PRELIMINARY REPORTS
MU-2 Lost in Bahamas
Mitsubishi MU-2B-40, May 15, 2017, Eleuthera, Bahamas—A commercial pilot with 1,480 hours of flight experience was presumed killed, along with his three passengers, when his Mitsubishi MU-2B-40 twin turboprop went down in international waters in IFR conditions somewhere near Eleuthera, Bahamas. The airplane was en route from Rafael Hernandez Airport (TJBQ), Aguadilla, Puerto Rico, to Space Coast Regional Airport, Titusville, Fla. (KTIX), flying at 24,000 feet for 2.5 hours when the radar return went into “coast” mode as the airplane transitioned from Nassau ATC to Miami (ZMA). The Miami ARTCC controller attempted to contact the pilot, but was unsuccessful. The target disappeared from radar. A three-day U.S. Coast Guard search by air and sea found nothing beyond some floating debris and a fuel sheen on the surface of the water near where the last radar target was recorded.
The airplane was manufactured in 1981 and had an annual inspection completed on December 30 last year at 4,634.2 hours on the airframe. According to FAA records, the airplane was a recent purchase, registered on January 23 this year. A review of its flight history revealed that the accident pilot flew it on the same route as the accident flight several times during the four months he had operated the Mitsubishi. The airplane was scheduled for a 100-hour inspection on May 16, one day after the accident.
Weather 80 miles west of the airplane's track at the time of the accident was scattered clouds at 1,200 ft, broken ceiling at 3,000 feet, and an overcast ceiling at 10,000 feet, calm wind, with visibility of 10 statute miles in light rain. The temperature was 26 degrees C, and the dew point was 23 degrees C. The altimeter setting was 29.97. Satellite imagery in the area surrounding the radar track depicted a consistent cloud layer with tops around FL400, and upper air soundings confirmed icing conditions between -10 and -20 degrees C in cloud. At 1:40 p.m., a Pirep was received from a 737 for light to moderate rime icing.
Dust Devil Tosses Twin Otter
DHC-6 Twin Otter 300, May 24, 2017, Perris Valley, Calif.—A DHC-6 Twin Otter 300 set up for skydiving was landing at Perris Valley Airport, Calif., with just crew aboard after releasing a load of skydivers when witnesses said it appeared to encounter a dust devil on touchdown, causing it to careen into a gas truck on the ramp, damaging the aircraft beyond repair. The right wing separated just outboard of the engine, the nose gear was sheared off and the nose of the aircraft was heavily damaged. No one was seriously injured in the accident.
EC135 Down in Delaware
Airbus Helicopters EC135P2, May 25, 2017, New Castle, Del.—An ATP-rated helicopter pilot practicing instrument approaches in an EC135 registered to the University of Pennsylvania was killed during a missed approach procedure when the helicopter crashed near New Castle, Del., in IMC conditions with 2.5 miles visibility, seven-knot wind and a ceiling of 500-foot overcast. The pilot, who had flown to New Castle from Atlantic City (KACY), had completed an ILS approach to Runway 1 at New Castle (KILG) and was executing the missed approach, climbing on course to 2,525 feet msl, when it began to turn right and descended rapidly, according to ATC radar data.
The helicopter crashed into a water retention ditch 3,200 feet before the threshold of Runway 1 and was partially consumed by a post-crash fire. Control continuity of the cyclic and collective was confirmed to the rotor head from the cockpit through examination of several breaks and fractures. The cyclic, collective and antitorque pedals were separated and located in the main wreckage. All four blades of the main rotor remained attached to the rotor head. One blade exhibited impact damage but no fire damage, while the other blades were consumed by fire. All pitch links remained attached to the rotor head. The transmission mounts were separated from the helicopter. Investigators rotated the compressor turbine disc and compressor by hand. The left-engine power turbine was removed and the drive shaft showed torsional deformation and fractures. In addition, the power turbine wheel exhibited rotational scoring. The right engine separated from its mounts during the crash. Investigators removed the right-engine power turbine and found the drive shaft exhibited torsional twisting deformation and fractures. In addition, the power turbine wheel exhibited rotational scoring.
Investigators retained the central warning panel and Sky Connect tracker unit and sent them to the NTSB Recorders Laboratory in Washington, D.C., for download.
Hard Landing Takes Out Grand Caravan Main Gear
Cessna 208B Grand Caravan, May 30, 2017, Ilaga Airport, Papua, Indonesia—A Cessna 208B Grand Caravan operated by Missionary Aviation Fellowship on a domestic non-scheduled passenger flight from Nabire Airport (NBX) to Ilaga Airport (ILA) in Indonesia sustained substantial damage during a hard landing at Ilaga, injuring two of the five occupants. The main landing gear separated on the left side, bending upwards, causing the aircraft’s belly pod to scrape the runway as it came to a sudden stop.
Wheels-up Landing in Mogadishu By Dornier
Dornier Do-328Jet-310, May 30, 2017, Mogadishu Aden Adde International Airport, Somalia—A U.S.-registered Dornier Do-328Jet-310 with two crew and two passengers made a gear-up landing at Mogadishu's Aden Adde International Airport in Somalia while landing after an uneventful flight from Entebbe, Uganda. No one was injured. The aircraft was being operated on behalf of Bancroft Global Development, a U.S. private military company that supports the African Union Peacekeeping Mission in Somalia and provides military training to the Somali national forces. The aircraft had been used to fly the Somali President.
FINAL REPORTS
Hard Landing Blamed on Ineffective CRM and Unstable Approach
Beechcraft King Air A100, Aug. 16, 2015, Dartmouth, Nova Scotia—The Transportation Safety Board of Canada (TSB) found that ineffective crew resource management (CRM) and an unstable approach led to the hard landing and subsequent main landing gear collapse of a King Air A100 in Margaree, Nova Scotia. There were no injuries, but the aircraft was substantially damaged.
The King Air was on a charter flight from Halifax Stanfield International Airport to Margaree Aerodrome, Nova Scotia, with two pilots and two passengers on board. After a visual approach to Runway 1, the airplane touched down hard 260 feet beyond the runway threshold, crumpling the right main landing gear and causing the right propeller and wing to contact the runway. The aircraft then slid along the runway for 1,350 feet before veering off the runway to the right.
The TSB investigation found that the crew did not anticipate the elevated workload that attended landing on a short runway at an unfamiliar airport surrounded by high terrain. The crew did not recognize the steep rate of descent and the unstable approach condition. The aircraft crossed the runway threshold with insufficient energy to cushion the rate of descent in the landing flare, resulting in the hard landing.
The TSB placed the crux of blame for the accident on a lack of effective CRM. The TSB used this accident as a basis for calling on Transport Canada to require smaller commercial operators to provide their crews with updated CRM training. As a result, Transport Canada has proposed new CRM training standards.
The charter company involved in the accident already had a safety management system (SMS) in place but used it primarily as a reactive method to address potential safety concerns. After the accident, the company revised its procedures by adding a preflight risk assessment checklist, a requirement to calculate accelerate-stop distance when taking off from shorter runways, and enhanced training with greater emphasis on stabilized approach criteria and avoidance of controlled flight into terrain.
Cracked Bracket Failure Caused Flap-disagreement Warning
Embraer EMB-120ER, Oct. 25, 2016, Adelaide, South Australia—A Brasilia on a chartered flight departed from Adelaide Airport, South Australia, with four crew and 29 passengers on board when a bracket securing a flap roller failed, preventing the left outboard flap from retracting fully during the climb. A flap disagreement warning prompted the pilots to troubleshoot the issue, and they ultimately returned to Adelaide for a precautionary landing. There were no injuries and the aircraft sustained no damage beyond the fractured bracket and shroud. The Australian Transport Safety Bureau (ATSB) determined that pre-existing cracking and subsequent fracture of a bracket supporting the left outboard flap shroud prevented the flap from retracting fully during climb and resulted in the flap disagreement warning.
During the initial climb, the pilot attempted to retract the flaps fully from their takeoff position (flaps 15). The crew received a flap disagreement warning from the outboard pair of flaps. The other two pairs of flaps (inboard and nacelle) retracted normally. A flap disagreement fault is triggered when one flap within a pair is unable to move to its selected position. To prevent wing asymmetry and control issues, the pairing flap will also not move. The crew reported no noticeable aircraft handling or control issues as a result.
The crew contacted ATC to notify controllers of the fault and requested a climb to 4,000 feet on their current heading. After leveling off and reducing power to a cruise setting, the crew consulted the quick-reference handbook, which advised cycling the flaps to their original position and back again. The fault cleared when the flap control was lowered to 15 degrees, but reoccurred again upon retraction.
The crew chose to return to Adelaide, with the first officer flying the aircraft while the captain conducted landing calculations and determined that they had sufficient runway to land with flaps 15, in case they could not be deployed further. During approach, the flaps extended fully to 45 degrees and the aircraft landed without further incident. The flaps were retracted after landing, and all three pairs moved to flaps zero without the fault recurring. The crew visually inspected the flap and immediately identified a damaged bracket and fiberglass shroud. The failed bracket secured a roller to the underside of the wing. This roller supported the inboard side of the left-hand outboard flap shroud and served to guide the flap shroud as it was deployed and retracted.
The aircraft was manufactured in 1992 and at the time of the incident had flown 41,961 hours. It was being maintained by a Civil Aviation Safety Authority (CASA)-approved maintenance organization and its most recent comprehensive inspection had been performed approximately 600 hours before the incident, in November 2014. No problems with the outboard flap shroud or bracket were identified at that time.
The CASA Service Difficulty Report (SDR) database shows two other reports of unserviceable flaps on Brasilias. Both involved the left-hand outboard flap; however, the fault in both cases was unrelated to the inboard bracket or flap track. Likewise, no reports of issues with this part could be found in the U.S. FAA SDR database.
The ATSB praised the crew for its by-the-book troubleshooting and excellent coordination with ATC, which resulted in minimal damage to the aircraft and no injuries.