Contributor - Safety

David Jack Kenny

Preliminary Reports

 


Eight Deaths in Fiery Takeoff Accident

 


IAI 1124A WestWind II, March 29, 2020, Ninoy Aquino International Airport, Manila, the Philippines – All eight on board perished and the aircraft was destroyed after catching fire during its takeoff roll on Runway 06.&nbsp;The medevac flight was departing for Haneda, Japan.&nbsp;Witnesses reported seeing sparks coming off the runway before the jet reached Taxiway R2.&nbsp;They continued until the airplane departed the runway safety area at the H1 intersection, struck two runway edge lights and a concrete electric junction box, and came to rest against the airport perimeter fence, where it was consumed by fire.&nbsp;Chunks of rubber, metal debris, and scrape marks from the hub of the right main wheel were found on the runway.&nbsp;Scrape marks from the left main wheel began near H1, where much of the left main tire was recovered.&nbsp;In addition to six Filipinos, the casualties included one U.S. and one Canadian citizen.&nbsp;

 


Czech Billionaire Among Heli-Skiing Victims

 


Eurocopter AS350B3, March 27, 2021, Knik Glacier, Alaska – Billionaire Petr Kellner, reputed to be the Czech Republic’s wealthiest citizen, was among five fatalities when a chartered helicopter struck a ridgetop during heli-skiing operations in the Chugach Mountain Range.&nbsp;The other victims included the pilot, two guides, and another skier.&nbsp;A single survivor, also a Czech national, was rescued with serious injuries.&nbsp;

 


Passengers boarded the helicopter at a lodge on Wasilla Lake for the 20-minute flight to the mountains.&nbsp;Data from a handheld GPS found in the wreckage showed that it flew multiple short legs in that area between 4:12 and 6:07 p.m.&nbsp;The final segment began at 6:27 when the helicopter climbed to 5,900 feet on a northwest heading.&nbsp;At 6:33 it slowed to a groundspeed of 1 knot at 6,266 feet, an estimated 14 feet above a ridgetop.&nbsp;It maneuvered&nbsp;at low altitude and airspeed for another three minutes before the data track ended near the site of the main wreckage.

 


After the ship did not return by its scheduled time of 8&nbsp;p.m., the company initiated a helicopter search that discovered the wreckage at about 9:30.&nbsp;An initial aerial survey of the site by NTSB investigators showed that the helicopter struck the ridge 15 to 20 feet below its the top, then slid some 900 feet down the slope.

 


Fatal Crash Mars Polar Bear Census

 


Aerospatiale AS350B2, April 25, 2021, Resolute Bay, Nunavut, Canada – Two pilots and a renowned polar bear biologist were killed when their helicopter went down while conducting a polar bear census in Lancaster Sound for Nunavut’s Department of the Environment.&nbsp;The chartered aircraft was reported missing at about 4:45 p.m. after it failed to return to base Sunday afternoon.&nbsp;A company Twin Otter was dispatched to its last known location and located the wreckage on Griffith Island, 22 km (13.7 miles) southwest of Resolute Bay.&nbsp;Rescuers reached the site early the next morning and found no survivors.&nbsp;Transportation Safety Board investigators were deployed to the site on April 29.

 


<h2>Final Reports</h2>

 


Unstable Approach Ends in Wing Strike

 


Beechcraft Hawker 850XP, July 26, 2017, Mykonos State Airport, Greece – The Turkey-registered corporate jet landed hard and its left wing struck the runway after an unstable approach in which the captain (acting as pilot monitoring) warned of an excessive descent rate, the stick shaker and stick pusher activated simultaneously, and the first officer ignored two instructions to go around on short final.&nbsp;The winglet, the trailing end of the flap, and the aileron drive cover were damaged, and the outer left main tire was flat-spotted.&nbsp;There were no injuries to either pilot or the sole passenger.

 


The flight from Istanbul was routine. Shortly after the crew was cleared to land and completed their landing checklist, the flight deck voice recorder captured the captain’s voice saying “Speed, speed vert” [sic].&nbsp;The stick shaker and stick pusher both activated during the descent from 200 to 100 feet; at 30 feet, the captain called for a go-around.&nbsp;After landing, the first officer laughed and said, “What have I done, my friend?”

 


The captain’s report attributed the hard landing to windshear, an explanation not supported by the airplane’s instruments, its voice and data recordings, or ground-based observations of steady five-knot winds from 180 degrees.&nbsp;The flight data recorder showed that during the last 1,400 feet of the descent, airspeed decayed from 125 to 100 knots, well below the calculated reference speed of 131 and barely above the 97-knot stall speed at its actual landing weight, with a left roll of 13.7 degrees upon touchdown.&nbsp;

 


Training, Regulatory Lapses Cited in Oahu Skydive Disaster

 


Beech 65-A90, June 21, 2019, Dillingham Airfield, Oahu, Hawaii – The NTSB’s analysis of the takeoff crash of a 52-year-old skydiving platform cataloged sweeping deficiencies in the FAA’s monitoring of flight instructor performance and its oversight of revenue flights conducted under FAR Part 91 in addition to specific shortcomings of the accident pilot and his employer, the Oahu Parachute Center (OPC).&nbsp;The pilot and all 10 passengers were killed when the 1967 King Air banked left just after takeoff, rolled inverted, and struck the ground in a 45-degree nose-down attitude.&nbsp;While the proximate cause was found to be “the pilot’s aggressive takeoff maneuver, which resulted in an accelerated stall and subsequent loss of control at an altitude that was too low for recovery,” the Board also cited uncorrected structural damage that reduced the airplane’s stall margin, an insufficient regulatory framework for skydiving and other for-profit Part 91 flights and the pilot’s substandard flight training as contributing factors.&nbsp;Passive FAA oversight of flight instructor performance as measured by student pass rates was implicated in the inadequacy of his initial instruction.

 


Investigators found that the 42-year-old, 900-hour pilot had failed the initial practical tests for his private pilot, instrument rating, and commercial pilot certificate.&nbsp;The areas requiring reexamination included “takeoffs, landings, go-arounds, performance and ground reference maneuvers, and multiengine operations” as well as instrument approach procedures.&nbsp;In each case, he passed the retest.&nbsp; Only 59 percent&nbsp;of his instructor’s students passed their checkrides on the first take, well below the national average of 80 percent&nbsp;during the same period, and most of the 52.5 hours of King Air time his CFI—who did not cooperate with the investigation—logged as “dual instruction” was apparently spent on long cross-country flights carrying passengers for a paying client.&nbsp;Other skydive pilots at Dillingham Field recalled that the accident pilot initially made “normal” takeoffs and landings&nbsp;but began to pitch and bank the airplane increasingly aggressively after takeoff to provide a “thrill ride” for his passengers.

 


The airplane, which had accrued some 15,000 hours and 25,000 cycles, had also suffered an accident on a skydiving flight in California in 2016.&nbsp;That pilot inadvertently stalled and spun the airplane three times before regaining control, overstressing it&nbsp;and separating the right horizontal stabilizer and elevator during the recovery.&nbsp;(The parachutists jumped during the second spin.)&nbsp;The stabilizer was replaced with a unit from an earlier model Beech 65-90 that was not approved for use in the accident airplane.&nbsp;Photographs taken after the occurrence and video shot on the ferry flight to Hawaii also showed wrinkles in the left wing’s upper skin, a raised ridge just aft of its forward spar, and compression buckling in the fairing covering the top rear spar attachment.&nbsp;None of these were addressed.&nbsp;The pilot who gave the accident pilot his check-out training said the airplane would not fly straight and level unless the aileron trim was in its full left-wing down position, which the airplane’s owner ascribed to “the left wing being bent.”&nbsp;Unairworthy conditions recorded in its logbooks included cable tensions far outside their nominal ranges that were left unadjusted and none of the daily engine compressor washes required when operating in a marine environment.

 


In response, the NTSB reiterated its call for tighter regulation of Part 91 passenger-carrying operations made in response to New York’s Liberty Helicopters accident and issued additional safety recommendations advocating closer FAA oversight of skydiving operations and development of an automatic system alerting FAA inspectors to instructors with substandard student pass rates.

 


Checklist Slippage Faulted in Metroliner Runway Excursion

 


Fairchild SA227-DC Metro 3, Feb.&nbsp;24, 2020, Dryden Regional Airport, Ontario, Canada – A runway excursion that caused severe airframe and powerplant damage was traced to the pilots’ failure to restart an interrupted checklist.&nbsp;The flight deck&nbsp;voice recording showed that as the first officer began the “Start Locks” item of the “Before Taxi” checklist, the captain had him stand by while he discussed flight plans and departure details with the destination radio operator.&nbsp;Rather than resuming “Before Taxi,” he then called for the “Before Takeoff” checklist, leading the Metroliner to begin its takeoff roll with the right propeller’s start locks still engaged. The flight data recording showed increasing torque on the left engine but not the right.&nbsp;

 


The airplane veered off the right side of Dryden Regional Airport’s Runway 12 and struck a frozen snowbank.&nbsp;The composite wood-epoxy blades of both propellers shattered, penetrating the fuselage skins and reinforcement panels on both sides of the fuselage.&nbsp;One passenger was seriously injured by propeller fragments penetrating the cabin.&nbsp;Both engines and both propeller hubs were subsequently found to be free of pre-impact abnormalities.&nbsp;The TSB noted that composite propeller blades are lighter than aluminum equivalents but “have poor ductile qualities, resulting in a shattering failure mode” rather than bending or curling.

 


The TSB also noted that slips of attention during “routine, well-practiced tasks” are a hazard that checklists are intended to mitigate.&nbsp;Interruptions can cause users to lose track of their point in the sequence.&nbsp;In this case, crew resource management might also have been impeded by an unusually steep authority gradient: the captain was a 20-year, 20,000-hour veteran, while the first officer was on the first day of his line indoctrination training.

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