Hyannis-Barnstable

The commercial pilot stated that, shortly after taking off for a cross-country, personal flight and while accelerating, he noticed high airplane nose-down control forces and that the airplane became increasingly difficult to control. He used manual trim to attempt to trim out the control forces and verified that the autopilot was not engaged; however, the nose-down tendency continued, and the pilot had trouble maintaining altitude. During the subsequent emergency landing, the airframe sustained substantial damage. Postaccident examination of the airplane revealed that the elevator trim push rod assembly was separated from the elevator trim tab actuator, and the end of the elevator trim push rod assembly was found wedged against the elevator's main spar. The elevator trim indicator in the cockpit was found in the nose-up stop position; however, the elevator trim tab was deflected 24° trailing edge up/airplane nose down (the maximum airplane nose-down setting is 6°). A drilled bolt was recovered from inside the right elevator; however, the associated washer, castellated nut, and cotter pin were not found. Examination of the bolt revealed that the threads were damaged and that the bolt hole on one of the clevis yoke halves exhibited deformation, consistent with the bolt separating. About 2 weeks before the accident, the pilot flew the airplane to a maintenance facility for an annual inspection. At that time, Airworthiness Directive (AD) 2016-07-24, which required installation of new hardware at both ends of the pushrod for the elevator trim tab, was overdue. While the airplane was in for the annual inspection, AD 2016-07-24 was superseded by AD 2016-17-08, which also required the installation of new hardware. The ADs were issued to prevent jamming of the elevator trim tab in a position outside the normal limits of travel due to the loss of the attachment hardware connecting the elevator trim tab actuator to the elevator trim tab push-pull rod, which could result in loss of airplane control. While in for the annual inspection, the airplane was stripped and painted, which would have required removal of the right elevator. Although the repair station personnel indicated that they did not disconnect the elevator trim pushrod from the elevator trim tab actuator when they painted the airplane, photographs taken of the airplane while it was undergoing inspection and painting revealed that the pushrod likely had been disconnected. The repair station owner reported that he reinstalled the right elevator and the elevator trim pushrod after the airplane was painted; however, he did not replace the hardware at either end of the pushrod as required by the ADs. Subsequently, the airplane was approved for return to service. After the annual inspection, no work, repairs, or adjustments were made to the elevator trim system. The airplane had accrued about 58 hours since the annual inspection at the time of the accident. Although reusing the self-locking nut might have resulted in it coming off by itself, the cotter pin should have prevented this from happening. Therefore, although the castellated self-locking nut, washer, and cotter pin normally used to secure the elevator trim pushrod at the elevator trim tab actuator were not found, given the evidence it is likely that the hardware, which was not the required hardware, was not properly secured at installation, which allowed it to separate in flight. It is also likely that the pushrod assembly then moved aft and jammed in a position well past the maximum nose-down trim setting, which rendered controlled flight impossible.

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.

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.

The airplane was level at 2,000 feet, in instrument meteorological conditions, when the pilot reported 'we've just lost our ahh artificial horizon.' About 5 minutes later, air traffic control lost radar contact, and communications with the airplane. A witness about 1 mile north of the accident site stated he heard the sound of engine noise coming from the water and he described the sound as loud and constant. The sound lasted for about 30 seconds and was followed by an 'explosive collision/impact sound.' He further stated he walked to the shore and attempted to locate the source of the sound, but 'because of the fog, I couldn't see anything at all.' The airplane was located in about 25 feet of water, and was scattered over a 150 to 200 foot area. The recovered wreckage consisted of both engines, parts of the airplane's left wing, empennage, fuselage, seats, and interior. The airplane's attitude indicator was not recovered. A faint needle impression was found on the face of the airplane's vertical speed indicator between minus 2,500 and 3,000 feet per minute. Examination of the left and right vacuum pumps did not reveal any malfunctions or failures.

The airplane was on an ILS runway 15 approach and collided in-flight with static wires, approximately 2 miles north of the runway. The wires were located in the airplane's flight path, and in a direct line with the ILS final approach course. At the time of the accident the local control tower was closed. Three other aircraft made the approach prior to N402BK, and the pilots of those aircraft all agreed that at about 500 to 700 feet msl, on the final approach course, they encountered downdrafts and turbulence. All the pilots agreed, the downdrafts caused their airplanes to fall below the glide slope, and that in order to rejoin the glide slope, they had to increase power or change the airplane's pitch attitude. The Otis Air National Guard Base 2155 weather observation was; indefinite ceiling 100 sky obscured, visibility 3/4 miles, light rain and fog, temperature 59° F, dew point 58° F, wind 170°, 14 knots, gust to 19, altimeter 29.96 inches hg.

Shortly after the initial power reduction during takeoff, the pilot noted a partial loss of power in the right engine. He said he 'went to full power on both engines' and noted an 'extremely high' fuel flow indication to the right engine. He said, 'thinking that the engine was flooding, I placed the boost pump switch from high to off to possibly eliminate the problem with no result. I then placed the pump back to high and tried to decrease the fuel flow by leaning the mixture. This also did not seem to eliminate the problem.' While troubleshooting the problem, he turned to a downwind and stayed in the traffic pattern, but could not maint altitude. Subsequently, a wheels-up landing was made in an area of small trees approximately 1/2 mile before reaching runway 24. An examination of the right engine revealed the spark plugs were wet with fuel and black with soot. Also, its #5 fuel nozzle had been cross-threaded and was knocked out of its hole during impact. During an initial test, the right fuel pressure sensing switch did not sense operating pressure (over 6 psi); this would have resulted in a high boost/fuel flow condition. Later, the switch was tested ok. All nine occupants escaped uninjured.

Aircraft collided with trees during final approach to runway 24. No evidence of pre-impact failure or malfunction of the aircraft was found. Reported weather at crash site indefinite 100 feet sky obscured. RVR 2,400 feet. Aircraft should have encountered a decreasing headwind and probably moderate turbulence on the final descent. The aircraft was destroyed and all eight occupants were injured, three seriously.

Shortly after takeoff from Hyannis-Barnstable Airport, while on a cargo flight to Nantucket, the twin engine airplane entered an uncontrolled descent and crashed. Both occupants were killed.

Before loading the aircraft for takeoff from LaGuardia, the flight crew checked the enroute weather for the return flight to Hyannis and learned that a landing at the en route stop at New Bedford might not be possible. When they were advised of the weather situation, the passengers destined for New Bedford decided to remain in LaGuardia. At 2132, flight 248 departed LaGuardia for Hyannis on the last leg of the day. There were eight passengers and two flight crew members aboard. According to the first officer's and a passenger's testimony at the public hearing during the investigation of the accident, flight 248 was normal until the approach for landing at Hyannis. At 2234:08, flight 248 contacted Otis Approach Control and reported level at 5,000 feet. At 2239:05, the flight was given the current Hyannis weather which included an indefinite ceiling of 200 feet, sky obscured, visibility 3/4 mile in fog, wind 210° at 10 knots. It also included a visibility of 1 1/8 in light drizzle on runway 24. At 2244:36, flight 248 was 4 nmi north-northeast of the outer marker when Otis Approach Control gave the flight a vector of 210° to intercept the localizer at 1,700 feet for an ILS approach to runway 24 at the Barnstable Airport. At 2245:34, flight 248 was instructed to contact the Barnstable Airport tower. About 2247, the flight complied with this request and reported crossing the outer marker. The flight was cleared to land, however, no further transmissions were heard form the aircraft. The Boston Air Route Traffic Control Center (Boston Center) was able to track flight 248 to within 2.8 nmi of the intended touchdown point on runway 24. Boston Center's computer printout showed the flight's position at 2246:51 about 0.35 nmi northeast of the ILS outer marker at 1,700 feet. It also showed the flight about 0.15 nmi southwest of the outer marker at 1,500 feet at 2247:03. The last radar position shown for the flight was about 1.1 nmi southwest of the outer marker at 2247:27 at 1,100 feet. The first officer stated that the captain was flying the aircraft during the approach to Hyannis. He said that he made the following callouts: localizer alive, outer marker, 500 feet above, 200 feet above, 100 feet above, minimums, and 100 feet below. He said that the captain did not acknowledge any of these calls. The first officer said that when he called 'minimums', the aircraft was one dot below the ILS glidepath. The first officer said that it appeared that the aircraft was in a continual descent without any excessive sink rates or descent angles from 5,000 feet until impact, with the airspeed near 130 knots for the entire approach. He stated that, as he called '100 feet below', he looked outside the cockpit because he believed that the captain had the approach lights in sight. The first officer said that he did not see the ground before the aircraft crashed about 2248 into a heavily wooded area located 1.5 nmi from the approach end of runway 24, on the runway centerline extended. The accident occurred during the hours of darkness. The captain was killed while all other occupants were injured, some of them seriously.