Crash of a Dornier DO228-200 in Goma: 29 killed

Date & Time: Nov 24, 2019 at 0910 LT
Type of aircraft:
Operator:
Registration:
9S-GNH
Flight Phase:
Survivors:
No
Site:
Schedule:
Goma - Butembo
MSN:
8030
YOM:
1984
Location:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
17
Pax fatalities:
Other fatalities:
Total fatalities:
29
Circumstances:
The twin engine airplane departed runway 17 at Goma International Airport on a schedule service to Butembo (first service of the day). After takeoff, while in initial climb, the airplane lost height and crashed onto several houses located in the district of Birere, south of the airport, and burst into flames. All 19 occupants were killed as well as 10 people on the ground.

Crash of a Cessna 414A Chancellor in Colonia: 1 killed

Date & Time: Oct 29, 2019 at 1058 LT
Type of aircraft:
Registration:
N959MJ
Flight Type:
Survivors:
No
Site:
Schedule:
Leesburg - Linden
MSN:
414A-0471
YOM:
1980
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
7173
Captain / Total hours on type:
1384.00
Aircraft flight hours:
7712
Circumstances:
The pilot was conducting a GPS circling instrument approach in instrument meteorological conditions to an airport with which he was familiar. During the final minute of the flight, the airplane descended to and leveled off near the minimum descent altitude (MDA) of about 600 ft mean sea level (msl). During this time, the airplane’s groundspeed slowed from about 90 knots to a low of 65 knots. In the few seconds after reaching 65 knots groundspeed, the flight track abruptly turned left off course and the airplane rapidly descended. The final radar point was recorded at 200 ft msl less than 1/10 mile from the accident site. Two home surveillance cameras captured the final few seconds of the flight. The first showed the airplane in a shallow left bank that rapidly increased until the airplane descended in a steep left bank out of camera view below a line of trees. The second video captured the final 4 seconds of the flight; the airplane entered the camera view already in a steep left bank near treetop level, and continued to roll to the left, descending out of view. Both videos showed the airplane flying below an overcast cloud ceiling, and engine noise was audible until the sound of impact. Postaccident examination of the airplane revealed no evidence of preimpact mechanical malfunctions that would have precluded normal operation. The propeller signatures, witness impact marks, audio recordings, and witness statements were all consistent with the engines producing power at the time of impact. The pilot likely encountered restricted visibility of about 2 statute miles with mist and ceilings about 700 ft msl. When the airplane deviated from the final approach course and descended below the MDA, the destination airport remained 3.5 statute miles to the northeast. Although the airplane was observed to be flying below the overcast cloud layer, given the restricted visibility, it is likely that the pilot was unable to visually identify the airport or runway environment at any point during the approach. According to airplane flight manual supplements, the stall speed likely varied from 76 to 67 knots indicated airspeed. The exact weight and balance and configuration of the airplane could not be determined. Based upon surveillance video, witness accounts, and automatic dependent surveillance-broadcast data, it is likely that, as the pilot leveled off the airplane near the MDA, the airspeed decayed below the aerodynamic stall speed, and the airplane entered an aerodynamic stall and spin from which the pilot was unable to recover. Based on a readout of the pilot’s cardiac monitoring device and autopsy findings, while the pilot had a remote history of arrhythmia, sudden incapacitation was not a factor in this accident. Autopsy findings suggested that the pilot’s traumatic injuries were not immediately fatal; soot material in both the upper and lower airways provided evidence that the pilot inhaled smoke. This autopsy evidence supports that the pilot’s elevated carboxyhemoglobin level was from smoke inhalation during the postcrash fire. In addition, there were no distress calls received from the pilot and there was no evidence found that would indicate there was an in-flight fire. Thus, carbon monoxide exposure, as determined by the carboxyhemoglobin level, was not a contributing factor to the accident.
Probable cause:
The pilot’s failure to maintain airspeed during a circling instrument approach procedure, which resulted in an exceedance of the airplane’s critical angle of attack and an aerodynamic stall and spin.
Final Report:

Crash of a Piper PA-31-350 Navajo Chieftain in Popayán: 7 killed

Date & Time: Sep 15, 2019 at 1406 LT
Operator:
Registration:
HK-5229
Flight Phase:
Survivors:
Yes
Site:
Schedule:
Popayán - López de Micay
MSN:
31-7405212
YOM:
1974
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
7
Captain / Total flying hours:
3291
Captain / Total hours on type:
991.00
Copilot / Total flying hours:
300
Copilot / Total hours on type:
55
Aircraft flight hours:
12304
Circumstances:
The twin engine airplane departed Popayán-Guillermo León Valencia Airport runway 26 at 14:06:06. The aircraft encountered difficulties to gain sufficient height. About 20 seconds after liftoff, at a speed of 82 knots, the aircraft rolled to the right then entered an uncontrolled descent and crashed onto two houses located 530 metres past the runway end. Two passengers were seriously injured and seven other occupants were killed.
Probable cause:
A loss of in-flight control of the aircraft due to possible excess weight. The aircraft probably managed to take off due to "ground effect", but, once in the air and out of ground effect, it was not able to obtain the speed that would allow it to safely accomplish the climb.
Contributing Factors:
- Absence of Dispatch procedures of the operator to perform a correct Weight and Balance of the aircraft, and the effective control of the boarded cargo.
- Incorrect calculation of the weight and balance of the aircraft by the crew, by not considering all the cargo that was loaded, causing the aircraft to take off with a possible excess weight.
- Weak operational safety management processes of the operator by not considering the operating characteristics of airfields such as Popayán (high altitude, high ambient temperature) that significantly limit the operation.
Final Report:

Crash of a Beechcraft 350 Super King Air in Pansol: 9 killed

Date & Time: Sep 1, 2019 at 1510 LT
Operator:
Registration:
RP-C2296
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Dipolog - Manila
MSN:
FL-196
YOM:
1998
Location:
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
9
Circumstances:
The airplane encountered a loss of control in flight while approaching Manila and crashed into a private resort located in Barangay Pansol, Calamba, Laguna, Philippines. It lost radar contact with Manila Approach after being cleared to descent from 9,000 feet for 5,000 feet tracking-in radial 170, 25 DME to Ninoy Aquino International Airport (RPLL). The aircraft wreckage was found in a private resort with coordinates of 14°10’33.62” N and 121°11’34” E and heading approximately 228° with most its fuselage totally burned. All the nine (9) occupants were fatally injured and two (2) other persons on the ground sustained serious injuries. The aircraft took off from Dipolog Principal Airport (RPMG), Dipolog City, Zamboanga del Norte bound for Manila (RPLL) on a MEDEVAC flight. Instrument Metrological Condition (lMC) prevailed at the time of the accident.
Probable cause:
The aircraft experienced a loss of control in flight (LOC-I) after encountering adverse and hazardous atmospheric turbulent weather conditions which led to an inflight breakup.
The following contributing factors were identified:
- The presence of adverse and potentially hazardous atmospheric conditions on route of the flight.
- Failure of the flight crew to maintain situational awareness.
- Break-down of CRM to apply appropriate emergency procedures to recover the aircraft from the unusual situation they encountered.
Final Report:

Crash of a Cessna T303 Crusader in Lagrangeville: 2 killed

Date & Time: Aug 17, 2019 at 1613 LT
Type of aircraft:
Registration:
N303TL
Flight Phase:
Flight Type:
Survivors:
Yes
Site:
Schedule:
Sky Acres - Farmingdale
MSN:
303-00286
YOM:
1984
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
1586
Captain / Total hours on type:
358.00
Aircraft flight hours:
2932
Circumstances:
After flying one flight leg earlier in the day, the pilot flew to an intermediate stop on the way to his home base to purchase fuel. A surveillance video recording from the fueling airport showed the airplane land and taxi to the self-serve fuel pump where the engines were shut down for about 10 minutes while the airplane was fueled. The pilot then had difficulty starting both engines over several minutes. After the engines were running, the airplane taxied to the runway and did not appear to stop for an engine run-up. The pilot performed a rolling takeoff, and the airplane lifted off after a roll of about 2,100 ft, slightly more than half the available runway length. A passenger reported that after liftoff, at an altitude of about 50 to 100 ft above ground level (agl), both engines lost partial power and began “stuttering,” which continued for the remainder of the flight. He further reported that the engines did not stop, but they were “not producing full RPM.” The airplane drifted left of centerline, which a witness described as a left yawing motion. The pilot corrected the drift and flew the runway heading over the grass on the left side of the runway; however, the airplane would not climb. After crossing the end of the runway, the pilot pitched the airplane up to avoid obstacles. Automatic dependent surveillance-broadcast data indicated that the airplane climbed from about 20 to 120 ft agl in a gradual left turn. During this time the groundspeed decreased from about 80 knots to about 69 knots. The altitude then decreased to about 50 ft agl, the groundspeed decreased to about 66 knots, and the left turn decreased in radius until the recorded data ended about 100 ft west of the accident site. The airplane descended and
impacted a house. Witness descriptions of the airplane yawing to the left while over the runway and again during its final left turn suggest that the loss of engine power may not have been symmetric (that is, one engine may have suffered more of a loss than the other).
Probable cause:
A partial loss of engine power in both engines during initial climb for reasons that could not be determined based on the available information.
Final Report:

Crash of a Beechcraft 350i Super King Air in Islamabad: 19 killed

Date & Time: Jul 30, 2019 at 1400 LT
Operator:
Registration:
766
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Chaklala - Chaklala
MSN:
FL-766
YOM:
2011
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
19
Circumstances:
The twin engine airplane departed Chaklala-Nur Khan AFB with five crew members on board for a local training flight. In flight, it went out of control and crashed onto several houses located in the suburb of Mora Kalu, about 10 km south of Chaklala-Nur Khan AFB, Islamabad, bursting into flames. The aircraft and several houses were destroyed. All five crew members as well as 14 people on the ground were killed.

Crash of an Antonov AN-2 in Novoshchendrinskaya

Date & Time: Jul 16, 2019
Type of aircraft:
Operator:
Registration:
RA-3098K
Flight Phase:
Flight Type:
Survivors:
Yes
Site:
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The pilot, sole on board, was engaged in an aerial photography mission. In flight, he encountered engine problems and was forced to attempt an emergency landing. The aircraft crashed onto a barn located in Novoshchedrinskaya, about 15 km north of Gudermes. The pilot and three people in the barn were injured.

Crash of a Britten Norman BN-2B-27 Islander in Puerto Montt: 6 killed

Date & Time: Apr 16, 2019 at 1050 LT
Type of aircraft:
Registration:
CC-CYR
Flight Phase:
Survivors:
No
Site:
Schedule:
Puerto Montt - Ayacara
MSN:
2169
YOM:
1983
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
6
Captain / Total flying hours:
1414
Captain / Total hours on type:
437.00
Aircraft flight hours:
22330
Circumstances:
The twin engine airplane departed Puerto Montt-Marcel Marchant (La Paloma) Airport Runway 01 at 1050LT on a charter flight to Ayacara, carrying five passengers and one pilot. About 36 seconds after takeoff, while climbing, the pilot declared an emergency. The airplane entered a left turn then stalled and crashed onto a house located in a residential area, about 450 metres from the runway end, bursting into flames. The houses and the airplane were destroyed by a post crash fire and all six occupants were killed. One person in the house was injured.
Probable cause:
Loss of control of the airplane in flight, during a left turn, due to the failure of the right engine (n°2) during takeoff, caused by a fuel exhaustion.
The following contributing factors were identified:
- Failure of the pilot to comply with the pre takeoff checklist,
- Failure of the pilot to check the fuel selector switch and the fuel quantity prior to start the engines,
- Failure of the pilot to feather the propeller of the right engine (n°2) during an emergency situation,
- Failure of the pilot to bring the flaps to the neutral position during an emergency situation,
- Decrease of the speed and altitude of the airplane,
- Increase bank of the wing during a left turn.
Final Report:

Crash of a Piper PA-31-350 Navajo Chieftain in Madeira: 1 killed

Date & Time: Mar 12, 2019 at 1516 LT
Operator:
Registration:
N400JM
Flight Phase:
Survivors:
No
Site:
Schedule:
Cincinnati - Cincinnati
MSN:
31-8152002
YOM:
1981
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
6421
Captain / Total hours on type:
1364.00
Aircraft flight hours:
19094
Circumstances:
The commercial pilot was conducting an aerial observation (surveying) flight in a piston engineequipped multiengine airplane. Several hours into the flight, the pilot advised air traffic control (ATC) that the airplane had a fuel problem and that he needed to return to the departure airport. When the airplane was 8 miles from the airport, and after passing several other airports, the pilot informed ATC that he was unsure if the airplane could reach the airport. The final minutes of radar data depicted the airplane in a descent and tracking toward a golf fairway as the airplane's groundspeed decreased to a speed near the single engine minimum control airspeed. According to witnesses, they heard an engine sputter before making two loud "back-fire" sounds. One witness reported that, after the engine sputtered, the airplane "was on its left side flying crooked." Additional witnesses reported that the airplane turned to the left before it "nose-dived" into a neighborhood, impacting a tree and private residence before coming to rest in the backyard of the residence. A witness approached the wreckage immediately after the accident and observed a small flame rising from the area of the left engine. Video recorded on the witness' mobile phone several minutes later showed the airplane engulfed in flames. Examination of the wreckage revealed no evidence of any preimpact mechanical malfunctions or failures of either engine. The fuel systems feeding both engines were damaged by impact forces but the examined components generally displayed that only trace amounts of fuel remained; with the exception of the left engine nacelle fuel tank. Given the extent of the fire damage to this area of the wreckage, and the witness report that the post impact fire originated in this area, it is likely that this tank contained fuel. By design, this fuel in this tank was not able to supply fuel directly to either engine, but instead relied on an electric pump to transfer fuel into the left main fuel tank. Fire damage precluded a detailed postaccident examination or functional testing of the left nacelle fuel transfer pump. Other pilots who flew similar airplanes for the operator, along with a review of maintenance records for those airplanes, revealed at least three instances of these pumps failing in the months surrounding the accident. The other pilots also reported varying methods of utilizing fuel and monitoring fuel transfers of fuel from the nacelle fuel tanks, since there was no direct indication of the quantity of fuel available in the tank. These methods were not standardized between pilots within the company and relied on their monitoring the quantity of fuel in the main fuel tanks in order to ensure that the fuel transfer was occurring. Had the pilot not activated this pump, or had this pump failed during the flight, it would have rendered the fuel in the tank inaccessible. Given this information it is likely that the fuel supply available to the airplane's left engine was exhausted, and that the engine subsequently lost power due to fuel starvation. The accident pilot, along with another company pilot, identified fuel leaking from the airplane's left wing, about a week before the accident. Maintenance records showed no actions had been completed to the address the fuel leak. Due to damage sustained during the accident, the origin of the fuel leak could not be determined, nor could it be determined whether the fuel leak contributed to the fuel starvation and eventual inflight loss of power to the left engine. Because the left engine stopped producing power, the pilot would have needed to configure the airplane for single-engine flight; however, examination of the left engine's propeller found that it was not feathered. With the propeller in this state, the pilot's ability to maintain control the airplane would have been reduced, and it is likely that the pilot allowed the airplane's airspeed to decrease below the singleengine minimum controllable airspeed, which resulted in a loss of control and led to the airplane's roll to the left and rapid descent toward the terrain. Toxicology results revealed that the pilot had taken doxylamine, an over-the-counter antihistamine that can decrease alertness and impair performance of potentially hazardous tasks. Although the toxicology results indicated that the amount of doxylamine in the pilot's cavity blood was within the lower therapeutic range, review of ATC records revealed that the pilot was alert and that he was making necessary decisions and following instructions. Thus, the pilot's use of doxylamine was not likely a factor in the accident.
Probable cause:
Fuel starvation to the left engine and the resulting loss of engine power to that engine, and a loss of airplane control due to the pilot's failure to maintain the minimum controllable airspeed.
Final Report:

Crash of a Cessna 414A Chancellor in Yorba Linda: 5 killed

Date & Time: Feb 3, 2019 at 1345 LT
Type of aircraft:
Operator:
Registration:
N414RS
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Fullerton – Minden
MSN:
414A-0821
YOM:
1981
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
10235
Aircraft flight hours:
9610
Circumstances:
The commercial pilot departed for a cross-country, personal flight with no flight plan filed. No evidence was found that the pilot received a preflight weather briefing; therefore, it could not be determined if he checked or received any weather information before or during the accident flight. Visual meteorological conditions existed at the departure airport; however, during the departure climb, the weather transitioned to instrument meteorological conditions (IMC) with precipitation, microburst, and rain showers over the accident area. During the takeoff clearance, the air traffic controller cautioned the pilot about deteriorating weather conditions about 4 miles east of the airport. Radar data showed that, about 5 1/2 minutes after takeoff, the airplane had climbed to about 7,800 ft above ground level before it started a rapid descending right turn and subsequently impacted the ground about 9.6 miles east of the departure airport. Recorded data from the airplane’s Appareo Stratus 2S (portable ADS-B receiver and attitude heading and reference system) revealed that, during the last 15 seconds of the flight, the airplane’s attitude changed erratically with the pitch angle fluctuating between 45° nose-down and 75°nose-up, and the bank angle fluctuating between 170° left and 150° right while descending from 5,500 to 500 ft above ground level, indicative of a loss of airplane control shortly after the airplane entered the clouds. Several witnesses located near the accident site reported seeing the airplane exit the clouds at a high descent rate, followed by airplane parts breaking off. One witness reported that he saw the airplane exit the overcast cloud layer with a nose down pitch of about 60°and remain in that attitude for about 4 to 5 seconds “before initiating a high-speed dive recovery,” at the bottom of which, the airplane began to roll right as the left horizontal stabilizer separated from the airplane, immediately followed by the remaining empennage. He added that the left wing then appeared to shear off near the left engine, followed by the wing igniting. An outdoor home security camera, located about 0.5 mile north-northwest of the accident location, captured the airplane exiting the clouds trailing black smoke and then igniting. Examination of the debris field, airplane component damage patterns, and the fracture surfaces of separated parts revealed that both wings and the one-piece horizontal stabilizer and elevators were separated from the empennage in flight due to overstress, which resulted from excessive air loads. Although the airplane was equipped with an autopilot, the erratic variations in heading and altitude during the last 15 seconds of the flight indicated that the pilot was likely hand-flying the airplane; therefore, he likely induced the excessive air loads while attempting to regain airplane control. Conditions conducive to the development of spatial orientation existed around the time of the in-flight breakup, including restricted visibility and the flight entering IMC. The flight track data was consistent with the known effects of spatial disorientation and a resultant loss of airplane control. Therefore, the pilot likely lost airplane control after inadvertently entering IMC due to spatial disorientation, which resulted in the exceedance of the airplane’s design stress limits and subsequent in-flight breakup. Contributing to accident was the pilot’s improper decision to conduct the flight under visual flight rules despite encountering IMC and continuing the flight when the conditions deteriorated. Toxicology testing on specimens from the pilot detected the presence of delta-9-tetrahydrocanninol (THC) in heart blood, which indicated that the pilot had used marijuana at some point before the flight. Although there is no direct relationship between postmortem blood levels and antemortem effects from THC, it does undergo postmortem redistribution. Therefore, the antemortem THC level was likely lower than detected postmortem level due to postmortem redistribution from use of marijuana days previously, and it is unlikely that the pilot’s use of marijuana contributed to his poor decision-making the day of the accident. The toxicology testing also detected 67 ng/mL of the sedating antihistamine diphenhydramine. Generally, diphenhydramine is expected to cause sedating effects between 25 to 1,120 ng/mL. However, diphenhydramine undergoes postmortem redistribution, and the postmortem heart blood level may increase by about three times. Therefore, the antemortem level of diphenhydramine was likely at or below the lowest level expected to cause significant effects, and thus it is unlikely that the pilot’s use of diphenhydramine contributed to the accident.
Probable cause:
The pilot’s failure to maintain airplane control after entering instrument meteorological conditions (IMC) while climbing due to spatial disorientation, which resulted in the exceedance of the airplane’s design stress limits and subsequent in-flight break-up. Contributing to accident was the pilot's improper decision to conduct the flight under visual flight rules and to continue the flight when conditions deteriorated.
Final Report: