Addison

The pilot, co-pilot, and eight passengers departed on a cross-country flight in the twin-engine airplane. One witness located on the ramp at the airport reported that the airplane sounded underpowered immediately after takeoff “like it was at a reduced power setting.” Another witness stated that the airplane sounded like it did not have sufficient power to takeoff. A third witness described the rotation as “steep,” and other witnesses reported thinking that the airplane was performing aerobatics. Digital video from multiple cameras both on and off the airport showed the airplane roll to its left before reaching a maximum altitude of 100 ft above ground level; it then descended and impacted an airport hangar in an inverted attitude about 17 seconds after takeoff and an explosion immediately followed. After breaching a closed roll-up garage door, the airplane came to rest on its right side outside of the hangar and was immediately involved in a postimpact fire. Sound spectrum analysis of data from the airplane’s cockpit voice recorder (CVR) estimated that the propeller speeds were at takeoff power (1,714 to 1,728 rpm) at liftoff. About 7 seconds later, the propeller speeds diverged, with the left propeller speed decreasing to about 1,688 rpm and the right propeller speed decreasing to 1,707 rpm. Based on the airplane’s estimated calibrated airspeed of about 110 knots and the propeller rpm when the speeds diverged, the estimated thrust in the left engine decreased to near 0 while the right engine continued operating at slightly less than maximum takeoff power. Analysis of available data estimated that, 2 seconds after the propeller speed deviation, the airplane’s sideslip angle was nearly 20°. During the first 5 seconds after the propeller speed deviation, the airplane’s roll rate was about 5° per second to the left; its roll rate then rapidly increased to more than 60° per second before the airplane rolled inverted. Witness marks on the left engine and propeller, the reduction in propeller speed, and the airplane’s roll to the left suggest that the airplane most likely experienced a loss of thrust in the left engine shortly after takeoff. The airplane manufacturer’s engine-out procedure during takeoff instructed that the landing gear should be retracted once a positive rate of climb is established, and the propeller of the inoperative engine should be feathered. Right rudder should also be applied to balance the yawing moment imparted by a thrust reduction in the left engine. Examination of the wreckage found both main landing gear in a position consistent with being extended and the left propeller was unfeathered. The condition of the wreckage precluded determining whether the autofeather system was armed or activated during the accident flight. Thus, the pilot failed to properly configure the airplane once the left engine thrust was reduced. Calculations based on the airplane’s sideslip angle shortly after the propeller speed deviation determined that the thrust asymmetry alone was insufficient to produce the sideslip angle. Based on an evaluation of thrust estimates provided by the propeller manufacturer and performance data provided by the airplane manufacturer, it is likely that the pilot applied left rudder, the opposite input needed to maintain lateral control, before applying right rudder seconds later. However, by then, the airplane’s roll rate was increasing too rapidly, and its altitude was too low to recover. The data support that it would have been possible to maintain directional and lateral control of the airplane after the thrust reduction in the left engine if the pilot had commanded right rudder initially rather than left rudder. The pilot’s confused reaction to the airplane’s performance shortly after takeoff supports the possibility that he was startled by the stall warning that followed the propeller speed divergence, which may have prompted his initial, improper rudder input. In addition, the NTSB’s investigation estimated that rotation occurred before the airplane had attained Vr (rotation speed), which decreased the margin to the minimum controllable airspeed and likely lessened the amount of time available for the pilot to properly react to the reduction in thrust and maintain airplane control. Although the airplane was slightly over its maximum takeoff weight at departure, its rate of climb was near what would be expected at maximum weight in the weather conditions on the day of the accident (even with the extended landing gear adding drag); therefore, the weight exceedance likely was not a factor in the accident. Engine and propeller examinations and functional evaluations of the engine and propeller controls found no condition that would have prevented normal operation; evidence of operation in both engines at impact was found. Absent evidence of an engine malfunction, the investigation considered whether the left engine’s thrust reduction was caused by other means, such as uncommanded throttle movement due to an insufficient friction setting of the airplane’s power lever friction locks. Given the lack of callouts for checklists on the CVR and the pilot’s consistently reported history of not using checklists, it is possible that he did not check or adjust the setting of the power lever friction locks before the accident flight, which led to uncommanded movement of the throttle. Although the co-pilot reportedly had flown with the pilot many times previously and was familiar with the B-300, he was not type rated in the airplane and was not allowed by the pilot to operate the flight controls when passengers were on board. Therefore, the co-pilot may not have checked or adjusted the friction setting before the flight’s departure. Although the investigation considered inadequate friction setting the most likely cause of the thrust reduction in the left engine, other circumstances, such as a malfunction within the throttle control system, could also result in loss of engine thrust. However, heavy fire and impact damage to the throttle control system components, including the power quadrant and cockpit control lever friction components, precluded determining the position of the throttle levers at the time of the loss of thrust or the friction setting during the accident flight. Thus, the reason for the reduction in thrust could not be determined definitively. In addition to a lack of callouts for checklists on the CVR, the pilots did not discuss any emergency procedures. As a result, they did not have a shared understanding of how to respond to the emergency of losing thrust in an engine during takeoff. Although the co-pilot verbally identified the loss of the left engine in response to the pilot’s confused reaction to the airplane’s performance shortly after takeoff, it is likely the co-pilot did not initiate any corrective flight control inputs, possibly due to the pilot’s established practice of being the sole operator of flight controls when passengers were on board. The investigation considered whether fatigue from inadequately treated obstructive sleep apnea contributed to the pilot’s response to the emergency; however, the extent of any fatigue could not be determined from the available evidence. In addition, no evidence indicates that the pilot’s medical conditions or their treatment were factors in the accident. In summary, the available evidence indicates that the pilot improperly responded to the loss of thrust in the left engine by initially commanding a left rudder input and did not retract the landing gear or feather the left propeller, which was not consistent with the airplane manufacturer’s engine out procedure during takeoff. It would have been possible to maintain directional and lateral control of the airplane after the thrust reduction in the left engine if right rudder had been commanded initially rather than left rudder. It is possible that the pilot’s reported habit of not using checklists resulted in his not checking or adjusting the power lever friction locks as specified in the airplane manufacturer’s checklists. However, fire and impact damage precluded determining the position of the power levers or friction setting during the flight.

The pilot in the multi-engine, retractable landing gear airplane reported that, during an instrument flight rules cross-country flight, about 5,000 ft above mean sea level, the left engine surged several times and he performed an emergency engine shutdown. Shortly afterward, the right engine lost power. During the emergency descent, the airplane struck treetops, and landed hard in a field with the landing gear retracted. The airplane sustained substantial damage to both wings, the engine mounts, and the lower fuselage. The pilot reported that he had requested 200 gallons of fuel from his home airport fixed base operator, but they did not fuel the airplane. The pilot did not check the fuel quantity during his preflight inspection. According to the Federal Aviation Administration Airplane Flying Handbook, Chapter 2, page 2-7, pilots must always positively confirm the fuel quantity by visually inspecting the fuel level in each tank. The pilot reported that there were no mechanical malfunctions or failures with the airplane that would have precluded normal operation.

While in cruise flight at 24,000 feet msl, the pilot of the Piper Malibu Mirage advised Memphis Center that he had encountered icing conditions and was experiencing a fuel imbalance. The pilot requested and was cleared to deviate to the north. Subsequently, radio and radar contact were lost. A witness reported hearing the sound of the airplane's engine stop running and observed the airplane descending from the dark clouds in a nose down attitude and rotating clockwise. Residents of the area reported that the weather at the time of the accident was high ceilings with heavy rain just before and after the accident. There were thunderstorms with lightning in the area at the time of the accident. The wreckage of the airplane was scattered along an area of about four miles. The airplane was equipped with an autopilot, weather radar, and an ice protection system. The pilot had recently purchased the 1999 model airplane and had completed a Mirage initial training course. At the time of the accident the pilot had accumulated a total of 21.4 hours in the make and model of the accident aircraft. No anomalies were found with the airframe or engine that would have prevented normal operation.

During daylight flight, the airplane lost its right engine due to failed piston assembly because of engine overheating. The overheating was due to the engine air cooling baffle not being installed and the improper oil filter being installed. The airplane would not sustain flight due to the inoperative main landing gear which was locked in the down position and the propeller that could not feather due to corrosion. The pilot and his passenger were seriously injured in the landing due to the lack of seat belts. The airplane was operated with 137 known deficiencies.

The pilot reported that shortly after lifting off, the airplane began decelerating slowly. He thought the throttles had retarded; however, all of the engine instruments indicated takeoff power. Realizing that he could not return to the airport, the pilot selected a forced landing area and aimed the airplane between two trees. Investigation revealed that both props were at or near feather pitch angles at impact and being driven under power. Both engines had been changed immediately prior to the flight and both ground idle stops had been adjusted after the engine change with the left engine being slaved to the right. The system operated off of a squat switch on the right gear. Misriging of the right engine would be reflected in the left and allow oil pressure to be vented from the domes, which in turn would allow the propeller cylinder springs to drive the props toward feather as the right strut extended during takeoff. The pilot, sole on board, was seriously injured.

The crew departed Memphis on a flight to Addison, Texas. En route, the crew was cleared to climb to FL300 but the aircraft continued to climb without authorization until FL440. ATC tried to contact the crew without success. It was decided to dispatch a USAF Northrop T-38 Talon fighter and his pilot confirmed that the cockpit windows were covered by frost and that he was unable to contact the crew. The aircraft continued its route to the south, entered the Mexican airspace and few minutes later, after both engines failed due to fuel exhaustion, the aircraft entered a dive and crashed near Cuatro Ciénegas. The aircraft disintegrated on impact and both pilots were killed, among them the NASA astronaut-candidate Susan Reynolds aged 27.

Aircraft was destroyed when it struck power lines and the ground during a single engine go-around. Following a left engine shut down due to severe vibrations, the pilot overflew one airport to return to his home base. En route, he elected not to go to full power due to a 3 minutes limitation he did not want to exceed. The pilot overshot the runway while manually extending the nose gear and elected to attempt a right 270° turn to return to final while at 100-150 feet agl. Nose landing did not extend due to hydraulic pump being on left engine and no pressure. During the turn, the pilot lost control and the aircraft struck the wires. Investigation revealed that one of the blade pitch change links on the left prop had disconnected, allowing one blade to free float. The link pin assembly had backed out as a result of the safety screw backing out due to damaged and stripped threads and an improper length screw being installed. Props had 1/4' safety screws installed instead of 3/8'.

Witnesses reported a normal takeoff and climb was made to an altitude of approximately 400 feet agl at which time engine power ceased/decreased. The right wing then dropped, the nose and left wing rose and the aircraft entered a near vertical descent to ground impact. Post accident examination of the engines and turbochargers failed to disclose any pre-impact failures. Examination of the prop governors disclosed an rpm setting below takeoff or climb power; however, exact rpm setting could not be determined. The pilot had recently purchased this aircraft and most of his multi-engine experience was in Beech Barons. The throttle quadrant location of the throttle and prop controls on the Baron are in the reverse position of those on the Cessna 421. The pilot also had not been check out in the Cessna 421. All four occupants were killed.

Approximately 7 minutes after takeoff (at 1441), the pilot declared an emergency and said the left engine had lost power. He feathered the engine, diverted back toward the airport and descended to VFR conditions below the clouds. At 1448, the pilot said he had the airport in sight and turned onto a left downwind for runway 15. Reportedly, he extended the landing gear and began a left turn toward the runway. Reportedly, the aircraft was too close in and/or the pilot chose to make a right turn away from the airport to land. Witnesses lost sight of the aircraft during the turn due to low clouds or obstructions. The pilot lost sight of the airport for a short time, then relocated it, but said he had his 'hands full.' Shortly thereafter, the aircraft entered a steep descent, hit the edge (roof) of a building, crashed into a utility pole and the ground and burned. There was evidence the aircraft was inverted just before impact. An exam of the left engine revealed evidence the #6 connecting rod had failed from oil exhaustion. Only one cup of oil was found in the engine and it had a history of high oil consumption. The pilot, sole on board, was killed.

The aircraft was cleared for Mena NDB approach and to maintain 5,000 feet msl until established on the approach. Aircraft descended to 4,800 feet msl on approximately ground track of 040° to 030° after NDB passage. Aircraft then turned to a ground track of 116°. After 12 seconds the aircraft turned to a ground track of 350° during which the ground speed decreased to 93 knots. The aircraft descended to 4,600 feet msl with ground speed increasing to 140 knots. N68152 reported 'we've broken below - will cancel in just a moment.' Radar contact was lost with the aircraft descending to 3,000 feet msl on a heading of 304°. The wreckage was found 6 miles northwest of the airport at an elevation of 2,000 feet msl. The outbound approach heading is 080° with procedure turn heading of 125° and 305°. Reported winds aloft at 5,000 feet msl, 4,000 feet msl and 3,000 feet msl were 191° at 34 knots, 169° at 30 knots and 151° at 32 knots respectively. Both occupants were killed.