Private

The pilot and passenger departed on a cross-country flight. Automatic dependent surveillance – broadcast (ADS-B) data indicated that the airplane flew at a cruise altitude between 11,000 ft and 13,000 ft mean sea level (msl) on a north to northeast heading consistent with its planned destination for most of the flight. About 30 minutes before the end of the flight, the airplane began a descent and then turned east. Shortly thereafter, the pilot of the airplane declared minimum fuel with air traffic control (ATC). A few minutes later the pilot declared critical fuel due to a fuel leak. The pilot stated in his last communication that he would attempt to make a nearby airport. Subsequently, the airplane impacted hilly, desert terrain at an elevation of about 5,780 ft and on a heading of about 034°. An acquaintance of the pilot who was a flight instructor stated that, on the two previous flights he had flown with the pilot, the left wing of the airplane felt heavy. The accident pilot thought it was because of a fuel imbalance. The postaccident examination revealed that the left tank fuel valve was positioned ON and the right tank valve was positioned OFF, consistent with the pilot balancing the fuel by feeding from the left-wing fuel tank. It is possible that when the pilot noticed the minimum fuel status, he failed to recall that he had previously selected the rightside fuel tank OFF, and thus did not have this fuel available. Given that the cruise altitudes on the accident flight were similar to what the previous owner used to make his fuel range and duration estimates, even with about a 20% reduction in fuel due to the pilot allowing 2 inches from the top of the fuel tanks during refueling, the airplane should have had adequate fuel to make its destination. A strong smell of fuel and fuel staining were also observed at the accident site. Page 2 of 11 WPR22FA173 A review of radar imagery from Boise, Idaho, revealed that the airplane flew through several areas of light to moderate intensity echoes as it proceeded northward, and then after turning eastward, the airplane’s fight track was through an area of moderate to heavy intensity echoes. The accident site was located on the southeast edge of the echo. Light-to-moderate icing conditions in the clouds with clear to mixed type icing below 12,000 ft msl were expected. Thus, it is likely that the airplane, which was not certified for flight in icing, encountered icing in the final portion of the flight. The pilot was flying with insulin-dependent diabetes, having type 1 diabetes mellitus. Given the urine glucose level of 29mg/dL, no detectable glucose in vitreous fluid, and ongoing verbal communication, it is unlikely that the pilot was experiencing significant metabolic disturbance from high blood glucose. Whether he was experiencing less severe effects of high blood sugar could not be determined. Whether he had symptoms of low blood glucose, such as diminished concentration or increased nervousness, is unknown. The pilot’s use of diphenhydramine (Benadryl), which can cause sleepiness, was likely not a factor due to fact that it was detected only in the urine and not in the blood. Thus, it is unlikely that effects of the pilot’s diphenhydramine use contributed to the accident. Accident site signatures and a review of the weather were consistent with a loss of control of the airplane. In addition, an examination of the airframe and engine revealed no evidence of any preimpact mechanical failures or malfunctions that would have precluded normal operation. It is likely that, while maneuvering to an alternate airport due to a critical fuel situation, in icing conditions, the pilot failed to maintain the proper airspeed, which resulted in the exceedance of the airplane’s critical angle of attack and the airplane experiencing an aerodynamic stall.

The pilot reported that, before the flight, the airplane was fueled with 140 gallons of Jet A fuel. Shortly after takeoff, both engines lost total power. Because the airplane had insufficient altitude to return to the airport, the pilot executed a forced landing to a field and the left wing sustained substantial damage. A postcrash fire ensued. The investigation determined that the airplane was inadvertently fueled with Jet A fuel rather than AVGAS, which was required for the airplane’s reciprocating engines. The line service worker who fueled the airplane reported that there were no decals at the airplane fuel ports; however, postaccident examination of the airplane found that a decal specifying AVGAS was present at the right-wing fuel port. The investigation could not determine whether the same or a similar decal was present at the left-wing fuel port because the left wing was partially consumed during the postimpact fire.

The single engine airplane departed Port-au-Prince-Toussaint Louverture Airport on a private flight to Jacmel, some 45 km southwest of the capital city. On board were four passengers and one pilot. During climbout, the pilot encountered problems and the airplane lost height until it collided with a truck and crashed on a road located in Carrefour, some 12 km southwest of Port-au-Prince Airport. A passenger was seriously injured while four other occupants as well as the truck driver were killed. The aircraft was destroyed. The only survivor died from his injuries few hours later.

The pilot, sole on board, departed Los Mochis International Airport on a flight to the Club Aéreo Nuevo Santa Rosa located east-northeast of the city. After landing on a road, the airplane suffered an apparent undercarriage failure, veered to the right and came to rest in a grassy area, bursting into flames. The pilot evacuated safely while the aircraft suffered serious damages due to fire.

The twin engine airplane departed Acapulco-General Juan N. Álvarez Airport on a private flight to Cuernavaca, carrying six passengers and one pilot. On final approach to Cuernavaca Airport runway 20, the airplane crashed on a supermarket located in Temixco, some 2 km short of runway. The pilot and two passengers were killed while four other occupants were injured.

Before departing on the flight, the pilot of the turbo-propeller-equipped, single-engine airplane and student pilot-rated passenger seated in the right front seat of the airplane attempted to enter a flight plan into the airplane’s integrated flight management system. They ultimately did not complete this task prior to takeoff with the pilot remarking, “we’ll get to it later.” The pilot subsequently departed and climbed into instrument meteorological conditions (IMC) without an instrument flight rules (IFR) flight plan. After entering IMC, he contacted air traffic control and asked for visual flight rules (VFR) flight following services and an IFR clearance to the destination airport. From shortly after when the airplane leveled after takeoff through the final seconds of the flight, the pilot attempted to program, delete, reprogram, and activate a flight plan into the airplane’s flight management system as evidenced by his comments recorded on the airplane’s cockpit voice recorder (CVR). After departing, the pilot also attempted to navigate around restricted airspace that the airplane had flown into. The CVR audio showed that during the final 10 minutes of the flight, the pilot was unsure of the spelling of the fix he should have been navigating to in order to begin the instrument approach at the destination airport, and more generally expressed frustration and confusion while attempting to program the integrated flight management system. As the pilot continued to fixate on programming the airplane’s flight management system and change the altimeter setting, the airplane’s pitch attitude increased to 10° nose up, while the airspeed had decayed to 109 knots. As a result of his inattention to this airspeed decay, the stall warning system activated and the autopilot disconnected. During this time the airplane began climbing and turning to the right and then to the left before entering a steep descending right turn that continued until the airplane impacted the ocean. For the final 2 and 1/2 minutes of the flight, the pilot was provided with stall warnings, stick shaker activations, autopilot disconnect warnings, and terrain avoidance warning system alerts. The airplane impacted the ocean about 3 miles from the coast. Examination of the recovered sections of the airplane did not reveal evidence of any mechanical failures or malfunctions of the airframe or engine that would have precluded normal operation. The instrument meteorological conditions present in the area at the time of the accident were conducive to the development of spatial disorientation. The airplane’s erratic flight track in the final 2 minutes of flight, culminating in the final rapidly descending right turn, were consistent with the known effects of spatial disorientation. It is likely that the pilot’s inadequate preflight planning, and his subsequent distraction while he unsuccessfully attempted to program the airplane’s flight management system during the flight resulted in his failure to adequately monitor the airplane’s speed. This led to the activation of the airplane’s stall protection and warning systems as the airplane approached and entered an aerodynamic stall. The resulting sudden deactivation of the autopilot, combined with his inattention to the airplane’s flight attitude and speed, likely surprised the pilot. Ultimately, the pilot failed to regain control of the airplane following the aerodynamic stall, likely due to spatial disorientation. The pilot had a history of mantle cell lymphoma that was in remission and his maintenance treatment with a rituximab infusion was over 60 days prior to the accident. The pilot also had a history of back pain and had received steroid injections and nonsteroidal anti-inflammatory drugs. By self-report, he had taken oxycodone for pain management; it is unknown how frequently he used this medication or if he had used the medication on the day of the accident. While oxycodone can result in fatigue and dizziness, and may interfere with reaction time, given the information from the CVR, it could not be determined if the pilot had these side effects. A few weeks prior to the accident, the pilot reported having COVID-19 and receiving a 5-day treatment course of hydroxychloroquine and ivermectin. While there are some impairing side effects associated with the use of those medications, enough time had elapsed that no adverse effects would be expected. There is an increased risk of a sudden incapacitating cardiovascular event such as a dysrhythmia, stroke, or pulmonary embolism in people who have recovered from their COVID-19 infection. The risk is slight for those not hospitalized for the infection. The pilot did not have an underlying cardiovascular disease that would pose an increased risk for a sudden incapacitating event and the CVR did not provide evidence of a sudden incapacitating event occurring. Thus, it could not be determined if the pilot’s medical conditions of mantle cell lymphoma, back pain, and recent history of COVID-19 and the medications used to treat these conditions, including rituximab, oxycodone, hydroxychloroquine, and ivermectin, were contributing factors to this accident.

The airplane had recently undergone an annual inspection, and the pilot planned to fly the airplane back to his home base. After receiving clearance from air traffic control, the pilot proceeded to take off. The airplane accelerated and reached a peak groundspeed of 81 kts about 2,075 ft down the 4,097-ft runway. Once airborne, the airplane drifted slightly to the right and the pilot radioed an urgent need to return to the airport. The controller cleared the airplane to land and no further transmissions were received from the accident airplane. The airplane’s flight path showed that it slowed before turning back toward the left and the airplane’s speed continued to decrease throughout the remainder of the data. The final data point recorded the airplane at a groundspeed of 45 kts. The groundspeed would equate to 60 kts airspeed when considering the 15-kt headwind. The stall speed chart for the airplane listed the minimum stall speed for any configuration as 64 kts. Postaccident examinations of the airframe and engine revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation. External and internal engine damage indicated that the engine was producing power at the time of impact, but the amount of power output could not be determined. Based on the available information, the pilot perceived an urgent need to return the airplane to the airport; however, due to the amount of damage from the impact and postimpact fire, the reason that the pilot was returning to the airport could not be determined. Stall speed information for the airplane, the recorded winds, and flight track data, indicated that the airplane encountered an aerodynamic stall before impacting the ground near the departure end of the runway. Since the airplane stalled and impacted the ground before reaching the perimeter of the airport, the pilot may not have had sufficient altitude to execute a forced landing to the empty field off the departure end of the runway.

En route, the pilot encountered engine problems and elected to make an emergency landing on a motorway. Upon landing, the aircraft impacted the road bank, lost its left wing and came to rest. All six occupants evacuated with minor injuries and the aircraft was damaged beyond repair.

After landing at Brasília-Nelson Piquet Airport, the single engine airplane went out of control and veered off runway. It went down into a ravine and came to rest into trees. All five occupants evacuated safely while the aircraft was destroyed. The pilot reported he encountered strong winds upon landing.

Following an uneventful flight from Oxford-Kidlington Airport, the airplane landed at night on runway 27 at Heraklion-Nikos Kazantzakis Airport. After touchdown, the nose gear failed and the airplane slid for few dozen metres before coming to rest. All seven occupants evacuated safely and the airplane was later considered as damaged beyond repair.