Crash of a Cessna 340A near Boynton Beach: 1 killed

Date & Time: Jun 8, 2013 at 1002 LT
Type of aircraft:
Registration:
N217JP
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Fort Lauderdale – Leesburg
MSN:
340A-0435
YOM:
1978
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
16561
Captain / Total hours on type:
56.00
Aircraft flight hours:
4209
Circumstances:
Four minutes after taking off on an instrument flight rules flight, during an assigned climb to 4,000 feet, the pilot advised the departure air traffic controller that the airplane was having "instrument problems" and that he wanted to "stay VFR" (visual flight rules), which the controller acknowledged. As directed, the pilot subsequently contacted the next sector departure controller, who instructed him to climb to 8,000 feet. The pilot stated that he would climb the airplane after clearing a cloud and reiterated that the airplane was having "instrument problems." The controller told the pilot to advise when he could climb the airplane. About 30 seconds later, the pilot told the controller that he was climbing the airplane to 8,000 feet, and, shortly thereafter, the controller cleared the airplane to 11,000 feet, which the pilot acknowledged. Per instruction, the pilot later contacted a center controller, who advised him of moderate-to-heavy precipitation along his (northbound) route for the next 10 miles and told him that he could deviate either left or right and, when able, proceed direct to an intersection near his destination. The pilot acknowledged the direct-to-intersection instruction, and the controller told the pilot to climb the airplane to 13,000 feet, which the pilot acknowledged. The pilot did not advise the center controller about the instrument problems. The airplane subsequently began turning east, eventually completing about an 80-degree turn toward heavier precipitation, and the controller told the pilot to climb to 15,000 feet, but the pilot did not respond. After two more queries, the pilot stated that he was trying to maintain "VFR" and that "I have an instrument failure here." The controller then stated that he was showing the airplane turning east, which "looks like a very bad idea." He subsequently advised the pilot to turn to the west but received no further transmissions from the airplane. Radar indicated that, while the airplane was turning east, it climbed to 9,500 feet but that, during the next 24 seconds, it descended to 7,500 feet and, within the following 5 seconds, it descended to just above ground level (the ground-based radar altitude readout was 0 feet). The pilot recovered the airplane and climbed it northeast-bound to 1,500 feet during the next 20 seconds. It then likely stalled and descended northwest-bound into shallow waters of a wildlife refuge. Weather radar returns indicated that the airplane's first descent occurred in an area of moderate-to-heavy rain but that the second descent occurred in light rain. The ceiling at the nearest recording airport, located about 20 nautical miles from the accident site, was 1,500 feet, indicating that the pilot likely climbed the airplane back into instrument meteorological conditions (IMC)before finally losing control. The investigation could not determine the extent to which the pilot had planned the flight. Although a flight plan was on file, the pilot did not receive a formal weather briefing but could have self-briefed via alternative means. The investigation also could not determine when the pilot first lost situational awareness, although the excessive turn to the east toward heavier precipitation raises the possibility that the turn likely wasn't intentional and that the pilot had already lost situational awareness. Earlier in the flight, when the pilot reported an instrument problem, the two departure controllers coordinated between their sectors in accordance with air traffic control procedures, allowing him to remain low and out of IMC. Although the second controller told the pilot to advise when he was able to climb, the pilot commenced a climb without further comment. The controller was likely under the impression that the instrument problem had been corrected; therefore, he communicated no information about a potential instrument problem to the center controller. The center controller then complied with the level of service required by advising the pilot of the weather conditions ahead and by approving deviations. The extent and nature of the deviation was up to the pilot with controller assistance upon pilot request. The pilot did not request further weather information or assistance with deviations and only told the center controller that the airplane was having an instrument problem after the controller pointed out that the airplane was heading into worsening weather. Due to impact forces, only minimal autopsy results could be determined. Federal Aviation Administration medical records indicated that the 16,560-hour former military pilot did not have any significant health issues, and the pilot's wife was unaware of any preexisting significant medical conditions. The wreckage was extremely fractured, which precluded thorough examination. However, evidence indicated that all flight control surfaces were accounted for at the accident scene and that the engines were under power at the time of impact. The airplane was equipped with redundant pilot and copilot flight instruments, redundant instrument air sources, onboard weather radar, and a storm scope. The pilot did not advise any of the air traffic controllers about the extent or type of instrument problem, and the investigation could not determine which instrument(s) might have failed or how redundant systems could have been failed at the same time. Although the pilot stated on several occasions that the airplane was having instrument problems, he opted to continue flight into IMC. By doing so, he eventually lost situational awareness and then control of airplane but regained both when he acquired visual ground contact. Then, for unknown reasons, he climbed the airplane back into IMC where he again lost situational awareness and airplane control but was then unable to regain them before the airplane impacted the water.
Probable cause:
The pilot's loss of situational awareness, which resulted in an inadvertent aerodynamic stall/spin after he climbed the airplane back into instrument meteorological conditions (IMC). Contributing to the accident was the pilot's improper decision to continue flight into IMC with malfunctioning flight instrument(s).
Final Report:

Crash of a Piper PA-31T Cheyenne II in Fort Lauderdale: 3 killed

Date & Time: Mar 15, 2013 at 1621 LT
Type of aircraft:
Registration:
N63CA
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Fort Lauderdale - Fort Lauderdale
MSN:
31-7820033
YOM:
1978
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
10000
Aircraft flight hours:
5006
Circumstances:
The multiengine airplane had not been flown for about 4 months and was being prepared for export. The pilot was attempting a local test flight after avionics upgrades had been performed. Shortly after takeoff, the pilot transmitted that he was experiencing an "emergency"; however, he did not state the nature of the emergency. The airplane was observed experiencing difficulty climbing and entered a right turn back toward the airport. It subsequently stalled, rolled right about 90 degrees, and descended. The airplane impacted several parked vehicles and came to rest inverted. A postcrash fire destroyed the airframe. Both engines were destroyed by fire and impact damage. The left propeller assembly was fire damaged, and the right propeller assembly remained attached to the gearbox, which separated from the engine. Examination of wreckage did not reveal any preimpact malfunctions. It was noted that the left engine displayed more pronounced rotational signatures than the right engine, but this difference could be attributed to the impact sequence. The left propeller assembly displayed evidence of twisting and rotational damage, and the right propeller assembly did not display any significant evidence of twisting or rotational damage indicative of operation with a difference in power. The lack of flight recorders and the condition of the wreckage precluded the gathering of additional relevant information.
Probable cause:
The pilot's failure to maintain airplane control following an emergency, the nature of which could not be determined because of crash and fire damage, which resulted in an aerodynamic stall.
Final Report:

Crash of a Beechcraft C90GTi King Air off Oranjestad

Date & Time: Apr 3, 2012 at 0920 LT
Type of aircraft:
Operator:
Registration:
N8116L
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Wichita - Fort Lauderdale - Willemstad - Belo Horizonte
MSN:
LJ-2042
YOM:
2011
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
11700
Captain / Total hours on type:
2600.00
Copilot / Total flying hours:
3649
Copilot / Total hours on type:
33
Aircraft flight hours:
14
Circumstances:
On April 3, 2012, about 0920 atlantic standard time (ast), a Hawker Beechcraft C90GTx, N8116L, operated by Lider Taxi Aereo, was substantially damaged after ditching in the waters of the Caribbean Sea, 17 miles north of Aruba, following a dual loss of engine power during cruise. The flight departed Fort Lauderdale Executive Airport (FXE), Fort Lauderdale, Florida, and was destined for Hato International Airport (TNCC), Willemstad, Curacao. The airline transport pilot and the pilot rated passenger were uninjured. Visual meteorological conditions prevailed, and an instrument flight plan was filed for the delivery flight conducted under 14 Code of Federal Regulations Part 91. The Amsterdam arrived at the ditching location at 1120. The airplane was partially submerged. The crew of the Amsterdam attempted to prevent the airplane from sinking by placing a cable around it and hoisting it onboard. However during the attempted recovery, the fuselage broke in half and the airplane sank.
Probable cause:
Review of the fuel ticket revealed that the misspelled words; "Top Neclles" was handwritten on it. It was also signed by the pilot. Further review revealed that only 25 gallons had been uploaded to the airplane, and this number had been entered in the box labeled "TOTAL GALLONS DELIVERED". Review of the start reading and end reading from the truck meter also concurred with this amount. Furthermore, It was discovered that the "134 gallons" that the pilot believed had been uploaded to the airplane was in fact the employee number of the fueler that had topped off the nacelle tanks and had entered his employee number on the "FUEL DEL BY:" line. Utilizing the information contained on the fuel ticket, it was determined that the airplane had departed with only 261 gallons of fuel on-board. Review of performance data in the POH/AFM revealed that in order to complete the flight the airplane would have needed to depart with 328 gallons on-board.
Final Report:

Crash of a Cessna 650 Citation VII in Fort Lauderdale

Date & Time: Dec 28, 2011 at 0951 LT
Type of aircraft:
Registration:
N877G
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Lauderdale – Teterboro
MSN:
650-7063
YOM:
1995
Crew on board:
2
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
14950
Captain / Total hours on type:
190.00
Copilot / Total flying hours:
19000
Copilot / Total hours on type:
100
Aircraft flight hours:
5616
Aircraft flight cycles:
4490
Circumstances:
The crew stated that the preflight examination, takeoff checks, takeoff roll, and rotation from runway 26 were "normal." However, once airborne, and with the landing gear down and the flaps at 20 degrees, the airplane began a roll to the right. The captain used differential thrust and rudder to keep the airplane from rolling over, and as he kept adjusting both. He noted that as the airspeed increased, the airplane tended to roll more; as the airspeed decreased, the roll would decrease. The captain also recalled thinking that the airplane might have had an asymmetrical flap misconfiguration. Both pilots stated that there were no lights or warnings. As the airplane continued a right turn, runway 13 came into view. The captain completed a landing to the right of that runway, landing long and in the grass with a 9-knot, left quartering tailwind. The airplane then paralleled the runway and ran into an airport perimeter fence beyond the runway's end. The cockpit voice recorder revealed that the crew initially used challenge and reply checklists and that after completing the takeoff checklist, engine power increased. About 7 seconds after the first officer called "V1," the captain stated an expletive, and the first officer announced "positive rate." During the next 50 seconds, the captain repeated numerous expletives, an automated voice issued numerous "bank angle" warnings, and the first officer asked what he could do, to which the captain later told him to declare an emergency. There were no calls by either pilot for an emergency checklist nor were there callouts of any emergency memory items. Each of the airplane's wings incorporated four hydraulically-actuated spoiler segments. The outboard segment, the roll control spoiler, normally extends in conjunction with its wing aileron after the aileron has traveled more than about 3 degrees, and extends up to 50 degrees at full control wheel rotation. When the airplane was subsequently examined in a hangar, hydraulic power was applied to the airplane via a ground hydraulic power unit, and the right roll spoiler elevated to 7.9 degrees above the flush wing level. Multiple left/right midrange turns of the yoke, with the hydraulic ground power unit both on and off, resulted in the roll spoiler being extended normally, but still returning to a resting position of 7.8 to 7.9 degrees above the flush position. When the yoke was turned full right and left, whether the aileron boost was on or off, both wings' roll spoilers extended to their full positions per specifications; however, once the full deflection testing was completed, the right roll spoiler returned to 6.1 degrees above the flush position. A final yoke turn resulted in the roll spoiler being elevated to 5.5 degrees. The right wing roll spoiler actuator was subsequently examined at the airplane manufacturer, and the roll spoiler was found to jam. The roll spoiler actuator was disassembled, but no specific reason(s) for the jamming were found. The roll spoiler parts were also examined and no indications of why the actuator may have jammed were found. According to the flight manual, if any of the spoiler segments should float, moving the spoiler hold down switch to "Spoiler Hold Down" locks all spoiler panels down. The roll control spoilers may then be used in the roll mode by turning on the auxiliary hydraulic pump. Also, an "Aileron/Spoiler Disconnect" T-handle is available to release the tie between the ailerons and the roll control spoilers in the event of a jam in either system. When used, the pilot's yoke controls only the ailerons, and the copilot's yoke controls only the roll control spoilers. Although the jamming of the right spoiler initiated the event, the crew's proper application of emergency procedures should have negated the adverse effects. Memory items for an uncommanded roll include moving the spoiler hold-down switch to the "on" position, which was not done; the spoiler hold-down switch was found in the "off" position. (The captain thought that he may have had an asymmetrical flap configuration; however, if an asymmetry had been the initiating event, the flap system would have been automatically disabled and the flap segments would have been mechanically locked in their positions.) The aileron/spoiler disconnect T-handle was found pulled up, which the crew indicated had occurred when the first officer's shoe hit it as he evacuated the airplane. While pulling the aileron/spoiler disconnect T-handle would have been appropriate for a different emergency procedure to release the tie between the ailerons and the roll control spoilers in the event of a jam in either system, it would have actually hindered the captain's attempts to control the airplane in this case because it would have disconnected the left roll spoiler from the captain's yoke, making it more difficult to counter the effects of the displaced right roll spoiler. Although the crew indicated that the t-handle was pulled during the first officer's exit of the airplane, its position, safety cover, and means of activation make this unlikely. In addition, precertification testing of the airplane showed that even with the right roll spoiler fully deployed, as long as the pilot had the use of the left roll spoiler in conjunction with that aileron, the airplane should have been easily controlled.
Probable cause:
The crew's failure to use proper emergency procedures during an uncommanded right roll after takeoff, which led to a forced landing with a quartering tailwind. Contributing to the accident was a faulty right roll spoiler actuator, which allowed the right roll spoiler to deploy but not close completely.
Final Report:

Crash of a Rockwell Sabreliner 60 in Fort Lauderdale

Date & Time: Apr 9, 2011 at 1357 LT
Type of aircraft:
Operator:
Registration:
N71CC
Flight Type:
Survivors:
Yes
Schedule:
Fort Lauderdale – West Palm Beach
MSN:
306-71
YOM:
1974
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On approach to West Palm Beach Airport, the crew encountered technical problems with the undercarriage that could not be lowered. The crew decided to return to his base in Fort Lauderdale. On final, the crew was again unable to lower the gear so the decision was taken to complete a wheels-up landing. The airplane landed on its belly on runway 08 then slid for few dozen metres before coming to rest. The occupants escaped uninjured and the aircraft was damaged beyond repair.
Probable cause:
No investigation was carried out by the NTSB.

Crash of a Cessna 421B Golden Eagle II in Fort Lauderdale: 1 killed

Date & Time: Apr 17, 2009 at 1115 LT
Operator:
Registration:
N1935G
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Fort Lauderdale - Fernandina Beach
MSN:
421B-0836
YOM:
1974
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
23000
Captain / Total hours on type:
5000.00
Circumstances:
Prior to the accident flight witnesses observed the pilot "haphazardly" pouring oil into the right engine. The pilot then ran the engines at mid-range power for approximately 20 minutes. The airplane subsequently taxied out of the ramp area and departed. Fire was observed emanating from the right engine after rotation. The airplane continued in a shallow climb from the runway, flying low, with the right engine on fire. The airplane then banked right to return to the airport and descended into a residential area. Examination of the right engine revealed an exhaust leak at the No. 4 cylinder exhaust riser flange. Additionally, one of the flange boltholes was elongated, most likely from the resulting vibration. The fuel nozzle and B-nut were secure in the No. 4 cylinder; however, its respective fuel line was separated about 8 inches from the nozzle. No determination could be made as to when the fuel line separated (preimpact or postimpact) due to the impact and postcrash fire damage. Examination of the right engine turbocharger revealed that the compressor wheel exhibited uniform deposits of an aluminum alloy mixture, consistent with ingestion during operation, and most likely from the melting of the aluminum fresh air duct. Additionally, the right propeller was found near the low pitch position, which was contrary to the owner's manual emergency procedure to secure the engine and feather the propeller in the event of an engine fire.
Probable cause:
The pilot's failure to maintain aircraft control and secure the right engine during an emergency return to the airport after takeoff. Contributing to the accident was an in-flight fire of the right engine for undetermined reasons.
Final Report:

Crash of a Rockwell Shrike Commander 500S off Alice Town

Date & Time: Jun 9, 2008 at 1401 LT
Operator:
Registration:
N501AP
Flight Type:
Survivors:
Yes
Schedule:
Nassau – Fort Lauderdale
MSN:
500-3224
YOM:
1974
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On June 9, 2008, about 1401 eastern daylight time, an Aero Commander 500S, N501AP, registered to and operated by Gramar 500, Inc., experienced a loss of engine power in both engines and was ditched in the Atlantic Ocean about 1/2 mile south of North Bimini, Bahamas. Visual meteorological conditions prevailed in the area and a visual flight rules flight plan was filed for the 14 Code of Federal Regulations (CFR) Part 91 personal flight from Nassau International Airport (MYNN), Nassau, Bahamas, to Ft. Lauderdale Executive Airport (FXE), Ft. Lauderdale, Florida. The airplane was destroyed due to salt water immersion, and the airline transport rated pilot, the sole occupant, was not injured. The pilot stated that when the flight was past Bimini, the right engine started running rough and losing power. He turned southeast to enter a left base for runway 09 at South Bimini Airport, and the left engine also began to run rough and lost power. The pilot ditched the aircraft, evacuated into a life raft, and was rescued by a pleasure boater. The pilot also stated that 25 gallons of fuel were added while at MYNN, for a total fuel supply of 90 gallons. Both engines were test run 8 days after the accident using a test propeller. Both engines ran to near maximum RPM. One magneto from each engine was replaced prior to the test run.

Ground accident of a Rockwell Sabreliner 80 in Fort Lauderdale

Date & Time: Feb 1, 2008 at 1542 LT
Type of aircraft:
Operator:
Registration:
N3RP
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Fort Lauderdale - Brooksville
MSN:
380-42
YOM:
1976
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
8500
Captain / Total hours on type:
350.00
Copilot / Total flying hours:
14400
Copilot / Total hours on type:
360
Aircraft flight hours:
5825
Circumstances:
The Rockwell International Sabreliner had just been released from the repair station following several months of maintenance, primarily for structural corrosion control and repair. According to the pilots, they began to taxi away from the repair station. Initially, the brakes and steering were satisfactory, but then failed. The airplane then contacted several other airplanes and a tug with an airplane in tow, before coming to a stop. The airplane incurred substantial damage as a result of the multiple collisions. Neither crewmember heard or saw any annunciations to alert them to a hydraulic system problem. Postaccident examination revealed that there was no pressure in the normal hydraulic system, as expected, and that the auxiliary system pressure was adequate to facilitate emergency braking. Additional examination and testing revealed that the aural warning for low hydraulic system pressure was inoperative, but all other hydraulic, steering, and braking systems functioned properly. Both the pilot and copilot were type-rated in the Sabreliner, and each had approximately 350 hours of flight time in type. Neither crewmember had any time in Sabreliners in the 90 days prior to the accident. Operation of the emergency braking system in the airplane required switching the system on, waiting for system pressure to decrease to 1,700 pounds per square inch (psi), pulling the "T" handle, and then pumping the brake pedals 3 to 5 times. In addition, the system will not function if both the pilot's and copilot's brake pedals are depressed simultaneously. The investigation did not uncover any evidence to suggest the crew turned on the auxiliary hydraulic system, or waited for the system pressure to decrease to 1,700 psi in their attempt to use the emergency braking system.
Probable cause:
The depletion of pressure in the normal hydraulic system for an undetermined reason, and the pilots' failure to properly operate the emergency braking system. Contributing to the accident was an inoperative hydraulic system aural warning.
Final Report:

Crash of a Cessna 402C in Freeport

Date & Time: Apr 21, 2006 at 0023 LT
Type of aircraft:
Registration:
C6-KEV
Survivors:
Yes
Schedule:
Fort Lauderdale – Freeport
MSN:
402C-0051
YOM:
1979
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3033
Circumstances:
At approximately 0423UTC on April 21, 2006 the pilot reported that approximately 20 miles out of Freeport, both hydraulic pressure lights illuminated on the annunciator panel. He extended the gear and noticed only the right gear safe light illuminated. The pilot obtained the assistance of a passenger, who retrieved the aircraft pilot operating handbook and read the appropriate procedures as the pilot followed the instructions for emergency gear extension. The pilot stated that he landed the aircraft on the right main gear, hoping this action would release the left main and nose gear. After realizing that this manoeuvre was not successful, he decided to initiate a go-around. Before he could get the aircraft airborne the left propeller made contact with the ground. The aircraft touched down approximately 9,000 feet from the threshold of runway 06; which has a total length of 11,000 feet. The aircraft travelled approximately 1,500 feet on its right main wheel before it veered off the left shoulder of the runway, struck several trees and finally came to rest pointing in a northwesterly direction. The approximate final position was measured to be 180 feet from the side of the runway. The aircraft left wing burst into flames. The left wing and left side of the fuselage was substantially damaged by fire. The four occupants escaped with only minor injuries.
Probable cause:
The investigation determines that the probable causes of this accident to be the following;
• Substandard maintenance that was performed. (Due to the improper flange on the hydraulic line, the hydraulic line came loose from its housing and depleted the fluid from the hydraulic
reservoir).
• Failure of the back up emergency blow down bottle system. It has been determined from inspection that the cable that connects the emergency blow down bottle system in the nose well of the aircraft to the T-handle in the cockpit, exhibited excessive play. Therefore even though the cable was pulled all the way to its fullest extent, it did not allow movement of the pin that would have provided activation of the system. Annual inspection report completed in December 2005 revealed that the portion of the Annual Inspection that required inspection of the emergency blow down bottle was not signed off by the mechanic as having been accomplished. However, the aircraft was returned to service with this discrepancy outstanding.
• Pilot’s lack of qualification and unfamiliarity with this aircraft, its systems and emergency procedures. ( Evidence of falsification of qualification and time requirement exists in pilot’s logbook).
• Pilot’s poor decision making and impaired judgement. (Possibility of impaired judgement due to pilot fatigue).
• Pilot’s failure in assessing the severity of his situation.
• Pilot’s failure to notify ATC of his problem. (Problem was discovered 20 miles prior to the accident).
• Pilot’s failure to properly assess the conditions for landing and maintain vigilant situational awareness while manoeuvring the aircraft after landing. (From post accident inspection, it was noted that the flaps were not extended for the landing. Had it been extended the aircraft glide path as well as the distance required for roll out after landing may have been greatly decreased).
• Pilot’s failure to take immediate action once he realized his predicament. (Pilot stated that after the propeller made contact with the ground, he decided to apply power and go around, but it was too late. Failure to act also can be attributed to possible pilot fatigue as (pilot was out all day shopping and then decided to leave at such a late hour) well as pilot’s unfamiliarity with aircraft systems and performance capabilities).
• Pilot’s failure to request Emergency Service Assistance. Had this service been requested in a timely manner, preparations could have been made to prevent the fire from spreading to the degree in which it did.
Final Report:

Crash of a Douglas R4D-8 in Fort Lauderdale

Date & Time: Jun 13, 2005 at 1550 LT
Type of aircraft:
Operator:
Registration:
N3906J
Flight Phase:
Flight Type:
Survivors:
Yes
Site:
Schedule:
Fort Lauderdale – Marsh Harbour
MSN:
43344
YOM:
1943
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
18000
Copilot / Total flying hours:
8500
Aircraft flight hours:
19623
Circumstances:
The crew stated the airplane was hire by a private individual and had 220 gallons of fuel onboard, and was carrying 6 pieces of granite, weighing 3,200 lbs. The passenger was responsible for the granite during the flight. During takeoff, about 400 feet above the ground, a discrepancy with the left engine manifold pressure was noted, followed by a slight hesitation and mild backfire. Oil was seen leaking from the front nose section of the engine followed by an engine manifold pressure and rpm decrease. Smoke coming from the left engine was observed and reported by the airport controllers. The left engine's propeller failed to feather and the airplane wouldn't maintain altitude. The airplane impacted trees, vehicles, and the right wing struck a home before coming to a stop on the road. A fire ensued immediately after ground impact, all onboard exited without assistance. The fuselage from the cockpit to the tail section melted from the fire. The right wing was damaged by impact and fire, and the right engine remained intact on the wing. The left wing was separated 12 feet from the outboard and the engine separated from the firewall. Both engine's propellers were in the low pitch position. The flaps were full up and the landing gear were retracted. A weight and balance sheet was never furnished. The pieces of granite and limited cargo recovered from the wreckage weighed 3,140 lb. Examination of the airplane revealed all flight controls surface were present and flight control continuity was accounted for and established. No evidence of any pre-impact mechanical discrepancies with the airframe or its systems was found that wound have prevented normal operation of airplane. On December 09, 2004, the left engine's nose section assembly was found with six out of the ten retaining bolts broken. The section was inspected and all ten bolts were replaced with serviceable ones. The assembly of the dose dome section and installation to the engine was performed by the repair station mechanic. The remaining assembling of the engine was completed by the operator's mechanic/pilot. During the left engine post accident examination, the ten bolts securing the nose dome section flange to the stationary reduction gear were fractured with their respective safety wire still intact. The chamber for the propeller feathering oil system was not secured to the plate sections, producing a bypass of the oil for the propeller feathering process. Metal flakes and pieces were observed deposited in the oil breather screen, consistent with the master rod bearing in an advance stage of deterioration. The silver plated master rod bearing had a catastrophic failure. Silver like metal flakes and particles were observed throughout the nose section, reduction gear section, main oil screen, and oil filter housing of the engine. An indication of propeller shaft housing movement was evident. Metal flakes with carbon build up were observed in the propeller shaft support and sleeve assembly. A metallurgical examination of the ten bolts securing the nose dome assembly indicated all were fractured though the threaded section of the shanks. The fatigue zones propagated from the opposite sides toward the center of the bolts consistent with reversed bending of the bolt.
Probable cause:
The inadequate maintenance inspection by company maintenance personnel/pilot and other maintenance personnel of the left engine resulting in a total failure of the master rod bearing, and nose case partial separation, which prevented the left propeller from feathering. This resulted in the airplane not able to maintain altitude and a subsequent forced landing in a residential area.
Final Report: