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Crash of a Beechcraft 350i Super King Air in Addison: 10 killed

Date & Time: Jun 30, 2019 at 0911 LT
Operator:
Registration:
N534FF
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Addison – Saint Petersburg
MSN:
FL-1091
YOM:
2017
Location:
Crew on board:
2
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
10
Captain / Total flying hours:
16450
Captain / Total hours on type:
1100.00
Copilot / Total flying hours:
2357
Copilot / Total hours on type:
189
Aircraft flight hours:
691
Circumstances:
The pilot, co-pilot, and eight passengers departed on a cross-country flight in the twin-engine airplane. One witness located on the ramp at the airport reported that the airplane sounded underpowered immediately after takeoff “like it was at a reduced power setting.” Another witness stated that the airplane sounded like it did not have sufficient power to takeoff. A third witness described the rotation as “steep,” and other witnesses reported thinking that the airplane was performing aerobatics. Digital video from multiple cameras both on and off the airport showed the airplane roll to its left before reaching a maximum altitude of 100 ft above ground level; it then descended and impacted an airport hangar in an inverted attitude about 17 seconds after takeoff and an explosion immediately followed. After breaching a closed roll-up garage door, the airplane came to rest on its right side outside of the hangar and was immediately involved in a postimpact fire. Sound spectrum analysis of data from the airplane’s cockpit voice recorder (CVR) estimated that the propeller speeds were at takeoff power (1,714 to 1,728 rpm) at liftoff. About 7 seconds later, the propeller speeds diverged, with the left propeller speed decreasing to about 1,688 rpm and the right propeller speed decreasing to 1,707 rpm. Based on the airplane’s estimated calibrated airspeed of about 110 knots and the propeller rpm when the speeds diverged, the estimated thrust in the left engine decreased to near 0 while the right engine continued operating at slightly less than maximum takeoff power. Analysis of available data estimated that, 2 seconds after the propeller speed deviation, the airplane’s sideslip angle was nearly 20°. During the first 5 seconds after the propeller speed deviation, the airplane’s roll rate was about 5° per second to the left; its roll rate then rapidly increased to more than 60° per second before the airplane rolled inverted. Witness marks on the left engine and propeller, the reduction in propeller speed, and the airplane’s roll to the left suggest that the airplane most likely experienced a loss of thrust in the left engine shortly after takeoff. The airplane manufacturer’s engine-out procedure during takeoff instructed that the landing gear should be retracted once a positive rate of climb is established, and the propeller of the inoperative engine should be feathered. Right rudder should also be applied to balance the yawing moment imparted by a thrust reduction in the left engine. Examination of the wreckage found both main landing gear in a position consistent with being extended and the left propeller was unfeathered. The condition of the wreckage precluded determining whether the autofeather system was armed or activated during the accident flight. Thus, the pilot failed to properly configure the airplane once the left engine thrust was reduced. Calculations based on the airplane’s sideslip angle shortly after the propeller speed deviation determined that the thrust asymmetry alone was insufficient to produce the sideslip angle. Based on an evaluation of thrust estimates provided by the propeller manufacturer and performance data provided by the airplane manufacturer, it is likely that the pilot applied left rudder, the opposite input needed to maintain lateral control, before applying right rudder seconds later. However, by then, the airplane’s roll rate was increasing too rapidly, and its altitude was too low to recover. The data support that it would have been possible to maintain directional and lateral control of the airplane after the thrust reduction in the left engine if the pilot had commanded right rudder initially rather than left rudder. The pilot’s confused reaction to the airplane’s performance shortly after takeoff supports the possibility that he was startled by the stall warning that followed the propeller speed divergence, which may have prompted his initial, improper rudder input. In addition, the NTSB’s investigation estimated that rotation occurred before the airplane had attained Vr (rotation speed), which decreased the margin to the minimum controllable airspeed and likely lessened the amount of time available for the pilot to properly react to the reduction in thrust and maintain airplane control. Although the airplane was slightly over its maximum takeoff weight at departure, its rate of climb was near what would be expected at maximum weight in the weather conditions on the day of the accident (even with the extended landing gear adding drag); therefore, the weight exceedance likely was not a factor in the accident. Engine and propeller examinations and functional evaluations of the engine and propeller controls found no condition that would have prevented normal operation; evidence of operation in both engines at impact was found. Absent evidence of an engine malfunction, the investigation considered whether the left engine’s thrust reduction was caused by other means, such as uncommanded throttle movement due to an insufficient friction setting of the airplane’s power lever friction locks. Given the lack of callouts for checklists on the CVR and the pilot’s consistently reported history of not using checklists, it is possible that he did not check or adjust the setting of the power lever friction locks before the accident flight, which led to uncommanded movement of the throttle. Although the co-pilot reportedly had flown with the pilot many times previously and was familiar with the B-300, he was not type rated in the airplane and was not allowed by the pilot to operate the flight controls when passengers were on board. Therefore, the co-pilot may not have checked or adjusted the friction setting before the flight’s departure. Although the investigation considered inadequate friction setting the most likely cause of the thrust reduction in the left engine, other circumstances, such as a malfunction within the throttle control system, could also result in loss of engine thrust. However, heavy fire and impact damage to the throttle control system components, including the power quadrant and cockpit control lever friction components, precluded determining the position of the throttle levers at the time of the loss of thrust or the friction setting during the accident flight. Thus, the reason for the reduction in thrust could not be determined definitively. In addition to a lack of callouts for checklists on the CVR, the pilots did not discuss any emergency procedures. As a result, they did not have a shared understanding of how to respond to the emergency of losing thrust in an engine during takeoff. Although the co-pilot verbally identified the loss of the left engine in response to the pilot’s confused reaction to the airplane’s performance shortly after takeoff, it is likely the co-pilot did not initiate any corrective flight control inputs, possibly due to the pilot’s established practice of being the sole operator of flight controls when passengers were on board. The investigation considered whether fatigue from inadequately treated obstructive sleep apnea contributed to the pilot’s response to the emergency; however, the extent of any fatigue could not be determined from the available evidence. In addition, no evidence indicates that the pilot’s medical conditions or their treatment were factors in the accident. In summary, the available evidence indicates that the pilot improperly responded to the loss of thrust in the left engine by initially commanding a left rudder input and did not retract the landing gear or feather the left propeller, which was not consistent with the airplane manufacturer’s engine out procedure during takeoff. It would have been possible to maintain directional and lateral control of the airplane after the thrust reduction in the left engine if right rudder had been commanded initially rather than left rudder. It is possible that the pilot’s reported habit of not using checklists resulted in his not checking or adjusting the power lever friction locks as specified in the airplane manufacturer’s checklists. However, fire and impact damage precluded determining the position of the power levers or friction setting during the flight.
Probable cause:
The pilot’s failure to maintain airplane control following a reduction of thrust in the left engine during takeoff. The reason for the reduction in thrust could not be determined. Contributing to the accident was the pilot’s failure to conduct the airplane manufacturer’s emergency procedure following a loss of power in one engine and to follow the manufacturer’s checklists during all phases of operation.
Final Report:

Crash of a Cessna 421C Golden Eagle III in Kennesaw: 1 killed

Date & Time: Jul 19, 1985 at 1116 LT
Operator:
Registration:
N5473G
Flight Phase:
Survivors:
Yes
Schedule:
Kennesaw – Saint Petersburg
MSN:
421C-0220
YOM:
1976
Crew on board:
2
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
1770
Captain / Total hours on type:
450.00
Aircraft flight hours:
1700
Circumstances:
The aircraft lost power on right engine shortly after take-off. The aircraft crashed and burned in a wooded area several miles southwest of the airport. The right engine was severely damaged in the fire. No pre-impact malfunction could be documented. Examination of the propeller did not reveal damage consistent with that usually found when a propeller is in the feathered position. The flap jack screw was found in the 10-15° position. Both engines had a history of shut down at low power settings during taxi. The right engine had 'burbled' during the previous flight and the left engine shut down after landing.
Probable cause:
Occurrence #1: loss of engine power (total) - mech failure/malf
Phase of operation: takeoff - initial climb
Findings
1. (c) operation with known deficiencies in equipment - improper - pilot in command
2. (c) miscellaneous - undetermined
3. (c) reason for occurrence undetermined
----------
Occurrence #2: forced landing
Phase of operation: descent - emergency
Findings
4. (c) remedial action - not performed - pilot in command
5. (c) propeller feathering - not used - pilot in command
6. (c) lack of total experience in type of aircraft - pilot in command
----------
Occurrence #3: in flight collision with object
Phase of operation: descent - emergency
Findings
7. Object - tree(s)
----------
Occurrence #4: in flight collision with terrain/water
Phase of operation: descent - emergency
Final Report:

Crash of a Piper PA-31-350 Navajo Chieftain near Saint Petersburg

Date & Time: Aug 31, 1984
Operator:
Registration:
N4469R
Flight Type:
Survivors:
Yes
MSN:
31-8152120
YOM:
1981
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The pilot, sole on board, was completing an illegal flight and attempted to land in a remote area near St Petersburg when the aircraft crash landed in unclear circumstances. The aircraft was destroyed and the pilot was not found.

Crash of a Douglas C-118A Liftmaster in San Manuel

Date & Time: Apr 28, 1984 at 1630 LT
Type of aircraft:
Registration:
N92860
Flight Type:
Survivors:
Yes
Schedule:
Saint Petersburg – Chandler
MSN:
44619/549
YOM:
1955
Crew on board:
3
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
6983
Captain / Total hours on type:
3200.00
Circumstances:
The aircraft skidded off the departure end of the runway collapsing the landing gear in a ditch as it caught on fire. This aircraft was on a ferry flight and had several mechanical problems. Among these was the prop reversers which failed on landing. The anti-ice/de-ice systems failed to work properly which contributed to the need to land short of destination. The copilot reported that she did not check the anti-icing equipment on pre-flight. She was also not qualified to be a copilot on this flight. The airspeed indicators were malfunctioning during landing. The crew members all said that they knew the airspeed was much too high. The copilot said she could not understand how the pilot thought he could land at such a high speed. She also said he called for reverse and applied brakes too late in the rollout.
Probable cause:
Occurrence #1: overrun
Phase of operation: landing - roll
Findings
1. (f) weather condition - tailwind
2. (c) wrong runway - selected - pilot in command
3. (f) pressure induced by others - pilot in command
4. (f) propeller system/accessories,reversing system - failure,partial
5. (c) airspeed - excessive - pilot in command
6. (f) anti-ice/deice system,windshield - inoperative
7. (c) proper touchdown point - not attained - pilot in command
8. (c) operation with known deficiencies in equipment - performed - pilot in command
9. (f) precautionary landing - premature - pilot in command
10. (c) judgment - poor - pilot in command
11. (f) procedures/directives - not followed - pilot in command
----------
Occurrence #2: main gear collapsed
Phase of operation: landing - roll
Findings
12. (f) landing gear, main gear - overload
Final Report:

Crash of a Convair CV-240-8 in Clewiston: 2 killed

Date & Time: Sep 4, 1978 at 1130 LT
Type of aircraft:
Registration:
N7177B
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Clewiston - St Petersburg
MSN:
38
YOM:
1949
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
Shortly after takeoff from Clewiston Airport, on a positioning flight to St Petersburg, the crew reported engine problems and elected to return for an emergency landing when the airplane went out of control and crashed in flames near the airport. The aircraft was destroyed and both occupants were killed.
Probable cause:
Uncontrolled collision with ground during initial climb due to engine failure. The following contributing factors were reported:
- Inadequate preflight preparation,
- Water in fuel,
- lack of familiarity with aircraft,
- Poor judgment on part of the pilot-in-command,
- The pilot was not type rated in Convair 240.
- ELT not found.
Final Report:

Crash of a Curtiss C-46F-1-CU Commando off Aguadilla

Date & Time: Aug 8, 1975 at 1530 LT
Type of aircraft:
Operator:
Registration:
N4873V
Flight Type:
Survivors:
Yes
Schedule:
Saint Petersburg - Aguadilla
MSN:
22415
YOM:
1945
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
22000
Captain / Total hours on type:
11100.00
Circumstances:
The airplane was completing a cargo flight from St Petersburg to Aguadilla, carrying two pilots and a load of 9,000 lbs of dynamite. While approaching Aguadilla, both engines lost power and stopped almost simultaneously. The crew elected to ditch the aircraft that crashed into the sea about 800 meters offshore. The airplane sank by 50 feet of water and its wreckage was not recovered. Both pilots, slightly injured, were evacuated.
Probable cause:
Double engine failure caused by a fuel exhaustion. The following contributing factors were reported:
- Inadequate preflight preparation,
- Improper in-flight decisions por planning,
- Mismanagement of fuel,
- Fuel exhaustion.
Final Report:

Crash of a Lockheed L-1049 Super Constellation in Tamarac

Date & Time: Aug 5, 1973 at 1925 LT
Registration:
N6202C
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Freeport - Saint Petersburg
MSN:
4002
YOM:
1952
Location:
Crew on board:
5
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
17000
Captain / Total hours on type:
3000.00
Circumstances:
On a positioning flight from Freeport to St Petersburg, the crew was trying to transfer fuel when all four engines stopped simultaneously. The captain reduced his altitude and attempt an emergency belly landing in a open field located in Tamarac. The airplane slid on its belly for few dozen yards before coming to rest. While all eight occupants escaped uninjured, the aircraft was damaged beyond repair.
Probable cause:
Engine failure in flight caused by inadequate supervision of flight and improper use of equipment. The following factors were reported:
- Fuel starvation,
- Improper emergency procedures,
- Intentional wheels-up landing,
- Inadequate inspection of aircraft on part of the maintenance personnel,
- Failure of the fuel system: pumps as the protective devices were corroded,
- Inadequate preflight preparation,
- Improper transfer of fuel,
- Circuit breaker corroded.
Final Report:

Crash of a Piper PA-31-310 Navajo Chieftain in Tallahassee

Date & Time: Apr 14, 1970 at 0115 LT
Type of aircraft:
Operator:
Registration:
N411AA
Survivors:
Yes
Schedule:
Saint Petersburg – Tallahassee
MSN:
31-24
YOM:
1967
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
10245
Captain / Total hours on type:
220.00
Circumstances:
On final approach to Tallahassee Airport by night, the pilot failed to realize his altitude was insufficient when the airplane struck tree tops and crashed few hundred yards short of runway threshold. All four occupants were seriously injured and the aircraft was destroyed.
Probable cause:
Improper IFR operation on part of the pilot-in-command.
Final Report: