United States of America

The pilot departed his home airport for a 90 mile personal flight with eight passengers. The pilot stated he departed with 24 gallons of fuel in the outboard tanks, and 80 gallons of fuel in the main tanks. After landing, the airplane was refueled with 100 low-lead aviation gasoline; 12 gallons in each main fuel tank. Before departing for the return flight, the pilot performed a preflight inspection of the airplane, which did not include a visual check of the airplane's fuel tanks. After takeoff, the pilot experienced a "small surge in both engines," while climbing through 1,150 and 3,300 feet, respectively. He further described the surges as "minor but still noticeable." About 30 minutes later, after the airplane had descended, and was leveling at 1,500 feet, the pilot experienced an intermittent illumination of the "right aux fuel pump light," which was followed by a total loss of power on the right engine. Shortly thereafter, the left engine began "surging," and after about "three or four minutes, at most," he feathered the left engine propeller. The pilot ditched the airplane in Massachusetts Bay. The airplane was recovered about 1 month later. The fuel selectors were positioned to the outboard tanks, and the airplane's fuel tanks revealed fluid consistent with seawater with "some odor of fuel;" however, no visible evidence of fuel was observed. According to the airplane's information manual, the airplane's total fuel capacity was 192 gallons, of which, 182 gallons were usable. Examination of the airframe and engine did not reveal evidence of any pre-impact mechanical malfunctions. The pilot reported he had purchased the airplane and attended 5-day type specific training course in March 2001. He reported about 1,050 hours of total fight experience, which included 800 hours in multi-engine airplanes, of which 65 hours was in the make and model. Additionally, the pilot reported he had not experienced any prior mechanical problems. He believed he had flown the airplane the day prior to the accident as well. The last documented refueling of the airplane prior to the date of the accident occurred on May 3, 2001, when the airplane was refueled with 128 gallons of aviation gasoline. The last flight documented in the pilot's logbook was on May 4, 2001, when the pilot logged 1.9 hours in the accident airplane. The pilot said he normally flew a 65 percent power, an "a little rich," and experienced a fuel burn of about 20 to 21 gallons per hour, for each engine.

The pilot obtained a weather briefing, filed an IFR flight plan, and departed on a nonscheduled domestic cargo flight, carrying 270 pounds of freight. The flight proceeded uneventfully until it was established on the VOR/DME-C approach. Radar data indicates that after turning inbound towards the VORTAC from the DME arc, the airplane began its descent from 10,600 feet to the VOR crossing altitude of 9,200 feet. Enlargement of the radar track showed the airplane correcting slightly to the left as it proceeded inbound to the VORTAC at 9,400 feet. Shortly thereafter, aircraft track and altitude deviated 0.75 miles northwest and 9,700 feet, 0.5 miles southeast and 9,600 feet, and 0.5 miles northwest and 9,400 feet before disappearing from radar. Witnesses said the weather at the time of the accident was 600 foot overcast, 1.5 miles visibility in "misting" rain that became "almost slushy on the ground," and a temperature of 36 degrees Fahrenheit. One weather study indicated "an icing potential greater than 50% and visible moisture" in the accident area. Another report said "icing conditions were likely present in the area of the accident." The airplane was equipped and certified for flight into known icing conditions. The wreckage was found in a closely area. There was no evidence of pre-impact airframe, engine, or propeller malfunction/failure. The pilot was properly certificated, but his flight time in aircraft make/model was only 38 hours. He had previously recorded 16 icing encounters, totaling 11.2 hours in actual meteorological conditions. He recorded no ice encounters and only 1.0 hour of simulated (hooded) instrument time in the Cessna 208. Microscopic examination of annunciator light bulbs revealed the GENERATOR OFF light was illuminated. This condition indicates a generator disconnection due to a line surge, tripped circuit breaker, or inadvertent switch operation. The operator's chief pilot agreed, noting that one of the items on the Before Landing Checklist requires the IGNITION SWITCH be placed in the ON position. The START SWITCH is located next to the IGNITION SWITCH. Inadvertently moving the START SWITCH to the ON position would cause the generator to disconnect and the GENERATOR OFF annunciator light to illuminate. He said this would be distracting to the pilot.

Visual meteorological conditions prevailed for the planned cross-country flight for which the pilot obtained a weather briefing, filed an IFR flight plan, and received an ATC clearance. Approximately 8 minutes after takeoff, radar indicated the airplane was at 11,200 feet msl, heading 241 degrees, with a ground speed of 180 knots. No distress calls or additional communications with the pilot were recorded, and radar contact was lost. The airplane impacted the ground in an uncontrolled descent. The right wing tip tank separated from the airplane and was found 0.18 nautical miles from the main wreckage. The teardown and examination of both engines disclosed that the type and degree of damage was indicative of engine power section rotation and operation at the time of impact. There were no complete systems intact at the accident site due to the impact sequence and post-impact fire which consumed the aircraft. The landing gear and flaps were found in the retracted position. The portion of the right propeller shaft coupling found at the site was fractured through 360 degrees. Metallurgical examination revealed that the propeller shaft coupling failed in fatigue. The presence of the fatigue cracks indicated the coupler fractured in fatigue in service, and the fatigue cracks were not the result of ground impact. The circumferential fracture intersected the ends of several internal spline teeth. The origin of the fatigue crack could not be determined because of severe corrosion damage on the fracture surface. Fatigue propagation was in the aft direction and from the inside to the outside of the coupling. The engine core rotating components would have bee free to rotate when uncoupled from the propeller shaft. The maintenance records indicated that the failed coupling had accumulated approximately 4,000 hours since new, and 1,250 hours since engine overhaul in 1989. Since 1990, as a result of fatigue fractures, the manufacturer introduced several design changes for the propeller shaft coupling via optional Service Bulletins to be accomplished at the next access or hot section inspection (HSI). Impact and thermal damage of the right propeller precluded a determination of the in-flight blade angles. The calculations by the airplane manufacturer indicated that "the [intact] airplane was capable of continued flight" with the right propeller feathered, and that the "airplane can keep attitude, but cannot climb and cannot maintain altitude" with the right propeller in the flat pitch or wind milling positions, respectively. Metallurgical examination of the component brackets and associated bolts from the right tip tank revealed the separation of the tip tank resulted from a single-event overstress fracture of both the forward and aft tank attachment fittings. Calculations showed that a 3.763 radians per second (35.9 RPM) spin rate would cause the failure of the forward wing fuel tank attachment fitting. There had not been a previous in-flight separation of a wing tip fuel tank on this model airplane.

The pilot said the preflight, engine start, run-up, taxi and takeoff were "normal". The pilot said that during the climb after takeoff, approximately 1,000 to 1,500 feet above the ground, the airplane's engine "spooled down, slowly and smoothly, like a loss of torque or the propeller going to feather." The pilot performed a forced landing to a field, where the airplane nosed over, and came to rest inverted. Examination of the engine and propeller revealed that the propeller-reversing lever was installed on the wrong side of the reversing lever guide pin, and that the reversing linkage carbon block was no longer installed, and had departed the airplane. Examination of the airplane's maintenance records revealed that the carbon block was replaced during a 100-hour maintenance inspection, 5 hours prior to the accident. Installation of the reversing lever on the incorrect side of the guide pin resulted in improper seating and premature wear of the carbon block. According to the engine manufacturer, any disconnection in operation of the propeller control linkage will cause the propeller governor beta control valve to extend, and drive the propeller into feather.

Upon arrival at the destination airport, the commercial pilot of the Part 135 cargo flight reported to the tower that he was 7 miles to the east, intending to land on runway 13. Subsequently, the pilot reported that he would circle the airport a few times "because he was having trouble with his autopilot." After circling, the pilot positioned the airplane on final approach to runway 13. The pilot of another airplane in the traffic pattern observed the accident airplane on a "one to two mile final, in a normal flight attitude but possibly a little low." After looking at her instruments for several seconds, she made visual contact again and observed the airplane impact the ground with the "tail of the aircraft falling forward on top of a fence." She further stated that all of the radio transmissions from the accident airplane were "calm and completely un-alarmed prior to the accident." Another witness, who was located at a fixed base operator at the airport, observed the airplane turn onto final. He stated that the airplane "suddenly stalled and slammed into the ground from about two hundred feet." The 1,140 hour pilot had accumulated a total of 70 hours in the Cessna 402. The airplane was found to be within its prescribed weight and balance limitations at the time of the accident. Ground impressions and airframe deformations indicated that the impact angle was approximately 25 degrees nose down on a magnetic heading of 155 degrees with the landing gear extended and the flaps partially extended. A post-impact fire destroyed the airplane. Flight control continuity was established from the aft section of the cockpit to the rudder and elevator flight control surfaces. The elevator trim tab (located on the right elevator) was measured with a protractor and found to be in the 28 degrees tab-up position (aircraft nose down). According to the airplane manufacturer's specifications, the maximum tab-up travel limit (when connected) is 5 degrees. The trim tab would not move freely by hand forces and appeared to be jammed. The elevator skin was cut open (top side) to observe the trim tab connecting hardware. It was observed that the clevis end of the trim tab actuator rod was wedged against the front spar of the elevator's internal structure. Additionally, the bolt which connected the clevis end of the tab actuator rod to the actuator screw, was missing. After further inspection, neither the bolt nor the nut were found in the cavity of the elevator structure or the surrounding area. The clevis end of the actuator rod and the actuator screw were not damaged, and no impact damage was apparent on the trim tab. The operator's maintenance records showed that the right elevator had been replaced 10 flight hours prior to the accident.

Witnesses observed N262MM taxi to runway 29 left and the pilot perform what appeared to be a normal engine runup. The airplane then taxied onto runway 29 left for takeoff. The wind was from the east, making the takeoff with a tail wind. During the takeoff, the engine seemed to operate at a steady level, but appeared to be low on power. The flight lifted off about halfway down the runway and the landing gear was retracted. The airplane climbed slowly and turned slowly to the left. The airplane then entered a 60-80 degree left bank followed by the airplane rolling level and the wings rocking back and forth. The airplane was now on a southerly heading and the nose dropped. The airplane then collided with trees about 15-20 feet above the ground, fell to the ground, and burst into flames. Witnesses stated they saw no smoke or flames coming from the airplane prior to impact with the trees. At the time of the accident the landing gear was retracted and the engine was running. Transcripts of recorded communications show that at 1205:40, the local controller instructed the flight to taxi into position and hold on runway 29 left. At 1206:43, N262MM was cleared for takeoff and a north bound departure was approved. At 1208:03, the passenger transmitted "we need to land we have to turn around". The local controller cleared the flight to return to the airport when able. At 1208:20, the passenger transmitted "two mike mike we're going down we're going down", followed by "over the golf (unintelligible)". The local controller responded "copy over the golf course". No further transmissions were received from the flight. Analysis of background noise contained on the ATC recordings show that at the time the passenger on N262MM transmitted to controllers that they were ready for takeoff and when he acknowledged the takeoff clearance, the propeller was rotating at 1,261 and 1,255 respectively. When the passenger transmitted to controllers after takeoff, that they needed to land, the propeller was rotating at 1,980 rpm. When the passenger transmitted we have to turn around, shortly after the above transmission, the propeller was rotating at 2,017 rpm. When the passenger made his last transmission stating they were going down, the propeller rpm was 1,965. The maximum propeller speed at takeoff is 2,000 rpm. Additional evidence was found indicating electrical arcing and progressive fatigue cracking in the engine’s P3 line, which could result in a rapid rollback of engine power. Simulator testing showed that a P3 line failure would result in the engine decelerating from full takeoff power (2,000 propeller rpm) and stabilizing at an idle power setting in less than 9 seconds. However, the sound spectrum analysis of the first radio transmission indicated the propeller rpm was 1,980, and two subsequent radio transmissions, the last of which was made 17 seconds after the initial transmission, detected the propeller rpm at near takeoff speed. Thus, there was no evidence of dramatic rpm loss, making the P3 line failure an unlikely cause of the accident. Postcrash examination of the aircraft structure, flight controls, engine, and propeller, showed no evidence of failure or malfunction. Witnesses indicated the flight used about 3,650 feet of runway for takeoff or about half of the 7,296 foot long runway. Charts contained in the Piper PA-46-500TP, Pilot's Operating Handbook, indicated that for the conditions at the time of the accident, the airplane should have used about 2,000 feet of runway for the ground roll during the takeoff with no wing flaps extended. The charts also show that the airplane indicated stall speed at 60 degrees of bank angle with the landing gear and wing flaps retracted is 111 knots.

At 1623:41, the pilot requested taxi clearance. The Green Bay (GRB) tower (ATCT) told the pilot to taxi to runway 18. At 1626:47 the pilot said that he was ready for takeoff. The ATCT local controller (LC) told the pilot, "proceed on course, cleared for takeoff". At 1627:33, radar showed the airplane began to accelerate down runway 18. At 1628:17 the LC told the pilot to contact departure control. The pilot responded, "ah papa charlie we have a little problem here we're going to have to come back." The LC asked the pilot, "what approach would you like?" The pilot responded, "like to keep the vis." At 1628:35, the LC asked the pilot, "like the contact approach that what you're saying?" There was no response from the pilot. At 1628:50, GRB radar showed the airplane on a heading of 091 degrees, at an altitude of 855 feet msl (160 feet agl), and at an airspeed of 206 knots. The airplane was 1.28 miles southeast of the airport radar. Radar contact with the airplane was lost at 1628:55. A witness to the accident said, "It was snowing moderately at that time. The road was wet but not slippery. Crossing the intersection of Morning Glory Rd. & Main St., I noted a white private jet flying from the south. It was flying at approximately a 75-80 degree angle perpendicular to the ground with its left wing down & teetering slightly." The witness said, "It then crossed Main Street with the lower wing tip approximately 20 to 30 feet above the power wires. The plane became more perpendicular to the ground at a 90 degree angle with the left wing down & (and) lost altitude crashing into the Morning Glory Dairy warehouse building." An examination of the airplane revealed no anomalies. At 1638, GRB weather was reported as ceilings of 200 feet broken, 800 feet overcast, visibility 1/2 statute mile with snow and fog, temperature 32 degrees F, dew point 32 degrees F, winds 120 degrees at 3 knots, and an altimeter setting of 29.99 inches Hg. Witnesses at the FBO said the pilot arrived to pick up the airplane after 1600. The pilot was briefed by the mechanic as he did his walk around inspection of the airplane. The pilot then
got into the airplane. The airplane was towed out and the tow bar removed. About two minutes later, the engines started. Less than five minutes after the engines started, the airplane taxied. The NTSB Audio Laboratory reviewed radio communications between ATCT and the pilot to determine from the speech evidence the pilot's level of psychological stress and workload. The examination indicated the pilot's speech characteristics were consistent with an increased stress/workload that might accompany a developing emergency. Referring to the pilot's final transmissions, "His unusually long reaction time suggests that he was distracted by competing cockpit priorities and/or was having a difficult time determining his answer, while his fast speech and microphone keying provide further evidence of an urgency to return to other cockpit activities." The report states that the pilot's statements remained rational and showed good word choice and grammar. "These factors, along with the relatively small change in fundamental frequency, suggest that the pilot did not reach an extreme level of stress."

The pilot and 21 jumpers were aboard the airplane for the local skydiving flight. The airplane took off to the north on the wet grass runway. Jumpers reported that during the initial takeoff climb, the aircraft assumed a "very steep angle of attack," and described the pilot "winding the wheel on the lower right side of the chair clockwise, frantically," and "busy with a wheel between the seats." The airplane impacted trees and terrain approximately 250 yards east of the runway. The pilot reported that the "airplane flew through a dust devil" and did not have enough altitude for a complete recovery. The pilot stated the winds were northerly at 6 to 8 knots with "extreme" turbulence. The nearest weather observation facility reported clear skies with calm wind. Takeoff weight and center of gravity (CG) were calculated at 9,118.05 lbs and 161.92 inches. The AFM listed the maximum gross weight at 8,000 pounds and the aft CG limit at 152.2 inches. Further, an AFM WARNING stated: C. G. POSITION OF THE LOADED AIRCRAFT MUST BE CHECKED AND VERIFIED PRIOR TO TAKE-OFF, AND APPROPRIATE TRIM SETTINGS SHOULD BE USED; OTHERWISE ABNORMAL STICK FORCES AND POSITIONS MAY RESULT. The elevator trim wheel is located on the righthand side of the pilot's seat. Post-accident examination of the airplane revealed that there were 16 seatbelts in the cabin section and 2 seatbelts in the cockpit. Additionally, a placard installed in the cockpit stated, in part, THIS AIRPLANE IS LIMITED TO THE OPERATION OF NINE PASSENGERS OR LESS. Regarding the discrepancy between the placarded 9 passenger limit and the 21 jumpers aboard, the pilot stated that parachute jumpers are not considered to be passengers and therefore, he did not have to comply with the placarded limit.

Witnesses watching N900CE's approach for landing to runway 17 at Marco Island Executive Airport stated the pilot appeared to have difficulty aligning the Machen modified Aerostar with the runway centerline. They stated the aircraft appeared unstable about the yaw and roll axes, and appeared too fast. Winds were from the southwest at about 15 knots, gusting to about 20 knots. One pilot/witness close to the touchdown area saw the right wheel touch down instantly, and climb back up to about 50 feet, agl without the full addition of engine power. Most witnesses thought he was either performing a go-around or an extended touch down further down the runway. The airplane continued, "..more and more wobbly" until it entered a climbing attitude and sharp left bank and turn. About half way down the runway the left wing dropped until it contacted the terrain left of the runway, and the aircraft slid into mangrove trees and burned. During postcrash examination, flight control continuity from surface to cockpit floorboards was confirmed. No condition was found with either engine or propeller that would have precluded proper operation, precrash. A witness listening to the pilot's initial radio call up for approach and landing stated that no abnormality was reported by the pilot. Postmortem toxicology testing on specimens obtained from the pilot by the FAA Toxicology and Accident Research Laboratory and the Dade County Medical Examiner revealed quinine found in the blood and urine. The side effects of quinine can include disturbances of vision, hearing, and balance.

On March 29, 2001, about 1901:57 mountain standard time, a Gulfstream III, N303GA, owned by Airbourne Charter, Inc., and operated by Avjet Corporation of Burbank, California, crashed while on final approach to runway 15 at Aspen-Pitkin County Airport (ASE), Aspen, Colorado. The charter flight had departed Los Angeles International Airport (LAX) about 1711 with 2 pilots, 1 flight attendant, and 15 passengers. The airplane crashed into sloping terrain about 2,400 feet short of the runway threshold. All of the passengers and crew members were killed, and the airplane was destroyed. The flight was being operated on an instrument flight rules (IFR) flight plan under 14 Code of Federal Regulations (CFR) Part 135.