to Eagle1's right, between Eagle1 and the tower, and established on a right downwind about 500 ft below Eagle1's position. N6ZP was about 1 mile forward and to the left of Eagle1, heading northeast and departing the area. Mistakenly identifying the Cessna to the right of Eagle1 as N6ZP, the LC instructed the N6ZP pilot to make a right 360° turn to rejoin the downwind when, in fact, N1285U was the airplane to the right of Eagle1. (The LC stated in a postaccident interview that he thought the turn would resolve the conflict with Eagle1 and would help the Cessna avoid Eagle1's wake turbulence.) The N6ZP pilot acknowledged the LC's instruction and began turning; N1285U continued its approach to runway 26R. However, the LC never visually confirmed that the Cessna to Eagle1's right (N1285U) was making the 360° turn. Ten seconds later, the LC instructed the Eagle1 flight crew to turn base and land on runway 26R, which put the accident airplanes on a collision course. The LC looked to ensure that Eagle1 was turning as instructed and noticed that the Cessna on the right downwind (which he still mistakenly identified as N6ZP) had not begun the 360° turn that he had issued. The LC called the N6ZP pilot, and the pilot responded that he was turning. In the first communication between the LC and the N1285U pilot (and the first between the controllers in the ATCT and that airplane's pilot in almost 6 minutes), the LC transmitted the call sign of N1285U, which the pilot acknowledged. N1285U and Eagle1 collided as the LC tried to verify N1285U's position. A postaccident examination of both airplanes did not reveal any mechanical anomalies that would have prevented the airplanes from maneuvering to avoid an impact.

On 12 August 2015, a PAC-750XL aircraft, registered PK-KIG, was being operated by PT. Komala Indonesia on an unscheduled passenger flight from Wamena Airport (WAJW) Papua to Ninia Airstrip , Yahukimo, Papua that was located on radial 127° from Wamena with a distance of approximately 26 Nm. At 0733 LT (2233 UTC), the aircraft departed from Wamena Airport with an estimated time of arrival at Ninia of 2248 UTC. The flight was uneventful until approaching Ninia. On board the aircraft were one pilot, one engineer and 4 passengers. According to the pilot statement, an airspeed indicator malfunction occurred during flight. Video footage taken by a passenger showed that, during the approach at an altitude of approximately 6,500 feet, the airspeed indicators indicated zero and the aural stall warning activated. The aircraft then flew on the left side and parallel to the runway. Thereafter the aircraft climbed, turned left and impacted the ground about 200 meters south-west of the runway. The engineer on board was fatally injured, one passenger had minor injuries and the other occupants, including the pilot, were seriously injured. Two occupants were evacuated to a hospital in Jayapura Airport and four others, including the fatally injured, were evacuated to a hospital in Wamena.

The private pilot reported that he was approaching the airport for landing in the multi-engine airplane when both engines began to surge. The pilot attempted to switch to the auxiliary fuel tanks, but inadvertently switched the left engine fuel selector to the off position. The left engine subsequently experienced a total loss of engine power. On final approach for landing, the airplane impacted terrain and was subsequently consumed by a postimpact fire; the fuel onboard the airplane at the time of the accident could not be determined. An examination of the airplane's engines and systems revealed no mechanical anomalies that would have precluded normal operation.

The private pilot, who was experienced flying the accident airplane, was conducting a personal flight with three passengers on board the single-engine turboprop airplane. Earlier that day, the pilot flew uneventfully from his home airport to an airport about 1 hour away. During takeoff for the return flight, the airplane impacted wooded terrain about 0.5 mile northwest of the departure end of the runway. There were no witnesses to the accident, but the pilot's radio communications with flight service and on the common traffic advisory frequency were routine, and no distress calls were received. A postcrash fire consumed a majority of the wreckage, but no preimpact mechanical malfunctions were observed in the remaining wreckage. Examination of the propeller revealed that the propeller reversing lever guide pin had been installed backward. Without the guide pin installed correctly, the reversing lever and carbon block could dislodge from the beta ring and result in the propeller blades traveling to an uncommanded feathered position. However, examination of the propeller components indicated that the carbon block was in place and that the propeller was in the normal operating range at the time of impact. Additionally, the airplane had been operated for about 9 months and 100 flight hours since the most recent annual inspection had been completed, which was the last time the propeller was removed from and reinstalled on the engine. Therefore, the improper installation of the propeller reversing lever guide pin likely did not cause the accident. Review of the pilot's autopsy report revealed that he had severe coronary artery disease with 70 to 80 percent stenosis of the right coronary artery, 80 percent stenosis of the left anterior descending artery, and mitral annular calcification. The severe coronary artery disease combined with the mitral annular calcification placed the pilot at high risk for an acute cardiac event such as angina, a heart attack, or an arrhythmia. Such an event would have caused sudden symptoms such as chest pain, shortness of breath, palpitations, or fainting/loss of consciousness and would not have left any specific evidence to be found during the autopsy. It is likely that the pilot was acutely impaired or incapacitated at the time of the accident due to an acute cardiac event, which resulted in his loss of airplane control.

The airplane was fueled with 140 gallons of fuel before the second of three flight segments. The pilot reported that, while en route on the third segment, a fuel crossfeed light illuminated. He reset the indicator and decided to land the airplane to troubleshoot. He requested to divert to the nearest airport, which was directly beneath the airplane. Subsequently, the right engine lost power, and the autofeather system feathered the right engine propeller. He reduced power on the left engine, lowered the nose, and extended the landing gear while entering the traffic pattern. The pilot indicated that, after the landing gear was extended, the electrical system "failed," and shortly after, the left engine would not respond to power lever inputs. As the flight was on a base leg approach, the airplane was below the intended flightpath to reach the runway. The pilot stated that he pulled "gently on the control wheel"; however, the airplane impacted an embankment and came to rest on airport property, which resulted in substantial damage to both wings and the fuselage. Postaccident examination of the engines and airframe revealed no evidence of mechanical malfunctions or abnormalities that would have precluded normal operation. Signatures on the left propeller indicated that the engine was likely producing power at the time of impact; however, actual power settings could not be conclusively determined. Signatures on the right propeller indicated that little or no power was being produced. The quantity of fuel in the airplane's fuel system, as well as the configuration of the fuel system at the time of the accident, could not be determined based on the available evidence. Although the position of the master switch (which includes the battery, generator 1, and generator 2) was found in the OFF position, the airplane had been operating for about 30 minutes when the electrical power was lost; thus, it is likely that the airplane had been operating on battery power throughout the flight. This could have been the result of the pilot's failure to activate, or his inadvertent deactivation of, the generator 1 and 2 switch. If the flight were operating on battery power, it would explain what the pilot described as an electrical system failure after the landing gear extension due to the exhaustion of the airplane's battery. The postaccident examination of the left engine and propeller revealed that the engine was likely producing some power at the time of impact, and an explanation for why the engine reportedly did not respond to the pilot's throttle movements could not be determined. Additionally, given the available evidence, the reason for the loss of power to the right engine could not be determined.

Following an uneventful flight from Ulyanovsk, the crew started the descent to Moscow-Domodedovo Airport. While following the approach checklist, the crew realized that the nose gear failed to deploy and remained stuck in its wheel well. Several attempts to lower the gear manually failed and the crew eventually decided to carry out a nose gear-up landing on runway 32L. After a holding circuit of about 45 minutes, the aircraft landed then slid on its nose for few dozen metres before coming to rest. All 31 occupants evacuated safely and the aircraft was damaged beyond repair.

The aircraft had positioned to Milan earlier in the day, flown by the same pilot, and was returning to Blackbushe with the pilot and three passengers on board. After descending through the London Terminal Manoeuvring Area (TMA) it was handed over from London Control to Farnborough Approach. Its descent continued towards Blackbushe and, having reported that he had the airfield in sight, the pilot was instructed to descend at his own discretion. When the aircraft was approximately four miles south of its destination, he was instructed to contact Blackbushe Information. The weather at Blackbushe was fine with light and variable winds, visibility in excess of ten kilometres, and no low cloud. HZ-IBN entered the left-hand circuit for Runway 25 via the crosswind leg. Towards the end of the downwind leg, it overtook an Ikarus C42 microlight aircraft, climbing to pass ahead of and above that aircraft. As the climb began, at approximately 1,000 ft aal, the TCAS of HZ-IBN generated a ‘descend’ RA alert to resolve a conflict with the microlight. The TCAS RA changed to ‘maintain vertical speed’ and then ‘adjust vertical speed’, possibly to resolve a second conflict with a light aircraft which was above HZ-IBN and to the east of the aerodrome. Neither the microlight nor the light aircraft was equipped with TCAS. Following this climb, HZ-IBN then flew a curving base leg, descending at up to 3,000 feet per minute towards the threshold of Runway 25. The aircraft’s TCAS annunciated ‘clear of conflict’ when HZ-IBN was 1.1 nm from the runway threshold, at 1,200 ft aal, and at a speed of 146 KIAS, with the landing gear down and flap 3 selected. The aircraft continued its approach at approximately 150 KIAS. Between 1,200 and 500 ft aal the rate of descent averaged approximately 3,000 fpm, and at 500 ft aal the descent rate was 2,500 fpm. The aircraft’s TAWS generated six ‘pull up’ warnings on final approach. The aircraft crossed the Runway 25 threshold at approximately 50 ft aal at 151 KIAS. The aircraft manufacturer calculated that the appropriate target threshold speed for the aircraft’s mass and configuration was 108 KIAS. The AFISO initiated a full emergency as the aircraft touched down, because “it was clear at this time that the aircraft was not going to stop”. Tyre marks made by the aircraft at touchdown indicated that it landed 710 m beyond the Runway 25 threshold. The Runway 25 declared Landing Distance Available (LDA) was 1,059 m; therefore the aircraft touched down 349 m before the end of the declared LDA. The paved runway surface extended 89 m beyond the end of the LDA. The aircraft continued along the runway, decelerating, but departed the end of the paved surface at a groundspeed of 83 kt (84 KIAS airspeed) and struck an earth bank, which caused the aircraft to become airborne again. It then struck cars in a car park, part of a large commercial site adjacent to the aerodrome. The wing separated from the fuselage, and the fuselage rolled left through 350° before coming to rest on top of the detached wing, on a heading of 064°(M), 30° right side down and in an approximately level pitch attitude. A fire broke out in the underside of the aft fuselage and burned with increasing intensity. The aerodrome’s RFFS responded to the crash alarm but their path to the accident site was blocked by a locked gate between the aerodrome and commercial site. The first two RFFS vehicles arrived at the gate 1 minute and 34 seconds after the aircraft left the runway end. The third RFFS vehicle, which carried a key for the gate, arrived approximately one minute later, and the three RFFS vehicles proceeded through the gate 2 minutes and 46 seconds after the aircraft left the runway. As the aircraft was located in an area of the car park surrounded by a 2.4 m tall wire mesh fence, the RFFS vehicles had to drive approximately 400 m to gain access to the accident site. Despite applying all their available media, the RFFS was unable to bring the fire under control. The intensity of the fire meant that it was not possible to approach the aircraft to save life. All four occupants of the aircraft survived the impact and subsequently died from the effects of fire. Subsequently, local authority fire appliances arrived and the fire was extinguished.

The airline transport pilot was landing at the destination airport after a cross-country flight in visual meteorological conditions. The tower controller stated that the airplane's landing gear appeared to be extended during final approach and that the airplane landed within the runway's touchdown zone. The tower controller stated that, although the airplane made a normal landing, he heard a squealing noise that continued longer than what he believed was typical. The pilot subsequently transmitted "go-around." The tower controller acknowledged the go-around and cleared the pilot to enter a left traffic pattern. The tower controller stated that he heard the engine speed accelerate while the airplane maintained a level attitude over the runway until it passed midfield. He then saw the airplane pitch up and enter a climbing left turn. The tower controller stated that the airplane appeared to enter an aerodynamic stall before it descended into terrain in a left-wing-down attitude. Another witness reported that he saw the airplane, with its landing gear extended, in a steep left turn before it descended rapidly into terrain. A postaccident examination did not reveal any evidence of flight control, landing gear, or engine malfunction. An examination of the runway revealed numerous propeller slash marks that began about 215 ft past the runway's touchdown zone; however, there was no evidence that any portion of the airframe had impacted the runway during the landing. Additionally, measurement of the landing gear actuators confirmed that all three landing gear were fully extended at the accident site. Therefore, the pilot likely did not adequately control the airplane's pitch during the landing, which allowed the propeller to contact the runway. Due to the propeller strikes, the propeller was likely damaged and unable to provide adequate thrust during the go-around. Further, based on the witness accounts, the pilot likely did not maintain adequate airspeed during the climbing left turn, which resulted in the airplane exceeding its critical angle of attack and experiencing an aerodynamic stall at a low altitude.