Preliminary Reports

Three Killed in Florida Training Accident

Beech King Air C90, Dec. 8, 2017, Geneva, Florida—A flight instructor and two commercially rated pilots under instruction died when their King Air C90 crashed into Lake Harney during a practice instrument approach. The aircraft was operated by the L3 Airline Academy and had just concluded a flight from the Baldwin County airport in Milledgeville, Georgia, to Sanford, Florida, by flying an approach to Runway 09L. After controllers switched the active runway to 27R, the King Air departed on an IFR flight plan to conduct an ILS approach to that runway. 

Two minutes after providing a vector to join the localizer with an approach clearance, the controller issued a low-altitude alert and instructed the pilot to climb to 1,600 feet. Someone replied, “I am, sir, I am” just before radio and radar contact were lost. A fisherman on the lake reported hearing the airplane before he saw it below a 250- to 300-foot ceiling. After a rapid initial climb, it dived “vertically” into the lake. 

Operator’s Certificate Suspended Following Wreck in Rural Saskatchewan

ATR42-320, Dec. 13, 2017, Fond-du-Lac, Saskatchewan—Nine days after its ATR-42 crashed just after takeoff from a remote village in northern Saskatchewan, West Wind Aviation’s air operator certificate was suspended by Transport Canada, grounding all of the provincial airline’s flights until further notice. All 25 occupants were injured, seven seriously, when the 44-seat twin-engine turboprop went down in the forest less than a mile west of the Fond-du-Lac airport. One, a 19-year-old who’d been pinned beneath the wreckage, died two weeks later in a Saskatoon hospital. 

The investigation is ongoing, but the Transportation Safety Board has determined that both of the airplane’s engines were operating up to the moment of impact. Transport Canada’s December 22 press release cited “deficiencies in the company’s operational control system” discovered during a post-accident inspection as grounds for the suspension. Conditions for a possible reinstatement were not specified.

Villagers with blankets, tools, and snow machines reached the scene within minutes. Their quick response is credited with minimizing the loss of life.

Cessna Mustang Crash in Germany Claims Three

Cessna 510, Dec. 14, 2017, Sieberatsreute, Waldburg, Germany—The chief pilot and managing director of Austrian charter operator Skytaxi Luftfahrt, his copilot, and their passenger were killed when their Cessna Mustang went down in wooded terrain near Sieberatsreute, Germany. The accident occurred near the end of the flight from the Frankfurt Egelsbach Airport. Though hampered by heavy snow, first responders located the wreckage about 10 miles northeast of its destination of Friedrichshafen. The client, a 79-year-old German businessman, has not been publicly identified.

A notice on Skytaxi Luftfahrt’s website reported that the company had suspended operations indefinitely.

Final Reports

TAIC Cites Safety Culture in New Zealand Heli-skiing Accident

Eurocopter AS350B2, Aug. 16, 2014, Mount Alta, Otago, New Zealand—New Zealand’s Transport Accident Investigation Commission suggested that a widespread “culture...of operating their aircraft beyond the published and placarded limits” likely contributed to a heli-skiing accident that killed one passenger, caused serious injuries to three more, and minor to moderate injuries to the remaining two passengers and pilot. Five of the seven occupants including the pilot were ejected when the aircraft hit downsloping terrain nose-low during an attempted escape maneuver after failing to establish an out-of-ground-effect (OGE) hover on approach to its intended landing zone.   

While the TAIC’s final report found the operator’s procedures and training standards to be comparable to those of its competitors, it characterized the use of standardized passenger weights in flight planning as “inappropriate” for flights involving full passenger loads. Its investigation determined that the helicopter was outside its authorized weight-and-balance envelope at the time of the crash, with its center of gravity 3 cm (1.2 inches) forward of limits and weight about 30 kg (66 pounds) above the authorized maximum gross. The altitude of the landing zone was 245 feet above the helicopter’s estimated OGE hover ceiling under that day’s conditions. 

The flight was the fourth of the day for the accident aircraft, one of five supporting heli-skiing operations between Mount Aspiring National Park and Lake Wanaka. Making a shallow approach to a landing zone near the summit of Mount Alta in very light winds, the pilot was unable to maintain his planned descent angle as airspeed decreased to near zero. He turned left toward his planned escape route down the mountainside and attempted to accelerate, but the helicopter “rapidly and unexpectedly” sank. It hit the slope before he could arrest its descent, tumbling some 315 meters (1,030 feet) downhill. One passenger was struck by the broken right skid and pinned beneath the wreckage; he died at the scene. The TAIC noted that he and three of the other four passengers ejected were wearing only three-point restraints fastened very loosely, compromising their effectiveness. 

Overpressurization Damage Linked to Insect Nest

Gulfstream GIV, April 10, 2015, over the Caribbean Sea—An overpressurization event during a positioning flight from Caracas, Venezuela, to Fort Lauderdale, Florida, was caused by a blocked static port for the cabin pressurization relief/safety valve (CPRV), according to a final NTSB report The jet was in cruise flight at FL430 about 200 miles south of Nassau, Bahamas, when the crew advisory system displayed a red “9.8 CABIN DFRN” warning followed by a red “DOOR MAIN” warning. The two pilots immediately donned oxygen masks and consulted the Quick Reference Handbook’s emergency checklist. After hearing a loud bang they initiated an emergency descent, manually opening the cabin pressure dump valve. The flight levelled off at 12,000 feet and continued to Fort Lauderdale Executive Airport without further incident. No anomalies were found during their post-flight walk-around.

The airplane was flown to Boca Raton for scheduled maintenance the following day. Maintenance staff’s discovery of damage to several floor beams and the frame below the right galley door prompted an inspection by Gulfstream engineers, who found deformation and fractures of floorboards, intercostal installations, wing links, and one floor beam. The overpressurization was attributed to obstruction of the CPRV’s static port by dirt and insect parts from a mud dauber’s nest, which prevented the CPRV from measuring the cabin-to-atmosphere pressure differential. The loudspeaker of the aural warning system was also found inoperative, possibly delaying the crew’s becoming aware of the hazard.

No Evidence of Failure in Citation’s Flight Instruments

Cessna 525, Jan. 18, 2016, Cedar Fort, Utah—Investigators were unable to find any sign of pre-impact malfunction in the instruments of a Cessna Citation that broke up in flight after its pilot reported failure of the flight management system (FMS) and autopilot followed by the loss of “different instruments.” The NTSB’s finding of probable cause listed the accident’s defining event as “other or unknown” and specifically noted that “numerous avionics system components were tested with no evidence of any malfunctions or anomalies that would have precluded normal operation.” In particular, examination of the standby attitude indicator by its manufacturer “revealed no evidence to indicate that the component was not operating normally prior to impact with terrain.” The breakup itself was attributed to overload caused by the pilot’s loss of control due to spatial disorientation in IMC.

Five minutes after departing from Salt Lake City on an instrument flight plan to Tucson, the pilot reported “a failure on my FMS” and advised that he would be exceeding his assigned altitude of 14,000 feet. Twenty-five seconds later he reported an autopilot failure and requested “a climb to whatever altitude straight ahead.” Two and a half minutes later, the pilot declared “MAYDAY...I do need to get up higher...I am losing different instruments, I’d really like to get into clear weather.” The Citation reached a maximum altitude of 21,000 feet before entering a tightening right turn and disappearing from radar at 16,000 feet; its final descent rate reached 36,000 fpm.The debris field measured 0.75 miles long and 0.33 miles wide.

The airline transport pilot had 1,587.5 hours of jet experience, all in the accident airplane, including 97.8 hours since its avionics suite had been replaced with independent dual Garmin GTN 750 GPS navigators.

Drone Pilot Faulted in Collision with U.S. Army Black Hawk

Sikorsky UH-60M, Sept. 21, 2017, Hoffman Island, New York—The operator of a DJI Phantom 4 small unmanned aerial system (sUAS) that collided with a U.S. Army Black Hawk helicopter deliberately flew the aircraft some 2.5 miles from his location in violation of federal regulations limiting recreational drone flights to the operator’s direct line of sight and was unaware of a temporary flight restriction (TFR) established for the U.N. General Assembly meeting. In its final report the NTSB noted that the operator’s log recorded a flight earlier the same evening that reached an altitude “in excess of 547 feet” at a distance of 1.8 miles, violating both the line-of-sight requirement and the ceiling of 400 feet imposed by Part 101 of the Code of Federal Regulations. 

The collision took place two minutes before the end of civil evening twilight at an altitude of 274 feet in airspace restricted by the TFR. The helicopter was the lead of two aircraft returning to their base at Linden, New Jersey, after a local orientation flight in the TFR area. The sUAS operator had just transmitted a return-to-home command, tracking the aircraft’s position via his tablet computer. He learned of the collision when contacted by the NTSB, having assumed the drone had crashed into the water following some malfunction. The report characterized him as having “only a general cursory awareness of regulations and good operating practices.”

The helicopter sustained damage to one main rotor blade characterized as “minor.” The sUAS was destroyed.