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Accidents: April 2019
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Preliminary and final reports
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Preliminary and final reports
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Preliminary Reports


King Air Lost in Frederick Sound


Beech 200, Jan. 29, 2019, Kake, Alaska—A Guardian Flight air ambulance en route to pick up a patient crashed into the waters of Frederick Sound after veering off course during an instrument approach to the coastal village of Kake, Alaska. The pilot, paramedic, and flight nurse are all presumed to have been killed. The Anchorage-based airplane’s radio communications with air traffic control were normal through the time the flight was cleared to change to the airport’s local advisory frequency, after which no further transmissions were received.


In its preliminary report, the NTSB described radar track data that show the aircraft beginning a gradual descent after crossing the initial approach fix at 5,000 feet. Before reaching the next waypoint 10.5 miles to the northeast, it turned right to a southerly heading and began to descend rapidly, losing 2,575 feet in 14 seconds (a rate of more than 11,000 feet per minute). The following day search-and-rescue teams located floating wreckage near Point Gardiner in the Chatham Strait, about 22 miles west of the airport.


A February 12 story in the Anchorage Daily News reported that boat-based sonar equipment had detected signals from the cockpit voice recorder’s “pinger” off the southern tip of Admiralty Island. At press time neither the aircraft nor the remains of its crew had been recovered.


Tourism and Aviation Minister Among Seven Casualties in Nepalese Helicopter Crash


Eurocopter AS350B3E, Feb. 27, 2019, Taplejung District, Nepal—Nepal’s Minister of Tourism and Civil Aviation, two deputy directors of the country’s Civil Aviation Authority, and a personal aide to the prime minister were among the seven killed when an Air Dynasty helicopter went down in the northeastern Taplejung district. The other casualties included the pilot, an army officer, and Air Dynasty’s chairman, a well-known tourism entrepreneur. The helicopter had just taken off from the famed Pathibara Devi temple, located at an elevation of 12,448 feet; the crash site was downslope at about 10,000 feet. 


Poor weather was reported across Nepal the afternoon of the accident, and initial accounts suggested that the helicopter went out of control and hit a cliff face after entering a cloud.  About 45 minutes before the accident, the pilot had advised controllers at the Taplejung Airport that he was unable to depart due to heavy snowfall. Interviews with local residents conducted in the initial stage of the inquiry suggest that the pilot might have been influenced by reports of better conditions at lower elevations.


Photographs from the scene show that the aircraft was almost entirely consumed by a post-crash fire, with only a small portion of the tailboom remaining recognizable. Following their temple visit, the occupants had intended to inspect the airport construction site at Chuhan Danda.


No Survivors in Red River Turboprop Crash


Piper PA-31-350P Malibu Mirage DLX, Feb. 28, 2019, Shreveport, Louisiana—The pilot and sole passenger were killed when their single-engine airplane went down in the Red River while attempting to return to Shreveport Downtown Airport just after takeoff. The airport’s control tower received a distress call shortly before contact with the aircraft was lost. Using sonar, searchers from the Bossier and Caddo Parish Sheriff’s Departments located the wreckage just off the departure end of Runway 33 in about 17 feet of water, but they were unable to send in divers due to the swift current and poor visibility. Commercial divers using heavy equipment recovered the aircraft and its occupants’ remains three days later.


The 1999-model airplane’s original 350-horsepower piston engine had been replaced with a 560-horsepower Pratt and Whitney turbine in 2016 under a supplemental type certificate issued to JetProp LLC. The airplane departed on an IFR flight plan for Vernon, Texas. According to an NTSB investigator on the scene, it made two left 360-degree turns before turning right and descending into the river.


Five Killed Departing Kenyan Island Preserve


Bell 505 Jet Ranger X,  March 3, 2019, Central Island National Park, Lake Turkana, Kenya—One of the personal pilots of Kenya’s deputy president and four American tourists died in a late-evening crash on Lake Turkana’s Central Island National Park. The accident helicopter was one of a flight of two transporting visitors to the “Gem of Lake Turkana,” known for its three crater lakes and diversity of wildlife. The other helicopter landed uneventfully after the 15-minute return flight to the group’s base camp.


The passengers were reportedly pursuing plans to develop a helicopter tourism business based at Lake Turkana, described by Kenya Wildlife Services as the world’s largest permanent desert lake. They had flown to the island earlier in the evening to watch the sunset, but rising winds and worsening weather delayed their return. The passengers chose to return to base rather than spend the night at the island’s tent camp, and both aircraft lifted off a few minutes apart in near-darkness at about 8:30 p.m. The Kenyan military mobilized search-and-rescue efforts after the accident aircraft failed to arrive, discovering the wreckage around 3:30 a.m. 


Final Reports


Air-tour Accident Attributed to Missing Oil Filter


Eurocopter EC 130 B4, June 27, 2017, Boulder City, Nevada—The loss of power that brought down a Grand Canyon air tour helicopter has been traced to miscommunication between the helicopter’s operator and manufacturer during routine preventive maintenance. The pilot responded to indications of an engine failure by attempting an autorotation to a nearby helipad but was forced to make an up-slope landing on mountainous terrain after the retreating main rotor blade clipped a power line. Two of six passengers on the sightseeing flight suffered minor injuries; the pilot and the remaining passengers were unhurt.


The NTSB attributed the seizure of the gas generator and power turbine to oil starvation precipitated by obstruction of the number two oil jet of the axial compressor rear bearing. This obstruction was in turn traced to the fact that the helicopter had been operated without an oil filter, which had been removed by the manufacturer as part of its normal arrival inspection procedure after the accessory gearbox was separated from the engine during scheduled maintenance. Logbook review determined that the gearbox was not due for overhaul, and after some confusion, it was returned to the operator and approved for reinstallation. The NTSB concluded that the manufacturer neither replaced the oil filter nor advised the aircraft’s operator that it had been removed. The helicopter flew for 109.6 hours without a filter before the engine seized.


Brake Failure Causes Taxi Collision


Cessna Citation Bravo 550, April 15, 2018, Winnipeg, Manitoba, Canada—A U.S.-registered Cessna Citation collided with a parked Canadian-registered Challenger 605 after the Citation’s brakes failed while taxiing for takeoff. The Cessna’s right wing struck the Challenger’s nose gear and its nose hit the Challenger’s right wing. The airport ground crew contained a fuel leak from the Cessna’s right wing without a fire, but the collision caused substantial damage to both aircraft.


The Citation was departing for Bedford, Massachusetts, after a 20-minute fuel stop en route from Calgary, Alberta. When the pilot attempted to follow a marshaller’s signals to turn left onto Taxiway C, the airplane did not respond to left brake pressure and continued to accelerate without turning. The pilot applied both toe brakes without effect but did not trigger the pneumatically powered emergency brakes. He shut down the airplane’s engines after the collision, and he and his passenger deplaned through the cabin door.


Post-accident examination found that the electric motor boosting the power brake system’s hydraulic pump had failed due to excessive binding between the armature and stator. In addition, the LO BRK PRESS annunciator light on the airplane’s instrument panel was inoperative due to the low-pressure switch activating the circuit having jammed open, possibly because of corrosion. Both the pump and the annunciator circuit were last inspected on May 1, 2017, approximately 82 flight hours before the accident.


Pilot Inexperience, Departure Path Cited in Quebec Floatplane Accident


de Havilland Canada DHC-2 Beaver, July 1, 2018, Jules Lake, Quebec, Canada—The pilot of a de Havilland Canada Beaver that went into trees after a rejected takeoff had relatively little floatplane experience and had flown into the accident site only twice, both times in the preceding week and both times departing in an empty aircraft. Company records indicate that most of his 4,450 hours of flight experience had been logged in wheeled aircraft operating between paved airports. His 387 hours in the DHC-2 included proficiency checks involving small-lake operations and rejected takeoffs. However, he’d acknowledged uneasiness with departures from Jules Lake due to the restricted takeoff distance available and rising terrain surrounding the site.


After boarding three passengers at a lakefront cottage, the pilot attempted to take off in a straight line rather than turning east to align with the lake’s longest axis, the practice typically followed by other floatplane pilots. This reduced the available takeoff distance from about 3,200 feet to 2,500 while also requiring the airplane to climb over steeper terrain once airborne. After the Beaver lifted “onto the step,” the pilot concluded that not enough distance remained to allow it to clear obstructions on the far shore; he consequently closed the throttle but was unable to bring the aircraft to a stop before it struck the bank and collided with trees. No injuries resulted. The pilot and passengers were evacuated by another company aircraft, and the accident aircraft was subsequently flown back to Lake Margane, where it was found to be loaded within weight-and-balance limitations. There was no evidence of mechanical malfunction.


The Transportation Safety Board noted that the airplane’s operator, Air Saguenay, is one of relatively few in the bush-flying industry that imposes systematic training and experience requirements on pilots operating to and from lakes with “limiting conditions” including short departure paths.

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