Massachusetts

The pilot contacted air traffic control and requested clearance to taxi for departure approximately an hour after the scheduled departure time. About 4 minutes later, the flight
was cleared for takeoff. A witness observed the airplane as it taxied, and found it strange that the airplane did not stop and "rev up" its engines before takeoff. Instead, the airplane taxied into the runway and proceeded with the takeoff without stopping. The airplane took off quickly, within 100 yards of beginning the takeoff roll, became airborne, and entered a steep left bank. The bank steepened, and the airplane descended and impacted the ground. Post accident examination of the wreckage revealed that the pilot's four-point restraint was not fastened and that at least a portion of the cockpit flight control lock remained installed on the control column. One of the pre-takeoff checklist items was, "Flight controls - Unlocked - Full travel." The airplane was not equipped with a control lock design, which, according to the airframe manufacturer's previously issued service bulletins, would "minimize the possibility of the aircraft becoming airborne when take off is attempted with flight control locks inadvertently installed." In 1990, Transport Canada issued an airworthiness directive to ensure mandatory compliance with the service bulletins; however, the Federal Aviation Administration did not follow with a similar airworthiness directive until after the accident.

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.

Approximately 3 minutes prior to the accident, the airplane was flying in a northeast direction, at 17,100 feet, and was instructed by air traffic controllers to contact Boston Center. He acknowledged the instruction, and no further transmissions were received from the pilot. Radar data indicated the airplane continued level at 17,100 feet on a northeasterly heading, and maintained a groundspeed of 255 knots, for approximately 2 minutes after the last transmission. The airplane then climbed 300 feet, and descended abruptly, losing 10,700 feet during the next 46 seconds, while maintaining an approximate ground speed of 255 knots. The airplane then initiated a climb from 6,700 feet to 7,600 feet, maintained an altitude of 7,600 feet for 4 seconds, and then entered a continuous descent until the last radar contact 17 seconds later, at an altitude of 2,400 feet. Several witnesses observed the airplane prior to it impacting the ground. All of the witness described the airplane in a "flat spin" with the engines running prior to impact. Examination of recorded weather data revealed several areas of light-to-moderate precipitation echoes in the vicinity of the accident site. The maximum echo tops were depicted ranging from 14,000 to 25,000 feet, with tops near 17,000 feet in the immediate vicinity of the accident site. Recorded radar images depicted the airplane traveling through an area of lower echoes for approximately 5-minutes immediately prior to the accident. AIRMET Zulu was current for icing conditions from the freezing level to 22,000 feet over the route of flight and the accident site. Four PIREPs were also issued indicating light-to-moderate rime to mixed icing in the clouds from the freezing level to 16,000 feet. Cloud tops were reported from 16,000 to 17,000 feet by two aircraft. Examination of the airplane and engines revealed no pre-impact mechanical anomalies. Additionally, examination of the cockpit overhead switch panel indicated propeller de-ice, engine intake heat, windshield anti-ice, and wing de-ice were all in the 'off' position. According to the pilot's toxicology test results, pseudoephedrine and diphenhydramine was detected in the pilot's urine. Diphenhydramine was not detected in the blood.

The pilot was conducting an instrument landing system approach during night instrument meteorological conditions. The airplane was observed to descend toward the runway threshold to an altitude consistent with the approach decision height. A witness reported that he heard the airplane overhead, and assumed that the pilot had performed a missed approach. He described the engine noise as "cruise power" and did not hear any unusual sounds. Shortly thereafter, he received a call from airport operations stating that an airplane had crashed. The airplane impacted the ground about 1/4 mile to the left of the runway centerline, about 3,500 feet beyond the approach end of the runway. Examination of the airplane did not reveal any pre-impact mechanical malfunctions. A weather observation taken around the time of the accident, included a visibility 1/2 statue mile in fog, and an indefinite ceiling at 100 feet. The witness described the weather at the time of the accident as thick fog, and "pitch black."

The accident flight was the first flight after maintenance personnel replaced the forward elevator trim cable. When the flightcrew received the airplane, the captain did not address the recent cable change noted on his maintenance release. The captain also did not perform a first flight of the day checklist, which included an elevator trim check. Shortly after takeoff, the flightcrew reported a runway trim, and manually selected nose-up trim. However, the elevator trim then traveled to the full nose-down position. The control column forces subsequently increased to 250 pounds, and the flightcrew was unable to maintain control of the airplane. During the replacement of the cable, the maintenance personnel skipped a step in the manufacturer's airliner maintenance manual (AMM). They did not use a lead wire to assist with cable orientation. In addition, the AMM incorrectly depicted the elevator trim drum, and the depiction of the orientation of the cable around the drum was ambiguous. The maintenance personnel stated that they had completed an operational check of the airplane after maintenance. The Safety Board performed a mis-rigging demonstration on an exemplar airplane, which reversed the elevator trim system. An operational check on that airplane revealed that when the electric trim motor was activated in one direction, the elevator trim tabs moved in the correct direction, but the trim wheel moved opposite of the corresponding correct direction. When the manual trim wheel was moved in one direction, the elevator trim tabs moved opposite of the corresponding correct direction.

While on approach to the airport, the airplane entered a left turn, which the surviving passenger described as "almost completely upside down." The airplane briefly leveled, then entered another left turn with a bank angle of the same severity. The airplane seemed to roll level, then entered a steep dive, until it impacted a building. The passenger reported that the engines were running normally throughout the entire flight, and the steep turns performed by the pilot did not concern her, as she had flown with him before and knew he "liked to make sharp turns." Examination of the airplane and engines revealed no pre-impact mechanical anomalies, and weather at the time of the accident included a broken cloud ceiling of 1,100 feet, with 3 miles visibility in mist. According to the FAA, Airplane Flying Handbook,"...[An] airplane will stall at a higher indicated airspeed when excessive maneuvering loads are imposed by steep turns, pull-ups, or other abrupt changes in its flightpath." A review of the "Stall Speeds - Power Idle" chart from the POH revealed that with approach flaps selected, at a bank angle of 60 degrees, the airplane would stall at about 123 knots. Radar data indicated the airplane descended along the approach course at an average speed of 120 knots. Toxicology testing performed on the pilot revealed imipramine and carbamazepine in the pilot's urine and blood, and morphine in the pilot's urine. According to the pilot's medical and pharmacy records, he suffered from a severe neurological disorder, possibly a seizure disorder, which resulted in frequent, unpredictable episodes of debilitating pain. Additionally, approximately three months prior to the accident, the pilot was diagnosed with viral meningitis, and a severe skin infection with multiple abscesses on his extremities. The pilot had been prescribed imipramine, an antidepressant that has detrimental effects on driving skills and other cognitive functions. He had also been prescribed carbamazepine, typically used to control seizures or treat certain chronically painful conditions. Carbamazepine has measurable impairment of performance on a variety of psychomotor tests. Morphine, a prescription opiate painkiller, is also a metabolite of heroin and many prescription medications, such as codeine, used to control moderate pain. No indication was observed in the pilot's medical records that he was recently prescribed any opiates. Neither the pilot's medical condition, nor the medication he was routinely taking was reported on his application for an airman medical certificate.

After a normal cross country flight, the airplane was on final approach for landing to runway 20, when the air traffic controller instructed the pilot to "go-around" because a preceding airplane had not cleared the runway. The airplane was observed to pitch up and enter a steep, almost 90 degree left bank. The passenger in the rear seat described the flights from and to BAF as "smooth." She stated she thought that the airplane would be landing; however, then realized the airplane was in a left turn. The airplane impacted on the roof of a commercial building, and came to rest upright on a heading of 020 degrees, in a parking lot, about 1/4 mile east of the approach end the runway. Examination of the airplane, which included a teardown of the engine, did not reveal evidence of any pre-impact malfunctions. Weather reported at the airport about the time of the accident included winds from 240 degrees at 7 knots; visibility 10 status miles and few clouds at 6,500 feet. The pilot owned the airplane and had accumulated about 1,660 hours of total flight experience.

Witnesses reported hearing an airplane engine at night, at high power for about 5 seconds followed by impact. They went to the scene and found the airplane on the left side of the approach end of runway 03, on fire. The pilot was removed and the fire was extinguished. The airplane had struck a runway threshold light located about 25 feet to the left side of the runway, and slid about 100 feet into trees, angling away from the runway on a heading of 360 degrees. The outboard 5 feet of the left wing was bent up about 20 degrees. Ground scars were found corresponding to the positions of the left, right, and nose landing gears, all of which had collapsed. The inboard section of the left wing came to rest on the nose of the airplane. The propeller blades were deformed with "S" bending and leading edge gouges. Flight control continuity was verified to the rudder and elevator. The aileron control cables had separated with puffed ends. All separations occurred at other than attach points. The pilot had received head injuries and has no memory of the accident.

The pilot accepted an intersection departure and waived the wake turbulence holding time. A Boeing 737-300 departed ahead of him, and according to pilot, the Boeing's nosewheel lifted off the runway just as it passed him. The pilot also noted that the Boeing and its exhaust smoke drifted to the left of the runway's centerline. A wake turbulence advisory and takeoff clearance were issued by the tower controller and acknowledged by the pilot. The pilot initiated the takeoff, and after liftoff, the left wing dropped. It contacted the runway, and the airplane rolled inverted. The airplane then slid off the left side of the runway and a post-crash fire developed.

The pilot departed his home airport for a 90 mile personal flight with eight passengers. The pilot stated he departed with 24 gallons of fuel in the outboard tanks, and 80 gallons of fuel in the main tanks. After landing, the airplane was refueled with 100 low-lead aviation gasoline; 12 gallons in each main fuel tank. Before departing for the return flight, the pilot performed a preflight inspection of the airplane, which did not include a visual check of the airplane's fuel tanks. After takeoff, the pilot experienced a "small surge in both engines," while climbing through 1,150 and 3,300 feet, respectively. He further described the surges as "minor but still noticeable." About 30 minutes later, after the airplane had descended, and was leveling at 1,500 feet, the pilot experienced an intermittent illumination of the "right aux fuel pump light," which was followed by a total loss of power on the right engine. Shortly thereafter, the left engine began "surging," and after about "three or four minutes, at most," he feathered the left engine propeller. The pilot ditched the airplane in Massachusetts Bay. The airplane was recovered about 1 month later. The fuel selectors were positioned to the outboard tanks, and the airplane's fuel tanks revealed fluid consistent with seawater with "some odor of fuel;" however, no visible evidence of fuel was observed. According to the airplane's information manual, the airplane's total fuel capacity was 192 gallons, of which, 182 gallons were usable. Examination of the airframe and engine did not reveal evidence of any pre-impact mechanical malfunctions. The pilot reported he had purchased the airplane and attended 5-day type specific training course in March 2001. He reported about 1,050 hours of total fight experience, which included 800 hours in multi-engine airplanes, of which 65 hours was in the make and model. Additionally, the pilot reported he had not experienced any prior mechanical problems. He believed he had flown the airplane the day prior to the accident as well. The last documented refueling of the airplane prior to the date of the accident occurred on May 3, 2001, when the airplane was refueled with 128 gallons of aviation gasoline. The last flight documented in the pilot's logbook was on May 4, 2001, when the pilot logged 1.9 hours in the accident airplane. The pilot said he normally flew a 65 percent power, an "a little rich," and experienced a fuel burn of about 20 to 21 gallons per hour, for each engine.