Contributor - Safety

David Jack Kenny

<h1><b>Preliminary Reports</b></h1>
<h2><b>One Killed, Five Hurt in North Sea Training Accident</b></h2>
<h3>Sikorsky S-92A, Feb. 28, 2024,15 nm west of Bergen, Norway</h3>
<p>A search-and-rescue (SAR) crew located five of the six crew members after the helicopter crashed into the sea near Sotra Island but had to return to base for fuel before locating the sixth. By the time a second flight found her, the 61-year-old nurse had been in the water more than 25 minutes. She was pronounced dead on arrival at the hospital; one survivor was hospitalized in critical condition and a second was described as seriously hurt.</p>
<p>The wreckage was subsequently recovered from a depth of 220 meters (720 feet). Records retrieved from the flight data recorder led investigators to conclude that the crash “cannot be described as a controlled emergency landing,” possibly explaining why the aircraft’s emergency floats did not activate. The accident, which prompted a brief safety standdown, occurred while the crew was training to conduct SAR operations.</p>
<h2><b>Five Perish in ILS Undershoot</b></h2>
<h3>IAI 1125 Westwind, March 10, 2024, Hot Springs, Virginia</h3>
<p>Both pilots and all three passengers were killed when the twin-engine jet struck trees about 300 feet short of the threshold of Runway 25 of Ingalls Field Airport (KHSP). Although the operator, SkyJet Elite, held a Part 135 charter certificate, the trip from Florida’s Fort Lauderdale/Hollywood International Airport was filed as a personal flight under FAR Part 91.</p>
<p>The passengers had planned to attend a conference in Hot Springs while the crew was set to continue to Teterboro Airport in New Jersey.</p>
<p>At about 14:30 local time when the aircraft was 60 nm south of Hot Springs, the crew checked in with Washington Air Route Traffic Control Center and was instructed to inform on which instrument approach they wanted to use. At 14:32, a controller again asked about the approach and if they had the current weather and notams. The crew requested ILS approach to Runway 25 and said their weather information was about an hour old.</p>
<p>About 14:41, the flight crew advised they had the current weather and notams and a few minutes later were cleared to fly direct to the AHLER intersection, which was an initial fix for the ILS approach to Runway 25 about 10 nm northeast of the airport. The flight crew read back the clearance and requested radar vectors for the approach, but were subsequently told to proceed directly to AHLER and cleared for the approach. At 14:47 the flight crew advised that they would cancel their IFR flight plan once on the ground at Hot Springs with the flight service station, and ATC said that the crew could cancel with the controller on the ground. The ATC told the crew there was no traffic observed between their aircraft and the airport and advised them to switch to the common traffic advisory frequency (CTAF). The flight crew readback the instruction; it was the final communication with the controller.</p>
<p>An airport staff member heard the crew announce their intention to land over the CTAF. Shortly after, he heard the aircraft crash and saw smoke rising from the approach end of Runway 25.</p>
<p>The debris path was approximately in line with the runway centerline, oriented 250 to 255 degrees, and spanned 151 feet. Extensive impact damage precluded confirming flight control continuity. Investigators determined that the landing gear was down and flaps extended to 40 degrees; damage to both engines suggested they were operating until impact.</p>
<p>A weather observation recorded three minutes after the accident included winds from 280 degrees at 19 knots gusting to 38, 10 miles visibility, and scattered clouds at 2,000 feet beneath a 2,400-foot broken layer and a 4,500-foot overcast.</p>
<h2><b>Few Clues about Cause of Hawker Fatal</b></h2>
<h3>Beechcraft Hawker 900XP, Feb. 7, 2024, Westwater, Utah</h3>
<p>The National Transportation Safety Board’s (NTSB) preliminary report on the fatal accident contains details of the final flight. However, it sheds little light on what might have caused the twinjet to descend seemingly out of control and crash near Westwater, Utah. The two pilots were killed in the planned Part 91 IFR positioning flight from Grand Junction Regional Airport (KGJT), Colorado, to Gig Harbor, Washington.</p>
<p>The airplane, operated by Vici Aviation and managed by Clay Lacy Aviation, arrived at West Star Aviation’s facility at GJT on Dec. 20, 2023, for routine maintenance. According to West Star, multiple routine inspections had been completed on the airplane, including a requirement to remove the wing leading edges and TKS panels to inspect for cracks and signs of corrosion. After the inspections were completed, the airplane was returned to service on February 6.</p>
<p>During the positioning flight, the pilots planned to perform a stall warning and systems check per the airframe manufacturer’s requirements. These requirements, listed in the pilot’s operating manual, included an altitude above 10,000 feet agl, 10,000 feet above clouds, and below 18,000 feet msl. In addition, this check could be conducted only during day VMC with a good visual horizon, the autopilot disengaged, an operative stall warning system, the external surfaces free of ice, the ventral fuel tank empty, and weather radar on standby.</p>
<p>After the airplane departed GJT at 10:37 and entered a climb on a southeast heading, ATC approved the pilots’ request for a block of altitude from FL180 to FL200. At about 10:44, the aircraft leveled off at FL200. Three minutes later, ADS-B flight track data showed the airplane in a rapid descent in a circular pattern that resembled the shape of a corkscrew.</p>
<p>The airplane made multiple rotations before crashing into open terrain. The flight data recorder and cockpit voice recorder were recovered and the wreckage has also been retained for further examination. The accident site was IMC at the time of the accident.</p>
<h1><b>Final Reports</b></h1>
<h2><b>Pilot Inexperience Cited in Fatal Approach Crash</b></h2>
<h3>Piper PA-46-500TP, Nov. 9, 2022, Bignell, Nebraska</h3>
<p>The NTSB identified the 505-hour private pilot’s “lack of total instrument experience” as having contributed to “spatial disorientation, loss of control, and an impact with terrain” during flight into low instrument conditions and turbulence.</p>
<p>The pilot and his only passenger were killed when the single-engine turboprop veered left from the course of the ILS approach to Runway 30 of the North Platte Regional Airport (KLBF), descending at a rate that eventually exceeded 5,000 fpm.</p>
<p>Prevailing conditions included a 300-foot overcast with light freezing drizzle; an Airmet for low-level wind shear was in effect for a 20-knot change in wind speed within 2,000 feet of the surface. Sounding data “indicated a high potential for moderate or greater turbulence between 3,600 and 5,500 feet msl” in a temperature inversion.</p>
<p>The 41-year-old pilot had purchased the airplane about three weeks earlier and received 10 hours of ground instruction and 15.1 hours of dual instruction in the accident airplane in the course of his transition training.</p>
<p>The instructor “gave the pilot a low average score at the completion of the training” which included 1.0 hour in actual instrument conditions encountered in the course of high-altitude instruction. He flew another 9.4 hours in the 12 days after completing transition training but had logged only 5.2 total hours in actual instrument conditions.</p>
<p>ADS-B track data showed that during the last minute of the flight the airplane’s descent rate increased from 500 to 3,000 fpm. In the last 30 seconds it entered a 2,000-fpm climb, then entered a descending left turn that exceeded 5,000 fpm. The pilot of a Cessna 208 freighter inbound from Omaha behind the accident flight recalled current weather reported as one to two miles visibility under a 200-foot overcast with light freezing rain.</p>
<p>He anticipated a “very demanding” approach with potential icing and a tailwind when landing on Runway 30 and acknowledged that the terminal area forecasts provided to himself and the accident pilot “were somewhat behind the actual reported weather conditions.” He flew two holding patterns before diverting to an airport farther south after that aircraft could not be located.</p>
<h2><b>Glacier Impact Attributed to Flat Light</b></h2>
<h3>Bell 206L, June 28, 2023, Grise Fiord, Nunavut, Canada</h3>
<p>Flat light conditions and featureless terrain were cited in the helicopter’s collision with a glacier in the Devon Ice Cap while attempting to drop markers to better define a landing zone. The pilot and both passengers, surveyors for the Polar Continental Shelf Program, escaped with minor injuries.</p>
<p>The accident occurred on the second attempt to land on the glacier, the pilot having broken off the first after determining that the surface was too indistinct for a safe landing approach. The helicopter returned to Truelove Inlet so the pilot could “make markers to drop onto the glacier to improve the surface definition at the landing area.”</p>
<p>The second flight departed at 10:18, flying in unrestricted visibility at an altitude of 3,800 feet under an overcast layer. The pilot crossed the glacier at an altitude of 75 feet to 100 feet, slowing the rotorcraft to about 30 knots.</p>
<p>After passing rocks serving as a reference point, the pilot lost visual contact with the surface and allowed the helicopter to enter a shallow descent, coming into contact with rising terrain in “a slight lateral motion to the right” that progressed to dynamic rollover. There was no fuel spill or post-impact fire, and after all three escaped the wreckage, a passenger was able to contact the program office in Resolute Bay via satellite phone. A rescue flight arrived two and a half hours later.</p>
<p>The Transportation Safety Board of Canada’s report notes that flat-light conditions can deprive pilots of both depth perception and contrast sensitivity, and scene photographs taken just after the accident confirm the lack of any definite horizon at the site.</p>


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