Crash of a Beechcraft B200 Super King Air in Melbourne: 5 killed

Date & Time: Feb 21, 2017 at 0858 LT
Registration:
VH-ZCR
Flight Phase:
Survivors:
No
Site:
Schedule:
Melbourne - King Island
MSN:
BB-1544
YOM:
1996
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
7681
Captain / Total hours on type:
2400.00
Aircraft flight hours:
6997
Circumstances:
On 21 February 2017, the pilot of a Beechcraft B200 King Air aircraft, registered VH-ZCR (ZCR), and operated by Corporate & Leisure Aviation, was conducting a charter passenger flight from Essendon Airport, Victoria to King Island, Tasmania. There were four passengers on board. ZCR had been removed from a hangar and parked on the apron the previous afternoon in preparation for the flight. The pilot was first seen on the apron at about 0706 Eastern Daylight-saving Time. Closed-circuit television recorded the pilot walking around the aircraft and entering the cabin, consistent with conducting a pre-flight inspection of the aircraft. At about 0712, the pilot entered ZCR’s maintenance provider’s hangar. A member of staff working in the hangar reported that the pilot had a conversation with him that was unrelated to the accident flight. The pilot exited the hangar about 0715 and had a conversation with another member of staff who reported that their conversation was also unrelated to the accident flight. The pilot then returned to ZCR, and over the next 4 minutes he was observed walking around the aircraft. The pilot went into the cabin and re-appeared with an undistinguishable item. The pilot then walked around the aircraft one more time before re-entering the cabin and closing the air stair cabin door. At about 0729, the right engine was started and, shortly after, the left engine was started. Airservices Australia (Airservices) audio recordings indicated that, at 0736, the pilot requested a clearance from Essendon air traffic control (ATC) to reposition ZCR to the southern end of the passenger terminal. ATC provided the clearance and the pilot commenced taxiing to the terminal. At the terminal, ZCR was refueled and the pilot was observed on CCTV to walk around the aircraft, stopping at the left and right engines before entering the cabin. The pilot was then observed to leave the aircraft and wait for the passengers at the terminal. The passengers arrived at the terminal at 0841 and were escorted by the pilot directly to the aircraft. At 0849, the left engine was started and, shortly after, the right engine was started. At 0853, the pilot requested a taxi clearance for King Island, with five persons onboard, under the instrument flight rules. ATC instructed the pilot to taxi to holding point 'TANGO' for runway 17, and provided an airways clearance for the aircraft to King Island with a visual departure. The pilot read back the clearance. Airservices Automatic Dependent Surveillance Broadcast (ADS-B) data (refer to section titled Air traffic services information - Automatic Dependent Surveillance Broadcast data) indicated that, at 0854, ZCR was taxied from the terminal directly to the holding point. The aircraft did not enter the designated engine run-up bay positioned near holding point TANGO. At 0855, while holding at TANGO, the pilot requested a transponder code. The controller replied that he did not have one to issue yet. Two minutes later the pilot contacted ATC and stated that he was ready and waiting for a transponder code. The controller responded with the transponder code and a clearance to lineup on runway 17. At 0858, ATC cleared ZCR for take-off on runway 17 with departure instructions to turn right onto a heading of 200°. The pilot read back the instruction and commenced the takeoff roll. The aircraft’s take-off roll along runway 17 was longer than expected. Witnesses familiar with the aircraft type observed a noticeable yaw to the left after the aircraft became airborne. The aircraft entered a relatively shallow climb and the landing gear remained down. The shallow climb was followed by a substantial left sideslip, while maintaining a roll attitude of less than 10° to the left. Airservices ADS-B data indicated the aircraft reached a maximum height of approximately 160 ft above ground level while tracking in an arc to the left of the runway centreline. The aircraft’s track began diverging to the left of the runway centreline before rotation and the divergence increased as the flight progressed. Following the sustained left sideslip, the aircraft began to descend and at 0858:48 the pilot transmitted on the Essendon Tower frequency repeating the word ‘MAYDAY’ seven times in rapid succession. Approximately 10 seconds after the aircraft became airborne, and 2 seconds after the transmission was completed, the aircraft collided with the roof of a building in the Essendon Airport Bulla Road Precinct - Retail Outlet Centre (outlet centre), coming to rest in a loading area at the rear of the building. CCTV footage from a camera positioned at the rear of the building showed the final part of the accident sequence with post-impact fire evident; about 2 minutes later, first responders arrived onsite. At about 0905 and 0908 respectively, Victoria Police and the Metropolitan Fire Brigade arrived. The pilot and passengers were fatally injured and the aircraft was destroyed. There was significant structural, fire and water damage to the building. Additionally, two people on the ground received minor injuries and a number of parked vehicles were damaged.
Probable cause:
From the evidence available, the following findings are made with respect to the collision with terrain involving Beechcraft B200 King Air, registered VH-ZCR that occurred at Essendon Airport, Victoria on 21 February 2017. These findings should not be read as apportioning blame or liability to any particular organisation or individual.

Contributing factors:
- The aircraft's rudder trim was likely in the full nose-left position at the commencement of the take-off.
- The aircraft's full nose-left rudder trim setting was not detected by the pilot prior to take-off.
- Following a longer than expected ground roll, the pilot took-off with full left rudder trim selected. This configuration adversely affected the aircraft's climb performance and controllability, resulting in a collision with terrain.

Other factors that increased risk:
- The flight check system approval process did not identify that the incorrect checklist was nominated in the operator’s procedures manual and it did not ensure the required checks, related to the use of the cockpit voice recorder, were incorporated.
- The aircraft's cockpit voice recorder did not record the accident flight, resulting in a valuable source of safety related information not being available.
- The aircraft's maximum take-off weight was likely exceeded by about 240 kilograms.
- Two of the four buildings within the Bulla Road Precinct Retail Outlet Centre exceeded the obstacle limitation surface (OLS) for Essendon Airport, however, the OLS for the departure runway was not infringed and VH-ZCR did not collide with those buildings.

Other findings:
- The presence of the building struck by the aircraft was unlikely to have increased the severity of the outcome of this accident.
- Both of the aircraft’s engines were likely to have been producing high power at impact.
Final Report:

Crash of a Boeing 747-412F in Bishkek: 39 killed

Date & Time: Jan 16, 2017 at 0719 LT
Type of aircraft:
Operator:
Registration:
TC-MCL
Flight Type:
Survivors:
No
Site:
Schedule:
Hong Kong - Bishkek - Istanbul
MSN:
32897/1322
YOM:
2003
Flight number:
TK6491
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
39
Captain / Total flying hours:
10808
Captain / Total hours on type:
820.00
Copilot / Total flying hours:
5894
Copilot / Total hours on type:
1758
Aircraft flight hours:
46820
Aircraft flight cycles:
8308
Circumstances:
On 16.01.2017, the crew of the Boeing 747-412F TC-MCL aircraft was performing a THY6491 flight from Hong Kong via Bishkek (Manas Airport) to Istanbul (Ataturk Airport) in order to transport the commercial cargo (public consumer goods) of 85 618 kg. The cargo was planned to be offloaded in Istanbul (Ataturk Airport). Manas Airport was planned as a transit airport for crew change and refueling. From 12.01.2017 to 15.01.2017, the crew had a rest period of 69 h in a hotel in Hong Kong. The aircraft takeoff from the Hong Kong Airport was performed at 19:12 on 5.01.2017, with the delay of 2 h 02 min in respect to the planned takeoff time. During the takeoff, the climb and the on-route cruise flight, the aircraft systems operated normally. At 00:41, on 16.01.2017, the aircraft entered the Bishkek ATC Area Control Center over the reference point of KAMUD at flight level of 10 400 m (according to the separation system, established in the People's Republic of China). At 00:51, the crew requested a descent and reached the FL 220 (according to the separation system, established in the Kyrgyz Republic). At 00:59, the crew received the weather information for Manas Airport: "the RVR at the RWY threshold 400 m, the RWY midpoint and RWY end 300 m, the vertical visibility 130 ft". At 01:01, the crew received the specified data: " in the center of the runway RVR three zero zero meters, vertical visibility one five zero feet." At 01:03, the crew requested a descent, the controller cleared for the descent not below FL 180. At 01:05, the crew was handed over to the Approach Control. At 01:06, the crew was cleared for the descent to FL 60, TOKPA 1 ILS approach chart, RWY 26. At 01:10, the controller reported the weather: wind calm, visibility 50 m, RVR 300 m, freezing fog, vertical visibility 160 ft, and requested the crew if they would continue the approach. The crew reported that they would continue the approach. The crew conducted the approach to RWY 26 in accordance with the standard approach chart. At 01:11, the controller informed the crew: "… transition level six zero" and cleared them for the ILS approach to RWY 26. At 01:15, the crew contacted the Tower controller. The Tower controller cleared them for landing on RWY 26 and reported the weather: "…wind calm… RVR in the beginning of the runway four hundred meters, in the middle point three hundred two five meters and at the end of the runway four hundred meters and vertical visibility one six zero... feet". The aircraft approached the RWY 26 threshold at the height significantly higher than the planned height. Continuing to descend, the aircraft flew over the entire length of the RWY and touched the ground at the distance of 900 m away from the farthest end of the runway (in relation to the direction of the approach) (the RWY 08 threshold). After the touchdown and landing roll, the aircraft impacted the concrete aerodrome barrier and the buildings of the suburban settlement and started to disintegrate, the fuel spillage occurred. As a result of the impact with the ground surface and the obstacles, the aircraft was completely disintegrated, a significant part of the aircraft structure was destroyed by the post-crash ground fire. At 01.17 UTC, the Tower controller requested the aircraft position, but the crew did not respond.
Probable cause:
The cause of the Boeing 747-412F TC-MCL aircraft accident was the missing control of the crew over the aircraft position in relation to the glideslope during the automatic approach, conducted at night in the weather conditions, suitable for ICAO CAT II landing, and as a result, the measures to perform a go-around, not taken in due time with the aircraft, having a significant deviation from the established approach chart, which led to the controlled flight impact with terrain (CFIT) at the distance of ≈930 m beyond the end of the active RWY.
The contributing factors were, most probably, the following:
- the insufficient pre-flight briefing of the flight crew members for the flight to Manas aerodrome (Bishkek), regarding the approach charts, as well as the non-optimal decisions taken by the crew when choosing the aircraft descent parameters, which led to the arrival at the established approach chart reference point at a considerably higher flight altitude;
- the lack of the crew's effective measures to decrease the aircraft vertical position and its arrival at the established approach chart reference point while the crew members were aware of the actual aircraft position being higher than required by the established chart;
- the lack of the requirements in the Tower controllers' job instructions to monitor for considerable aircraft position deviations from the established charts while the pertinent technical equipment for such monitoring was available;
- the excessive psycho-emotional stress of the crew members caused by the complicated approach conditions (night time, CAT II landing, long-lasting working hours) and their failure to eliminate the flight altitude deviations during a long time period. Additionally, the stress level could have been increased due to the crew's (especially the PIC's) highly emotional discussion of the ATC controllers' instructions and actions. Moreover, the ATC controllers' instructions and actions were in compliance with the established operational procedures and charts;
- the lack of the crew members' monitoring for crossing the established navigational reference points (the glideslope capture point, the LOM and LIM reporting points);
- the crew's failure to conduct the standard operational procedure which calls for altitude verification at the FAF/FAP, which is stated in the FCOM and the airline's OM. On the other hand, the Jeppesen Route Manual, used by the crew, contains no FAF/FAP in the RWY 26 approach chart;
- the onboard systems' "capture" of the false glideslope beam with the angle of ≈9°;
- the design features of the Boeing 747-400 aircraft type regarding the continuation of the aircraft approach descent in the automatic mode with the constant descent angle of 3° (the inertial path) with the maintained green indication of the armed automatic landing mode (regardless of the actual aircraft position in relation to the RWY) while the aircraft systems detected that the glideslope signal was missing (after the glideslope signal "capture"). With that, the crew received the designed annunciation, including the aural and visual caution alerts;
- the absence of the red warning alert for the flight crew in case of a "false" glideslope capture and the transition to the inertial mode trajectory, which would require immediate control actions from the part of the crew;
- the lack of monitoring from the part of the crew over the aircraft position in regard to the approach chart, including the monitoring by means of the Navigation Display (ND), engaged in the MAP mode;
- the crew's failure to conduct the Airline's Standard Operational Procedures (SOPs), regarding the performance of the go-around procedure in case the "AUTOPILOT" (the AP switching to the inertial mode) and "GLIDESLOPE" (the EGPWS annunciation of the significant glideslope deviation) alerts during the automatic CAT II landing at true heights below 1000 ft (with no visual reference established with either the runway environment or with the lighting system);
- the delayed actions for initiating the go-around procedure with no visual reference established with the runway environment at the decision height (DH). In fact, the actions were initiated at the true height of 58 ft with the established minimum of 99 ft.
Final Report:

Crash of an Epic LT in Port Orange: 2 killed

Date & Time: Dec 27, 2016 at 1756 LT
Type of aircraft:
Registration:
N669WR
Flight Type:
Survivors:
No
Site:
Schedule:
Millington – Port Orange
MSN:
029
YOM:
2009
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
4246
Captain / Total hours on type:
956.00
Aircraft flight hours:
822
Circumstances:
The private pilot obtained a full weather briefing before departing on a long cross-country flight. The destination airport was forecast to be under visual meteorological conditions, but there was an AIRMET and Center Weather Advisory (CWA) issued for low instrument flight rules (IFR) conditions later that day. The briefer told the pilot to check the weather again en route to see if the AIRMET and CWA had been updated. At the time the pilot stopped for fuel, another CWA was issued for low IFR conditions at his destination airport; however, there were no records to indicate that the pilot obtained this information during the fuel stop or after departing on the last leg of the flight. A review of air traffic control communications revealed that, about 10 minutes before arriving at the airport, the pilot reported that he had obtained the current weather conditions at his destination airport. The most recent observation, about 1 hour before the accident indicated good visibility; however, the weather reporting equipment did not provide ceiling heights. It is unknown if the pilot obtained weather information from nearby airports, which were reporting low instrument meteorological conditions (visibility between 1/4 and 1/2 mile and ceilings 200-300 ft above ground level [agl]). Additionally, three pilot reports (PIREPs) describing the poor weather conditions were filed within the hour before the accident. The controller did not relay the PIREPs or the CWA information to the pilot, so the pilot was likely unaware of the deteriorating conditions. Based on radar information and statements from witnesses, the pilot's approach to the airport was unstabilized. He descended below the minimum descent altitude of 440 ft, and, after breaking through the fog about 100 ft agl, the airplane reentered the fog and completed a 360° right turn near the approach end of the runway, during which its altitude varied from 100 ft to 300 ft. The airplane then climbed to an altitude about 800 ft before radar contact was lost near the accident site. The airplane came to rest inverted, consistent with one witness's statement that it descended through the clouds in a spin before impact; post accident examination revealed no preimpact anomalies with the airplane or engine that would have precluded normal operation. Although the pilot was instrument rated, his recent instrument experience could not be established. The circumstances of the accident, including the restricted visibility conditions and the pilot's maneuvering of the airplane before the impact, are consistent with a spatial disorientation event. It is likely that the pilot experienced a loss of control due to spatial disorientation, which resulted in an aerodynamic stall and spin.
Probable cause:
The pilot's loss of airplane control due to spatial disorientation, which resulted in the exceedance of the airplane's critical angle of attack and an aerodynamic stall/spin. Contributing to the accident was the pilot's failure to fly a stabilized approach consistent with the published instrument approach procedure.
Final Report:

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

Date & Time: Aug 1, 2016 at 1605 LT
Operator:
Registration:
HS-FGB
Survivors:
Yes
Site:
Schedule:
Nakhon Ratchasima – Bangkok
MSN:
31-7652156
YOM:
1976
Flight number:
TRB106
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
While descending to Bangkok-Suvarnabhumi Airport, the twin engine aircraft crashed in unknown circumstances in a swamp and came to rest against a wood bridge. The wreckage was found about 15 km from the airport, along the borders of Nong Chok and Min Buri districts. The captain was killed while three other occupants were injured.

Crash of an Embraer EMB-820C Navajo in Londrina: 8 killed

Date & Time: Jul 31, 2016 at 2057 LT
Operator:
Registration:
PT-EFQ
Flight Type:
Survivors:
No
Site:
Schedule:
Cuiabá – Londrina
MSN:
820-030
YOM:
1976
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
8
Captain / Total flying hours:
2833
Copilot / Total flying hours:
1567
Aircraft flight hours:
3674
Circumstances:
Owned by Fenatracoop (Federação Nacional dos Trabalhadores Celestitas nas Cooperativas no Brasil), the twin engine aircraft departed Cuiabá-Marechal Rondon Airport on a flight to Londrina, carrying two pilots and six passengers, three adults and three children. On final approach to Londrina-Governador José Richa Runway 13, the pilot informed ATC about a loss of power on the left engine. Shortly later, control was lost and the aircraft crashed on a hangar housing six tanker trucks and located 9,2 km short of runway. Several explosions occurred and the aircraft and the hangar were totally destroyed. All eight occupants were killed but there were no injuries on the ground.
Probable cause:
Contributing factors.
- Communication – undetermined
It is possible that difficulties for the dialogue between pilots on matters related to the operation of the aircraft have favored a prejudicial scenario to the expression of assertiveness in the communication in the cabin, interfering in the effective management of the presented abnormal condition.
- Team dynamics – undetermined
It is possible that a more passive posture of the copilot combined with the commander's decisions and actions from the presentation of the abnormal condition in flight interfered with the quality of the team's integration and in the efficiency of the cabin dynamics during the occurrence, bringing losses to the emergency management presented.
- Emotional state – undetermined
It is not possible to discard the hypothesis that a more anxious emotional state of the pilots contributed to an inaccurate evaluation of the operational context experienced, favoring ineffective judgments, decisions and actions to manage the abnormal condition presented.
- Aircraft maintenance – a contributor
On the right engine, it was found that the fuel tube fixing nut that left the distributor for No. 3 cylinder was loose, favoring the fuel leakage, as well as the bypass valve clamp of the turbocharger that was bad adjusted, providing leakage of gases from the exhaust that would be directed to the compressor and, later to the engine, to equalize its power. On the left engine, impurity composed of an agglomerate of soil and fuel were found on the side of the nozzles n° 2, 4 and 6, which migrated to the inside of these nozzles, causing them to become clogged. It was not possible to determine the origin of this material, but there is a possibility that it may have been deposited during the long period the aircraft spent in the maintenance shop, undergoing general overhaul and the revitalization of its interior (13DEC2012 until 29APR2016).
- Insufficient pilot’s experience – undetermined
The pilots had little experience with the GARMIN GTN 650 navigation system. The lack of familiarity with this equipment may have favored the misidentification of the approach fixes for Londrina. This way, it is possible that they have calculated their descent to the final approach fix (waypoint LO013), believing that it was the position relative to threshold 13 (waypoint RWY13).
- Decision-making process – undetermined
The decision to take off from Cuiabá to Londrina without the identification of the reason for the warning light to be ON in the alarm panel and the possible late declaration of the emergency condition showed little adequate decisions that may have increased the level of criticality of the occurrence.
- Support systems – undetermined
The similarity of the waypoints names in the RNAV procedure, associated with the lack of familiarity of the pilots with the new navigation system installed in the aircraft, may have confused the pilots as to their real position in relation to the runway.
Final Report:

Crash of a Comp Air CA-9 in Campo de Marte: 7 killed

Date & Time: Mar 19, 2016 at 1523 LT
Type of aircraft:
Operator:
Registration:
PR-ZRA
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Campo de Marte – Rio de Janeiro
MSN:
0420109T01
YOM:
2012
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
7
Captain / Total flying hours:
215
Circumstances:
Shortly after takeoff from Campo de Marte Airport runway 30, the single engine airplane entered a right turn without gaining altitude. Less than one minute after liftoff, the aircraft impacted a building located in the Frei Machado Street, some 370 metres from runway 12 threshold. The aircraft was totally destroyed by impact forces and a post crash fire and all seven occupants were killed. One people on the ground was slightly injured. Owned by the Brazilian businessman Roger Agnelli, the aircraft was on its way to Santos Dumont Airport in Rio de Janeiro. Among the victims was Roger Agnelli, his wife Andrea, his both children John and Anna Carolina, the pilot and two other friends. They were enroute to Rio to take part to the wedding of the nephew of Mr. Agnelli.
Probable cause:
Contributing factors
- Pilot judgment - undetermined
The absence of manuals and performance charts to guide the operation and actions based only on empirical knowledge about the aircraft may have taken to an inadequate evaluation of certain parameters related to its operation. In this case, the performance of the aircraft under conditions of weight, altitude and high temperatures may have provided its conduction with reduced margins of safety during takeoff that resulted in the on-screen accident.
- Flight planning - undetermined
The informality present in the field of experimental aviation, associated with the absence of support systems, may have resulted in an inadequacy in the work of flight preparation, particularly with regard to performance degradation in the face of adverse conditions (high weight, altitude and temperature), compromising the quality of the planning carried out, thus contributing to it being carried out a takeoff under marginal conditions.
- Project - undetermined
During the PR-ZRA assembly process, changes were incorporated into the Kit's original design that directly affected the airplane's take-off performance. Since the submission of documentation related to in-flight testing or performance graphics was not required by applicable law, it is possible that the experimental nature of the project has enabled the operation of the aircraft based on
empirical parameters and inadequate to their real capabilities.
- Support systems - undetermined
The absence of a support system, in the form of publications that allowed obtaining equipment performance data in order to carry out proper planning, added risk to operations and may have led to an attempt to take off under unsafe conditions.
Final Report:

Crash of a Beechcraft 200 Super King Air in New Delhi: 10 killed

Date & Time: Dec 22, 2015 at 0938 LT
Operator:
Registration:
VT-BSA
Flight Phase:
Survivors:
No
Site:
Schedule:
New Delhi - Ranchi
MSN:
BB-1485
YOM:
1994
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
10
Captain / Total flying hours:
964
Captain / Total hours on type:
764.00
Copilot / Total flying hours:
891
Copilot / Total hours on type:
691
Aircraft flight hours:
4766
Aircraft flight cycles:
2745
Circumstances:
Beechcraft Super King Air B-200 aircraft, VT-BSA belonging to BSF Air Wing was involved in an accident on 22.12.2015 while operating a flight from IGI Airport, New Delhi to Ranchi. The flight was under the command of a CPL holder with another CPL holder as Second-in-Command. There were ten persons on board including two flight crew members. As per the scheduling procedure of the Operator, the flying programme for 22.12.2015 was approved by the ADG (Logistics) on the recommendation of the DIG (Air) for VT-BSA on 21.12.2015. The programme included names of the flight crew along with the following sectors: from Delhi to Ranchi ETD 0800 ETA 1030 and from Ranchi to Delhi ETD 1300 ETA 1600. The task was as per instructions on the subject dated 23rd July 2015. As per the weight & load data sheet there were 8 passengers with 20 Kgs. of baggage in the aft cabin compartment. The actual take-off weight shown was 5668.85 Kgs as against the maximum take-off weight of 5669.9 Kgs. Fuel uplifted was 1085 Kgs. The aircraft was taken out of hangar of the Operator at 0655 hrs on 22.12.2015 and parked outside the hangar for operating the subject flight. At around 0745 hrs, the passengers reached the aircraft who were mainly technical personnel supposed to carry out scheduled maintenance of Mi-17 helicopter of the Operator at Ranchi. They were carrying their personnel baggage along with tools and equipment required for the maintenance. At around 0915 hrs the flight crew contacted ATC Delhi and requested for clearance to operate the flight to Ranchi. The aircraft was cleared to Ranchi via R460 and FL210. Runway in use was given as 28. At 0918 hrs the doors were closed and the flight crew had started carrying out the check list. After the ATC issued taxi clearance, the aircraft had stopped for some time after commencing taxiing. The pilot informed the ATC that they will take 10 minutes delay for further taxi due to some administrative reasons. The taxi clearance was accordingly cancelled. After a halt of about 6 to 7 minutes, the pilot again requested the ATC for taxi clearance and the same was approved by the ATC. Thereafter, the aircraft was given take-off clearance from runway 28. The weather at the time of take-off was: Visibility 800 meters with Winds at 100°/03 knots. Shortly after take-off and attaining a height of approximately 400 feet AGL, the aircraft progressively turned left with simultaneous loss of height. It had taken a turn of approximately 180o and impacted some trees before hitting the outside perimeter road of the airport in a left bank attitude. Thereafter, it impacted 'head on' with the outside boundary wall of the airport. After breaking the outside boundary wall, the wings impacted two trees and the aircraft hit the holding tank of the water treatment plant. The tail portion and part of the fuselage overturned and went into the water tank. There was post impact fire and the portion of the aircraft outside the water tank was destroyed by fire. All passengers and crew received fatal injuries due impact and fire. The ELT was operated at 0410 hours UTC (0940 hours IST). The fire fighting team reached the site and extinguished the fire. The bodies were then recovered from the accident site. 08 bodies were recovered from the holding tank of the water treatment plant and bodies of both pilots were recovered from the heavily burnt portion of the cockpit lying adjacent (outside) to the wall of the holding tank of the water treatment tank.
Probable cause:
The accident was caused due to engagement of the autopilot without selecting the heading mode by the flight crew just after liftoff (before attaining sufficient height) in poor foggy conditions and not taking corrective action to control the progressive increase in left bank; thereby, allowing the aircraft to traverse 180° turn causing the aircraft to lose height in a steep left bank attitude followed by impact with the terrain.
Final Report:

Crash of a Piper PA-31-310 in Guatemala City

Date & Time: Nov 21, 2015 at 1240 LT
Type of aircraft:
Registration:
C6-TAK
Flight Phase:
Flight Type:
Survivors:
Yes
Site:
Schedule:
Guatemala City - Guatemala City
MSN:
31-228
YOM:
1968
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
191
Copilot / Total flying hours:
4735
Aircraft flight hours:
7600
Circumstances:
The crew departed Guatemala City-La Aurora Airport on a local training flight. Shortly after takeoff from runway 02, while in initial climb, the aircraft entered a right turn then lost height and crashed near an industrial building located about 900 metres from the runway 20 threshold. The aircraft was destroyed by impact forces and a post crash fire. Both pilots escaped uninjured.
Probable cause:
The aircraft stalled at low height after takeoff due to a poor crew coordination about flight controls.
Final Report:

Crash of a Cessna 402B in Acandí: 2 killed

Date & Time: Nov 17, 2015 at 1054 LT
Type of aircraft:
Operator:
Registration:
HK-4981G
Flight Phase:
Survivors:
Yes
Site:
Schedule:
Acandí – Medellín
MSN:
402B-1042
YOM:
1976
Location:
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
Shortly after takeoff from Acandí-Alcides Fernandez Airport, while in initial climb, the twin engine aircraft stalled and crashed in a house located in the district of Miramar, near the airport. The pilot and a passenger were killed and eight other occupants were injured. There were no victims on the ground and the aircraft was destroyed.
Probable cause:
Stall during initial climb due to the combination of the following factors:
- The total weight of the aircraft was above the MTOW,
- The CofG was outside the enveloppe,
- Poor flight planning.

Crash of a BAe 125-700A in Akron: 9 killed

Date & Time: Nov 10, 2015 at 1453 LT
Type of aircraft:
Operator:
Registration:
N237WR
Survivors:
No
Site:
Schedule:
Dayton – Akron
MSN:
257072
YOM:
1979
Flight number:
EFT1526
Crew on board:
2
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
9
Captain / Total flying hours:
6170
Captain / Total hours on type:
1020.00
Copilot / Total flying hours:
4382
Copilot / Total hours on type:
482
Aircraft flight hours:
14948
Aircraft flight cycles:
11075
Circumstances:
The aircraft departed controlled flight while on a non precision localizer approach to runway 25 at Akron Fulton International Airport (AKR) and impacted a four-unit apartment building in Akron, Ohio. The captain, first officer, and seven passengers died; no one on the ground was injured. The airplane was destroyed by impact forces and post crash fire. The airplane was registered to Rais Group International NC LLC and operated by Execuflight under the provisions of 14 Code of Federal Regulations (CFR) Part 135 as an on-demand charter flight. Instrument meteorological conditions prevailed, and an instrument flight rules flight plan was filed. The flight departed from Dayton-Wright Brothers Airport, Dayton, Ohio, about 1413 and was destined for AKR. Contrary to Execuflight’s informal practice of the captain acting as pilot flying on flights carrying revenue passengers, the first officer was the pilot flying, and the captain was the pilot monitoring. While en route, the flight crew began preparing for the approach into AKR. Although company standard operating procedures (SOPs) specified that the pilot flying was to brief the approach, the captain agreed to the first officer’s request that the captain brief the approach. The ensuing approach briefing was unstructured, inconsistent, and incomplete, and the approach checklist was not completed. As a result, the captain and first officer did not have a shared understanding of how the approach was to be conducted. As the airplane neared AKR, the approach controller instructed the flight to reduce speed because it was following a slower airplane on the approach. To reduce speed, the first officer began configuring the airplane for landing, lowering the landing gear and likely extending the flaps to 25° (the airplane was not equipped with a flight data recorder, nor was it required to be). When the flight was about 4 nautical miles from the final approach fix (FAF), the approach controller cleared the flight for the localizer 25 approach and instructed the flight to maintain 3,000 ft mean sea level (msl) until established on the localizer. The airplane was already established on the localizer when the approach clearance was issued and could have descended to the FAF minimum crossing altitude of 2,300 ft msl. However, the first officer did not initiate a descent, the captain failed to notice, and the airplane remained level at 3,000 ft msl. As the first officer continued to slow the airplane from about 150 to 125 knots, the captain made several comments about the decaying speed, which was well below the proper approach speed with 25° flaps of 144 knots. The first officer’s speed reduction placed the airplane in danger of an aerodynamic stall if the speed continued to decay, but the first officer apparently did not realize it. The first officer’s lack of awareness and his difficulty flying the airplane to standards should have prompted the captain to take control of the airplane or call for a missed approach, but he did not do so. Before the airplane reached the FAF, the first officer requested 45° flaps and reduced power, and the airplane began to descend. The first officer’s use of flaps 45° was contrary to Execuflight’s Hawker 700A non precision approach profile, which required the airplane to be flown at flaps 25° until after descending to the minimum descent altitude (MDA) and landing was assured; however, the captain did not question the first officer’s decision to conduct the approach with flaps 45°. The airplane crossed the FAF at an altitude of about 2,700 ft msl, which was 400 ft higher than the published minimum crossing altitude of 2,300 ft msl. Because the airplane was high on the approach, it was out of position to use a normal descent rate of 1,000 feet per minute (fpm) to the MDA. The airplane’s rate of descent quickly increased to 2,000 fpm, likely due to the first officer attempting to salvage the approach by increasing the rate of descent, exacerbated by the increased drag resulting from the improper flaps 45° configuration. The captain instructed the first officer not to descend so rapidly but did not attempt to take control of the airplane even though he was responsible for safety of the flight. As the airplane continued to descend on the approach, the captain did not make the required callouts regarding approaching and reaching the MDA, and the first officer did not arrest the descent at the MDA. When the airplane reached the MDA, which was about 500 ft above the touchdown zone elevation, the point at which Execuflight’s procedures dictated that the approach must be stabilized, the airspeed was 11 knots below the minimum required airspeed of 124 knots, and the airplane was improperly configured with 45° flaps. The captain should have determined that the approach was unstabilized and initiated a missed approach, but he did not do so. About 14 seconds after the airplane descended below the MDA, the captain instructed the first officer to level off. As a result of the increased drag due to the improper flaps 45° configuration and the low airspeed, the airplane entered a stalled condition when the first officer attempted to arrest the descent. About 7 seconds after the captain’s instruction to level off, the cockpit voice recorder (CVR) recorded the first sounds of impact.
Probable cause:
The National Transportation Safety Board determines that the probable cause of this accident was the flight crew’s mismanagement of the approach and multiple deviations from company standard operating procedures, which placed the airplane in an unsafe situation and led to an unstabilized approach, a descent below minimum descent altitude without visual contact with the runway environment, and an aerodynamic stall. Contributing to the accident were Execuflight’s casual attitude toward compliance with standards; its inadequate hiring, training, and operational oversight of the flight crew; the company’s lack of a formal safety program; and the Federal Aviation Administration’s insufficient oversight of the company’s training program and flight operations.
Final Report: