Crash of a Cessna 421C Golden Eagle III near Canadian: 2 killed

Date & Time: Feb 15, 2019 at 1000 LT
Registration:
N421NS
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Amarillo – Canadian
MSN:
421C-0874
YOM:
1980
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
5000
Aircraft flight hours:
6227
Circumstances:
The pilot was conducting a personal cross-country flight with one passenger in his twin-engine airplane. There was no record that the pilot received a weather briefing before the accident flight. While en route to the destination, the pilot was in contact with air traffic control and received visual flight rules flightfollowing services. About 18 miles from the destination airport, the radar service was terminated, as is typical in this geographic region due to insufficient radio and radar coverage below 7,000 ft. The airplane was heading northeast at 4,900 ft mean sea level (msl) (about 2,200 ft above ground level [agl]). About 4 minutes later, radar coverage resumed, and the airplane was 6 miles west of the airport at 4,100 ft msl (1,400 ft agl) and climbing to the north. The airplane climbed through 6,000 ft msl (3,300 ft agl), then began a shallow left turn and climbed to 6,600 ft msl (3,800 ft agl), then began to descend while continuing the shallow left turn ; the last radar data point showed the airplane was about 20 nm northwest of the airport, 5,100 ft msl (2,350 ft agl) on a southwest heading. The final recorded data was about 13 miles northwest of the accident site. A witness near the destination airport heard the pilot on the radio. He reported that the pilot asked about the cloud height and the witness responded that the clouds were 800 to 1,000 ft agl. In his final radio call, the pilot told the witness, "Ok, see you in a little bit." The witness did not see the airplane in the air. The airplane impacted terrain in a slightly nose-low and wings-level attitude with no evidence of forward movement, and a postimpact fire destroyed a majority of the wreckage. The damage to the airplane was consistent with a relatively flat spin to the left at the time of impact. A postaccident examination did not reveal any preimpact mechanical malfunctions or anomalies that would have precluded normal operation. A detailed examination of the cockpit instruments and other portions of the wreckage was not possible due to the fire damage. A cold front had advanced from the northeast and instrument meteorological conditions prevailed across the region surrounding the accident site and the destination airport; the cloud ceilings were 400 ft to 900 ft above ground level. The airplane likely experienced wind shear below 3,000 ft, and there was likely icing in the clouds. While moderate icing conditions were forecast for the accident site, about the time of the accident, investigators were unable to determine the amount and severity of icing the flight may have experienced. The weather conditions had deteriorated over the previous 1 to 2 hours. The conditions at the destination airport had been clear about 2 hours before accident, and visual flight rules conditions about 1 hour before accident, when the pilot departed. Based on the available evidence it is likely that the pilot was unable to maintain control of the airplane, which resulted in an aerodynamic stall and spin into terrain.
Probable cause:
The pilot's failure to maintain control of the airplane while in instrument meteorological conditions with icing conditions present, which resulted in an aerodynamic stall and spin into terrain.
Final Report:

Crash of a Convair C-131B Samaritan off Miami: 1 killed

Date & Time: Feb 8, 2019 at 1216 LT
Type of aircraft:
Operator:
Registration:
N145GT
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Nassau - Miami
MSN:
256
YOM:
1955
Flight number:
QAI504
Location:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
23000
Captain / Total hours on type:
725.00
Copilot / Total flying hours:
650
Copilot / Total hours on type:
305
Aircraft flight hours:
12701
Circumstances:
According to the first officer, during the first cargo flight of the day, the left engine propeller control was not working properly and the captain indicated that they would shut down the airplane and contact maintenance if the left engine propeller control could not be reset before the return flight. For the return flight, the engines started normally, and both propellers were cycled. The captain and the first officer were able to reset the left propeller control, so the airplane departed with the first officer as the pilot flying. The takeoff and initial climb were normal; however, as the airplane climbed through 4,000 ft, the left engine propeller control stopped working and the power was stuck at 2,400 rpm. The captain tried to adjust the propeller control and inadvertently increased power to 2,700 rpm. The captain then took control of the airplane and tried to stabilize the power on both engines. He leveled the airplane at 4,500 ft, canceled the instrument flight rules flight plan, and flew via visual flight rules direct toward the destination airport. The first officer suggested that they return to the departure airport, but the captain elected to continue as planned (The destination airport was located about 160 nautical miles from the departure airport). The first officer's postaccident statements indicated that he did not challenge the captain's decision. When the flight began the descent to 1,500 ft, the right engine began to surge and lose power. The captain and the first officer performed the engine failure checklist, and the captain feathered the propeller and shut down the engine. Shortly afterward, the left engine began to surge and lose power. The captain told the first officer to declare an emergency. The airplane continued to descend, and the airplane impacted the water "violently," about 32 miles east of the destination airport. The captain was unresponsive after the impact and the first officer was unable to lift the captain from his seat. Because the cockpit was filling rapidly with water, the first officer grabbed the life raft and exited the airplane from where the tail section had separated from the empennage. The first officer did not know what caused both engines to lose power. The airplane was not recovered from the ocean, so examination and testing to determine the cause of the engine failures could not be performed. According to the operator, the flight crew should have landed as soon as practical after the first sign of a mechanical issue. Thus, the crew should have diverted to the closest airport when the left engine propeller control stopped working and not continued the flight toward the destination airport.
Probable cause:
The captain's decision to continue with the flight with a malfunctioning left engine propeller control and the subsequent loss of engine power on both engines for undetermined reasons, which resulted in ditching into the ocean. Contributing to the accident was the first officer's failure to challenge the captain's decision to continue with the flight.
Final Report:

Crash of a Piper PA-46-350P Malibu Mirage in Aurora

Date & Time: Feb 6, 2019 at 1530 LT
Operator:
Registration:
N997MA
Flight Type:
Survivors:
Yes
Schedule:
Aurora - Aurora
MSN:
46-36126
YOM:
1997
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
970
Captain / Total hours on type:
23.00
Aircraft flight hours:
2670
Circumstances:
On February 6, 2019, about 1530 Pacific standard time, a Piper PA 46-350P, N997MA, was substantially damaged when it was involved in an accident near Aurora, Oregon. The private pilot and flight instructor were seriously injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight. The pilot reported that the purpose of the flight was to practice commercial pilot maneuvers. After practicing slow flight, chandelles, lazy eights, and eights on pylons, they returned to the airport and discussed how to conduct a practice a power-off 180° landing as they entered the traffic pattern. When the airplane was abeam the 1,000-foot runway markings, the pilot reduced the power to idle and started a left turn toward the runway. He stated that he realized that the airplane was “probably not going to make the runway” and that the airplane was “not on final course.” He recalled the airplane turning sharply to the left as he was pulled up on the control yoke and added right rudder. He could not recall whether he applied power. The pilot did not report any mechanical malfunctions or anomalies with the airplane. A video of the event showed the airplane in a left turn as it descended toward the runway. The airplane’s left bank decreased to a wings-level attitude before the airplane entered a steeper left bank, followed immediately by a right bank as the airplane descended into the ground short of the runway. The airplane’s right wing and fuselage sustained substantial damage.

Crash of a Cessna 414A Chancellor in Yorba Linda: 5 killed

Date & Time: Feb 3, 2019 at 1345 LT
Type of aircraft:
Operator:
Registration:
N414RS
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Fullerton – Minden
MSN:
414A-0821
YOM:
1981
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
10235
Aircraft flight hours:
9610
Circumstances:
The commercial pilot departed for a cross-country, personal flight with no flight plan filed. No evidence was found that the pilot received a preflight weather briefing; therefore, it could not be determined if he checked or received any weather information before or during the accident flight. Visual meteorological conditions existed at the departure airport; however, during the departure climb, the weather transitioned to instrument meteorological conditions (IMC) with precipitation, microburst, and rain showers over the accident area. During the takeoff clearance, the air traffic controller cautioned the pilot about deteriorating weather conditions about 4 miles east of the airport. Radar data showed that, about 5 1/2 minutes after takeoff, the airplane had climbed to about 7,800 ft above ground level before it started a rapid descending right turn and subsequently impacted the ground about 9.6 miles east of the departure airport. Recorded data from the airplane’s Appareo Stratus 2S (portable ADS-B receiver and attitude heading and reference system) revealed that, during the last 15 seconds of the flight, the airplane’s attitude changed erratically with the pitch angle fluctuating between 45° nose-down and 75°nose-up, and the bank angle fluctuating between 170° left and 150° right while descending from 5,500 to 500 ft above ground level, indicative of a loss of airplane control shortly after the airplane entered the clouds. Several witnesses located near the accident site reported seeing the airplane exit the clouds at a high descent rate, followed by airplane parts breaking off. One witness reported that he saw the airplane exit the overcast cloud layer with a nose down pitch of about 60°and remain in that attitude for about 4 to 5 seconds “before initiating a high-speed dive recovery,” at the bottom of which, the airplane began to roll right as the left horizontal stabilizer separated from the airplane, immediately followed by the remaining empennage. He added that the left wing then appeared to shear off near the left engine, followed by the wing igniting. An outdoor home security camera, located about 0.5 mile north-northwest of the accident location, captured the airplane exiting the clouds trailing black smoke and then igniting. Examination of the debris field, airplane component damage patterns, and the fracture surfaces of separated parts revealed that both wings and the one-piece horizontal stabilizer and elevators were separated from the empennage in flight due to overstress, which resulted from excessive air loads. Although the airplane was equipped with an autopilot, the erratic variations in heading and altitude during the last 15 seconds of the flight indicated that the pilot was likely hand-flying the airplane; therefore, he likely induced the excessive air loads while attempting to regain airplane control. Conditions conducive to the development of spatial orientation existed around the time of the in-flight breakup, including restricted visibility and the flight entering IMC. The flight track data was consistent with the known effects of spatial disorientation and a resultant loss of airplane control. Therefore, the pilot likely lost airplane control after inadvertently entering IMC due to spatial disorientation, which resulted in the exceedance of the airplane’s design stress limits and subsequent in-flight breakup. Contributing to accident was the pilot’s improper decision to conduct the flight under visual flight rules despite encountering IMC and continuing the flight when the conditions deteriorated. Toxicology testing on specimens from the pilot detected the presence of delta-9-tetrahydrocanninol (THC) in heart blood, which indicated that the pilot had used marijuana at some point before the flight. Although there is no direct relationship between postmortem blood levels and antemortem effects from THC, it does undergo postmortem redistribution. Therefore, the antemortem THC level was likely lower than detected postmortem level due to postmortem redistribution from use of marijuana days previously, and it is unlikely that the pilot’s use of marijuana contributed to his poor decision-making the day of the accident. The toxicology testing also detected 67 ng/mL of the sedating antihistamine diphenhydramine. Generally, diphenhydramine is expected to cause sedating effects between 25 to 1,120 ng/mL. However, diphenhydramine undergoes postmortem redistribution, and the postmortem heart blood level may increase by about three times. Therefore, the antemortem level of diphenhydramine was likely at or below the lowest level expected to cause significant effects, and thus it is unlikely that the pilot’s use of diphenhydramine contributed to the accident.
Probable cause:
The pilot’s failure to maintain airplane control after entering instrument meteorological conditions (IMC) while climbing due to spatial disorientation, which resulted in the exceedance of the airplane’s design stress limits and subsequent in-flight break-up. Contributing to accident was the pilot's improper decision to conduct the flight under visual flight rules and to continue the flight when conditions deteriorated.
Final Report:

Crash of a Beechcraft B200 Super King Air off Kake: 3 killed

Date & Time: Jan 29, 2019 at 1811 LT
Operator:
Registration:
N13LY
Flight Type:
Survivors:
No
Schedule:
Anchorage - Kake
MSN:
BB-1718
YOM:
2000
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
17774
Captain / Total hours on type:
1644.00
Aircraft flight hours:
5226
Circumstances:
The pilot of the medical transport flight had been cleared by the air traffic controller for the instrument approach and told by ATC to change to the advisory frequency, which the pilot acknowledged. After crossing the initial approach fix on the RNAV approach, the airplane began a gradual descent and continued northeast towards the intermediate fix. Before reaching the intermediate fix, the airplane entered a right turn and began a rapid descent, losing about 2,575 ft of altitude in 14 seconds; radar returns were then lost. A witness at the destination airport, who was scheduled to meet the accident airplane, observed the pilot-controlled runway lights illuminate. When the airplane failed to arrive, she contacted the company to inquire about the overdue airplane. The following day, debris was found floating on the surface of the ocean. About 48 days later, after an extensive underwater search, the heavily fragmented wreckage was located on the ocean floor at a depth of about 500 ft. A postaccident examination of the engines revealed contact signatures consistent with the engines developing power at the time of impact and no evidence of mechanical malfunctions or failures that would have precluded normal operation. A postaccident examination of the airframe revealed about a 10° asymmetric flap condition; however, significant impact damage was present to the flap actuator flex drive cables and flap actuators, indicating the flap actuator measurements were likely not a reliable source of preimpact flap settings. In addition, it is unlikely that a 10° asymmetric flap condition would result in a loss of control. The airplane was equipped with a total of 5 seats and 5 restraints. Of the three restraints recovered, none were buckled. The unbuckled restraints could suggest an emergency that required crewmembers to be up and moving about the cabin; however, the reason for the unbuckled restraints could not be confirmed. While the known circumstances of the accident are consistent with a loss of control event, the factual information available was limited because the wreckage in its entirety was not recovered, the CVR recording did not contain the accident flight, no non-volatile memory was recovered from the accident airplane, and no autopsy or toxicology of the pilot could be performed; therefore, the reason for the loss of control could not be determined. Due to the limited factual information that was available, without a working CVR there is little we know about this accident.
Probable cause:
A loss of control for reasons that could not be determined based on the available information.
Final Report:

Crash of an AMI DC-3-65TP in Kidron: 2 killed

Date & Time: Jan 21, 2019 at 0912 LT
Type of aircraft:
Operator:
Registration:
N467KS
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Kidron - Akron
MSN:
20175
YOM:
1944
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
15457
Captain / Total hours on type:
5612.00
Copilot / Total flying hours:
9969
Copilot / Total hours on type:
12
Aircraft flight hours:
37504
Circumstances:
The two pilots departed in a turbine powered DC-3C at maximum gross weight for a repositioning flight. The airplane was part of a test program for new, higher horsepower engine installation. Soon after liftoff and about 3 seconds after decision speed (V1), the left engine lost total power. The propeller began to auto-feather but stopped feathering about 3 seconds after the power loss. The airplane yawed and banked to the left, descended, and impacted terrain. Recorded engine data indicated the power loss was due to an engine flameout; however, examination of the engine did not determine a reason for the flameout or the auto-feather system interruption. While it is plausible that an air pocket developed in the fuel system during the refueling just before the flight, this scenario was not able to be tested or confirmed. It is possible that the auto-feather system interruption would have occurred if the left power lever was manually retarded during the auto-feather sequence. The power loss and auto-feather system interruption occurred during a critical, time-sensitive phase of flight since the airplane was at low altitude and below minimum controllable airspeed (Vmc). The acutely transitional phase of flight would have challenged the pilots' ability to manually feather the propeller quickly and accurately. The time available for the crew to respond to the unexpected event was likely less than needed to recognize the problem and take this necessary action – even as an immediate action checklist/memory item.
Probable cause:
The loss of airplane control after an engine flameout and auto-feather system interruption during the takeoff climb, which resulted in an impact with terrain.
Final Report:

Crash of a Canadair CL-601 Challenger in Ox Ranch

Date & Time: Jan 13, 2019 at 1130 LT
Type of aircraft:
Registration:
N813WT
Survivors:
Yes
Schedule:
Fort Worth - Ox Ranch
MSN:
3016
YOM:
1983
Crew on board:
3
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
9000
Captain / Total hours on type:
3500.00
Copilot / Total flying hours:
1015
Copilot / Total hours on type:
25
Aircraft flight hours:
8408
Circumstances:
The pilot, copilot, flight attendant, and six passengers departed on a corporate flight to a private airstrip. After leveling off at flight level 280, the flight crew checked the weather conditions at nearby airports. Based on the weather information that they had, the pilot planned for a visual approach to the runway. As the airplane neared the destination, the pilot flew over the runway and entered a left downwind visual traffic pattern to check if any animals were on the runway and what the windsock on the airstrip indicated. The pilot stated that they did not see the windsock as they passed over the runway. The pilot reported that there were turbulence and wind gusts from the hills below and to the west. When the airplane was over the runway about 50 ft above ground level (agl), the pilot reduced the engine power to idle. The pilot reported the airplane then encountered wind shear; the airspeed dropped rapidly, and the airplane was "forced down" to the runway. A representative at the airstrip reported that the airplane hit hard on landing. The pilot unlocked the thrust reversers, applied brakes, and reached to deploy the ground spoilers. As he deployed the thrust reversers, the pilot said it felt like the right landing gear collapsed. He applied full left rudder and aileron, but the airplane continued to veer to the right. The pilot tried using the tiller to steer to the left but got no response. The airplane left the side of the runway and went into the grass, which resulted in substantial damage; the right main landing gear was broken aft and collapsed under the right wing. Postaccident examinations of the airplane revealed no preimpact mechanical malfunctions or failures that would have precluded normal operation. A review of weather conditions showed surface winds out of the north to northwest at 15 kts, with some gusts up to 20 kts. There was potential for turbulence and wind shear below 5,000 ft, but there were no direct observations. The area forecast about 30 minutes after the accident called for northwesterly winds at 10 to 17 kts with a few higher gusts in the afternoon for the general area. Data from an onboard enhanced ground proximity warning system (EGPWS) revealed that the crew received a terrain alert just before the airplane crossed the runway threshold. At the time the airplane was over the runway threshold, it was 48 ft agl and in a 1,391 ft per minute rate of descent. The airplane impacted the runway 3 seconds later. Given the pilot's account, the weather information for the area, and the data from the airplane's EGPWS, it is likely that the airplane encountered wind shear while transitioning from approach to landing.
Probable cause:
The airplane's encounter with wind shear on short final approach to the runway, which resulted in a hard landing and fracture of the right main landing gear.
Final Report:

Crash of a Cessna 560 Citation V in Atlanta: 4 killed

Date & Time: Dec 20, 2018 at 1210 LT
Type of aircraft:
Operator:
Registration:
N188CW
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Atlanta - Millington
MSN:
560-0148
YOM:
1991
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
2300
Captain / Total hours on type:
110.00
Aircraft flight hours:
6854
Circumstances:
The pilot departed on an instrument flight rules flight into instrument meteorological conditions (IMC). Radar data indicated that the airplane entered a left turn after takeoff, consistent with the pilot's instrument clearance. As the airplane climbed to an altitude about 2,410 ft above ground level, its rate of climb increased from about 3,500 ft per minute to 9,600 ft per minute, the stick shaker activated, and the airplane decelerated to about 75 knots. The airplane then entered a descending right turn and rolled inverted before impacting terrain about 1 mile from the airport. All major components of the airplane were located at the accident site, and examination of the wreckage revealed no anomalies with the airplane that would have precluded normal operation. The weather conditions about the time of the accident included an overcast cloud ceiling about 600 ft above ground level. It is likely that the pilot became spatially disoriented after entering the cloud layer, which resulted in the airplane's high rate of climb, rapid loss of airspeed, and a likely aerodynamic stall. The steep descending right turn, the airplane's roll to an inverted attitude, and the high-energy impact are also consistent with a loss of control due to spatial disorientation.
Probable cause:
The pilot's loss of airplane control due to spatial disorientation during initial climb in instrument meteorological conditions.
Final Report:

Crash of a Piper PA-46-350P Malibu off Mayport: 2 killed

Date & Time: Dec 20, 2018 at 0904 LT
Registration:
N307JM
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Kissimmee - Princeton
MSN:
46-36253
YOM:
2000
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
390
Captain / Total hours on type:
30.00
Aircraft flight hours:
3785
Circumstances:
The aircraft impacted the Atlantic Ocean near Mayport, Florida. The private pilot and pilot-rated passenger were fatally injured. The airplane was destroyed. The airplane was privately owned and operated under the provisions of Title 14 Code of Federal Regulations Part 91. Instrument meteorological conditions prevailed at the time and the flight was operating on an instrument flight rules (IFR) flight plan. The personal flight originated from Kissimmee Gateway Airport, Orlando, Florida, about 0821, and was destined for Princeton Airport, Princeton/Rocky Hill, NJ. According to preliminary air traffic control radar and voice data provided by the Federal Aviation Administration (FAA), at 0859:02, one of the airplane's occupants contacted the Jacksonville Air Route Traffic Control Center (ZJX ARTCC) R-73 sector controller and reported passing through Flight Level (FL) 220 for FL230. The controller advised the pilot there were moderate and some heavy precipitation along the route of flight extending for 200 nautical miles. The occupant acknowledged the controller and advised they would be watching the weather. FAA radar data indicated at 0900:22 the flight reached FL227. Preliminary review of weather data revealed that this altitude was above the freezing level, and at that time the flight entered an area of weather radar returns with intensities between 10 to 30 dBZ (which equated to light to moderate precipitation). While in the weather radar-indicated precipitation, the flight climbed to FL230. At 0902:14, while at the edge of the precipitation, the airplane started a slight left turn before entering a right turn at 0902:28 at FL226. The turn had not been directed by the controller or announced by either occupant. Between 0902:28 and 0903:10, the airplane descended from FL226 to FL202. At 0903:10, the airplane was descending through FL202 when the controller attempted to contact the flight, but there was no reply. The controller attempted to communicate with the flight several more times, and at 0903:27 in response to one attempt, while at 14,500 feet mean sea level (msl), an occupant advised, "were not ok we need help." The controller asked the pilot if he was declaring an emergency and "whats going on." At 0903:35, while at 12,600 feet msl an occupant stated, "I'm not sure whats happening", followed by, "I have anti-ice and everything." At 0903:40 the controller asked the flight if it could maintain altitude, an occupant responded that they could not maintain altitude. The controller provided vectors to a nearby airport west of their position, but the flight did not reply to that transmission or a subsequent query. At about 0904:32 (which was the last communication from the airplane), while at 3,300 feet msl, an occupant advised the controller that the airplane was inverted and asked for assistance. The last radar recorded position with altitude read-out of the flight was at 0904:40, at an altitude of 1,700 feet msl, and 30.40069° north latitude and -81.3844° west longitude. The U.S. Coast Guard initiated a search for the missing airplane, but the wreckage was not located and the search was suspended on December 22, 2018. A privately-funded search for the airplane was initiated and the wreckage was located and recovered on February 6, 2019. The recovered wreckage was retained for further investigation.
Probable cause:
An in-flight loss of control following an encounter with supercooled large droplet icing conditions, which ultimately resulted in an uncontrolled descent and subsequent inflight breakup. Also causal was the pilot’s failure to maintain an appropriate airspeed for flight in icing conditions.
Final Report:

Crash of a Cessna 550 Citation II in Fargo

Date & Time: Nov 30, 2018 at 1353 LT
Type of aircraft:
Operator:
Registration:
N941JM
Flight Type:
Survivors:
Yes
Schedule:
Williston - Fargo
MSN:
550-0146
YOM:
1980
Crew on board:
1
Crew fatalities:
Pax on board:
10
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
1513
Captain / Total hours on type:
253.00
Aircraft flight hours:
7180
Circumstances:
The commercial pilot was conducting a cross-country, business flight with 10 passengers onboard the 8-passenger airplane. He reported that air traffic control cleared the flight for an instrument landing system (ILS) approach to the runway. While descending, the airplane entered instrument meteorological conditions (IMC) at 3,100 ft mean sea level (msl), and ice started to accumulate on the wing's leading edges, empennage, and windshield. The pilot activated the pneumatic deice boots multiple times during the approach and slowed the airplane to 120 knots. The airplane then exited the clouds about 400 ft above ground level (agl), and the pilot maintained 120 knots as the airplane flew over the airport fence; all indications for landing were normal. About 100 ft agl, the airplane started to pull right. He applied left correction inputs, but the airplane continued to pull right. He applied engine power to conduct a goaround, but the airplane landed in grass right of the runway, sustaining damage to the wings and landing gear. Witnesses and passengers reported that the airplane stalled. During examination of the airplane immediately after the accident, about 1/2 to 1 inch of mixed ice was found on the right wing's leading edge, the vertical and horizontal stabilizers, and the angle of attack probe. Ice was also observed on the windshield. The flaps were found in the "up" position. Flight control continuity was established. Although the airplane was originally certificated for two-pilot operation, the pilot was flying the airplane under a single-pilot exemption. The pilot received a logbook endorsement indicating that he had received single-pilot training and was properly qualified under the single-pilot exemption. However, he
had not met the turbine flight time qualifications (1,000 hours) to be properly authorized to conduct the flight under the single-pilot exemption because he only had 500 hours. A review of cockpit voice recorder information indicated that, although the pilot verbalized that the landing gear was "all green," followed by stating "check, check, check," he did not verbalize all the approach or landing checklist items nor did he make any audible comments about activating the pneumatic deice boots or windshield anti-ice. A review of radar data for the flight indicated that, during the last 2 minutes of flight, while the airplane was on final approach to the runway, the indicated airspeed got as low as 99 knots. The last recorded radar return indicated that the airplane had an airspeed of 104 knots at 900 ft msl. The pilot's lack of minimum flight experience required to fly the airplane without a copilot likely led to task saturation as he flew the airplane entered IMC and icing conditions while on an ILS approach. He subsequently failed to lower the flaps during the approach, which resulted in a no-flap approach instead of a full-flap landing. The ice on the leading edges of the wings, the no-flap approach, and the low airspeed likely led to the exceedance of the airplane's critical angle of attack, which resulted in an aerodynamic stall.
Probable cause:
The pilot's failure to lower the flaps during the approach and maintain sufficient airspeed while flying in instrument meteorological and icing conditions and the accumulation of ice on the wings' leading edges, which resulted in the exceedance of the airplane's critical angle of attack and subsequent aerodynamic stall. Contributing to the accident was the pilot's lack of proper qualification to operate the airplane under a single-pilot exemption due to his lack of total turbine time, which led to task saturation and his failure to properly configure the flaps for landing.
Final Report: