Raytheon 390 Premier I

The aircraft planned to fly from Avignon Airport, France to Blackpool Airport, with two flight crew and two passengers. The co-pilot performed the external checks; this included checking the fluid level in the hydraulic reservoir, as stated in the ‘Pilot Checklist’. The aircraft was refuelled to 3,000 lb and, after the passengers boarded, it departed for Blackpool. The commander was the pilot flying (PF). The takeoff and cruise to Blackpool were uneventful. Prior to the descent the crew noted ATIS Information ‘Lima’, which stated: Runway 10, wind from 150° at 18 kt, visibility 9 km, FEW clouds at 2,000 ft aal, temperature 11°C, dew point 8°C, QNH 1021 hPa, runway damp over its whole length. The commander planned and briefed for the NDB approach to Runway 10, which was to be flown with the autopilot engaged. Whilst descending through FL120, the left, followed by the right, hydraulic low pressure cautions illuminated. Upon checking the hydraulic pressure gauge, situated to the left of the commander’s control column, the pressure was noted to be ‘cycling up and down’, but for the majority of the time it indicated about 2,800 psi (in the green arc). During this time the hydraulic low pressure cautions went on and off irregularly, with the left caution being on more often than the right. The co-pilot then actioned the ‘HYDRAULIC SYSTEM - HYDRAULIC PUMP FAILURE’ checklist. It stated that if the hydraulic pressure was a minimum of 2,800 psi, the flight could be continued. Just before the aircraft reached the Blackpool NDB, the commander commented “it’s dropping”, but he could not recall what he was referring to. This was followed by the roll fail and speed brk [brake] fail caution messages illuminating. The co-pilot then actioned the applicable checklists. These stated that the Landing Distances Required (LDR) would increase by approximately 65% and 21%, respectively. As the roll fail LDR increase was greater than that of the speed brk fail, the crew used an LDR increase of 65% which the co-pilot equated to 5,950 ft. Runway 10 at Blackpool has an LDA of 6,131 ft, therefore they elected to continue to Blackpool. The roll fail checklist stated that a ‘FLAPS UP’ landing was required. The co-pilot then calculated the VREF of 132 kt, including a 20 kt increment, as stipulated by the ‘FLAPS UP, 10, OR 20 APPROACH AND LANDING’ checklist. The commander then continued with the approach. At about 4 nm on final approach the co-pilot lowered the landing gear, in response to the commander’s request. About 8 seconds later the commander said “just lost it all”; referring to the general state of the aircraft. This was followed almost immediately by the landing gear unsafe aural warning, as the main landing gear was not indicating down and locked. Whilst descending through 1,000 ft, at just over 3 nm from the threshold, the commander asked the co-pilot to action the ‘ALTERNATE GEAR EXTENSION’ checklist. The commander then discontinued the approach by selecting ALT HOLD, increased engine thrust and selected a 500 ft/min rate of climb on the autopilot. However, a few seconds later, before the co-pilot could action the checklist, the main gear indicated down and locked. The commander disconnected the autopilot and continued the approach. The crew did not consider reviewing the ‘HYDRAULIC SYSTEM - HYDRAULIC PUMP FAILURE’ checklist as they had not recognised the symptoms of loss of hydraulic pressure. When ATC issued the aircraft its landing clearance the wind was from 140° at 17 kt. This equated to a headwind component of about 10 kt and a crosswind of about 12 kt. As the aircraft descended through 500 ft (the Minimum Descent Altitude (MDA) for the approach) at 1.5 nm from the threshold, the commander instructed the co-pilot to advise ATC that they had a hydraulic problem and to request the RFFS to be put on standby. There was a slight delay in transmitting this request, due to another aircraft on frequency, but the request was acknowledged by ATC. The aircraft touched down about 1,500 ft from the start of the paved surface at an airspeed of 132 kt and a groundspeed of 124 kt. When the commander applied the toe (power) brakes he felt no significant retardation. During the landing roll no attempt was made to apply the emergency brakes, as required in the event of a power brake failure. The co-pilot asked if he should try to operate the lift dump, but it failed to function, due to the lack of hydraulic pressure. At some point, while the aircraft was on the runway, the co-pilot transmitted a MAYDAY call to ATC. When an overrun appeared likely, the commander shut down the engines. The aircraft subsequently overran the end of the runway at a groundspeed of about 80 kt. The commander later commented that he was in a “state of panic” during the landing roll and was unsure whether or not he had applied the emergency brake. As the aircraft left the paved surface the commander steered the aircraft slightly right to avoid a shallow downslope to the left of runway’s extended centreline. The aircraft continued across the rough, uneven ground, during which the nose gear collapsed and the wing to fuselage attachments were severely damaged (Figure 1). Once it had come to a stop, he shut down the remaining aircraft systems. The passengers and crew, who were uninjured, vacated the aircraft via the entry/exit door and moved upwind to a safe distance. The RRFS arrived shortly thereafter.

The pilot and passenger departed on a night personal flight. A review of the cockpit voice recorder (CVR) transcript revealed that, immediately after departure, the passenger asked the pilot if he had turned on the heat. The pilot subsequently informed the tower air traffic controller that he needed to return to the airport. The controller then cleared the airplane to land and asked the pilot if he needed assistance. The pilot replied "negative" and did not declare an emergency. The pilot acknowledged to the passenger that it was hot in the cabin. The CVR recorded the enhanced ground proximity warning system (EGPWS) issue 11 warnings, including obstacle, terrain, and stall warnings; these warnings occurred while the airplane was on the downwind leg for the airport. The airplane subsequently impacted trees and terrain and was consumed by postimpact fire. Postaccident examination of the airplane revealed no malfunctions or anomalies that would have precluded normal operation. During the attempted return to the airport, possibly to resolve a cabin heat problem, the pilot was operating in a high workload environment due to, in part, his maneuvering visually at low altitude in the traffic pattern at night, acquiring inbound traffic, and being distracted by the reported high cabin temperature and multiple EGPWS alerts. The passenger was seated in the right front seat and in the immediate vicinity of the flight controls, but no evidence was found indicating that she was operating the flight controls during the flight. Although the pilot had a history of coronary artery disease, the autopsy found no evidence of a recent cardiac event, and an analysis of the CVR data revealed that the pilot was awake, speaking, and not complaining of chest pain or shortness of breath; therefore, it is unlikely that the pilot's cardiac condition contributed to the accident. Toxicological testing detected several prescription medications in the pilot's blood, lung, and liver, including one to treat his heart disease; however, it is unlikely that any of these medications resulted in impairment. Although the testing revealed that the pilot had used marijuana at some time before the accident, insufficient evidence existed to determine whether the pilot was impaired by its use at the time of the accident. Toxicology testing also detected methylone in the pilot's blood. Methylone is a stimulant similar to cocaine and Ecstasy, and its effects can include relaxation, euphoria, and excited calm, and it can cause acute changes in cognitive performance and impair information processing. Given the level of methylone (0.34 ug/ml) detected in the pilot's blood, it is likely that the pilot was impaired at the time of the accident. The pilot's drug impairment likely contributed to his failure to maintain control of the airplane.

According to the cockpit voice recorder (CVR), during cruise flight, the unqualified pilot-rated passenger was manipulating the aircraft controls, including the engine controls, under the supervision and direction of the private pilot. After receiving a descent clearance to 3,000 feet mean sea level (msl), the pilot told the pilot-rated passenger to reduce engine power to maintain a target airspeed. The cockpit area microphone subsequently recorded the sound of both engines spooling down. The pilot recognized that the pilot-rated passenger had shutdown both engines after he retarded the engine throttles past the flight idle stops into the fuel cutoff position. Specifically, the pilot stated "you went back behind the stops and we lost power." According to air traffic control (ATC) radar track data, at the time of the dual engine shutdown, the airplane was located about 18 miles southwest of the destination airport and was descending through 6,700 feet msl. The pilot reported to the controller that the airplane had experienced a dual loss of engine power, declared an emergency, and requested radar vectors to the destination airport. As the flight approached the destination airport, the cockpit area microphone recorded a sound similar to an engine starter spooling up; however, engine power was not restored during the attempted restart. A review of the remaining CVR audio did not reveal any evidence of another attempt to restart an engine. The CVR stopped recording while the airplane was still airborne, with both engines still inoperative, while on an extended base leg to the runway. Subsequently, the controller told the pilot to go-around because the main landing gear was not extended. The accident airplane was then observed to climb and enter a right traffic pattern to make another landing approach. Witness accounts indicated that only the nose landing gear was extended during the second landing approach. The witnesses observed the airplane bounce several times on the runway before it ultimately entered a climbing right turn. The airplane was then observed to enter a nose low, rolling descent into a nearby residential community. The postaccident examinations and testing did not reveal any anomalies or failures that would have precluded normal operation of the airplane. Although the CVR did not record a successful engine restart, the pilot was able to initiate a go-around during the initial landing attempt, which implies that he was able to restart at least one engine during the initial approach. The investigation subsequently determined that only the left engine was operating at impact. Following an engine start, procedures require that the respective generator be reset to reestablish electrical power to the Essential Bus. If the Essential Bus had been restored, all aircraft systems would have operated normally. However, the battery toggle switch was observed in the Standby position at the accident site, which would have prevented the Essential Bus from receiving power regardless of whether the generator had been reset. As such, the airplane was likely operating on the Standby Bus, which would preclude the normal extension of the landing gear. However, the investigation determined that the landing gear alternate extension handle was partially extended. The observed position of the handle would have precluded the main landing gear from extending (only the nose landing gear would extend). The investigation determined that it is likely the pilot did not fully extend the handle to obtain a full landing gear deployment. Had he fully extended the landing gear, a successful single-engine landing could have been accomplished. In conclusion, the private pilot's decision to allow the unqualified pilot-rated passenger to manipulate the airplane controls directly resulted in the inadvertent dual engine shutdown during cruise descent. Additionally, the pilot's inadequate response to the emergency, including his failure to adhere to procedures, resulted in his inability to fully restore airplane systems and ultimately resulted in a loss of airplane control.

On Monday 4 March 2013, the pilot and two passengers arrived at Annemasse aerodrome (France) at about 7 h 00. They planned to make a private flight of about five minutes to Geneva airport on board the Beechcraft Premier 1A, registered VP-CAZ. The temperature was -2°C and the humidity was 98% with low clouds. The aeroplane had been parked on the parking area of the aerodrome since the previous evening. At 7 h 28, the Geneva ATC service gave the departure clearance for an initial climb towards 6,000 ft with QNH 1018 hPa towards the Chambéry VOR (CBY). At about 7 h 30, when the CVR recording of the accident flight started, the engines had already been started up. At about 7 h 34, the pilot called out the following speeds that would be used during the takeoff roll:
- V1 : 101 kt
- VR : 107 kt
- V2 : 120 kt.
At about 7 h 35, the pilot performed the pre-taxiing check-list. During these checks, he called out “anti-ice ON”, correct operation of the flight controls, and the position of the flaps on 10°.
Taxiing towards runway 12 began at 7 h 36. At 7 h 37 min 43, the pilot called out the end of the takeoff briefing, then activation of the engine anti-icing system. At 7 h 38 min 03, the pilot called out the start of the takeoff roll. Fifteen seconds later, the engines reached takeoff thrust. The aeroplane lifted off at 7 h 38 min 37. Several witnesses stated that it adopted a high pitch-up attitude, with a low rate of climb. At 7 h 38 min 40, the first GPWS “Bank angle - Bank angle” warning was recorded on the CVR. It indicated excessive bank. A second and a half later, the pilot showed his surprise by an interjection. It was followed by the aural stall warning that lasted more than a second and a further GPWS “Bank angle - Bank angle” warning. At about 7 h 38 min 44, the aeroplane was detected by the Dole and Geneva radars at a height of about 80 ft above the ground. Other “Bank Angle” warnings and stall warnings were recorded on the CVR on several occasions. Several witnesses saw the aeroplane bank sharply to the right, then to the left. At 7 h 38 min 49 the aeroplane was detected by the radars at a height of about 150 ft above the ground. At 07 h 38 min 52, the main landing gear struck the roof of a first house. The aeroplane then collided with the ground. During the impact sequence, the three landing gears and the left wing separated from the rest of the aeroplane. The aeroplane slid along the ground for a distance of about 100 m before colliding with a garden shed, a wall and some trees in the garden of a second house. The aeroplane caught fire and came to a stop. The pilot and the passenger seated to his right were killed. The female passenger seated at the rear was seriously injured. According to the NTSB and BEA, the airplane was owned by Chakibel Associates Limited n Tortola and operated by Global Jet Luxembourg.

Aircraft was destroyed following a collision with a utility pole, trees, and terrain following a go-around at Thomson-McDuffie Regional Airport (HQU), Thomson, Georgia. The airline transport-rated pilot and copilot were seriously injured, and five passengers were fatally injured. The airplane was registered to the Pavilion Group LLC and was operated by the pilot under the provisions of 14 Code of Federal Regulations Part 91 as a business flight. Night visual meteorological conditions prevailed, and an instrument flight rules flight plan was filed. The flight originated at John C. Tune Airport (JWN), Nashville, Tennessee, about 1828 central standard time (1928 eastern standard time). The purpose of the flight was to transport staff members of a vascular surgery practice from Nashville to Thomson, where the airplane was based. According to initial air traffic control information, the pilot checked in with Augusta approach control and reported HQU in sight. About 2003, the pilot cancelled visual flight rules flight-following services and continued toward HQU. The last recorded radar return was observed about 2005, when the airplane was at an indicated altitude of 700 feet above mean sea level and 1/2 mile from the airport. There were no distress calls received from the crew prior to the accident. Witnesses reported that the airplane appeared to be in position to land when the pilot discontinued the approach and commenced a go-around. The witnesses observed the airplane continue down the runway at a low altitude. The airplane struck a poured-concrete utility pole and braided wires about 59 feet above ground level. The pole was located about 1/4 mile east the departure end of runway 10. The utility pole was not lighted. During the initial impact with the utility pole, the outboard section of the left wing was severed. The airplane continued another 1/4 mile east before colliding with trees and terrain. A postcrash fire ensued and consumed a majority of the airframe. The engines separated from the fuselage during the impact sequence. On-scene examination of the wreckage revealed that all primary airframe structural components were accounted for at the accident site. The landing gear were found in the down (extended) position, and the flap handle was found in the 10-degree (go-around) position. An initial inspection of the airport revealed that the pilot-controlled runway lights were operational. An examination of conditions recorded on an airport security camera showed that the runway lights were on the low intensity setting at the time of the accident. The airport did not have a control tower. An inspection of the runway surface did not reveal any unusual tire marks or debris. Weather conditions at HQU near the time of the accident included calm wind and clear skies.