United States of America

The commercial pilot departed under special VFR conditions on a CFR part 135 flight for a remote lake. During the flight, low clouds, rain, and fog were present in an area of mountainous terrain along the route of flight. The pilot stated that he intended to utilize a narrow mountain pass to transit the area, and as he entered the mountain pass, discovered that the ceiling and visibility would not allow safe passage. He said that he made an emergency 180 degree turn in an attempt to exit the pass, and subsequently collided with terrain. After initial impact, the airplane slid downhill about 100 feet, and came to rest on a 35 degree slope. The pilot stated that weather conditions at the time of the accident consisted of: Ceiling, 500 foot overcast; visibility, 2 miles with rain and fog; wind 360 degrees, at 8 knots. The pilot noted that there were no pre accident anomalies with the airplane.

Shortly after takeoff, the No. 2 engine failed and shutdown procedures for the No. 2 engine were accomplished. The flight crew declared an emergency and requested to return to the airport. On approach, an engine out go-around was required as ATC had instructed the flight crew of a B-747 to "position and hold" on the end of the runway. The first officer was the pilot flying. Following an uneventful touchdown, as the airplane slowed to about 80 knots, the captain took control of the airplane. Shortly thereafter, the right main landing gear (MLG) collapsed and the airplane slid to a stop on the runway. Examination of the No. 2 engine revealed that 80 percent of the main fuel pump main drive shaft was worn to the spline root. The examination also revealed that the grease used to lubricate the main drive shaft output splines was not the authorized grease specified per OHM 73-11-1 or MIL-G-81322. Additionally, the magnetic seal compression O-ring that rides on the drive gear journal outer diameter was hardened and exhibited inner diameter axial cracks. The component manufacturer indicated that the failure of the magnetic seal was the first such reported incident in 30 years; however, it agreed to review operational data from airlines to reevaluate the mean time between overhaul intervals for the seal and to recommend an inspection interval, as necessary. Examination of the right MLG revealed a fracture failure of the trunnion bearing support fitting that was caused by fatigue cracking and stress corrosion cracking.

The airplane was dispatched as a cargo flight to pick up a load of 118 boxes of automotive seatbelts. After refueling and loading the cargo on board, the flight crew taxied to runway 22 for a no-flap takeoff, which called for a V1 speed of 141 knots. The first officer was the flying pilot for this leg of the flight. The crew reported that the initial takeoff roll from the 11,009 foot runway was normal. At approximately 120 knots, the flight crew reported hearing a loud bang followed by a vibration. The captain called for the first officer to abort the takeoff. The captain later stated that he believed he saw the #2 engine "roll back." The flight crew reported that the brakes were not effective in slowing the airplane. A witness stated that the airplane was going west on the runway at a high rate of speed when it "went up to two feet, then came back down." Another witness stated that he saw the airplane "exit off the end of the runway" and after about "seventy-five to one hundred feet, the front wheels lifted off the ground about ten feet." The airplane overran the departure end of the runway, went through the airport's chain link perimeter fence, across a 4-lane highway, collided with 3 vehicles on the roadway, and went through a second chain link fence, before coming to rest. The airplane came to rest on its belly, 2,010 feet from the departure threshold of runway 22. The investigation revealed that the flight crew was provided an inaccurate weight for the cargo, and the airplane was found to be 942 pounds over the maximum takeoff weight at the time of the accident. The density altitude was calculated to be 5,614 feet at the time of the accident. Both crewmembers were current and properly certified; however, the captain had upgraded to his present position two months prior to the accident, and the first officer had accumulated a total of 123.8 hours in the Falcon 20 at the time of the accident. Both engines were operated in a test cell and performed within limits. About 90% of the right outboard main landing gear tire's retread was found on the runway approximately 7,200 feet from where the aircraft had commenced its takeoff roll. The operator stated that since the aircraft was over maximum gross weight, the long taxi to the runway could have resulted in the brakes and tires heating more than normal.

The pilot had filed an instrument flight rules (IFR) flight plan for 25,000 feet mean sea level (MSL), and he amended it to 27,000 feet MSL en route. About 36 minutes after the altitude change to 27,000 feet, the pilot advised air traffic control (ATC) that he had lost cabin pressurization and needed an immediate descent. About 20 seconds later he was cleared to 25,000 feet, then 15 seconds later to 15,000 feet. Shortly after the pilot acknowledged the lower altitudes, the radio communications deteriorated to microphone clicks with no carrier. The aircraft started a shallow descent with slight heading changes, then was observed to make a rapid descent into desert terrain. About 10 months prior to the accident the aircraft had been inspected in accordance with the Piper Cheyenne Progressive Inspection 100-hour Cycle, event No. 1. According to the servicing agency, the aircraft inspection was completed and the aircraft was returned to service with a 12,500 feet MSL altitude restriction due to unresolved oxygen system issues. The last oxygen bottle hydrostatic check noted on the bottle was October 1989. The oxygen system was in need of required maintenance and the masks were in a rotted condition. The pilot failed to report his severe coronary artery disease condition, medications, and other conditions to his FAA medical examiner for the required flight physical.

Upon reaching an altitude of 400 agl after takeoff, the left side door on the nose baggage door opened. The pilot-in- command initiated a left turn to return to the airport. During the turn the stall horn sounded. The airplane then descended and impacted the terrain. Investigation revealed that both pilots did a portion of the aircraft preflight inspection. Both pilots were qualified to act as PIC for the flight and this flight would typically have been a single pilot operation. However, the company who hired the operator to transport their employees requested two pilots. The operator did not have any written procedures regarding the division of duties for a two pilot operation on this type of aircraft.

Witnesses observed the flight enter downwind for runway 30, after it had completed a published approach to runway 12, with a circle to land on runway 30. The witnesses, one of which was a commercial pilot said that there were jagged ceilings at the time about 400 to 500 feet above the ground. He and two other men with him saw the airplane below the clouds. As the airplane proceeded downwind, it momentarily entered a cloud. As the airplane came out of the cloud, it turned left in about a 30 degree turn. The angle of bank increased to about 70 to 80 degrees, the tail of the airplane came up, and the airplane impacted the ground nose first. Several pilots at the airport heard someone from N69BS make a radio transmission on the UNICOM frequency. What was heard by several people was that N69BS had broken out at 2200 feet. They then heard, 'N69BS turning base,' immediately followed by 'lookout' and 'oh ....' All of the eye witnesses agreed that at no time did they see or hear any problems with the engine. They all said that the sounds coming from the engine never changed. The published approach in use at the time of the accident was the GPS (global positioning system) runway 12. The pilot made his initial approach to runway 12, broke off the approach to the right, entered a right downwind for a landing on runway 30. The published circling minimums for the approach were MDA (minimum descent altitude) 4,800 feet, HAT (height above terrain) 869 feet. Using an approach speed of 90 knots, the minimum visibility was 1 mile. Using an approach speed of 120 knots, the minimum visibility was 1 1/4 miles. The field elevation was 3,931 feet. The profile for the GPS runway 12 approach showed that after the IAF (Jesee way point), the course was 204 degrees, at 7,000 feet, to the Dezzi way point, from Dezzi the course was 114 degrees, descend to 5,600, to Sophi way point, after Sophi descend to 4,800 feet to the missed approach point at the Ruste way point. The distance from Dezzi to Ruste was 10 miles.

The pilot reported the airplane decelerated during the takeoff roll. He applied the brakes and as he advanced the throttles to full power the airplane accelerated. The airplane cleared the end of the runway then stalled into Lake Michigan, flipped inverted and sank. One passenger reported that it felt as if someone put on the brakes. One passenger drowned. The pilot used 32' of manifold pressure for takeoff versus 37.3' as placarded. The pilot operating handbook lists normal takeoff speed as 91 KIAS, however the airplane was equipped with vortex generators. The pilot reported looking for 105 to 110 KIAS for takeoff. No evidence was found of the pilot having a multi-engine rating. No evidence of a mechanical failure/malfunction was found.

The captain said the airplane felt 'sluggish' during the takeoff roll. At V1/Vr, the airplane was rotated for liftoff. It climbed 10 feet, 'shuddered,' and sank. The captain elected to abort the takeoff. He landed the airplane on the runway, applied brakes and deployed the drag chute. The drag chute separated and the airplane went off the runway, down a hill, through a fence, across a road and grassy area, across another road, through a chain link fence, and collided with a power pole. The captain said they had calculated the takeoff performance using inappropriate tables, and failed to consider the wet runway and wind shift. The drag chute riser fractured at a point where it passed through a lightning hole. The lightning hole bore no evidence of a nylon grommet having been installed.

The pilot dropped off a passenger at Newton Airport before continuing the flight. The passenger, who was a contract pilot for the company, reported there had been no indications of any problem with the airplane. The pilot conducted a low pass followed by a steep climb to 10,000 feet when he departed Newton. Seven minutes later in the flight, the cockpit voice recorder revealed the pilot stating, 'You're going to pitch up now and take it all the way around here.' The pilot said, 'Pitch up, twenty degrees up.' After the pilot called for the nose to be pitched up, he did not make any statements for about 27 seconds. Then the pilot stated, 'Oh, Jim.' Eight seconds later the airplane impacted the ground. Radar data indicated that airplane's altitude about the time the nose was pitched up was 15,900 feet msl, and it impacted the ground about 37 seconds later. All flight control surfaces were found at the impact site. No maneuver in the pilot's manual or the FAA's Commercial test guide required the nose to be pitched up 20 degrees while maintaining 250 knots. The aircraft was certified as a Transport Category aircraft and was not certified for aerobatic flight.

An aircraft mechanic working abeam of the point on the runway that the airplane lifted off was attracted by the sound of engine roughness, and observed black smoke trailing from the left engine. The airplane continued to climb to about 150 feet above ground level, entered a series of shallow left turns at about the airport's east boundary at a slow speed, and then entered a rapid left roll and pitched down. The pilot transmitted an unreadable call on FAA tower frequency, but the words, 'we got a..' and 'engine' were clearly discernable. The airplane crashed in dense brush about 1.25 miles northeast of the airport. Contamination was found in the left engine fuel system. Post crash testing of the left fuel servo revealed it would not sustain a steady state fuel flow above about one half throttle due to contamination.