United States of America

On November 30, 2018, about 1028 central standard time, a Cessna 525A (Citation) airplane, N525EG, was destroyed when it was involved in an accident near Memphis, Indiana. The pilot and two passengers were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 business flight. The cross-country flight originated from Clark Regional Airport (JVY), Jeffersonville, Indiana, and was en route to Chicago Midway International Airport (MDW), Chicago, Illinois. The airplane was equipped with automatic dependent surveillance–broadcast (ADS-B), which recorded latitude and longitude from GPS, pressure and geometric altitude, and selected altitude and heading. The airplane was also equipped with a cockpit voice recorder (CVR), which recorded the accident flight and annunciations from the enhanced ground proximity warning system (EGPWS). It was not equipped with a flight data recorder (FDR) nor was it required to be. Review of the CVR transcript showed that the pilot operated as a single pilot but verbalized his actions as he configured the airplane before departure. He referenced items from the Before Taxi checklist and included in his crew briefing that in the event of a problem after takeoff decision speed, he would handle it as an in-flight emergency and “fly the airplane, address the problem, get the autopilot on, talk on the radios, divert over to Stanford.” The air traffic controller provided initial clearance for the pilot to fly direct to the STREP intersection and to climb and maintain 3,000 ft mean sea level. Before the departure from JVY, the pilot announced on the common traffic advisory frequency that he was departing runway 36 and verbalized in the cockpit “this is three six” before he advanced the throttles. The flight departed JVY about 1024:36 into instrument meteorological conditions. The CVR recorded the pilot state that he set power to maximum cruise thrust, switched the engine sync on, and turned on the yaw dampers. The pilot also verbalized his interaction with the autopilot, including navigation mode, direct STREP, and vertical speed climb up to 3,000 ft. According to the National Transportation Safety Board’s (NTSB) airplane performance study, the airplane climbed to about 1,400 ft msl before it turned left onto a course of 330° and continued to climb. The CVR recorded the pilot state he was turning on the autopilot at 1025:22. At 1025:39, the pilot was cleared up to 10,000 ft and asked to “ident,” and the airplane was subsequently identified on radar. The pilot verbalized setting the autopilot for 10,000 ft and read items on the After Takeoff/Climb checklist. The performance study indicated that the airplane passed 3,000 ft about 1026, with an airspeed between 230 and 240 kts, and continued to climb steadily. At 1026:29, while the pilot was conducting the checklist, the controller instructed him to contact the Indianapolis Air Route Traffic Control Center; the pilot acknowledged. At 1026:38, the pilot resumed the checklist and stated, “uhhh lets seeee. Pressurization pressurizing anti ice de-ice systems are not required at this time.” The performance study indicated that, at 1026:45, the airplane began to bank to the left at a rate of about 5° per second and that after the onset of the roll, the airplane maintained airspeed while it continued to climb for 12 seconds, consistent with engine power not being reduced in response to the roll onset. At 1026:48, the CVR recorded the airplane’s autopilot disconnect annunciation, “autopilot.” The performance study indicated that about this time, the airplane was in about a 30° left bank. About 1 second later, the pilot stated, “whooooaaaaah.” Over the next 8 seconds, the airplane’s EGPWS annunciated six “bank angle” alerts. At 1026:57, the airplane reached its maximum altitude of about 6,100 ft msl and then began to descend rapidly, in excess of 11,000 ft per minute. At 1026:58, the bank angle was about 70° left wing down, and by 1027:05, the airplane was near 90° left wing down. At 1027:04, the CVR recorded a sound similar to an overspeed warning alert, which continued to the end of the flight. The performance study indicated that about the time of the overspeed warning, the airplane passed about 250 kts calibrated airspeed at an altitude of about 5,600 ft. After the overspeed warning, the pilot shouted three expletives, and the bank angle alert sounded two more times. According to the performance study, at 1027:18, the final ADS-B data point, the airplane was about 1,000 ft msl, with the airspeed about 380 kts and in a 53° left bank. At 1027:11, the CVR recorded the pilot shouting a radio transmission, “mayday mayday mayday citation five two five echo golf is in an emergency descent unable to gain control of the aircraft.” At 1027:16, the CVR recorded the EGPWS annunciating “terrain terrain.” The sound of impact was recorded about 1027:20. The total time from the beginning of the left roll until ground impact was about 35 seconds. The accident site was located about 8.5 miles northwest of JVY.

The pilot and two medical crewmembers were repositioning the airplane to pick up a patient for aeromedical transport. Dark night instrument meteorological conditions prevailed for the flight. Radar data showed the airplane climb to 14,000 ft mean sea level after departure and proceed direct toward the destination airport before beginning a right descending turn. The airplane subsequently broke up inflight and impacted terrain. No distress calls were received from the pilot before the accident. Although weather conditions were conducive for inflight icing, no evidence of structural icing was identified at the scene. The debris field was 2,500 ft long and the disbursement of the wreckage confirmed that both wings, the horizontal stabilizer, both elevators, and both engines separated from the airplane before impacting the ground. Examination of the wreckage revealed that the initiating failure was the failure of the wing where it passed through the center of the airplane. The three wing spars exhibited S-bending deformation, indicative of positive overload producing compressive buckling and fracture. Further, impact signatures as black paint transfers and gouged aluminum, were consistent with the left outboard wing separating when it was struck by the right engine after the wing spars failed. There was no evidence of any pre-exiting conditions that would have degraded the strength of the airplane structure at the fracture locations. Flight control continuity was confirmed. An examination of the engines, propellers, and available systems showed no mechanical malfunctions or failure that could have contributed to the accident. The descending right turn was inconsistent with the intended flight track and ATC-provided clearance. However, there was insufficient information to determine how it was initiated and when the pilot became aware of the airplane's state in the dark night IMC conditions. Yet, the
absence of a distress call or communication with ATC about the airplane's deviation suggests that the pilot was not initially aware of the change in state. The structural failure signatures on the airplane were indicative of the wings failing in positive overload, which was consistent with the pilot initiating a pullup maneuver that exceeded the airplane spars' structural integrity during an attempted recovery from the spiral dive.

The airplane sustained substantial damage when it collided with terrain during an approach to landing at the Myrtle Beach International Airport (MYR), Myrtle Beach, South Carolina. The commercial pilot was seriously injured. The airplane was privately owned and operated under the provisions of Title 14 Code of Federal Regulations Part 91 as a personal flight. Instrument meteorological conditions prevailed, and an instrument flight rules flight plan was filed for the flight that departed Greater Cumberland Regional Airport (CBE), Cumberland, Maryland. According to the pilot, he was following radar vectors for the downwind leg of the traffic pattern to runway 36 at MYR. He turned for final approach and was inside the outer marker, when he encountered heavy turbulence. As he continued the approach, he described what he believed to be a microburst and the airplane started to descend rapidly. The pilot added full power in an attempt to climb, but the airplane continued to descend until it collided with the Atlantic Ocean 1 mile from the approach end of runway 36. A review of pictures of the wreckage provided by a Federal Aviation Administration inspector revealed the cockpit section of the airplane was broken away from the fuselage during the impact sequence. At 1456, the weather recorded at MYR, included broken clouds at 6,000 ft, few clouds at 3,500 ft and wind from 010° at 8 knots. The temperature was 14°C, and the dew point was 9°C. The altimeter setting was 30.27 inches of mercury. The airplane was retained for further examination.

Shortly after takeoff, the pilot smelled smoke. As he began to turn the airplane back to the airport, the engine lost total power. He conducted a forced landing in a field just short of the airport, during which the airplane struck a metal fence and pipe. All occupants egressed, and the pilot then noticed that a fire had erupted under the airplane's engine cowling. Postaccident examination revealed that the airplane sustained fire damage to the roof and forward end of the baggage compartment along with the engine accessory area between the firewall and aft air baffles. Further examination revealed that one of the engine exhaust crossover pipe assemblies was misaligned at the slip joint. An engine manufacturer service bulletin (SB) called for inspections of the exhaust system slip and flange joints to identify misaligned exhaust components. The last maintenance event occurred about 7 1/2 flight hours before the accident, during which the SB was performed and resulted in the replacement of crossover pipes. The mechanic who had performed the most recent maintenance did not follow the correct procedures for reinstallation of the crossover pipe, and the inspector who reviewed his work did not examine the installation as it progressed but instead inspected the pipes after they were installed and essentially hidden from view by their protective heat shield. As a result of the misaligned engine exhaust crossover pipe, hot exhaust gases escaped into the engine compartment and started a fire, which compromised critical engine fuel and oil lines, and resulted in the loss of engine power.

The flight crew was operating the business jet on an on-demand air taxi flight with passengers onboard. During landing at the destination airport, the cockpit voice recorder (CVR) recorded the sound of the airplane touching down followed by the pilot's and copilot's comments that the brakes were not operating. Air traffic controllers reported, and airport surveillance video confirmed, that the airplane touched down "normally" and the airplane's thrust reverser deployed but that the airplane continued down the runway without decelerating before overrunning the runway and impacting terrain. Postaccident examination of the airplane's brake system revealed discrepancies of the antiskid system that included a broken solder joint on the left-side inboard transducer and a reversal of the wiring on the right-side outboard transducer. It is likely that these discrepancies resulted in the normal braking system's failure to function during the landing. Before the accident flight, the airplane had been in long-term storage for several years and was in the process of undergoing maintenance to bring the airplane back to a serviceable condition, which in-part required the completion of several inspections, an overhaul of the landing gear, and the resolution of over 100 other unresolved discrepancies. The accident flight and four previous flights were all made with only a portion of this required maintenance having been completed and properly documented in the airplane's maintenance logs. A pilot, who had flown the airplane on four previous flights along with the accident pilot (who was acting as second-in-command during them), identified during those flights that the airplane's normal braking system was not operating when the airplane was traveling faster than 20 knots. He remedied the situation by configuring the airplane to use the emergency, rather than normal, braking system. That pilot reported this discrepancy to the operator's director of maintenance, and it is likely that maintenance personnel from the company subsequently added an "INOP" placard near the switch on the date of the accident. The label on the placard referenced the antiskid system, and the airplane's flight manual described that with the normal brake (or antiskid) system inoperative, the brake selector switch must be positioned to use the emergency braking system. Following the accident, the switch was found positioned with the normal braking system activated, and it is likely that the accident flight crew attempted to utilize the malfunctioning normal braking system during the landing. Additionally, the flight crew failed to properly recognize the failure and configure the airplane to utilize the emergency braking system, or utilize the parking brake, as described in the airplane's flight manual, in order to stop the airplane within the available runway.

The airline transport pilot of the multiengine airplane was cleared for the VOR approach. The weather at the airport was reported as 400 ft overcast with 4 miles visibility in drizzle. When the airplane failed to arrive at the airport as scheduled, a search was initiated, and the wreckage was located soon thereafter. Radar data indicated that the pilot was provided vectors to intercept the final approach course. The last radar return indicated that the airplane was at 2,200 ft and 8.1 miles from the runway threshold. It impacted terrain 3.5 miles from the runway threshold and left of the final approach course. According to the published approach procedure, the minimum descent altitude was 1,100 feet, which was 466 ft above airport elevation. Examination of the wreckage revealed that the airplane had impacted the tops of trees and descended at a 45° angle to ground contact; the airplane was destroyed by a postcrash fire, thus limiting the examination; however, no anomalies were observed that would have precluded normal operation. The landing gear was extended, and approach flaps had been set. Impact and fire damage precluded an examination of the flight and navigation instruments. Autopsy and toxicology of the pilot were not performed; therefore, whether a physiological issue may have contributed to the accident could not be determined. The location of the wreckage indicates that the pilot descended below the minimum descent altitude (MDA) for the approach; however, the reason for the pilot's descent below MDA could not be determined based on the available information.

The pilot of the float-equipped airplane reported that, during the initial climb after a water takeoff, about 200 feet, he turned right, and the engine lost power. He immediately switched fuel tanks and attempted to restart the engine to no avail. The airplane descended and struck trees, and the right wing impacted terrain. The airplane sustained substantial damage to the right wing. The pilot reported that there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation. The pilot reported to the Federal Aviation Administration inspector that, during the initial climb and after the engine lost power, he noticed that the center tank, which was selected for takeoff, was empty. He added that passengers stated that the engine did regain power after switching tanks, but the airplane had already struck trees. The pilot reported as a recommendation to more closely follow checklists.

The private pilot of the multi-engine airplane was conducting an instrument approach during night visual meteorological conditions. About 1.3 nautical miles (nm) from the final approach fix, the right engine lost total power. The pilot continued the approach and notified air traffic control of the loss of power about 1 minute and 13 seconds later. Subsequently, the pilot contacted the controller again and reported that he was unable to activate the airport's pilot-controlled runway lighting. In the pilot's last radio transmission, he indicated that he was over the airport and was going to "reshoot that approach." The last radar return indicated that the airplane was about 450 ft above ground level at 72 kts groundspeed. The airplane impacted the ground in a steep, vertical nose-down attitude about 1/2 nm from the departure end of the runway. Examination of the wreckage revealed that the landing gear and the flaps were extended and that the right propeller was not feathered. Data from onboard the airplane also indicated that the pilot did not secure the right engine following the loss of power; the left engine continued to produce power until impact. The airplane's fuel system held a total of 203 gallons. Fuel consumption calculations estimated that there should have been about 100 gallons remaining at the time of the accident. The right-wing locker fuel tank remained intact and contained about 14 gallons of fuel. Fuel blight in the grass was observed at the accident site and the blight associated with the right wing likely emanated from the right-wing tip tank. The elevator trim tab was found in the full nose-up position but was most likely pulled into this position when the empennage separated from the aft pressure bulkhead during impact. Examination of the airframe and engine revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation. Although there was adequate fuel on board the airplane, the pilot may have inadvertently moved the right fuel selector to the OFF position or an intermediate position in preparation for landing instead of selecting the right wing fuel tank, or possibly ran the right auxiliary fuel tank dry, which resulted in fuel starvation to the right engine and a total loss of power. The airplane manufacturer's Pilot Operating Handbook (POH) stated that the 20-gallon right- and left-wing locker fuel tanks should be used after 90 minutes of flight. However, 14 gallons of fuel were found in the right-wing locker fuel tank which indicated that the pilot did not adhere to the POH procedures for fuel management. The fuel in the auxiliary fuel tank should be used when the main fuel tank was less than 180 pounds (30 gallons) per tank. As a result of not using all the fuel in the wing locker fuel tanks, the pilot possibly ran the right auxiliary fuel tank empty and was not able to successfully restart the right engine after he repositioned the fuel selector back to the right main fuel tank. Postaccident testing of the airport's pilot-controlled lighting system revealed no anomalies. The airport's published approach procedure listed the airport's common traffic advisory frequency, which activated the pilot-controlled lighting. It is possible that the pilot did not see this note or inadvertently selected an incorrect frequency, which resulted in his inability to activate the runway lighting system. In addition, the published instrument approach procedure for the approach that the pilot was conducting indicated that the runway was not authorized for night landings. It is possible that the pilot did not see this note since he gave no indication that he was going to circle to land on an authorized runway. Given that the airplane's landing gear and flaps were extended, it is likely that the pilot intended to land but elected to go-around when he was unable to activate the runway lights and see the runway environment. However, the pilot failed to reconfigure the airplane for climb by retracting the landing gear and flaps. The pilot had previously failed to secure the inoperative right engine following the loss of power, even though these procedures were designated in the airplane's operating handbook as "immediate action" items that should be committed to memory. It is likely that the airplane was unable to climb in this configuration, and during the attempted go-around, the pilot exceeded the airplane's critical angle of attack, which resulted in an aerodynamic stall. Additionally, the pilot had the option to climb to altitude using singleengine procedures and fly to a tower-controlled airport that did not have any landing restrictions, but instead, he decided to attempt a go-around and land at his destination airport.

The commercial pilot and three passengers departed on a cross-country flight in a twin-engine airplane. As the flight neared the destination airport, the pilot canceled his instrument flight rules (IFR) clearance. The approach controller transferred the flight to the tower controller, and the pilot reported to the tower controller that the airplane was about 2 miles from the airport. However, the approach controller contacted the tower controller to report that the airplane was 200 ft over a nearby joint military airport at the time. GPS data revealed that, when pilot reported that the airplane was 2 miles from the destination airport, the airplane's actual location was about 10 miles from the destination airport and 2 miles from the joint military airport. The airplane impacted a remote wooded area about 8 miles northwest of the destination airport. At the time of the accident, thunderstorm cells were in the area. A review of the weather information revealed that the pilot's view of the airport was likely obscured because the airplane was in an area of light precipitation, restricting the pilot's visibility. A review of airport information noted that the IFR approach course for the destination airport passes over the joint military airport. The Federal Aviation Administration chart supplement for the destination airport noted the airport's proximity to the other airport. However, it is likely that the pilot mistook the other airport for the destination airport due to reduced visibility because of weather. The accident circumstances were consistent with controlled flight into terrain. The ethanol detected in the pilot's blood specimens but not in his urine specimens was consistent with postmortem bacteria production. The carbon monoxide and cyanide detected in the pilot's blood specimens were consistent with inhalation after the postimpact fire.

Owned by a construction company and registered under Vancon Holdings LLC (VanCon Inc.), the aircraft was parked at Spanish Fork-Springville Airport when it was stolen at night by a private pilot. After takeoff, hew flew southbound to Payson, reduced his altitude and voluntarily crashed the plane onto his house located in Payson. The airplane disintegrated on impact and was destroyed by impact forces and a post crash fire. The pilot was killed. His wife and daughter who were in the house at the time of the accident were uninjured despite the house was also destroyed by fire. Local Police declared that the pilot intentionally flew the airplane into his own home hours after being booked for domestic assault charges. An examination of the airplane found no anomalies with the flight controls that would have contributed to the accident. Toxicology testing revealed the presence of a medication used to treat depression, obsessive-compulsive disorder, some eating disorders, and panic attacks; the pilot did not report the use of this medication to the Federal Aviation Administration. The pilot had a known history of depression, anxiety, and anger management issues. The circumstances of the accident were consistent with the pilot's intentional flight into his home.