United States of America

The airport tower controller initially assigned the pilot to take off from runway 28L, which presented a 7-knot headwind. Shortly afterward, the controller informed the pilot of “a storm rolling in . . . from west to east,” and offered runway 10R. The pilot accepted the opposite direction runway for departure and added, “we’re ready to go when we get to the end . . . before the storm comes.” About 4 seconds after the airplane began accelerating during takeoff, the controller advised the pilot of a wind shear alert of plus 20 knots (kts) at a 1-mile final for runway 28L, and the pilot acknowledged the alert. In a postaccident statement, the pilot stated that departing with a 7-kt tailwind was within the operating and performance limitations of the airplane. The pilot reported that after a takeoff ground roll of about 4,000 ft “the left rudder didn’t seem to be functioning properly” and he decided to reject the takeoff. However, when he applied full braking, the airplane tended to turn to the right. He used minimal braking consistent with maintaining directional control of the airplane. The airplane ultimately overran the runway, impacted the airport perimeter fence, and encountered a ditch before it came to a rest. A postimpact fire ensued and consumed a majority of the fuselage. All four occupants evacuated safely.

The flight crew, which consisted of the pilot- and second-in-command (PIC and SIC), and a non-type-rated observer pilot, reported that during takeoff near 100 knots a violent shimmy developed at the nose landing gear (NLG). The PIC aborted the takeoff and during the abort procedure, the NLG separated. The airplane veered off the runway, and the right wing and right main landing gear struck approach lights, which resulted in substantial damage to the fuselage and right wing. The passengers and flight crew evacuated the airplane without incident through the main cabin door. Postaccident interviews revealed that following towing operations prior to the flight crew’s arrival, ground personnel were unable to get the plunger button and locking balls of the NLG’s removable pip pin to release normally. Following a brief troubleshooting effort by the ground crew, the pip pin’s plunger button remained stuck fully inward, and the locking balls remained retracted. The ground crew re-installed the pip pin through the steering collar with the upper torque link arm connected. However, with the locking balls in the retracted position, the pin was not secured in position as it should have been. Further, the ground personnel could not install the safety pin through the pip pin because the pin’s design prevented the safety pin from being inserted if the locking balls and plunger were not released. The ground personnel left the safety pin hanging from its lanyard on the right side of the NLG. The ground personnel subsequently informed their ramp supervisor of the anomaly. The supervisor reported that he informed the first arriving crewmember at the airplane (the observer pilot) that the nose pin needed to be checked. However, all three pilots reported that no ground crewmember told them about any issues with the NLG or pins. Examination of the runway environment revealed that the first item of debris located on the runway was the pip pin. Shortly after this location, tire swivel marks were located near the runway centerline, which were followed by large scrape and tire marks, leading to the separated NLG. The safety pin remained attached to the NLG via its lanyard and was undamaged. Postaccident examination and testing of the NLG and its pins revealed no evidence of preimpact mechanical malfunctions or failures. The sticking of the pip pin plunger button that the ground crew reported experiencing could not be duplicated during postaccident testing. When installed on the NLG, the locking ball mechanism worked as intended, and the pip pin could not be removed by hand. Although the airplane’s preflight checklist called for a visual check of the NLG’s torque link to ensure that it was connected to the steering collar by the pip pin and that the safety pin was installed, it is likely that none of the pilots noticed that the pip pin did not have its safety pin installed during preflight. Subsequently, during the takeoff roll, without the locking balls extended, the pip pin likely moved outward and fell from its position holding the upper torque link arm. This allowed the upper torque link arm to move freely, which resulted in the violent shimmy and NLG separation. The location of the debris on the runway, tire marks, and postaccident examination and testing support this likely chain of events. Contributing to the PIC and SIC’s omission during preflight was the ground crew’s failure to directly inform the PIC or SIC that there was a problem with the NLG pip pin. The ground crew also failed to discard the malfunctioning pip pin per the airplane’s ground handling procedures and instead re-installed the pip pin. Although the observer pilot was reportedly informed of an issue with a nose gear pin, he was not qualified to act as a required flight crewmember for the airplane and was on his cell phone when he was reportedly informed of the issue by the ramp supervisor. These factors likely contributed to the miscommunication and the PIC’s and SIC’s subsequent lack of awareness of the NLG issue.

The pilot was performing a short cross-country flight, which was his third solo flight in the high-performance single-engine airplane. The airplane departed and climbed to 20,000 ft mean sea level (msl) before beginning to descend. About 8 minutes before the accident, the airplane was southbound, descending to 11,000 ft, and the pilot established communications with air traffic control (ATC). About 4 minutes later, the controller cleared the pilot to descend to 10,000 ft msl and proceed direct to his destination; the pilot acknowledged the clearance. While descending through 13,000 ft msl, the airplane entered a descending left turn. The controller observed the left turn and asked the pilot if everything was alright; there was no response from the pilot. The controller’s further attempts to establish communications were unsuccessful. Following the descending left turn, the airplane entered a high speed, nose-down descent toward terrain. A witness observed the airplane at a high altitude in a steep nose-down descent toward the terrain. The witness noted no signs of distress, such as smoke, fire, or parts coming off the airplane, and he heard the airplane’s engine operating at full throttle. The airplane impacted two powerlines, trees, and the terrain in a shallow descent with a slightly left-wing low attitude. Examination of the accident site revealed a long debris field that was consistent with an impact at a high speed and relatively shallow flightpath angle. All major components of the airplane were located in the debris field at the accident site. Examination of the airframe and engine revealed no preimpact mechanical malfunctions or failures with the airplane that would have precluded normal operation. A performance study indicated the airplane entered a left roll and dive during which the airplane exceeded the airspeed, load factor, and bank angle limitations published in the Pilot’s Operating Handbook (POH). An important but unknown factor during these maneuvers was the behavior of the pilot and his activity on the flight controls during the initial roll and dive. The pilot responded normally to ATC communications only 98 seconds before the left roll started. It is difficult to reconcile an alert and attentive pilot with the roll and descent that occurred, but there is insufficient information available to determine whether the pilot was incapacitated or distracted during any part of the roll and dive maneuver. Although all the available toxicological specimens contained ethanol (the alcohol contained in alcoholic drinks such as beer and wine), the levels were very low and below the allowable level for flight (0.04 gm/dl). While it is possible that some of the identified ethanol had been ingested, it is also possible that all or most of the identified ethanol was from sources other than ingestion (such as postmortem production). In either case, the levels were too low to have caused incapacitation. It is therefore unlikely that any effects from ethanol contributed to the circumstances of the accident. There was minimal available autopsy evidence to support any determination of incapacitation. As a result, it could not be determined from the available evidence whether medical incapacitation contributed to the accident.

The pilot stated that on the morning of the accident he filled both wing fuel tanks to full. After takeoff, he climbed to his planned cruise altitude of 24,000 ft mean sea level (msl). While en route to his destination, the pilot reported that the left engine experienced a flame-out. The pilot opted to divert from the originally planned destination and descended. When the airplane was about 7,900 ft msl, the pilot reported that the right engine experienced a loss of power and that he was not going to be able to make it to the airport. Shortly thereafter, the airplane collided with trees and the airplane came to rest with the right wing and empennage severed from the fuselage.

The accident flight was the pilot’s second passenger sightseeing flight of the day that overflew remote inland fjords, coastal waterways, and mountainous, tree-covered terrain in the Misty Fjords National Monument. Limited information was available about the airplane’s flight track due to radar limitations, and the flight tracking information from the airplane only provided data in 1-minute intervals. The data indicated that the airplane was on the return leg of the flight and in the final minutes of flight, the pilot was flying on the right side of a valley. The airplane impacted mountainous terrain at 1,750 ft mean sea level (msl), about 250 ft below the summit. Examination of the wreckage revealed no evidence of pre accident failures or malfunctions that would have precluded normal operation. Damage to the propeller indicated that it was rotating and under power at the time of the accident. The orientation and distribution of the wreckage indicated that the airplane impacted a tree in a left-wing-low attitude, likely as the pilot was attempting to maneuver away from terrain. Review of weather information for the day of the accident revealed a conditionally unstable environment below 6,000 ft msl, which led to rain organizing in bands of shower activity. Satellite imagery depicted that one of these bands was moving northeastward across the accident site at the accident time. Federal Aviation Administration (FAA) weather cameras and local weather observations also indicated that lower visibility and mountain obscuration conditions were progressing northward across the accident area with time. Based on photographs recovered from passenger cell phones along with FAA weather camera imagery, the accident flight encountered mountain obscuration conditions, rain shower activity, and reduced visibilities and cloud ceilings, resulting in instrument meteorological conditions (IMC) before the impact with terrain. The pilot reviewed weather conditions before the first flight of the day; however, there was no indication that he obtained updated weather conditions or additional weather information before departing on the accident flight. Based on interviews, the accident pilot landed following the first flight of the day in lowering visibility, ceiling, and precipitation, and departed on the accident flight in precipitation, based on passenger photos. Therefore, the pilot had knowledge of the weather conditions that he could have encountered along the route of flight before departure. The operator had adequate policies and procedures in place for pilots regarding inadvertent encounters with IMC; however, the pilot’s training records indicated that he was signed off for cue-based training that did not occur. Cue-based training is intended to help calibrate pilots’ weather assessment and foster an ability to accurately assess and respond appropriately to cues associated with deteriorating weather. Had the pilot completed the training, it might have helped improve his decision-making skills to either cancel the flight before departure or turn around earlier in the flight. The operator’s lack of safety management protocols resulted in the pilot not receiving the required cue-based training, allowed him to continue operating air tours with minimal remedial training following a previous accident, and allowed the accident airplane to operate without a valid FAA registration. The operator was signatory to a voluntary local air tour operator’s group letter of agreement that was developed to improve the overall safety of flight operations in the area of the Misty Fjords National Monument. Participation was voluntary and not regulated by the FAA, and the investigation noted multiple instances in which the LOA policies were ignored, including on the accident flight. For example, the accident flight did not follow the standard Misty Fjords route outlined in the LOA nor did it comply with the recommended altitudes for flights into and out of the Misty Fjords. FAA inspectors providing oversight for the area reported that, when they addressed operators about disregarding the LOA, the operators would respond that the LOA was voluntary and that they did not need to follow the guidance. The FAA’s reliance on voluntary compliance initiatives in the local air tour industry failed to produce compliance with safety initiatives or to reduce accidents in the Ketchikan region.

The captain and first officer (FO) departed on a non-revenue flight operating under instrument flight rules with four passengers bound for Truckee, California. Most of the flight was uneventful. During the descent, air traffic control (ATC) told the flight crew to expect the area navigation (RNAV [GPS]) approach for runway 20. The captain (pilot flying [PF]) stated and the FO (pilot monitoring [PM]) calculated and confirmed that runway 20 was too short for the landing distance required by the airplane at its expected landing weight. Instead of making a request to ATC for the straight-in approach to runway 11 (the longer runway), the captain told the FO they could take the runway 20 approach and circle to land on runway 11, and the FO relayed this information to ATC. ATC approved, and the flight crew accepted the circle-to-land approach. Although the descent checklist required that the flight crew brief the new circle-to-land approach, and the flight crew’s acceptance of the new approach invalidated the previous straight-in approach brief, they failed to brief the new approach. ATC instructed the flight crew to hold, but the captain was slow in complying with this instruction, so the FO started the turn to enter the holding pattern and then informed ATC once they were established in the hold. About 20 seconds later, ATC cleared them for the approach. Before the FO confirmed the clearance, he asked the captain if he was ready for the approach, and the captain stated that he was. The FO subsequently commented that they had too much airspeed at the beginning of the approach and then suggested a 360° turn to the captain, but the captain never acknowledged the excessive airspeed and refused the 360° turn. After the FO visually identified the airport, he told the captain to make a 90° right turn to put the airplane on an approximate heading of 290°, which was parallel to runway 11 and consistent with the manufacturer’s operating manual procedures for the downwind leg of the circling approach. However, the FO instructed the captain to roll out of the turn prematurely, and the captain stopped the turn on a heading of about 233° magnetic, which placed the airplane at an angle 57° left of the downwind course parallel with runway 11. As a result of the early roll-out, the flight crew established a course that required an unnecessarily tight turning radius. When they started the turn to final, the airplane was still about 1.3 nautical miles (nm) from the maximum circling radius that was established for the airplane’s approach category. The FO also deployed flaps 45° after confirming with the captain (the manufacturer’s operating manual procedures for the downwind leg called for a flaps setting of 30°, but the manufacturer stated that a flight crew is not prohibited from a flaps 45° configuration if the approach remains within the limitations of the airplane’s flight manual). The airplane’s airspeed was 44 kts above the landing reference speed (Vref) of 118 kts that the flight crew had calculated earlier in the flight; the FO told the captain, “I’m gonna get your speed under control for you.” The FO likely reduced the throttles after he made this statement, as the engine fan speeds (N1) began to decrease from about 88% to about 28%, and the airplane began to slow from 162 kts. After the FO repeatedly attempted to point out the airport to the captain, the captain identified the runway; the captain's difficulty in finding the runway might have been the result of reduced visibility in the area due to smoke. The FO continuously reassured and instructed the captain throughout the circle-to-land portion of the approach. On the base leg to the runway and about 25 seconds before impact with the ground, the FO started to repeatedly ask for control of the airplane, but neither flight crewmember verbalized a positive transfer of control as required by the operator’s general operating manual (GOM); we could not determine who had control of the airplane following these requests. As the airplane crossed the runway extended centerline while maneuvering toward the runway, the FO noted that the airplane was too high. One of the pilots (recorded flight data did not indicate which) fully deployed the flight spoilers, likely to increase the airplane's sink rate. (The flight spoilers are deployed using a single control lever accessible to both pilots.) The airspeed at the time was 135 kts, 17 kts above the Vref based on the erroneous basic operating weight (BOW) programmed into the airplane’s flight management system (FMS). About 7 seconds later, the left bank became steeper, and the stall protection system (SPS) stick shaker and stick pusher engaged. The captain asked the FO, “What are you doing,” and the FO again asked the captain multiple times to “let [him] have the airplane.” The stick shaker and stick pusher then briefly disengaged before engaging again. The airplane then entered a rapid left roll, consistent with a left-wing stall, and impacted terrain. A postcrash fire consumed most of the wreckage. All six occupants, four passengers and two pilots, were killed.

Before taking off, the pilot canceled an instrument flight rules (IFR) flight plan that she had filed and requested a visual flight rules (VFR) on-top clearance, which the controller issued via the Monterey Five departure procedure. The departure procedure included a left turn after takeoff. The pilot took off and climbed to about 818 ft then entered a right turn. The air traffic controller noticed that the airplane was in a right-hand turn rather than a left-hand turn and issued a heading correction to continue a right-hand turn to 030o , which the pilot acknowledged. The airplane continued the climbing turn for another 925 ft then entered a descent. The controller issued two low altitude alerts with no response from the pilot. No further radio communication with the pilot was received. The airplane continued the descent until it contacted trees, terrain, and a residence about 1 mile from the departure airport. Review of weather information indicated prevailing instrument meteorological conditions (IMC) in the area due to a low ceiling, with ceilings near 800 ft above ground level and tops near 2,000 ft msl. Examination of the airframe and engines did not reveal any anomalies that would have precluded normal operation. The airplane’s climbing right turn occurred shortly after the airplane entered IMC while the pilot was acknowledging a frequency change, contacting the next controller, and acknowledging the heading instruction. Track data show that as the right-hand turn continued, the airplane began descending, which was not consistent with its clearance. Review of the pilot’s logbook showed that the pilot had not met the instrument currency requirements and was likely not proficient at controlling the airplane on instruments. The pilot’s lack of recent experience operating in IMC combined with a momentary diversion of attention to manage the radio may have contributed to the development of spatial disorientation, resulting in a loss of airplane control.

On July 10, 2021, about 1254 mountain standard time, a Beech C-90, turbo prop airplane, N3688P, was destroyed when it was involved in an accident near Wikieup, Arizona. The pilot and Air Tactical Group supervisor were fatally injured. The airplane was operated as a public use firefighting aircraft in support of the Bureau of Land Management conducting aerial reconnaissance and supervision. The airplane was on station for about 45 minutes over the area of the Cedar Basin fire. The ADS-B data showed the airplane had accomplished multiple orbits over the area of the fire about 2,500 ft above ground level (agl). The last ADS-B data point showed the airplane’s airspeed as 151 knots, its altitude about 2,300 ft agl, and in a descent, about 805 ft east southeast of the accident site. No distress call from the airplane was overheard on the radio. According to a witness, the airplane was observed in a steep dive towards the ground. The airplane impacted the side of a ridgeline in mountainous desert terrain. The main wreckage was mostly consumed by a post-crash fire. Debris was scattered over an area of several acres. Another witness observed the left wing falling to the ground after the aircraft had impacted the terrain. The left wing had separated outboard of the nacelle and was located about 0.79 miles northeast of the main wreckage and did not sustain thermal damage.

The pilot reported that he performed the “before starting engine” and “starting engine” checklists and everything was normal before taking off in the twin-engine airplane. He performed an engine runup and then started his takeoff roll. The pilot reported that about halfway down the runway the airplane was not accelerating as fast as it should. He attempted to rotate the airplane; however, “the airplane mushed off the runway.” The airplane settled back onto the runway, then exited the departure end of the runway, where it sustained substantial damage to the wings and fuselage. The airplane engine monitor data indicated the airplane’s engines were operating consistent with each other at takeoff power at the time of the accident. Density altitude at the time of the accident was 7,170 ft and according to performance charts, there was adequate runway for takeoff. The reason for the loss of performance could not be determined.

Transair flight 810, a Title 14 Code of Federal Regulations Part 121 cargo flight, experienced a partial loss of power involving the right engine shortly after takeoff and a water ditching in the
Pacific Ocean about 11.5 minutes later. This analysis summarizes the accident and evaluates (1) the right engine partial loss of power, (2) the captain's communications with air traffic control (ATC) and the first officer's left and right engine thrust reductions, (3) the first officer's misidentification of the affected engine and the captain's failure to verify the information, (4) checklist performance, and (5) survival factors. Maintenance was not a factor in this accident. The flight data recorder (FDR) showed that, when the initial thrust was set for takeoff, the engine pressure ratios (EPR) for the left and right engines were 2.00 and 1.97, respectively. Shortly after rotation, the cockpit voice recorder (CVR) recorded a “thud” and the sound of a low-frequency vibration. The captain (the pilot monitoring at the time) and the first officer (the pilot flying) reported that they heard a “whoosh” and a “pop,” respectively, at that time. As the airplane climbed through an altitude of about 390 ft while at an airspeed of 155 knots, the right EPR decreased to 1.43 during a 2-second period. The airplane then yawed to the right; the first officer countered the yaw with appropriate left rudder pedal inputs. The CVR showed that the captain and the first officer correctly determined that the No. 2 (right) engine had lost thrust within 5 seconds of hearing the thud sound. After moving the flaps to the UP position, the captain reduced thrust to maximum continuous thrust, causing the left EPR to decrease from 1.96 to 1.91 while the airplane was in a climb. (The right EPR remained at 1.43). The captain reported that he did not move the thrust levers again until after he became the pilot flying. The first officer stated that, after the airplane leveled off at an altitude of about 2,000 ft, he reduced thrust on both engines. FDR data showed that thrust was incrementally reduced to near flight idle (1.05 EPR on the left engine and then 1.09 EPR on the right engine) and that airspeed decreased from about 250 to 210 knots. (A decrease in airspeed to 210 knots was consistent with the operator’s simulator guide procedures for a single-engine failure after the takeoff decision speed [V1]. The simulator guide, which supplemented information in the company’s flight crew training manual, contained the most recent operator guidance for single-engine failure training at the time of the accident.) The captain was unaware of the first officer’s thrust changes because he was busy contacting the controller about the emergency. The captain told the controller, “we’ve lost an engine,” but he had declared the emergency to the controller twice before this point, as discussed later in this analysis. The captain instructed the first officer to maintain a target speed of 220 knots (which the captain thought would be “easy on the running engine”), a target altitude of 2,000 ft, and a target heading of 240°. (About 52 seconds earlier, the controller had issued the 240° heading instruction to another airplane on the same radio frequency.) About 3 minutes 14 seconds after the right engine loss of thrust occurred, the captain assumed control of the airplane; at that time, the airplane’s airspeed was 224 knots and heading was 242°, but the airplane’s altitude had decreased from about 2,100 ft (the maximum altitude that the airplane reached during the flight) to 1,690 ft. The captain increased the airplane’s pitch to 9°; the airplane’s altitude then increased to 1,878 ft, but the airspeed decreased to 196 knots. The captain subsequently stated, “let’s see what is the problem...which one...what's going on with the gauges,” and “who has the E-G-T [exhaust gas temperature]?” The first officer stated that the left engine was “gone” and “so we have number two” (the right engine), thus misidentifying the affected engine. The captain accepted the first officer’s assessment and did not take action to verify the information. Afterward, the EPR level on the right engine began to increase in response to the captain advancing the right thrust lever so that the airplane could maintain airspeed and altitude. Right EPR increased and decreased several times during the rest of the flight (coinciding with crew comments regarding the EGT on the right engine and low airspeed) while the left EPR remained near flight idle. The first officer asked the captain if they “should head back toward the airport” before the airplane traveled “too far away,” and the captain responded that the airplane would stay within 15 miles of the airport. During a postaccident interview, the captain stated that, because there was no fire and an engine “was running,” he intended to have the airplane climb to 2,000 ft and stay within 15 miles of the airport to avoid traffic and have time to address the engine issue. The captain also stated that he had been criticized by the company chief pilot for returning to the airport without completing the required abnormal checklist for a previous in-flight emergency. Although the captain’s decision resulted in the accident airplane flying farther away from the airport and farther over the ocean at night, the captain’s decision was reasonable for a single-engine failure event. The captain directed the first officer to begin the Engine Failure or Shutdown checklist and stated that he would continue handling the radios. The first officer began to read aloud the conditions for executing the Engine Failure or Shutdown checklist but then stopped to tell the captain that the right EGT was at the “red line” and that thrust should be reduced on the right engine. The captain then decided that the airplane should return to the airport and contacted the controller to request vectors. The flight crew continued to express concern about the right engine. The first officer stated, “just have to watch this though…the number two.” The captain asked the first officer to check the EGT for the right engine, and the first officer responded that it was “beyond max.” Afterward, the captain told the first officer to continue with the Engine Failure or Shutdown checklist and finish as much as possible. The first officer resumed reading aloud the conditions for performing the checklist but then stopped to state, “we have to fly the airplane though,” because the airplane was continuing to lose altitude and airspeed. The captain replied “okay.” As a result, the flight crew did not perform key steps of the checklist, including identifying, confirming, and shutting down the affected (right) engine. The first officer told the captain that the airplane was losing altitude; at that time, the airplane’s altitude was 592 ft, and its airspeed was 160 knots. The captain agreed to select flaps 1 (which the first officer had previously suggested likely because the airplane was slowing). The CVR then recorded the first enhanced ground proximity warning system (EGPWS) annunciation (500 ft above ground level); various EGPWS callouts and alerts continued to be annunciated through the remainder of the flight. The captain then told the controller that “we’ve lost number one [left] engine…there’s a chance we’re gonna lose the other engine too it’s running very hot….we’re pretty low on the speed it doesn't look good out here.” Also, the captain mentioned that the controller should notify the US Coast Guard (USCG) because he was anticipating a water ditching in the Pacific Ocean. Because of the high temperature readings on the right engine, the flight crew thought, at this point in the flight, that a dual-engine failure was imminent. During a postaccident interview, the captain stated that his priority at that time was figuring out how the airplane could stay in the air and return safely to the airport. The captain also stated that he attempted to resolve the airplane’s deteriorating energy state by advancing the right engine thrust lever. However, with the left engine remaining near flight idle, the right engine was not producing sufficient thrust to enable the airplane to maintain altitude or climb. The captain’s communication with the controller continued, and the first officer stated, “fly the airplane please.” The controller asked if the airport was in sight, and the captain then asked the first officer whether he could see the airport. The first officer responded “pull up we’re low” to the captain and “negative” to the controller; the captain was likely unable to respond to the controller because he was trying to control the airplane. The captain asked the first officer about the EGT for the right engine; the first officer replied “hot…way over.” The captain then asked about, and the controller responded by providing, the location of the closest airport. Afterward, the CVR recorded a sound similar to the stick shaker, which continued intermittently through the rest of the flight. The CVR then recorded sounds consistent with water impact. The airplane came down into the Pacific Ocean about two miles offshore and sank. Both crew members were rescued, one was slightly injured and a second was seriously injured. The wreckage was later recovered for investigation purposes.