Contributor - Safety

David Jack Kenny

<h2>Preliminary Reports</h2>

 


<h5>Taquan Suffers Two Fatal Accidents in One Week</h5>

 


de Havilland DHC-3 Otter and de Havilland DHC-2 Beaver, May 13, 2019, Ketchikan, Alaska; and de Havilland DHC-2 Beaver, May 20, 2019, Metlakatla, Alaska—Ketchikan-based air tour, charter, and commuter operator Taquan Air was staggered by fatal accidents on two successive Mondays, resulting in the deaths of one of its pilots and two passengers.&nbsp;Nine passengers on the first flight suffered serious injuries in a mid-air collision that killed all five on board a DHC-2 Beaver operated by Mountain Air Service, also based in Ketchikan.&nbsp;Taquan voluntarily suspended all flight operations after the second accident.&nbsp;Scheduled commuter flights resumed 10&nbsp;days later after an internal safety audit, and sightseeing flights resumed on June 3.

 


On May 13, Taquan’s Otter collided with Mountain Air’s Beaver over the west side of George Inlet as both airplanes were returning from sightseeing flights through the Misty Fjords National Monument.&nbsp;The accident occurred at an altitude of 3,350 feet as the Otter’s pilot was maneuvering to show his passengers a waterfall near Mahoney Lake.&nbsp;He did not observe any conflicting traffic on the airplane’s ADS-B display&nbsp;but did see “a flash” on his left side just before impact.&nbsp;He maintained partial control of the aircraft and was able to flare to cushion its descent; bystanders helped the occupants reach shore.&nbsp;The airplane subsequently sank in 80 feet of water about 400 feet offshore.&nbsp;The Beaver broke up in flight, scattering wreckage over a debris field measuring about 2,000 by 1,000 feet.&nbsp;The right wing showed a number of progressively deeper cuts “consistent with impacts from propeller blades.”&nbsp;Skies were reported to be clear with 10 miles’ visibility.

 


On May 20, a scheduled commuter flight carrying one passenger, cargo, and mail cartwheeled and sank during a water landing in Metlakatla Harbor, about 16 miles southeast of Ketchikan.&nbsp; The pilot and passenger were both killed.&nbsp;Weather was fair, with clear skies, 10 miles' visibility, and 10-knot winds from the southeast.&nbsp;Witnesses described the DHC-2 Beaver making a normal approach on a westerly heading, with some wing rock prior to touchdown.&nbsp;One reported seeing the right wingtip strike the water, while a second said that the tip of the right float dug in.&nbsp;Two boats responded to the scene, followed by EMTs on a Metlakatla police vessel.&nbsp;The occupants were extracted but pronounced dead on arrival at the Annette Island Health Center.

 


The company described the Beaver’s pilot as a “new seasonal hire.”&nbsp;He held a commercial pilot certificate with single-engine land, single-engine sea, and instrument airplane ratings, but at the time of his hiring, only five of his 1,606 hours were in floatplanes.&nbsp;Since then, however, he had completed company Part 135.293 and 135.299 checkrides, and subsequently fulfilled the initial operating experience requirements of Part 135.244.

 


<h6>Citation Pilot Lost Consciousness Before Ditching</h6>

 


Cessna 560, May 24, 2019, 310 miles east of Fort Lauderdale, Florida—U.S. Air Force pilots dispatched to intercept the jet after it overflew its destination observed the pilot “unconscious and slumped over the controls.” The interceptors continued to track the errant aircraft until it descended into the Atlantic Ocean some 310 miles out to sea.&nbsp;Neither the pilot, who is presumed to have been killed, nor the airplane has been recovered.

 


The airplane had been sold two days earlier.&nbsp;Following a progressive inspection completed on May 22, the new owner engaged a contract pilot to fly it to&nbsp;Fort Lauderdale Executive Airport (FXE) for avionics work.&nbsp;The pilot checked in with the Atlanta Air Route Traffic Control Center (ARTCC), reporting that he was in level flight in smooth conditions at Flight Level 390, but did not respond to a subsequent handoff to the Jacksonville ARTCC.&nbsp;Jacksonville continued to monitor the flight by radar as it passed through first its and then Miami’s airspace.&nbsp;The jet overflew FXE at FL390 and continued eastbound until it descended.

 


The 9,000-hour ATP held “numerous type ratings,” including single-pilot certification for the Cessna 560.&nbsp;The Coast Guard initiated a search but suspended it the following day.

 


<h5>Luxury Hotel’s Helicopter Downed in the Caucasus</h5>

 


Bell 505 JetRanger X, June 6, 2019, Kazbegi, Republic of Georgia—A helicopter owned by the Rooms, one of Georgia’s premium operators of luxury hotels, crashed in a remote area near Qulo mountain in Kazbegi municipality.&nbsp;The pilot and both passengers, described as employees of the hotel’s owner the Adjara Group, were killed.&nbsp;Kazbegi is a popular tourist destination known for its views of the Greater Caucasus mountain range, and the hotel offers its guests a variety of mountain excursions.&nbsp;Though a power line tower is visible in photographs of the accident scene, utility company EnergPro Georgia stated that the helicopter did not contact transmission cables; there were no service interruptions on that day.

 


<h5>Pilot Only Casualty of Manhattan Helicopter Crash</h5>

 


Agusta A109E, June 10, 2019, New York, New York—The solo pilot was killed and the aircraft largely consumed by fire after a helicopter crashed onto the roof of a 54-story building in midtown Manhattan.&nbsp;Weather was reported to include low clouds, with visibility of a mile and a quarter and heavy rain reported in Central Park.&nbsp;La Guardia International reported overcast ceilings at 700 feet, barely higher than the elevation of the accident site.&nbsp;The 58-year-old pilot had held a commercial helicopter rating since 2004 and was also a rotorcraft flight instructor but did not hold an instrument rating, and an FAA spokesman has stated that he was not in contact with air traffic control.

 


The pilot took off from the East 34th Street heliport at about 1:32 p.m. Unconfirmed reports suggest that his destination was the airport in Linden, New Jersey.&nbsp;Heliport staff told police that he subsequently radioed that he needed to return, but was unsure of his location.&nbsp;Tracking data show that he flew around Battery Park at the southern tip of Manhattan and then up the island’s west side before turning in toward midtown, an area subject to a TFR due to its proximity to Trump Tower. The accident site on Seventh Avenue was less than half a mile from that building, well inside the TFR.

 


The pilot had flown for the aircraft’s operator for five years and was described by colleagues as “deeply familiar” with the area.&nbsp;At press time, the NTSB’s preliminary report had&nbsp;not been released.

 


<h2>Final Reports</h2>

 


<h5>Runaway Trim, Inoperative Warning Circuits Implicated in Destruction of Brazilian Citation</h5>

 


Cessna 650, October 10, 2015, Chapadão Farm, Mato Grosso, Brazil—A pitch trim runaway that led to the airplane’s uncontrolled descent was attributed to a combination of an unresolved squawk in the physical flight-control system, failure of the instrument panel annunciator, and poor checklist discipline on the part of&nbsp; the pilots, who neglected to verify operation of the primary and secondary trim systems before takeoff.&nbsp;Two pilots and two passengers were killed when their airplane made an abrupt descent from FL380 at rates that eventually surpassed 30,000 feet per minute.

 


Cockpit voice recordings suggested that the crew was using checklists that had not been updated to include required tests of the Stabilizer Trim Backdrive Monitor.&nbsp;The CVR also recorded sounds consistent with the crew’s activating the secondary trim control, normally reserved as an emergency back-up, before takeoff.&nbsp;The recording further suggests that the pilots were unable to trigger the PRI TRIM FAIL and SEC FAULT annunciators using the standard test procedure, but chose to board passengers and take off anyway.&nbsp;Further conversations suggested that the primary pitch trim system remained inoperative, taking the autopilot off line as well.&nbsp;The flight proceeded uneventfully for 21 minutes, until the pilots attempted to re-engage the primary pitch trim system.&nbsp;A series of clacker noises indicating uncommanded movement of the horizontal stabilizer followed.&nbsp;The crew reduced power and attempted to re-engage the secondary trim circuit, but no further sounds indicating movement of the horizontal stabilizer were recorded afterward.

 


<h5>Multiple Irregularities Cited in Fox Glacier Crash</h5>

 


Airbus Helicopters AS350BA, November 21, 2015, Fox Glacier, New Zealand—The Transportation Accident Investigation Commission's final report identified several irregularities in the operator’s organization and procedures that the investigators viewed as conducive to fostering an inadequate safety culture.&nbsp;Six passengers and their pilot were killed when the aircraft crashed onto Fox Glacier shortly after landing on Chancellor Shelf, a landing zone and popular photo platform about 800 feet above the accident site.&nbsp;Rapidly changing weather on the morning of the accident had already forced cancelation of three sightseeing flights, but after transporting a group of glacier guides to a lower location in the Fox Glacier valley, the pilot concluded that conditions had improved enough to allow sightseeing flights.

 


Photographs downloaded from passengers’ cameras and cell phones retrieved from the debris field show the helicopter on the ground at Chancellor Shelf.&nbsp;At least one appears to show falling snow and minimal visibility.&nbsp;Examination of the wreckage showed that the helicopter struck the glacier at a high rate of forward speed with the engine and main rotor system developing power, suggesting that the pilot may have flown too close to the surface while proceeding down the valley in flat light.

 


The report also notes that thanks in part to their operations manual’s lack of any formal criteria for that qualification, the operator had promoted the pilot to “A” category—considered a senior pilot with authorization to fly unsupervised to any landing site—despite relatively low make-and-model and mountain flying experience and ambiguities in his training record.&nbsp;More seasoned pilots flying in the vicinity acknowledged feeling surprised that he chose to go farther up the valley given that morning’s rapidly changing weather conditions.

 


The report noted that the use of standardized passenger weights in place of physical weighing led to the helicopter taking off at least 65 kg (145 pounds) above its maximum gross weight.&nbsp;It was still 47 kg (97 pounds) above maximum gross when it lifted from the Chancellor Shelf, and its tail rotor servo had been operated for 38 hours past a maintenance deadline that had already been extended. Investigators listed neither as a contributing factor.

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