DuPage

On August 20, 2020, about 1542 central daylight time, a Beech B200 airplane (marketed as a King Air 200), N198DM, was destroyed when it was involved in an accident near Rockford, Illinois. The private pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations (CFR) Part 91 positioning flight. The purpose of the flight was to relocate the airplane to the pilot's home base at the DuPage Airport (DPA), West Chicago, Illinois. The airplane had been at Chronos Aviation, LLC (a 14 CFR Part 145 repair station), at the Rockford International Airport (RFD), Rockford, Illinois, for maintenance work. Multiple airport-based cameras recorded the accident sequence. The videos showed the airplane taking off from runway 19. Shortly after liftoff, the airplane started turning left, and the airplane developed a large left bank angle as it was turning. The airplane departed the runway to the left and impacted the ground. During the impact sequence, an explosion occurred, and there was a postimpact fire. A video study estimated the airplane’s maximum groundspeed during the takeoff as 105.5 knots (kts). Data recovered from an Appareo Stratus device onboard the airplane showed that about 1538, the airplane began taxing to runway 19. At 1540:34, the airplane crossed the hold short line for runway 19. At 1541:19, the airplane began a takeoff roll on runway 19. At 1541:42, the airplane began to depart the runway centerline to the left of the runway. Subsequent tracklog points showed the airplane gaining some altitude, and the tracklog terminated adjacent to a taxiway in a grassy area. The Appareo Stratus data showed the airplane began to increase groundspeed on a true heading of roughly 185° about 1541. Airplane pitch began to increase at 1541:41 as the groundspeed reached about 104 kts. The groundspeed increased to 107 kts within the next 2 seconds, and the pitch angle reached around 4° nose-up at this time. In the next few seconds, pitch lowered to around 0° as the groundspeed decayed to around 98 kts. The pitch then became 15° nose-up as the groundspeed continued to decay to about 95 kts. A right roll occurred of about 13° and changed to a rapidly increasing left roll over the next 5 seconds. The left roll reached a maximum of about 86° left as the pitch angle increasingly became negative (the airplane nosed down). The pitch angle reached a maximum nose down condition of -73°. The data became invalid after 1541:53.4. An airplane performance study based on the Appareo Stratus data showed that during the takeoff from runway 19, the airplane accelerated to a groundspeed of 98 kts and an airspeed of 105 kts before rotating and lifting off. The airplane pitched up, climbed, and gained height above the ground. Then, 4 seconds after rotation, the airplane began descending and slowing, consistent with a loss of power. A nose-left sideslip, a left side force, and a left roll were recorded, consistent with the loss or reduction in thrust of the left engine. The sideslip was reduced, likely due to opposite rudder input, and the airplane briefly rolled right. The airplane pitched up and was able to begin climbing again; however, it continued to lose speed. The sideslip then reversed, and the airplane rolled left again and impacted the ground. One witness reported that he observed the accident sequence. He did not hear any abnormal engine noises, nor did he see any smoke or flames emit from the airplane before impact. The airplane came to rest on a flat grass field to the east of runway 19 on airport property. The airplane sustained fire damage and was fragmented from impacting terrain.

The pilot reported that, during the approach following a positioning flight, he saw that the runway had a light dusting of snow on it and that the airplane touched down on speed in the first 1,000 ft of the 4,100- ft-long runway. The copilot, who was the pilot flying, applied heavy braking, but there appeared to be no braking effectiveness, and the airplane did not slow down as expected. The pilot added that, when the airplane reached about two-thirds of the way down the runway, he knew that it was going to overrun the runway due to the loss of only half of its airspeed. He thought that if he aborted the landing, there was a small chance the airplane could become airborne within the remaining runway. The copilot added engine power to abort the landing, and the nose landing gear lifted off, but insufficient runway was remaining to take off. The copilot reduced the engine power to idle, and the airplane overran the runway and went through the airport fence and a guardrail, across a highway, and into a field. Postaccident examination revealed no flat spots or evidence of skidding on the landing gear tires. The flaps were found in the “ground flaps” position, which is not allowed for takeoff. No evidence of any pre-accident mechanical malfunctions or failures were found with the airplane that would have precluded normal operation. Based on an airplane weight of 11,000 lbs, the airplane’s stopping distance would have been about 4,400
ft. The flight crew’s improper decision to land on a snow-covered runway that was too short to accommodate the landing in such conditions led to a runway overrun and impact with obstacles.

The twin-engine airplane was destroyed when it impacted trees and terrain shortly after takeoff. The airplane was consumed in a post-impact fire. Witnesses reported seeing the airplane climbing at a lower than normal rate just after takeoff. One witness did not hear the airplane. Another witness reported that the airplane sounded labored and this is what drew his attention to the airplane. The airplane came to rest in a wooded area about 3,500 feet from the departure end of the runway, and 700 feet left of the extended runway centerline. The wreckage path through the trees was about 65 degrees left of the runway heading. The first piece of wreckage along the wreckage trail was the left wingtip. Examination of the right propeller revealed chordwise scratching, leading edge damage, and bending and twisting opposite to the direction of rotation. In addition, several tree cuts were observed that were predominately on the right side of the wreckage path. No evidence of rotation was noted with respect to the left propeller, propeller blades, or propeller spinner. On-scene examination revealed no pre-impact anomalies with respect to the airframe, right engine, or right propeller. Follow-on examination of the left engine and propeller revealed no pre-impact anomalies. Calculations based on the power setting table, airspeed chart and en-route distance showed that the airplane would have burned a total of 56 to 71 gallons (28 to 35.5 gallons per side) of fuel for the previous leg of the round-trip flight. The main fuel tanks held a total of 112 gallons of fuel (56 gallons per side). Based on the fuel burn calculations, this quantity of fuel would not have been sufficient to complete the round-trip flight on the main fuel tanks alone. The outboard auxiliary fuel tanks held 40 gallons per side. The left fuel selector was found positioned to the inboard main fuel tank and the right fuel selector was found positioned to the outboard auxiliary fuel tank. The airplane flight manual for the airplane stipulates that only the main fuel tanks be used for takeoff and landing. No fuel was obtained for the return flight.

The pilot arrived at Mexia-Limestone County Airport (TX06), Mexia, Texas, sometime before 1100. Once onboard the airplane, a witness, and an acquaintance of the pilot, closed and locked the airplane's cabin door for the pilot, and walked away from the airplane. He also reported that after the engines to the airplane were started, the airplane stayed on the ramp and idled for 10 to 15 minutes. No one saw the pilot taxi to the runway, but he taxied to the north end of Runway 18 for a downwind takeoff to the south. Examination of the accident site found the wreckage oriented along a path consistent with an extended centerline of runway 18. The airplane was found along a fence line approximately 1/4 mile from the departure end of Runway 18. The airplane's track was along a 183-degree bearing, and there was a large burn area prior to and around the debris zone along the wreckage path. Examination of the cockpit revealed a 9/16-inch hex-head bolt inserted in the control lock pinhole for the control column. Under normal procedures Cockpit Check in the Duke 60 Airplane Flight Manual, for Preflight Inspection the first item listed is: 1. "Control Locks - REMOVE and STOW". In addition, under normal procedures Before Starting checklist in the Duke 60 Airplane Flight Manual, the fourth item to check is listed as: 4. "Flight Controls - FREEDOM OF MOVEMENT and PROPER RESPONSE"

The airplane departed runway 1L and radar data indicated the airplane maintained about a 110 knot ground speed for 37 seconds as it climbed to 1,400 feet msl (642 feet agl) with a 008 degree heading. The last radar 14 seconds later indicated the airplane's heading was 342 degrees and had a 130 knot ground speed. The winds were 290/11. Witnesses reported seeing the airplane flying low and slow, and then it made a turn like a "barrel roll" to the left before impacting the ground. Examination of the engines and airframe revealed no pre-existent anomalies. The left and right propellers exhibited leading edge damage and chordwise abrasions. The pilot had a total of about 1,175 flight hours with about 250 hours in the type and model aircraft. The copilot had 4,094 total hours, but had 10 hours of turbine time and no flight time in the type and model of aircraft. The pilot had indicated he was practicing simulated single engine failures. The gear was fully retracted. The trim settings were set for a right engine out situation. The flap selector was set to "UP" flaps, but the flaps were found in transit at approximately 2 degrees of flaps. The Airplane Flight Manual indicated that during "Engine Failure in Takeoff-Gear Fully Retracted" stated that the required airspeed before selecting flaps to 5 degrees was 140 KCAS. The Pilot's Operating Handbook stated the flaps take approximately 31 seconds to retract from 20 to 0 flaps, or 21 seconds to retract from 5 to 0 flaps.

This was the first flight of the Grumman G-21 in two years. Also, the pilot had not flown the G-21 for two years. Before taking off, the pilot reported that three takeoffs and landings would be needed for purposes of becoming current. After takeoff, he flew the airplane approximately one hour and made two full stop landings. During the third takeoff, the airplane was described as lifting off in a short distance and going into a nose high attitude below an altitude of 100 feet. The airplane then rolled left, struck the ground in a steep descent, and burned. Witnesses reported that the engines were providing power until impact; the engines and propellers had evidence of rotational damage. The flap actuators were found extended to a position that equated with 30° of flaps (half flaps). Four G-21 pilots were interviewed. According to them, flaps were not normally used for takeoff in this airplane. They reported that the turboprop engines had substantial power for the weight of the airplane, especially when the plane was not loaded, and that the G-21 would tend to become airborne quickly with flaps extended. No pre impact mechanical problem was noted during the investigation.

The pilot stated she felt the twin engined tailwheel cargo airplane yaw to the right during takeoff. The pilot stated she applied left rudder and set differential power to correct for the perceived right hand crosswind. As the airplane lifted off, it made a sharp right turn and performed left and right banks leveling off prior to colliding with the ground. The airplane slid through security fences and a fuel supply depot before stopping. The newspaper bundle cargo moved from the two forward bays to the aft end of the cargo compartment. The newspapers were covered with plastic wrapper. The cargo compartment floor was slippery when walked upon and had traces of snow on it. According to the pilot the cargo was covered by a cargo net secured at the forward end but not at the aft end. Two cargo straps were crisscrossed over the net and secured at the aft end of the cargo load. The left throttle was found in the full forward position. The right throttle was found one inch aft of the full forward position.

The pilot (a part time employee of the owner) was ferrying the aircraft for maintenance. Witnesses, who saw the pilot before take- off, noted that his speech was slurred and that he seemed angry because a tug would not start. One witness characterized him as being 'very mad' and said his face was 'flushed red.' The aircraft was observed to takeoff in a high nose-up attitude and climb about 500 to 1,000 feet before turning to the southwest and leveling. Subsequently, the plane turned back toward the airport, then it crashed and burned approximately 1-1/2 mile ssw of the airport while on a heading of northeast. Impact occurred while the aircraft was descending in a slightly left wing low attitude. The wreckage was scattered over an area that was approximately 600 feet long and about 45 feet wide at the widest point. According to witnesses, the engines were operating normally when the aircraft crashed. No preimpact mechanical problem was found. A toxicology check of the pilot's liver tissue fluid showed an alcohol level of 2,26‰. The pilot, sole on board, was killed.

Evidence shows copilot called, 'mayday, uncontrolled spin' after aIRCRAFT radar track showed decelERATION from 180 to 120 kNOts over 2 minUTES period while maintaining constant 4,000 feet cruise altitude. Constant altitude consistent with autopilot/autotrim use, particularly in view of reported turbulence/icing. Elevator trim found at approx 13° nose up. No evidence found of preimpact failure or malfunction in aircraft powerplants, structure or systems. Evidence suggests scenario of crew inattention after power reduction with autopilot altitude setting. On power application, aircraft pitched up from slow speed into uncontrolled flight. Duty day at time of mishap approaching 11 hours. All five occupants were killed.

The aircraft was on climbout on an IFR flight plan in VMC conditions when the engine failed. A restart was attempted and the engine ran for a minute or less. Subsequent attempts were unsuccessful. The aircraft was over Lake Michigan and had insufficient altitude to reach the shoreline. A successful water landing was made and the occupants were picked up by the Coast Guard unharmed. Subsequent examination of the engine revealed that the crankshaft had fractured.