Preliminary Reports
Runway Overrun Takes Out ILS at KJVY
Beechcraft King Air 100 , Oct. 30, 2016, Jeffersonville-Clark Regional Airport, Ind.—A Beech King Air 100 was damaged during takeoff when it ran off the end of 5,500-foot-long Runway 18 at Jeffersonville-Clark Regional Airport (KJVY) after an aborted takeoff. The pilot, copilot and eight passengers were not injured.
The pilot reported that the airplane's flight controls and engines were operating normally during the pre-takeoff check, and the elevator pitch trim was positioned correctly. The airplane did not accelerate as expected during the takeoff roll and the stall warning sounded at rotation so he aborted the takeoff. The airplane went off the end of the runway.
The pilot told NTSB investigators that he did not apply the brakes or reverse the propeller pitch. The left wing hit the runway ILS antenna, and the left main gear and nose gear collapsed. Once the airplane had come to rest, the pilot opened the cabin door and assisted the passengers in evacuating. There was no post-crash fire.
AStar Crash Kills Two, Injures four near Sochi, Russia
Airbus AS350B3e Ecureuil, Nov. 1, 2016, Sochi, Russia—One person died and another five were injured after an Airbus AS350B3e Ecureuil on a commercial sightseeing trip crashed into the courtyard of a house near Sochi in south Russia, according to the Interior Ministry’s transport department for the Southern Federal District. The helicopter was damaged beyond repair.
Rotor Hub Assembly Comes Unhinged from S-92
Sikorsky S-92, Nov. 10, 2016, Western Australia—The Australian Transport Safety Bureau (ATSB) is investigating a main rotor failure on a Sikorsky S-92, VH-ZUQ, at Broome Airport, Western Australia, that happened during start-up. The crew noticed unusual engine vibrations and shut down the engine. They found part of the rotor hub assembly detached from the helicopter. Subsequent inspection revealed the main rotor blade stops had been sheared off the hub assembly. As part of the investigation, the ATSB will interview the crew and seek to identify the cause of the failure.
Challenger Landing Gear Collapses
Bombardier Challenger 300, Nov. 14, 2016, Marcos A. Gelabert International Airport (MPMG), Albrook, Panama—No one was hurt, but the airplane was substantially damaged when the landing gear of a Challenger 300 collapsed during landing at Marcos A. Gelabert International Airport (MPMG), Albrook, Panama. The airplane is registered to Delaware Trust Company Trusteeof Wilmington, Del. VMC prevailed at the time of the accident, although the airplane was operating on an IFR flight plan on a local flight.
Air Ambulance Crashes on Takeoff at Elko
Piper Cheyenne II, Nov. 18, 2016, Elko, Nevada—An air ambulance Piper Cheyenne II carrying a cardiac patient and medical personnel crashed into a parking lot of Barrick Gold near Interstate 80 shortly after takeoff from Elko Regional Airport, Nev., killing all four on board.
The turboprop twin, bound for a Salt Lake City hospital, was in its initial climb in VMC a half-mile from the runway when it turned left 30 degrees and stopped climbing. A witness told the NTSB the aircraft then made an abrupt left bank and descended out of his line of sight before crashing into a parking lot and bursting into flames. The resulting fire burned oxygen on board and led to several secondary explosions that set nearby vehicles on fire. However, no one on the ground was injured.
All major structural components of the airplane were located within the wreckage. Detailed examinations of the airframe and engines are pending, and the cause of the crash remains under investigation.
Beechcraft King Air 200 Crashes Short of Runway After Missed Approach
Beechcraft King Air 200, Nov. 23, 2016, Moorehead, Minn.— A Beechcraft King Air 200 arriving from Baudette, Minn., to Moorhead Municipal Airport (KJKJ) in night instrument meteorological conditions hit the ground during a missed approach procedure after the pilot lost visual reference with the runway during the final segment of a GPS instrument approach.
The pilot and one passenger sustained minor injuries and five passengers were uninjured. The airplane came to rest substantially damaged in a field a half-mile short of Runway 30. Flight Development operated the aircraft under 14 CFR Part 135 as an on-demand passenger flight at the time of the accident.
FACTUAL REPORTS
Challenger Crashed After Downwind Landing In Aspen
Bombardier Challenger 604, Jan. 5, 2014, Aspen, Colo.—A Challenger 604 arriving from Tucson, Ariz., with a Mexican national crew hit the runway while attempting to land for the second time at Aspen-Pitkin County Airport/Sardy Field (KASE), destroying the airplane, killing the copilot and seriously injuring the captain and passenger. The airplane was registered to the Bank of Utah Trustee and operated by Vineland Corporation Company of Panama under Part 91. VMC prevailed. KASE is a high-altitude, terrain-limited airport and the aircraft was on an instrument flight plan.
Aspen airport Automated Surface Observation System (Asos) located east of the touchdown zone of Runway 15 reported the wind from 320 degrees at 14 knots gusting to 25 knots, with variable direction from 280 to 360, visibility 10 miles in haze, scattered clouds at 4,700 feet agl, with a ceiling broken at 6,000 feet during the accident approach. Peak wind was from 320 at 26 knots at 12:04 p.m. An urgent pilot report over Aspen at 12:05 p.m. MST from a Learjet 35 crew reported low-level wind shear with a 10-knot loss of airspeed on a two-mile final.
Performance data for the 604 indicated that the crew was operating the aircraft beyond published performance parameters for a tailwind component, and that the crew was aware of the shifting tailwind after performing its first missed approach. The CVR transcript indicated they were hoping the wind would subside on the second attempt to land.
Runway 15 at KASE begins at an elevation of 7,680 feet, and slopes upward with a 1.9-percent gradient, which creates extreme visual illusions for pilots. The aircraft's descent angle for the last nautical mile of flight was approximately four degrees and its airspeed was about 140 knots. During the last minute of flight the wind was variable from 280degrees to 360degrees at 14 knots, gusting to 25 knots, meaning they may have experienced a 21-knot crosswind and a 12-knot tailwind. The indicated peak wind was practically a pure tailwind.
According to the report, neither pilot had logged experience with the unusually steep approach into the sloping Runway 15 at KASE, a mountain valley airport that is often the site of rapidly changing wind conditions. The captain, who had logged just 14 hours in type, had flown once to Vail, Colo., but not KASE.
FINAL REPORTS
ATC Training and a Busy Pattern Caused Confusion and a Midair
North American Rockwell NA265-60SC Sabreliner and Cessna 172M, Aug. 16, 2015, Brown Field Municipal Airport (KSDM), San Diego, Calif.—A combination of ATC error and the inability of the pilots of two aircraft to see each other was the cause of the midair between a Cessna 172M and an experimental North American Rockwell NA265-60SC Sabreliner near San Diego, Calif., according to the NTSB. Five people died in the accident.
The privately owned Cessna was on a Part 91 personal flight, while the Sabreliner was registered to and operated by BAE Systems Technology Solutions & Services. Both aircraft were operating in the Brown Airport (KSDM) traffic pattern in VMC.
KSDM's airport traffic control tower had all control positions combined to one position staffed by a local controller (LC) who was conducting on-the-job training with a developmental controller (LC trainee). The LC trainee was transmitting instructions for all operations under close supervision. As traffic increased, the LC trainee made a mistaken transmission, at which point the qualified LC took over. The LC trainee remained in the tower to observe operations. In the two minutes after the handoff the LC made several errors. He confused an aircraft to the left of the Sabreliner and heading to the northeast with the Cessna 172M, which was between the Sabreliner and KSDM, on a closer-in right downwind leg. The LC instructed the pilot of Cessna 172 N6ZP, which he thought was the Cessna on right downwind, to make a right 360-degree turn over the airport and rejoin the downwind. Despite the fact that, at that time, N6ZP was 2.3 nm northeast of the airport and was departing the area, the pilot of N6ZP acknowledged the instruction and initiated a right turn.
The Sabreliner was instructed to turn base and cleared to land on Runway 26R. The LC said that after he cleared the Sabreliner to land, he looked up to ensure that theairplane was turning base and noticed that the Cessna on downwind (which he still thought was N6ZP) was continuing on its downwind track and had not begun the turn that he had issued. He contacted the pilot of N6ZP, who replied that he was turning. The Sabreliner CVR has its pilot commenting, “I see the shadow but I don't see him."
The LC transmitted, "November eight five Uniform" to the Cessna 172M; this was the first ATC transmission with the pilot in almost six minutes and the first communication between the LC and N1285U. The correct pilot acknowledged the transmission, "eight five Uniform." The LC then asked the pilot if he was still on the right downwind leg. The pilot of N1285U did not respond. The LC and the LC trainee then witnessed the midair.
Witnesses on the ground noted that neither airplane appeared to make any corrective action before the collision and stated that after the collision, the smaller airplane broke apart, while the larger airplane lost a wing, nosed downand struck the ground.
The wreckage was located in a large open area a mile-and-a-half northeast of KSDM and consisted of two primary debris fields, one for each airplane.
The LC said that, at that time, he had four issues to resolve, one of which was the potential conflict between the Sabreliner and the Cessna on the right. When the pilot of N6ZP acknowledged the turn, the LC believed that the pilot of the Cessna to the right of the jet had received the instructions and that the potential conflict would be resolved. The LC then instructed the jet pilots to turn base and cleared them to land on Runway 26R. When the LC was asked what caused him to realize that the Cessna was N1285U and not N6ZP, he said it dawned on him through a process of elimination. The LC trainee said that when the Cessna on the right did not start the right turn, he suggested to the LC that the intended aircraft might have been N1285U. The LC indicated that, in retrospect, he should have issued a traffic alert; however, the moment he realized that the jet was turning into N1285U, it was too late.
The NTSB reconstructed the airplanes' flight paths using radar data and examined the ability of the Cessna and Sabreliner’s pilots to see and avoid the other aircraft. Position and orientation information for both airplanes was estimated on thebasis of the radar data, combined with models of each airplane's aerodynamic performance. Investigators determined that the pilots might have been able to see each other at different points in the minute or two before the midair if they had known that the other aircraft was in proximity. By the time the aircraft were 0.1 nm apart, window posts in both aircraft might have obscured the view.
The absence of Tcas, ADS-B or FIS-B information in the cockpit and a lack of a timely traffic alert to both pilots by a controller using standard phraseology contributed to this accident. The NTSB also attributed the accident to human factors in high-workload ATC environments.