Executive/Corporate/Business

The pilot obtained two data user access terminal service (DUATS) preflight weather briefings for the intended flight from the U.S. to Nassau, Bahamas; the briefings included information that thunderstorms were forecasted. The pilot did not request a weather briefing with DUATS or Lockheed Martin flight service station before departure on the return accident flight. Although there was no way to tell whether he received a preflight weather briefing with Nassau Flight Service Station before departure on the accident flight, thunderstorms with associated severe turbulence were forecasted for the accident area well in advance of the aircraft's departure, and would have been available had the pilot requested/obtained a preflight weather briefing. After takeoff, and while in contact with Nassau terminal radar approach control, which had inoperative primary radar, the flight climbed to approximately 8,000 feet mean sea level and proceeded on a northwesterly heading with little deviation. The airplane, which was equipped with color weather radar and a stormscope, penetrated level 6 radar returns with numerous lightning strikes in the area, and began a steep descent. Prior to that there was no request by the pilot to air traffic control for weather avoidance assistance or weather deviation. Radar and radio communications were lost, and the wreckage and occupants were not recovered.

The flight was on a VHF Omni Range (VOR) instrument approach to the destination airport at the time of the accident. Radar track data indicated that the airplane passed the VOR at 2,800 feet. After passing the VOR, it turned right, becoming established on an approximate 017- degree magnetic course. The published final approach course was 341 degrees. The airplane subsequently entered a left turn, followed immediately by a right turn, until the final radar data point. Altitude returns indicated that the pilot initiated a descent from 2,800 feet upon passing the VOR. The airplane descended through 2,000 feet during the initial right turn, and reached a minimum altitude of 1,400 feet. The altitude associated with the final data point was 1,600 feet. The initial impact point was about 0.18 nautical miles from the final radar data point, at an approximate elevation of 1,235 feet. The minimum descent altitude for the approach procedure was 1,720 feet. Review of weather data indicated the potential for moderate turbulence and low-level wind shear in the vicinity of the accident site. In addition, icing potential data indicated that the pilot likely encountered severe icing conditions during descent and approach. The pilot obtained a preflight weather briefing, during which the briefer advised the pilot of current Airman's Meteorological Information advisories for moderate icing and moderate turbulence along the route of flight. The briefer also provided several pilot reports for icing and turbulence. A postaccident inspection of the airframe and engines did not reveal any anomalies associated with a preimpact failure or malfunction.

The 2,212-hour instrument rated commercial pilot collided with terrain while circling to land after completing an instrument approach to an uncontrolled non-towered airport. The airport had two instrument approaches to Runway 14; a VOR and a RNAV(GPS). The published minimums for a circling approach to Runway 32 are a 500 foot ceiling and one mile visibility (VOR14) and a 700 foot ceiling and one mile visibility for RNAV(GPS) to Runway 14. The weather at the airport at the time of the accident was reported as 300 overcast, visibility of 3/4 of a mile in mist, with winds from 020 degrees at 10 knots gusting to 14 knots. Two witnesses reported that the airplane circled over the airport and then descended straight to the ground. Radar data revealed that after the airplane made the instrument approach to Runway 14, at approximately 2,800 feet mean sea level (msl), the airplane initiated a circling turn to the left and a slight descent. The last radar hit showed the airplane at 2,600 feet at a groundspeed of 186 knots. A post impact fire consumed some of the airframe. The pilot's logbooks were not located during the course of the investigation and his instrument experience and currency could not be determined. The pilot was reported to be very familiar with the airport and the 2 instrument approaches. A detailed examination of the wreckage of the airplane failed to reveal any anomalies with the airframe, structure, or systems. Flight control continuity was established at the accident site. The engines were examined, and no mechanical anomalies were found. The propellers were shipped to the manufacturer's facility for examination and teardown. Both propellers were rotating at the time of ground impact. Neither of the two propellers was found in the feathered position. Blade damage was consistent with both propellers operating under power at the time of impact. No mechanical defects were noted with either propeller.

During the flight, the private pilot/operator was most likely seated in the left seat. He obtained his instrument rating about 7 months prior to the accident, and had accumulated approximately 300 hours of flight experience; of which, about 80 hours were in the accident airplane. The commercial pilot/company pilot was most likely seated in the right seat. He had accumulated approximately 1,000 hours of flight experience; of which, about 125 hours were actual instrument experience, and 80 hours were in the accident airplane. The commercial pilot had filed a flight plan to the wrong airport, received a weather briefing for the wrong airport, and therefore was not aware of the NOTAM in effect for an out of service approach lighting system at the destination airport. When the commercial pilot realized his error, he changed the flight plan, but did not request another weather briefing. According to radar information, the airplane flew the instrument landing system runway 5 approach fast, performed a steep missed approach to 1,000 feet, and then disappeared from radar, consistent with a loss of control during the missed approach. No preimpact mechanical malfunctions were identified with the airplane during the investigation. The reported weather at the accident airport included an overcast ceiling at 200 feet, visibility 1 mile in light rain and mist, and wind from 160 degrees at 4 knots. The investigation could not determine which pilot was flying the airplane at the time of the accident.

The airplane was operated by a company pilot. A noncompany pilot, who had not attended or completed a training course or received a checkout for Raytheon Aircraft Company Beech King Air 200 airplanes, was asked by the pilot to accompany him on the flight so that the noncompany pilot could accumulate flight time. The flight only required one pilot. While the airplane was in cruise flight (27,000 feet mean sea level), the cockpit voice recorder (CVR) recorded the sound of the windshield fracturing. The CVR transcript indicated that the company pilot was not in the cockpit when the windshield fractured because he was emptying trash in the cabin. This action showed poor judgment considering the noncompany pilot was not qualified in the airplane. Although the windshield stayed in place, the company pilot stated that “within seconds” after it fractured, he depressurized the airplane because he was unsure about the windshield’s “integrity.” However, the Beech King Air Airplane Flight Manual (AFM) states to maintain cabin pressurization in the event of a fractured windshield and further states that the airplane can continue flight for up to 25 hours with the windshield fractured. During the on-scene examinations, an unapproved document (not derived from the AFM) that contained several checklists was found on the airplane. The company pilot stated that he used this document and that it “came with the airplane.” The document did not include a checklist addressing a cracked or shattered windshield. The company pilot most likely was not aware that the airplane should not have been depressurized nor that it could operate for 25 hours after the fracture occurred and, therefore, that the fractured windshield did not present an in-flight emergency. The CVR transcript revealed that, after depressurizing the airplane, the pilots attempted to use the oxygen masks but were unable to receive any oxygen. (The pilots most likely did not turn the oxygen on once they needed it because they either forgot as a result of the emergency or because they did not have time to do so before they lost consciousness.) According to the company pilot, during his preflight inspection of the airplane, the oxygen system was functional. He stated that, after the inspection, he turned the oxygen system ready switch to the OFF position because he wanted to “save” the oxygen, which was not in accordance with the Before Start checklist in the AFM. Post accident functional testing of the oxygen system revealed normal operation. The unapproved checklists document did not include the instruction to leave the oxygen system on. Regardless, the pilot stated that he knew the approved checklist stated to leave the oxygen system on but that he still chose to turn it off. The pilot exhibited poor judgment by using an unapproved, incomplete checklists document and by knowingly deviating from approved preflight procedures. About 1 minute after the pilots tried to get oxygen, the CVR recorded the last comment by either pilot. For about the next 7 minutes until it stopped recording, the CVR recorded the sounds of increased engine propeller noise, the landing gear and overspeed warning horns, and altitude alerts indicating that the airplane had entered an uncontrolled descent. (The CVR’s 4-g impact switch was found in the open position during the on-scene examination, indicating that the airplane experienced at least 4 acceleration of gravity forces.) Further, a plot of two radar data points, recorded after the last pilot comment, showed that the airplane descended from 25,400 feet to 7,800 feet within 5 minutes. Shortly thereafter, the pilots regained consciousness and recovered from the uncontrolled descent. The airplane was substantially damaged by the acceleration forces incurred during the uncontrolled descent and subsequent recovery. Examination of the windshield revealed that a dense network of fractures was located on the inner glass ply; however, the windshield did not lose significant pieces of glass and maintained its structural integrity. Therefore, the fractures did not preclude safe continued flight. Post accident examinations revealed evidence that the fracture initiated due to a design deficiency in the glass. The manufacturer redesigned the windshield in 2001 (the accident airplane was manufactured in 1998), and no known similar fractures have occurred in the newly designed windshield. The manufacturer chose not to issue a service bulletin for a retrofit of the new windshield design in airplanes manufactured before 2001 because the fracture of one pane of glass is not a safety-of-flight issue.

Witnesses said that it appeared that the left engine sustained a loss of power just after rotation and liftoff. The airplane initially had a positive rate of climb, but then immediately yawed to the left as it cleared 30-foot-high power lines that were perpendicular across the flight path. The airport is at the east end of a lake in a mountain valley; the airplane departed to the west and was flying over the lake. The airplane was about 2 miles from the runway when witnesses observed dark smoke coming from the left engine, and the smoke increased significantly as the flight continued. The airplane banked hard left with the wings perpendicular to the ground, and then nosed in vertically. The landing gear remained down throughout the accident sequence. On site examination revealed that the top spark plugs for the left engine were black and sooty. A detailed examination revealed that the left turbocharger turbine wheel shaft fractured and separated. Extreme oxidation of the fracture surfaces prevented identification of the failure mode; however, the oxidation was the result of high temperature exposure indicating that the fracture occurred while the turbocharger was at elevated temperature during operation. The multiple planes exhibited by the fracture also were not consistent with a ductile torsional failure as would be expected from a sudden stoppage of either rotor. No evidence of a mechanical malfunction was noted to the right engine. The Cessna Owners Manual for the airplane notes that the most critical time for an engine failure is a 2-3 second period late in the takeoff while the airplane is accelerating from the minimum single-engine control speed of 87 KIAS to a safe single-engine speed of 106 KIAS. Although the airplane is controllable at the minimum control speed, the airplane's performance is so far below optimum that continued flight near the ground is improbable. Once 106 KIAS is achieved, altitude can more easily be maintained while the pilot retracts the landing gear and feathers the propeller. The best single-engine rate-of-climb is 108 KIAS with flaps up below 18,000 feet msl. Section VI of the manual provides operational data for single-engine climb capability. The data was only valid for the following conditions: gear and flaps retracted, inoperative propeller feathered, wing banked 5 degrees toward the operating engine, 39.5 inches of manifold pressure if below 18,000 feet, and mixture at recommended fuel flow.

Less than one minute after takeoff from Khabarovsk-Maly airport, while climbing to a height of 21 metres at a speed of 155 k /h, the right door opened and detached. It struck the right propeller, causing the right engine to fail. The crew lost control of the aircraft that stalled and crashed in a garden located less than one km from the airport, bursting into flames. The aircraft was destroyed by a post crash fire and all three occupants were seriously injured, among them Alexander Perkash, Director of the company.

Following an uneventful flight from Caracas-Maíquetia-Simón Bolívar Airport, the crew complete the approach to Barcelona-General José Antonio Anzoátegui Airport. The airplane landed normally and after a course of about 100 metres, both main gears collapsed. The aircraft skidded on runway and eventually came to rest, bursting into flames. All 8 occupants escaped uninjured while the aircraft was damaged beyond repair.

The pilot obtained a weather briefing from an Automated Flight Service Station (AFSS) and filed an IFR flight plan before departing on an IFR flight from Cornelia, Georgia, to Pensacola, Florida, on May 10, 2006.The flight service specialist provided information on a line of embedded thunderstorm activity along the route from Atlanta to Mobile including SIGMETs and advised that tops were forecasted to be at 41,000 to 50,000 feet. The specialist suggested that the pilot not depart immediately because of the weather, but said that it might be possible to land at an intermediate stop ahead of the weather, possibly in Pensacola or further north in the Crestview area. The pilot filed an IFR flight plan from Cornelia to Pensacola at 16,000 feet. The pilot called the AFSS again and requested an IFR clearance. The specialist responded that the clearance was on request, and that he would work on the void time and placed the pilot on hold. The specialist obtained the clearance from Atlanta Center and returned back to provide the clearance to the pilot. The pilot was not on the telephone line. The pilot departed Cornelia without an IFR clearance and contacted Atlanta Center. The controller informed the pilot on initial contact that he was not on his assigned heading, altitude, correct transponder code, and subsequently handed the pilot off to another controller. The flight was subsequently cleared direct to Panama City, Florida, and the pilot was instructed to climb to 16,000 feet. Atlanta Center broadcasted weather alerts over the radio frequency the pilot was on for Center Weather Advisory 101, SIGMETS 73C, 74C,and AIRMET Sierra between 0903 to 0913 CDT. The National Weather Service Storm Prediction Center, issued Severe Thunderstorm Watch 329 valid from 0635 CDT until 1300 CDT. The National Weather Service Aviation Weather Center issued Convective SIGMET 73C valid from 0855 CDT until 1055 CDT. The SIGMET was for a line of thunderstorms 40 nautical miles wide, and moving from 280 degrees at 35 knots. The tops of the thunderstorms were at 44,000 feet, with 2-inch hail, and possible wind gusts up to 60 knots. These weather alerts included the route of flight for the accident airplane. The controllers did not issue the pilot with severe radar-depicted weather information that was displayed on the controller's radar display. The airplane was observed on radar level at 16,000 feet at 09:19:48 CDT heading southwest. The airplane was observed to began a continuous left turn northwest bound at 15,700 feet at 09:20:38. The pilot called Atlanta center at 09:20:48 CDT and stated, "Aero Star six eight triple nine we're going to make a reverse." and there was no further radio contact with the pilot. The last radar return was at 09:20:59. The airplane was at 15, 600 feet. The wreckage was located on May 11, 2006. Examination of the wreckage revealed the right wing separated 9 feet 2 inches outboard of the wing root. The separated outboard section of the right wing was not recovered. The components were forwarded to the NTSB Laboratory for further examination. Examination of the components revealed the deformation patterns found on the fracture surfaces were consistent with upward bending overstress of the right wing.

A commercial pilot with two passengers on a business flight was arriving at the destination airport in a light twin-engine airplane. The air traffic tower controller advised the pilot to follow a slower airplane that was on base leg. The controller subsequently asked the accident pilot if he could reduce his speed,"a little bit." The accident pilot responded that he was slowing down. Less than a minute later, the controller told the accident pilot that he was cleared to land. The accident pilot's last radio transmission was his acknowledgement of the landing clearance. The controller stated that he did not see the accident airplane other than on the radar scope, but did see a plume of smoke on the final approach course for the active runway. Ground witnesses described the airplane as flying slowly with its wings wobbling, turn right, and dive into the ground. The majority of the airplane was consumed by a post crash fire. Inspection of the flight controls and engines disclosed no evidence of any preimpact mechanical problems. Low speed flight reduces the margin between a safe operating speed and an aerodynamic stall. Wing "wobble" at low speeds is often an indicator of an incipient aerodynamic stall. Toxicological samples from the pilot’s blood detected diphenhydramine (a sedating antihistamine commonly known by the trade name Benadryl) at a level consistent with recent use of at least the maximum over-the-counter dose. Diphenhydramine is used over-the-counter for allergies and as a sleep aid, and has been shown to impair the performance of complex cognitive and motor tasks at typical doses. The FAA does not specifically prohibit the use of diphenhydramine by pilots, though Federal Air Regulation 91.17, states, in part: "No crewmember may act, or attempt to act as a crewmember of a civil aircraft...while using any drug that affects the person's faculties in any way contrary to safety..."