Preliminary Reports
One Survivor Rescued from Jungle Accident Scene
Agusta Bell AB206B, May 2, 2018 }, Cacao, French Guiana—Two fatalities have been confirmed after a helicopter operated by Pilot Air crashed in dense forest during a daytime flight to a remote gold mine. The sole survivor was immediately airlifted to the hospital in Cayenne in critical condition. The flight was transporting two maintenance workers to the mine not far from the accident site.
Signals from the helicopter’s emergency locator transmitter were detected after radio contact with the control tower at the Félix Eboué de Rochambeau airport was lost. The wreckage was located by the “Dragon 973” search-and-rescue helicopter about four hours later. The survivor’s identity has not been reported. The wreckage was subsequently recovered, and the accident is under investigation by the French Bureau d'Enquêtes et d'Analyses (BEA).
Falcon Clips Wingtips on Approach
Dassault Falcon 900EX, May 3, 2018, Johannesburg, South Africa—During a crosswind landing on Runway 17 of Johannesburg’s Germiston-Rand Airport, the left wingtip scraped the runway. A subsequent inspection revealed damage to the right wingtip as well. Investigators surmised that the right wing had struck treetops as the pilot banked more steeply to avoid overshooting the base-to-final turn. Necessary repairs included replacing the slats and ailerons on both wings as well as both wingtips. No injuries were reported.
Two Killed in Himalayan Caravan Crash
Cessna 208B, May 16, 2018, Simikot, Nepal—Both pilots were killed when a Makalu Air cargo flight hit a mountainside near Simikot Pass at an elevation of 12,800 feet. The accident site in the Humla district is in one of the most remote parts of Nepal, with little access except by light aircraft.
The Cessna Caravan freighter departed the Surkhet airport for Simikot at 6:12 a.m., a flight expected to take about 45 minutes. Due to the lack of witnesses and reporting stations in the vicinity, weather conditions at the time of the accident remain unknown.
Final Reports
Runway Collision Tied to Flaws in Notam System
Hawker 400, Dec. 23, 2015, Telluride, Colorado—Weaknesses in the systems used to disseminate Notices to Airmen (Notams) contributed significantly to the ground collision between a Mexican-registered Hawker 400 and a snowplow, the NTSB concluded. The Board pointed to technical shortcomings that allow newly issued NOTAMs—in this case, one closing the airport for snow removal—to escape the attention of air traffic controllers. The accident flight was cleared for an instrument approach eight minutes after airport staff issued a Notam closing the field. The jet struck the snowplow from behind during its landing roll, separating the airplane’s right wing but causing only minor damage to the plow. There were no injuries to the two pilots, five passengers, or snowplow operator.
The closure Notam was posted via computer two minutes after the approach controller, whose workload was described as “heavy,” asked the flight crew whether they had current weather and Notam information and provided vectors for their arrival. The NTSB’s report noted that while Notams immediately became available to the controller, his display system did not automatically alert him of new Notams affecting the airports in his sector. Instead, the controller would have had to switch his display to a different screen, not practical while working multiple arrivals and departures at several fields. Before installation of the current system, airport operators had notified ATC of airport or runway closures by telephone.
Also contributing to the accident was the pilots’ failure to change to the airport’s Common Traffic Advisory Frequency and request traffic advisories after canceling their IFR flight plan.
Open Hatch, Pilot Distraction Blamed for Meridian Crash
Piper PA-46-500TP, Dec. 24, 2015, Corinth, Mississippi—A pilot distracted by an open access hatch on the engine cowling stalled the single-engine turboprop while attempting to turn back to the runway, according to the NTSB. The access door on the right side of the cowling had been left open by an airport lineman “as he always did” after disconnecting the aircraft from a battery charger; the pilot should have closed and latched it during his preflight inspection. The pilot and his daughter escaped with minor injuries after the airplane hit a tree and crashed into the yard of a vacant house. His wife and their daughter-in-law were knocked unconscious by the impact, and the daughter-in-law succumbed to head injuries 227 days later.
The pilot reported reducing power after seeing the door “flopping up and down,” only to have it open completely during a left turn to crosswind. At that point, he said, the airplane would not maintain altitude with full power, so he “put the nose back down.” A witness described the airplane flying “real slow” with its wings “wagging” before the left wing dropped and it fell into the trees. Data recovered from the airplane’s avionics suite showed it reaching a maximum speed of 102 knots at an altitude of 507 feet, then slowing to 80 knots as it entered a 45-degree left bank. The landing gear remained down and locked. The manufacturer’s test flight data showed that with the landing gear down and the flaps in the 10-degree takeoff position, the airplane would stall at 79 knots in a wings-level attitude and 95 knots in a 45-degree bank.
A checklist found by the pilot’s rudder pedals had been issued by a simulator training provider and was not authorized for use in the aircraft. Its only reference to the aircraft’s exterior read, “EXTERIOR PREFLIGHT … COMPLETE.” A detailed checklist for the preflight inspection appears in the Pilot’s Operating Handbook, which was found in the cabinet behind the pilot’s seat. The pilot’s daughter-in-law, who had been in the left rear seat, was found on the floor between the rear and middle seat rows. Her seat belt was unlatched with no indication of strain or damage, suggesting it was not fastened during the flight.
Helicopter Pilot Failedo Reverse Course
Aerospatiale AS355F1, March 29, 2017, Snowdonia, Wales—Echoing the findings of Britain’s Air Accidents Investigation Branch, a coroner’s inquest in Caernarfon, Gwynedd, confirmed that the pilot of the privately owned Twin Squirrel helicopter flew into clouds while approaching a mountainside rather than changing course to remain in visual conditions. Businessman Kevin Burke; his wife; Ruth; his brothers Donald and Barry; and Donald’s wife, Sharon, were killed instantly when his helicopter hit the southeast face of the Rhynog Fawr mountain at an elevation of 2,060 feet, about 300 feet below its summit. The family was traveling from Bedfordshire to the Weston Airport in Dublin to attend a christening; their aircraft was reported missing after they did not arrive as expected.
Burke held a private pilot license with night rating and had an estimated 3,650 hours of flight experience. He was not IFR-qualified, but during his most recent license proficiencyc heck he had demonstrated his ability to maintain altitude while making turns without visual references, simulating an escape from inadvertent entry into instrument conditions. The helicopter was not equipped with a terrain awareness and warning system, and the terrain alerting function on its Garmin 430 GPS had never been installed. The published maximum elevation figure for the area of the accident site was 3,300 feet.
A GPS-derived altitude profile showed the helicopter staying below 1,500 feet until it had passed abeam the Birmingham airport, consistent with the forecast and reported low ceilings near its point of departure. It climbed to a maximum altitude of 3,000 feet as it passed the RAF base at Shawbury, then began a gradual descent that accelerated in the last five minutes before impact. A witness four miles from the scene saw it fly into the clouds.
Physical evidence indicated that the aircraft was under control of the autopilot at the moment of impact. The AAIB suggested that Burke’s last sight of the ground might have been over lower terrain and that a failure to monitor his position on either the panel-mounted GPS or the aviation applications on his iPad would have left him unaware of the ridges just ahead. Northwest Wales coroner Dewi Pritchard Jones added, “Unfortunately the vertical profile shows the aircraft descending to a height where it was virtually inevitable it would collide with one of the ridges in that area."
Pilatus Oil Loss Traced to Incorrect Seal Installation
Pilatus PC-12, Aug. 7, 2017, Meekatharra, Western Australia—A maintenance technician’s reliance on his memory of the disassembly and the Pratt & Whitney Canada illustrated parts catalog rather than the maintenance manual led him to install parts in the wrong order, causing failure of the propeller shaft seal shortly after takeoff. The Royal Flying Doctor Service air ambulance flight returned to land safely at the Meekatharra Airport in Western Australia after the pilot noticed a spray of oil on the windshield during climb-out. The leakage increased enough to obscure his forward vision during the final approach to landing.
Investigators for the Australian Transport Safety Board found that the engineer had installed a half-flat spacer forward of the seal instead of aft, exposing the seal to accelerated wear from direct contact with the seal runner. The investigation confirmed that the parts catalog was not intended to serve as a reference for seal replacement and did not show the parts in their actual installed positions. Fatigue on the part of the technician, who had worked 23 of the preceding 27 days and acknowledged sleeping poorly the night before performing the work, may also have contributed to the error. The seal replacement was initiated after consultation with a supervisor to correct an earlier oil leak whose source could not readily be identified.