Oxford-Waterbury

Whilst on a cargo flight from Braunschweig, Germany, to Oxford, England, when approximately 30 nm from the English coast, the right engine started to run roughly. On checking the fuel gauges, the pilot observed that they were indicating in the ‘red sector’. The right engine subsequently stopped, shortly followed by the left engine. The aircraft then glided from FL100 towards the Suffolk coast and ditched in the sea approximately 9.5 nm southeast of Aldeburgh. The pilot was able to abandon the aircraft, which sank quickly. He was rescued from the sea some 18 minutes later by a Royal Air Force Search and Rescue helicopter and taken to hospital, where he was found to have suffered a fractured a vertebra. The investigation determined that the aircraft had run out of fuel, due to insufficient fuel for the intended journey being on-board the aircraft at the start of the flight.

The airplane was managed by and listed on the certificate of Jackson Air Charter, Inc. (JAC), a 14 Code of Federal Regulations (CFR) Part 135 on-demand operator; however, because the owner of the airplane was using it for personal use, the accident flight was flown under 14 CFR Part 91 regulations. The right-seat pilot, who was the chief pilot for JAC, was the flying pilot for the flight. The right-seat pilot had about 13,312 total flight hours, 833 hours of which were in Cessna 560 airplanes. The left-seat pilot, who was the nonflying pilot for the flight and had only worked for JAC for a little over a month, had not yet completed the company's Part 135 training but was scheduled to do so. The left-seat pilot had about 11,607 total flight hours, 557 hours of which were in Cessna 560 airplanes. The flight was planned to land at Rochester International Airport (RST), Rochester, Minnesota. The flight crew attempted to circumnavigate severe weather conditions and continue the planned descent for about 15 minutes even though a Minneapolis Air Route Traffic Control Center controller stated that the flight would have to deviate 100 miles or more to the north or 80 miles to the south to do so. The RST approach controller subsequently told the flight crew that there was "weather," including wind gusts, along the final approach course, and on-board radar and weather advisories also showed severe thunderstorms and wind gusts in the area. Given the overwhelming evidence of severe weather conditions around RST, the flight crew exhibited poor aeronautical decision-making by attempting to continue the preplanned descent to RST despite being aware of the severe weather conditions and by not diverting to a suitable airport earlier in the flight. The cockpit voice recorder (CVR) recorded the flight crew begin discussing an alternate destination airport about 3 minutes after contacting RST approach; however, the CVR did not record the left-seat pilot adequately communicate to air traffic control that the flight was going to divert. CVR evidence also showed that neither pilot took a leadership role during the decision-making process regarding the diversion. As a result, the flight crew chose an alternate airport, Ellen Church Field Airport (CJJ), Cresco, Iowa, from either looking at a map or seeing it out the cockpit window. The flight crew was not familiar with the airport, which did not have weather reporting capabilities. CVR evidence indicates that the flight crew did not use the on-board resources, such as the flight management system and navigational charts, to get critical information about CJJ, including runway direction and length. Further, the flight crew did not use on-airport resources, such as the wind indicator located on the left side of runway 33. During the approach and landing, the enhanced ground proximity warning system (EGPWS) alerted in the cockpit. However, the flight crew did not recognize or respond to the EGPWS warning, which alerted because the EGPWS did not recognize the runway since it was less than 3,500 feet long. CVR evidence indicated that the flight crew incorrectly attributed the warning to the descent rate. Further, the runway was not depicted on an on-board non-navigational publication, which only contained runways that were 3,000 feet or more long, and this was referenced and noted by the flight crew. In addition, the flight crew visually recognized during the final approach that the runway was shorter than the at least 5,000 feet they originally believed it to be (as stated by the right-seat pilot earlier in the flight). Despite all of these indications that the runway was not long enough to land safely, the flight crew continued the descent and landing. (After the accident, Cessna computed the landing distance for the accident conditions, which indicated that about 5,200 feet would have been required to stop the airplane on a wet runway with a 10-knot tailwind. Runway 33 is only 2,949 feet long. Further, the Cessna Aircraft Flight Manual does not recommend landing on precipitation covered runways with any tailwind component.) Because the flight crew did not look up the runway length and did not heed indications that the runway was too short, both of which are further evidence of the flight crew's poor aeronautical decision-making, they landed with inadequate runway length to either land the airplane on the runway or abort the landing. Subsequently, the airplane exited the runway and continued about 1,700 feet beyond its end. The airplane had sufficient fuel to have proceeded to an airport with a suitable runway length. In addition to the poor decision-making, the flight crew did not exhibit adequate crew resource management (CRM) throughout the flight. For example, the flight crew exhibited poor communication and decision-making skills, did not effectively use the available on-board resources to get information about the landing runway, and neither pilot took a leadership role during the flight. JAC did not have and was not required to have an approved CRM training program although, according to company pilots, some CRM training was incorporated into the company's simulator training. On December 2, 2003, the National Transportation Safety Board issued Safety Recommendation A-03-52, which asked the Federal Aviation Administration (FAA) to require that 14 CFR Part 135 on-demand charter operators that conduct dual-pilot operations establish and implement an FAA-approved CRM training program for their flight crews in accordance with 14 CFR Part 121, subparts N and O. On May 2, 2006, Safety recommendation A-03-52 was reiterated and classified "Open-Unacceptable Response" pending issuance of a final rule. Although the accident flight was operated under Part 91, if JAC, as an on-demand Part 135 operator, had provided all of its pilots CRM training, the benefits of such training would extend to the company's Part 91 flights. In November 2007, the Safety Board placed Safety Recommendation A-03-52 on its Most Wanted List of Transportation Safety Improvements because of continued accidents involving accident flight crew members. As a result of this accident, the Safety Board reiterated Safety Recommendation A-03-52 on May 1, 2008. The right-seat pilot had in his possession multiple prescription and nonprescription painkillers, nonprescription allergy and anti-acid medications, and one prescription muscle relaxant. None of these medications are considered illicit drugs and would not have been reportable on drug testing required under 49 CFR Part 40. The right-seat pilot was known to have problems with back pain, although no medical records of treatment for the condition could be located. On his most recent application for airman medical certificate, the pilot had reported no history of or treatment for any medical conditions and no use of any medications. Toxicology testing revealed recent use of a prescription muscle relaxant, which might have resulted in impairment. It is also possible that the right-seat pilot was impaired or distracted by the symptoms for which he was taking the muscle relaxant; however, it could not be determined what role the muscle relaxant or the physical symptoms might have played in this accident.

The airplane, which was not operating on a flight plan, was proceeding in clear skies to an airport where the passenger was joining his wife. After crossing a lake near the destination, the airplane flew over rising terrain, along a saddleback, until it struck a stand of old-growth trees that jutted above new-growth trees. During the last 48 seconds of radar coverage, the airplane climbed 600 feet with no erratic course deviations. From the accident location, the airport would have been about 5 nautical miles off the airplane's right wing. The pilot had 32,000 hours of flight experience. The passenger was under investigation for fraud, and attempted to obtain life insurance prior to the flight. The passenger had also loaned money to the pilot, and was receiving "flight services" in lieu of cash payment when the pilot failed to pay back the loan. A .380 caliber pistol magazine was found at the accident site with two rounds of ammunition missing; however, no weapon was located at the site, and no weapon of that caliber was known to be associated with either the pilot or the passenger. Premature ventricular complexes (PVCs) were found on electrocardiograms performed in conjunction with the pilot's airman medical certificate applications in 2002 and 2004. The pilot's autopsy report indicated "severe calcific... coronary disease, with 90 percent narrowing of the left anterior descending coronary artery and 75 percent narrowing of the right coronary artery." Cause of death, for both the pilot and passenger, was listed as "undetermined." The autopsy reports also noted that, "due to the inability to perform a complete autopsy...of either of the two aircraft occupants, it cannot be determined whether either the pilot or the passenger were alive or dead at the time of the crash." Post accident inspection of the airplane disclosed no evidence of any preimpact anomalies.

Towards the end of a flight from Brussels to Oxford (Kidlington), the pilot was cleared to land from a visual straight-in approach to Runway 01. The surface wind was reported as 030°/15 kt. As the aircraft crossed the airfield boundary, it started to roll to the left. Shortly after, it struck the ground to the west of the runway threshold. Despite an extensive investigation, no technical malfunction was identified which could have caused the apparent uncontrolled roll to the left. Although there was no other conclusive evidence which would explain the manoeuvre, it is possible that control of the aircraft was lost during application of power to adjust the flight path or in an attempted late go-around, or as a result of an unknown distraction. The passengers was the French businessman Paul-Louis Halley, CEO of Carrefour, accompanied by his wife. They were en route to England to take part to a wedding.

The aircraft completed an instrument approach and landed hard on the runway surface first with the left gear then the right gear. The tires burst and the lower fuselage came into contact with the runway surface. After the nose gear touched down, the right main landing gear collapsed and the pilot lost control of the aircraft. It veered to the left and departed the runway, coming to rest approximately 150 to 200 yards from the point of departure. Initial touch down occurred about 12 feet from the threshold, ten feet left of centerline.

According to witnesses, the weather was changing from minute to minute as the aircraft was arriving. Witnesses reported the wind was blowing from east to northeast at 10 to 15 knots, rain fall was varying from strong to periods of light rain, and the ceiling (cloud level) was variable. The pilot began an ILS runway 36 approach; however, before reaching the airport, the aircraft collided with trees and crashed about 2 miles short of the runway. The pilot was seriously injured and could not remember the accident, but did recalled receiving a wind shear alert. The pilot reported an intermittent problem with the autopilot heading mode; however, no other preimpact malfunction or failure of the acft was evident. All five occupants were injured, two seriously.

Shortly after climbing and leveling at 6,000 feet, the right engine bmep gage indicated a rapid power loss and the right engine rpm 'increased out of control' to about 3,100 rpm. The aircrew retarded the right throttle and reduced the right engine to 2,100 rpm by using the prop increase/decrease toggle switch. The aircrew were unable to feather the right propeller or maintain altitude, so they diverted to the nearest airport (Walker County). While turning downwind for runway 09, the right engine fire indicator activated and the copilot confirmed a fire. Both fire bottles were discharged and the right propeller stopped rotating. Injection water for the left engine was exhausted and the left engine began backfiring. The captain then maneuvered and landed on runway 27. After touchdown, the right main tires failed, the aircraft veered off the right side of the runway and hit a ditch and the gear collapsed. An exam revealed the #6 cylinder link rod and/or piston in the right engine had failed, resulting in further damage to the engine and #6 cylinder. Subsequently, fire and heat caused the right engine to seize and also damaged the right main tires which failed at touchdown. All 39 occupants were evacuated, among them two passengers were seriously injured.

The pilot requested an instrument approach to the airport and advised approach control (a/c) that he did not have an approach plate for the airport. A/c cleared the aircraft for an NDB approach to runway 24 and read the approach information to the pilot. When the pilot reported procedure turn inbound a/c advised the pilot he was approx 4 miles south of the final approach course and gave him a new heading to correct back to the airport. Radar contact was then lost over the airport but reappeared approx 1/2 mile west of the airport and appeared to be making a turn back to the airport. The wreckage was found about 4 miles west of the airport. Both occupants were killed.

Shortly after takeoff from Oxford Airport, one of the engine failed. The pilot initiated a right turn when the airplane entered an uncontrolled descent and crashed, bursting into flames. Both occupants were killed.