Rochester

The private pilot, who was experienced flying the accident airplane, was conducting a personal flight with three passengers on board the single-engine turboprop airplane. Earlier that day, the pilot flew uneventfully from his home airport to an airport about 1 hour away. During takeoff for the return flight, the airplane impacted wooded terrain about 0.5 mile northwest of the departure end of the runway. There were no witnesses to the accident, but the pilot's radio communications with flight service and on the common traffic advisory frequency were routine, and no distress calls were received. A postcrash fire consumed a majority of the wreckage, but no preimpact mechanical malfunctions were observed in the remaining wreckage. Examination of the propeller revealed that the propeller reversing lever guide pin had been installed backward. Without the guide pin installed correctly, the reversing lever and carbon block could dislodge from the beta ring and result in the propeller blades traveling to an uncommanded feathered position. However, examination of the propeller components indicated that the carbon block was in place and that the propeller was in the normal operating range at the time of impact. Additionally, the airplane had been operated for about 9 months and 100 flight hours since the most recent annual inspection had been completed, which was the last time the propeller was removed from and reinstalled on the engine. Therefore, the improper installation of the propeller reversing lever guide pin likely did not cause the accident. Review of the pilot's autopsy report revealed that he had severe coronary artery disease with 70 to 80 percent stenosis of the right coronary artery, 80 percent stenosis of the left anterior descending artery, and mitral annular calcification. The severe coronary artery disease combined with the mitral annular calcification placed the pilot at high risk for an acute cardiac event such as angina, a heart attack, or an arrhythmia. Such an event would have caused sudden symptoms such as chest pain, shortness of breath, palpitations, or fainting/loss of consciousness and would not have left any specific evidence to be found during the autopsy. It is likely that the pilot was acutely impaired or incapacitated at the time of the accident due to an acute cardiac event, which resulted in his loss of airplane control.

The commercial pilot and his wife departed New York in their turboprop airplane on a crosscountry flight to Florida. About 1 hour 40 minutes into the flight and while cruising at flight level (FL) 280, the pilot notified air traffic control (ATC) of an abnormal indication in the airplane and requested a descent to FL180. The responding controller instructed the pilot to descend to FL250 and turn left 30°, and the pilot acknowledged and complied with the instruction; he then again requested a lower altitude. Although the pilot declined emergency handling and did not specify the nature of the problem, the controller independently determined that the flight had encountered a pressurization issue and immediately coordinated with another ATC facility to clear nearby traffic. The controller then issued instructions to the pilot to descend to FL200 and change course; however, the pilot did not comply with the assignments despite acknowledging the instructions multiple times. The pilot's failure to comply with the controller's instructions, his long microphone pauses after concluding a statement over the radio, and his confusion were consistent with cognitive impairment due to hypoxia. Further, the pilot's transmissions to ATC indicated impairment within 2 minutes 30 seconds of reporting the abnormal indication, which is consistent with the Federal Aviation Administration's published time of useful consciousness/effective performance time ranges for the onset of hypoxia. Military airplanes were dispatched about 30 minutes after the pilot's final transmission to ATC to intercept and examine the airplane. The pilots of the military airplanes reported that the airplane appeared to be flying normally at FL250, that both occupants appeared to be asleep or unconscious, and that neither occupant was wearing an oxygen mask. Photographs taken from one of the military airplanes revealed that the airplane's emergency exit door was recessed into the fuselage frame, consistent with a depressurized cabin. The military airplanes escorted the airplane as it continued on a constant course and altitude until it approached Cuban airspace, at which point they discontinued their escort. Radar data indicated that the airplane continued on the same flight track until about 5 hours 48 minutes after takeoff, when it descended to impact in the Caribbean Sea north of Jamaica. The flight's duration was consistent with a departure with full fuel and normal cruise endurance. Some of the wreckage, including fuselage and engine components, was recovered from the ocean floor about 4 months after the accident. Data recovered from nonvolatile memory in the airplane's global air system controller (GASC) indicated that several fault codes associated with the cabin pressurization system were registered during the flight. These faults indicated that the overheat thermal switch (OTSW), which was associated with overheat protection, had activated, which resulted in a shutdown of the engine bleed air supply to the cabin pressurization system. Without a bleed air supply to maintain selected cabin pressure, the cabin altitude would have increased to the altitude of the outside environment over a period of about 4 minutes. The faults recorded by the GASC's nonvolatile memory and associated system alerts/warnings would have been displayed to the pilot, both as discrete system anomaly messages on the crew alerting system (CAS) and as master warning and/or master caution annunciations. A witness report indicated that the pilot was known to routinely monitor cabin altitude while flying in the airplane and in his previous pressurized airplanes. Based on his instrument scanning practices and the airplane's aural warning system, he likely would have observed any CAS message at or near its onset. Thus, the CAS messages and the associated alerts were likely the precipitating event for the pilot's call to ATC requesting a lower altitude. The pilot was likely not familiar with the physiological effects of hypoxia because he had not recently been in an altitude chamber for training, but he should have been familiar with the airplane's pressurization system emergency and oxygen mask donning procedures because he had recently attended a transition course for the accident airplane make and model that covered these procedures. However, the pressurization system training segment of the 5-day transition course comprised only about 90 minutes of about 36 total hours of training, and it is unknown if the pilot would have retained enough information to recognize the significance of the CAS messages as they appeared during the accident flight, much less recall the corresponding emergency procedures from memory. Coupled with the pilot's reported diligence in using checklists, this suggests that he would have attempted a physical review of the emergency procedures outlined in the Pilot's Operating Handbook (POH). A review of the 656-page POH for the airplane found that only one of the four emergency checklist procedures that corresponded to pressurization system-related CAS messages included a step to don an oxygen mask, and it was only a suggestion, not a mandatory step. The combined lack of emergency guidance to immediately don an oxygen mask and the rapid increase in the cabin altitude significantly increased the risk of hypoxia, a condition resistant to self-diagnosis, especially for a person who has not recently experienced its effects in a controlled environment such as an altitude chamber. Additionally, once the pilot reported the problem indication to ATC, he requested a descent to FL180 instead of 10,000 ft as prescribed by the POH. In a second transmission, he accepted FL250 and declined priority handling. These two separate errors were either early signs of cognitive dysfunction due to hypoxia or indications that the pilot did not interpret the CAS messages as a matter related to the pressurization system. Although the cabin bleed-down rate was 4 minutes, the pilot showed evidence of deteriorating cognitive abilities about 2 minutes 30 seconds after he initially reported the problem to ATC. Ultimately, the pilot had less than 4 minutes to detect the pressurization system failure CAS messages, report the problem to ATC, locate the proper procedures in a voluminous POH, and complete each procedure, all while suffering from an insidious and mentally impairing condition that decreased his cognitive performance over time. Following the accident, the airplane manufacturer revised the emergency procedures for newly manufactured airplanes to require flight crews to don their oxygen masks as the first checklist item in each of the relevant emergency checklists. Further, the manufacturer has stated that it plans to issue the same revisions for previous models in 2017. The airplane manufacturer previously documented numerous OTSW replacements that occurred between 2008 and after the date of the accident. Many of these units were removed after the GASC systems in their respective airplanes generated fault codes that showed an overheat of the bleed air system. Each of the OTSWs that were tested at the manufacturer's facility showed results that were consistent with normal operating units. Additionally, the OTSW from the accident airplane passed several of the manufacturer's functional tests despite the presence of internal corrosion from sea water. Further investigation determined that the pressurization system design forced the GASC to unnecessarily discontinue the flow of bleed air into the cabin if the bleed air temperature exceeded an initial threshold and did not subsequently fall below a secondary threshold within 30 seconds. According to the airplane manufacturer, the purpose of this design was to protect the structural integrity of the airplane, the system, and the passengers in case of overheat detection. As a result of this accident and the ensuing investigation, the manufacturer made changes to the programming of the GASC and to the airplane's wiring that are designed to reduce the potential for the GASC to shut off the flow of bleed air into the cabin and to maximize the bleed availability. Contrary to its normal position for flight, the cockpit oxygen switch was found in the "off" position, which prevents oxygen from flowing to the oxygen masks. A witness's description of the pilot's before starting engine procedure during a previous flight showed that he may not have precisely complied with the published procedure for turning on the oxygen switch and testing the oxygen masks. However, as the pilot reportedly was diligent in completing preflight inspections and checklists, the investigation could not determine why the cockpit oxygen switch was turned off. Further, because the oxygen masks were not observed on either occupant, the position of the oxygen switch would not have made a difference in this accident.

The private pilot was continuing a cross-country flight after having stopped for fuel. About 20 minutes into the flight, the pilot said both engines started running rough, and he turned the airplane toward the nearest airport and descended. The pilot reported that he did not think the airplane would make it to the airport, and that due to the rugged terrain, he felt it was better to ditch the airplane in a large lake he was flying over. The pilot reported there were no mechanical anomalies prior to the loss of engine power. He said he felt that fuel contamination was the cause of the engine problem, and that not fueling during heavy rain might have prevented the problem. Fuel samples were taken from the fuel supply where he added fuel, and the equipment used to fuel the airplane. No other instances of fuel contamination were reported, and according to the FAA inspector the fuel samples were tested, and found to be clean. The airplane was not recovered from the lake, and has not been examined by the NTSB.

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 departed from a maintenance facility, after installation of the right engine, with an unknown quantity of fuel. Shortly after takeoff, the pilot reported that he had "lost" an engine. He requested vectors for the departure airport, then amended his request to an alternate destination. From the original distress call to the last recorded radar target, approximately 2 ½ minutes, the airplane descended from 2,500 feet to 700 feet and slowed from 190 knots to about 87 knots. Several witnesses described the engine sound as "rough", and "cutting in and out" before the airplane descended out of view and sounds of impact were heard. The left wing was consumed by post-crash fire. Forty gallons of fuel were drained from the right inboard and nacelle tanks. Only trace amounts of fuel were visible in the right outboard tank. Both fuel selectors were found in the outboard tank position. Examination of flight times and ground-maintenance run times revealed that the engines were run for approximately 3 hours with the outboard tanks selected. The outboard tanks each held 40 gallons, for a total of 80 gallons. According to the pilot's operating manual, the fuel consumption rate at the maximum endurance power setting was 28 gallons per hour.

The pilot reported the right engine failed, followed by the left engine approximately one minute later while he was in cruise at 25,000 feet. He said he initiated a steep descent to get below 18,000 feet, and attempts at restarting the left engine were unsuccessful. The pilot landed 500 feet down a 1,900 feet long runway and ran off the departure end, 300 feet, into a wooded area. Post accident investigation found 130 gallons of fuel onboard in the main tanks. The fuel was tested and found to be free of water. The fuel lines were free of obstructions and the fuel pumps worked. A failed torque sensor was found on the left engine which would disconnect the left engine driven fuel pump. The right engine was test run satisfactorily.

The pilot was repositioning the airplane from an on-demand air taxi freight flight. He was en route from Rochester, NY to Huntsville, AL with a planned refuel stop at Louisville, KY. Near Falmouth, KY he changed his destination to Lexington 'due to a developing engine problem'. He saw the airport at Cynthiana and elected to land there. While on downwind, he noted the left engine cowling turning black and on base noted flames from the left engine. He reptd shutting the engine down and feathering the propeller but did not activate the fire extinguisher. During the landing roll, the airplane departed the runway to the right, and collided with the airport wind 't', a pole and a 't' hangar. Post accident investigation revealed that the left prop was not feathered and the fuel was not shut off. The left brake was ineffective due to fire damage. The evidence indicated that the fire began in the vicinity of the left engine accessory section. The specific fuel source of the fire was not identified.

The aircraft had just successfully completed a series of practice approaches to a full stop. The training flight was being conducted to give refresher training to the pilot who had not flown a Lear Jet in over a year and had never flown a lear model 35. The flight instructor requested a practice approach with a missed approach and was cleared for the option. Witnesses stated that the aircraft rolled right and then rolled left to an inverted position. Colliding with the ground shortly thereafter. All three occupants were killed.

Prior to takeoff the pilot was informed of wind shear as centerfield winds as 270° at 25 knots gust to 46 knots and northwest boundary winds as 280° at 13 knots. During takeoff the pilot reported an opened door and requested to return to land. The aircraft turned left and descended to the ground. Examination of the aircraft did not disclose evidence of malfunction. Examination of the aircraft doors revealed the right side cargo door securing mechanisms were relatively undamaged. Flight test conducted to evaluate the effects of a opened door disclosed in part the following. The door will open and remain open during rotation; results in noise and vibration; no abnormal flight characteristics; no significant change in multi-engine climb performance. Pilot landing in jet aircraft prior to accident reported moderate turbulence with a plus or minus 10 to 15 knots change in airspeed from 2,000 feet msl to the surface. The pilot, sole on board, was killed.

The pilot-in-command adopted a wrong approach configuration and passed over the runway 28 threshold at an excessive speed of 184 knots (61 knots above the Vref) in a nose down attitude. The nose gear landed first at a speed of 163 knots (40-45 knots above normal touchdown speed) 2,540 feet past the runway threshold (runway 28 is 5,500 feet long). Unable to stop within the remaining distance, the airplane overran, struck a drainage ditch, lost its undercarriage and came to rest 728 past the runway end. All 77 occupants were evacuated safely, one of them was slightly injured.