United States of America

The airplane collided with mountainous terrain during approach to the destination airport. While approaching the airport, the pilot requested vectors for a localizer approach to runway 19. Due to traffic, air traffic control (ATC) issued the pilot a holding clearance. The airplane was approaching the holding fix about 8,000 feet, when the pilot advised ATC that the airplane was picking up a little ice. ATC initially offered an amended clearance of 9,000 feet, but the pilot declined. Subsequently, he accepted the clearance and climbed back to 9,000 feet. ATC then told the pilot that after one more airplane had landed, he would be issued an approach clearance. The airplane was about 9,200 feet when the pilot replied "thank you." Review of radar data revealed that the accident airplane made one complete 360-degree turn, and one 270-degree turn on the non-holding side of the published holding pattern. During the two turns, the airplane descended to approximately 8,400 feet, climbed to 8,900 feet, then descended again to 8,300 feet. The two turns were tighter than the expected standard 2-minute turns in a holding pattern, with radii ranging from 0.3 to 0.4 nautical miles and 0.1 to 0.2 nautical miles respectively. Following the two holding turns, no more radio transmissions or radar returns were received by ATC. Examination of the wreckage did not reveal any preimpact mechanical malfunctions. Another pilot flying in the area reported moderate rime ice at 8,000 feet, but added that he climbed out of the ice and was between cloud layers at 9,000 to 10,000 feet.

The airplane was destroyed when it impacted the ground while maneuvering at a low altitude following a loss of control in instrument meteorological conditions. The airplane was on a flight in instrument meteorological conditions when radar and voice contact were lost. Prior to the loss of communication, controllers advised the pilot to check altitude. At this point, the radar data shows that the airplane was about 400 feet below the assigned altitude. Subsequently, the pilot said, "roger sir my auto pilot i just cut off uh correcting immediately." This was the last received transmission from the pilot. The radar data shows that the airplane then began a descending right turn at an average rate of descent of 1,276 feet per minute. This descent was followed by a climbing left turn with an average rate of climb of 5,423 feet per minute. The radar data shows that the radius of the left turn continued to decrease until radar contact was lost about 500 feet above the last assigned altitude. A witness who saw the airplane just prior to impact described the airplane maneuvering beneath the clouds prior to pulling up sharply and then pitching down and impacting the ground. There was a utility wire and associated poles running across the airplane's flight path in the field where the wreckage was located. The airplane exploded and burned upon impact. No anomalies were found with the airplane or associated systems. The autopilot section of the Pilot's Operating Handbook states, "Sustained elevator overpower will result in the autopilot trimming against the overpower force." The result is that if up elevator pressure is applied with the autopilot engaged, the autopilot will trim the airplane nose down.

While on an IFR clearance, the pilot reported to approach control that he was unable to maintain 4,000 feet msl, and did not give a reason. Shortly thereafter, the pilot contacted approach control and stated that he had "fuel starvation" in the right engine and the left engine had just quit. Radar data depicted the aircraft at an altitude of 3,400 feet. The controller asked the pilot if they were completely without power, and the pilot responded, "yes, we're now gliding." The controller gave the pilot instructions to the nearest airport, which was approximately 4.5 nautical miles away. After passing 2,100 feet, the pilot informed the controller that he would be landing short. During the forced landing, the airplane struck the top of a tree, crossed over a house, struck another tree, struck a telephone wire which crossed diagonally over a street, and then cleared a set of wires which paralleled the street. The airplane then impacted a private residence within a residential area, and a fire erupted damaging the airplane and the private residence. Ten gallons of fuel were drained from the left locker tank, which supplements the left main fuel tank. Examination of the airframe and engines did not disclose any structural or mechanical anomalies that would have prevented normal operation. Examination of the propeller revealed that neither propeller had been
feathered.

The pilot stated that on the day of the accident he ordered fuel only on the first flight of the day. He said he did not add additional fuel during subsequent flights. He said he flew the accident airplane from Fort Lauderdale Executive Airport, Fort Lauderdale, Florida, to Chubb Cay, Bahamas, to Big Whale Cay, Bahamas, back to the Fort Lauderdale Executive Airport. He said he then departed Fort Lauderdale Executive Airport with his next load of passengers and flew to the North Eleuthera Airport, North Eleuthera, Bahamas, without having refueled, and was returning from North Eleuthera, Bahamas, to the Fort Lauderdale International Airport, when he ditched the airplane off Dania Beach, Florida, in the Atlantic Ocean. When asked whether the fuel on board the airplane had been exhausted, the pilot stated, " the way the engines were acting, it seemed like the airplane ran out of fuel." On scene examination of the airplane, as well as follow on examination of its engines revealed no pre accident anomalies with the airplane or its systems. Information obtained from the FAA showed that at 1757, the pilot contacted FAA Miami Approach Control and advised "minimum fuel, further stating that he was not declaring an emergency at that time. At 1758, the controller responded, passing communications control to the FAA Fort Lauderdale Air Traffic Control Tower (ATCT). In response to the pilot's initial communications call to the Fort Lauderdale ATCT, the pilot was given a clearance to land on runway 09R, and told that he was number one. At 1758:43, the pilot replied, asking if there was any chance of getting runway 27L, and at 1759:17, the controller instructed the pilot to descend at his discretion and remain slightly south of final for landing on runway 27L, and to expect 27L. At 1800:07, the pilot contacted the controller and stated, "two five yankee would like to declare an emergency at this time." At 1800:10, the controller responded, "two five yankee yes sir runway two seven left you are cleared to land the wind zero one zero at six." At 1800:16 the pilot responded acknowledging the wind report, and at 1800:27, the controller asked whether the nature of the emergency was minimum fuel, to which the pilot responded, "exactly two five yankee may be coming in dead stick. At 1800:40, the pilot stated that he had the airport in sight and will try to glide, and at 1801:32, the pilot said "two five yankee I'm going to be short of the shore." At 1802, the pilot ditched the airplane about 300 yards from the Dania Beach shoreline, in the area of John Lloyd State Park, in about 15 feet of water. The occupants of the airplane consisted of the pilot and four passengers. All exited the airplane and one passenger drowned in the Atlantic Ocean when according to the pilot "he was in a state of panic" when he tried to instruct him in the use of the life vest while they was in the water, and subsequently tried to use him for flotation when he tried to help him. All remaining passengers confirmed that the pilot had not given them any pre departure safety related briefing prior to or during the accident flight.

The flight was cleared for the ILS approach to runway 5R. The flight was at mid runway, at 2,100 feet, heading 049 degrees, at a speed of 163 knots, when the pilot stated "...missed approach." He was instructed to maintain 2,000, and to fly runway heading. Radar showed N41003 started a right turn, was flying away from the airport/VOR, descending. At a point 0.57 miles from the airport/VOR, the flight had descended to 1,500 feet, was turning right, and increasing speed. The flight had descended 400 feet, and had traveled about 0.32 miles in 10 seconds. When radio and radar contact were lost, the flight was 2.35 miles from the airport/VOR, level at 1,600 feet, on a heading of 123 degrees, and at a speed of 169 knots. The published decision height (DH) was 620 feet mean sea level (msl). The published minimum visibility was 1/2 mile. The published Missed Approach in use at the time of the accident was; "Climb to 1,000 [feet], then climbing right turn to 2,500 [feet] via heading 130 degrees, and RDU R-087 [087 degree radial] to ZEBUL Int [intersection] and hold." A witness stated that the aircraft was flying low, power seemed to be in a cruise configuration, and maintaining the same sound up until the crash. The reported weather at the time was: Winds 050 at 5 knots, visibility 1/2 statute mile, obscuration fog and drizzle, ceiling overcast 100, temperature and dew point 11 C, altimeter 30.30 in HG. At the time of the accident the pilot had 10 total flight hours in this make and model airplane; 33 total night flight hours; and 59 total instrument flight hours.

The twin-turbojet, transport-category airplane was destroyed when it departed controlled flight during descent into its final destination and impacted terrain. The flight was cleared to descend from FL 390 to 10,000 feet, and the flight crew established a 4,000-foot/minute descent. As the airplane descended through FL 219, air traffic control requested the pilot contact approach control. However, the pilot read back an incorrect frequency and spoke an unintelligible word. The controller attempted to correct the pilot; however, no additional communications were received from the flight crew. Located within a pause in the pilot's last transmission, a 1680 Hz frequency could be heard for 0.1 seconds. There are only two systems in the airplane with aural warning systems within that frequency range; the cabin altitude warning, and the overspeed warning (both systems were destroyed during the accident sequence). Shortly after the last transmission from the pilot, radar data depicted the airplane climbing back up to FL 231 before entering a steep and rapid descent. A performance study indicated that just prior to the loss of control, the airplane exceeded its maximum operating airspeed of 300 knots calibrated. However, according to the manufacturer, the airplane had been successfully flown at airspeeds up to 400 knots calibrated without loss of control. The right wing and sections of the right horizontal stabilizer/elevator separated from the airplane just prior to its impact with terrain and were located approximately 200-250 feet from the main impact crater. No anomalies with the airframe or engine were found that would have led to the loss of control. A cockpit voice recorder was installed in the accident airplane; however, it did not record the accident flight.

The pilot said that the copilot was flying a visual approach to runway 15 at the Lawrence Municipal Airport, Lawrence, Kansas. The pilot said, "With gear down and full flaps at approximately 15 to 20 feet above the runway and 115 KTS, the nose abruptly dropped and there was no elevator effectiveness with the yoke pulled back to the mechanical stop." The pilot said, "After landing, I noticed that the stabilizer trim indicated full nose down in the cockpit and, upon exterior inspection, the stab was in that position." The copilot said, "I made my turn to base and proceeded to make my turn to final. No problems with the controllability were noted at this time. The turn to final was made and the airplane was lined up with the runway on final approach with normal glide path. My altitude was dropping normally and my airspeed was approximately 140 knots." The copilot said, "When it got time to pull the power back to idle for landing our airspeed was approximately 110 knots and power was reduced. At that point in time the nose of the aircraft seemed to pitch over towards the runway and increase speed. I pulled back on the yoke to raise the nose and at that same instance the pilot recognized the pitch over and pulled back on the yoke at the same time. The yoke did not seem to pull all of the way to its full extent of travel and felt to mechanically stop at about 3/4 the way travel. Even with both pilot's pulling on the yoke it seemed unresponsive and failed to raise the nose back to a proper landing attitude. The aircraft hit the runway very hard and came to a stop on the runway." A preliminary inspection of the airplane showed the stabilizer positioned at 4 degrees nose down. An examination of the airplane's systems revealed no anomalies.

The airline completed weight and balance and dispatch release forms for the initial flight showed an incorrect fuel load at the time the engines were started. The first officer performed a walk-around before the first flight leg which included checking the fuel tanks. A total of 460 gallons of fuel were added to the fuel tanks, and a delay loading cargo occurred. After both engines were started to begin the first flight, the engines remained operated for between 9-10 minutes before they were secured due to a radio problem. Maintenance personnel reracked the VHF radios, and again the engines were started where the airplane remained on the ramp 3-4 minutes before taxiing to the runway. The airplane remained at the runway hold short area for between 20 and 25 minutes before returning to the ramp due to a radio problem. The engines were secured, and a new VHF radio was purchased and installed. The company did not prepare new dispatch release, or weight and balance forms for the flight taking into account the additional fuel consumed with the engines operating. The engines were started, and the airplane was taxied to the runway and departed for the planned first leg. The airplane landed uneventfully at the destination airport where the cargo was offloaded. The first officer performed a walk-around which included checking the fuel tanks; 300 gallons of fuel were added to the fuel tanks (150 gallons in each side). The flight departed to return and when near the coastline, the flight was vectored to an airport other than the planned destination due to a issue with U.S. Customs. The flight landed uneventfully, and experienced a delay clearing customs. While on the ground before departure on the accident flight, the first officer reportedly performed a walk-around which included checking the fuel tanks with the captain looking on. The first officer reported that each fuel tank had approximately 1,100 pounds of fuel, and he and the captain both agreed before takeoff as to the quantity of fuel on-board as indicated by the magna-sticks. No fuel was purchased. Following starting of both engines for the accident flight, the first officer checked the fuel quantity gauges indications against the magna-sticks indications he observed; the fuel quantity gauges indicated approximately 200 pounds more. The flight departed, proceeded eastbound, and climbed to approximately 2,100 feet msl. During a right turn from a southeast to westerly heading, the right engine experienced a loss of horsepower which decreased from 900 to zero. The right engine was secured as a precaution, and priority handling to the destination airport was requested with air traffic control. The left engine horsepower remained the same (900) for a period of 31 seconds following the right engine horsepower decrease, then increased to 2,200, and remained at that value for 1 minute 13 seconds. The left engine horsepower then began to decrease and dropped to zero. The airplane was turned to the east, then turned to the south and ditched. The captain and first officer evacuated but remained with the airplane, and made it to shore where the first officer advised his wife that something was wrong with the fuel gauges. Following recovery of the airplane, pressure testing of the left fuel tank revealed no evidence of preimpact leakage. Pressure testing of the right fuel tank revealed slight leakage past the fuel cap. Boroscope examination of the engines, and functional test of each engine ignition system, fuel control units and fuel pumps revealed no evidence of preimpact failure or malfunction. Examination of the installed magna-sticks revealed no evidence of preimpact failure. The left fuel tank was drained and found to contain 2 gallons of Jet A fuel, while the right fuel tank was drained and found to contain approximately 540 gallons of salt water and 1/2 gallon of Jet A fuel. Fuel consumption calculations performed by FAA personnel revealed that at the time of engine start for the accident flight, the fuel tanks contained approximately 714 pounds of fuel. According to a representative of the engine manufacturer, the amount of fuel drained from the engine components post accident was consistent with, "low residual fuel."

The flight departed from Little Rock, Arkansas, about 2356 cst, and approximately 49 minutes after takeoff, the FAA approved un-augmented Automated Weather Observing System (AWOS-3) installed at the destination airport began reporting the visibility as 1/4 statute mile; the visibility continued to be reported as that value for several hours after the accident. Title 14 CFR Part 135.225 indicates no pilot may begin an instrument approach procedure to an airport with an approved weather reporting facility unless the latest weather report issued by that weather reporting facility indicates that weather conditions are at or above the authorized IFR landing minimums for that airport. The listed minimums for the ILS approach to runway 05 was in part 3/4 mile visibility. A METAR taken at the destination airport approximately 2 minutes after the accident indicated overcast clouds existed at 100 feet, the temperature and dew point were 4 and 2 degrees Celsius, respectively, and the altimeter setting was 30.16 inHg. No precipitation was present across Arkansas, Mississippi, or Alabama, and no radar echoes were noted along the accident airplane's route of flight. The freezing level near the departure and destination airports at the nominal time of 0600 (4 hours 17 minutes after the accident) was 12000 and 14,500 feet mean sea level, respectively. A witness at the airport reported the fog was the thickest he had seen since working at the airport for the previous year. The flight was cleared for an ILS approach to runway 05, and the pilot was advised frequency change was approved. The witness waiting at the airport reported hearing a sound he associated with a shotgun report. Radar data indicated that between 0138:47, and 0142:11, the airplane was flying on a northeasterly heading and descended from 2,400 feet msl, to 900 feet msl. At 0142:11, the airplane was located .43 nautical mile from the approach end of runway 05. The next recorded radar target 24 seconds later indicated 1,000 feet msl, and was .20 nautical mile from the approach end of runway 05. The touchdown zone elevation for runway 05 is 700 feet msl. The airplane crashed in a wooded area located approximately 342 degrees and .37 nautical mile from the approach end of runway 05; the wreckage was located approximately 4 hours after the accident. Examination of trees revealed evidence the airplane was banked to the left approximately 24 degrees, and the descent angle from the trees to the ground was calculated to be approximately 22 degrees. All components necessary to sustain flight were either attached to the airplane or in close proximity to the main wreckage. There was no evidence of post crash fire and a strong odor of fuel was noted at the scene upon NTSB arrival. A 8-inch diameter pine tree located near the initial ground impact sight exhibited black paint transfer and a smooth cut surface that measured approximately 46 inches in length. The bottom portion of the cut was located 4 feet above ground level. The flap actuator was found nearly retracted; examination of the components of the flap system revealed no evidence of preimpact failure or malfunction. Examination of the flight control system for roll, pitch, and yaw revealed no evidence of preimpact failure or malfunction. Examination of the engine and engine components with TSB of Canada oversight revealed no evidence of preimpact failure of the engine or engine components. Examination of the propeller with FAA oversight revealed no evidence of preimpact failure or malfunction. Examination of the components of the autopilot system, selected avionics and flight instruments from the airplane with FAA oversight revealed no evidence of preimpact failure or malfunction. The pilot's attitude indicator had been replaced on October 14, 2001, and according to FAA personnel, the mechanic and facility that performed the installation did not have the necessary equipment to perform the operational checks required to return the airplane to service. The FAA flight checked the ILS approach to runway 05 two times after the accident and reported no discrepancies.

A commercial pilot, who observed the airplane during the takeoff attempt, stated that it used "lots" of runway, and that the nose lifted "too early and way too slow." The airplane "struggled" to get in the air, and it appeared tail heavy, with "extreme" pitch, about 45 degrees nose-up. It also appeared that the only thing keeping the nose up was ground effect. The airplane became airborne for "a very short time," then sank to the ground, and veered off the left side of the runway. The nose was "up" the whole time, the airplane never "rolled off on a wing," and the wings never wobbled. The engines were "really loud," like a "shriek," and engine noise was "continuous until impact." Another witness at a different location confirmed the extreme nose high takeoff attitude and the brief time the airplane was airborne. It seemed odd to him that an airplane with that much power used so much runway. A runway inspection revealed no evidence of foreign objects or aircraft debris. Tire tracks from the airplane's main landing gear veered off the left side of the paved surface, at a 20-degree angle, about 3,645 feet from the runway's approach end. They continued for about 775 feet, then turned back to parallel the runway for another 650 feet, before ending about 50 feet prior to a chain link fence. There was no evidence that the nose wheel was on the ground prior to the fence. The fence, which was about 1,300 feet along the airplane's off-runway ground track and 200 feet to the left of the runway edge stripe, was bent over in the direction of travel. Ground scars began about 150 feet beyond the fence, and the main wreckage came to rest 300 feet beyond the beginning of the ground scars. The first officer advised a witness that he'd be making the takeoff; however, the pilot at the controls during the accident sequence could not be confirmed. When asked prior to the flight if he'd be making a high-performance takeoff, the captain replied that he didn't know. There was no evidence of mechanical malfunction.