Preliminary Reports

Loss of Twin Otter Claims Four

de Havilland Canada DHC6-400, September 18, 2019, 10 km from Kampung Mamontoga, Mimika Regency, Indonesia—Three crew members and one passenger perished after a DHC-6 Twin Otter disappeared from radar on a flight from Timika to the mountainous region of Ilaga in the remote eastern province of Papua. Weather at departure was described as good.  Search-and-rescue teams located the wreckage four days later on a mountainside at an elevation of 13,500 feet. In addition to the single passenger, the twin turboprop was reported to be carrying 1.7 tons of rice.

Two Fatalities in Tanzanian Takeoff Accident

Cessna 208, September 23, 2019, Serengeti, Tanzania—The pilot and only passenger were killed when an Auric Air Caravan crashed just after takeoff from the Seronera airstrip in the Serengeti desert. An announcement on the company’s Web site confirmed that no one else was on board. According to the commissioner of Tanzania National Parks, the flight was bound for Arusha to pick up tourists. Investigators were reported to have reached the scene the following day, but at press time no further details had been released.

Pilot Only Casualty in B.C. Helicopter Crash

September 24, 2019, Bell 206B-3, Campbell River, British Columbia, Canada—No ground injuries were reported after a “locally owned” Bell JetRanger hit the roof of a woodcarving shed in the Tyee Spit area of Campbell River and slid off into the parking lot. The pilot—who owned the helicopter company and was a veteran of many years of flying on Victoria Island—did not survive. Renowned local artist Bill Henderson was inside his studio at the time but not close to the portion of the roof penetrated by the main rotor blades and was unhurt.

One witness to the impact said that “the sound was not right. It looked like the motor was not running.” A second witness corroborated the impression that the main rotor blades had begun to slow as the helicopter apparently turned toward a nearby helicopter pad and “began to wobble.” British Columbia’s Transportation Minister confirmed that the pilot was Ed Wilcock, owner of E&B Helicopters and the veteran of many years of flying on Victoria Island that included transportation and emergency evacuation services for the forestry industry. In 2017, he received a lifetime-achievement-in-safety award from the B.C. Forestry Council citing his “understanding appreciation of workers’ safety in the forestry industry.” The initial investigation is being conducted by WorkSafe BC, the BC coroner’s office, and the Transportation Safety Board.

Five Killed in TBM 700 in Michigan

Socata TBM 700, October 3, 2019, Lansing, Michigan—The pilot and four passengers were killed when the business flight went down short of the runway during an ILS approach to Runway 10R of Landing, Michigan’s Capital Region International Airport. At press time, the fifth passenger remained hospitalized in critical condition. The accident occurred just under one hour after departure from Indiana’s Indy South Greenwood Airport. 

ADS-B position data suggest a routine descent from FL190 to 3,000 feet msl. The airplane joined the localizer and crossed the inner marker at 2,302 feet and 168 knots calculated true airspeed. The pilot’s readback of the landing clearance was the last transmission received from the aircraft. Over the next two minutes, as it continued to descend on the glideslope, it decelerated to 72 knots at an altitude of 180 feet above ground level half a mile from the threshold. Its speed dropped to 64 knots as it began a shallow climbing left turn, gaining just 20 feet. The final ADS-B data point came 300 feet north of the localizer centerline 0.36 feet short of the runway; the initial point of impact was 480 feet farther northeast.

Prevailing weather included calm winds with 1.25 miles visibility in light rain under a 400-foot overcast. The 1,404-hour commercial pilot had 86 hours in TBM 700 and 850-series airplanes, all during the preceding 12 months. Fuel was present at the scene, and there was no initial evidence of loss of power before impact.

Final Report

Unqualified Pilot Insisted on Flying Solo

Cessna 500, March 24, 2017, Marietta, Georgia—The 78-year-old owner of a 1976-model Cessna Citation insisted on flying the airplane solo despite never having completed either the initial or recurrent training required to exercise a single-pilot exemption, claiming instead to be covered by the conformity certificate issued to the previous owner. According to the NTSB’s probable cause report, a friend of the pilot told investigators that he was largely unable to fly the airplane without the autopilot and had never learned to program the GPS, leaving him ill-prepared to cope with any in-flight routing changes. The jet crashed into the front yard of a home in a flat spin after completing at least one 360-degree roll. Fire that consumed most of the wreckage and left the house uninhabitable. The residents were out and the pilot was the only casualty.

The friend, a 23,000-hour flight instructor and aircraft mechanic with multiple type ratings, had made several attempts to teach the pilot to program the Garmin GTN 750 he’d had installed three years earlier, but he continued to struggle “pulling up pages” and “correlating the data.” Instead, he had preloaded routes between the only four destinations he flew to; if air traffic control amended his routing, he “would get confused and not know how to amend the flight plan.” He was also heavily dependent on the autopilot, engaging it just after takeoff and leaving it on until short final, but erroneously believed that the autopilot controlled the trim, which he would therefore not adjust. The chronic out-of-trim condition led him to complain that the airplane was “uncontrollable.”

In cruise flight from Cincinnati to Atlanta at FL220, the pilot responded to an amended routing via an arrival procedure by reporting “difficulty with my GPS” and requesting a direct clearance to the airport. During the next 10 minutes, the cockpit voice recorder picked up the pilot’s voice saying, “I have no idea what’s going on” and the sound of the autopilot disconnecting before the pilot radioed that he was having “a steering problem” and “could not steer the airplane very well.” After receiving a descent clearance to the minimum vectoring altitude, he descended 500 feet below, then reported that he had his “autopilot back…so it gives me some stability.” He was unable to change frequencies to approach control and asked the Center controller to “take me in.” About a minute later he said he was “just barely able” to keep the airplane straight and level. Two minutes after that the CVR recorded the pilot saying, “It’s going down, it’s going down.” The recording ended 19 seconds afterward.

'Intentional Noncompliance' Cited in West Virginia Freighter Crash

Short Brothers & Harland SD3 30, May 5, 2017, Charleston, West Virginia—Operating in low instrument conditions, the crew of Air Cargo Carriers (ACC) Flight 1260 declined a straight-in localizer approach in favor of a circling VOR-A approach with higher minimums, prematurely descended below the procedure’s first step-down altitude, then initiated a steep turning descent within half a mile of the displaced threshold. A performance study based on returns from Charleston Yeager Airport’s ASR-8 Surveillance Radar showed the airplane’s descent rate increasing to 2,500 feet per minute in a 42-degree left bank before moderating to 600 fpm in the last seconds before impact.  The pilot and first officer were killed when the cargo plane crashed onto Runway 05 330 feet beyond the displaced threshold, sliding off the runway and down an 85-foot embankment.

The NTSB’s probable cause report called out not only the flight crew’s violations of both company procedure and the Federal Aviation Regulations, but also the approach controller’s failure to advise them of a special weather observation recorded seven minutes before their first radio contact. The Board also noted ACC’s lack of any formal safety reporting program or “method to evaluate trends of safety or monitor pilots…with previous performance issues.”

The flight departed from Louisville (Kentucky) International Airport at 5:41 a.m, and obtained Charleston’s ATIS Information November while in cruise flight at 9,000 feet. Ceilings were reported as broken at 1,300 feet agl. At 6:37 the first officer contacted Charleston Approach; the controller provided the local altimeter setting but did not advise of the 6:30 observation including a 500-foot overcast. Told to expect the localizer approach to runway 05, which has a minimum descent altitude of 373 feet, the first officer requested and was cleared for the VOR-A approach, which has a 653-foot MDA. After crossing the VOR the freighter descended to 1,600 feet (120 below the charted step-down altitude), leveling off four miles from the extended threshold. A pilot on the ground saw it “hugging the bases” less than a mile west of the airport. Security camera footage captured its steep, descending left turn half a mile out.

Standing FAA orders require issuing a new ATIS message “upon receipt of any new official weather.” Regulations for circling approaches by Part 135 operators require initiating a missed approach if the aircraft is not in position to land “on the intended runway…at a normal descent rate using normal maneuvers … within the touchdown zone.” Radar tracks and surveillance footage of three previous VOR-A approaches to Charleston showed that the captain, a former Alaska bush pilot, had descended below the MDA while in instrument conditions on all three; the first officer had told friends that he had “difficulty staying on heading, speed, and course while flying in IMC” and once “lost situational awareness during a missed approach and almost flew into a mountain.” The Board cited this accident as an example of “procedural intentional noncompliance…a longstanding concern…highlighted on the NTSB’s 2015 Most Wanted List.”