Crash of a Pilatus PC-12/47E in Ubatuba

Date & Time: May 1, 2018 at 1743 LT
Type of aircraft:
Pilatus PC-12
Operator:
Registration:
PR-WBV
Flight Phase:
Landing (descent or approach)
Flight Type:
Private
Survivors:
Yes
Site:
Airport (less than 10 km from airport)
Schedule:
Angra dos Reis – Campo de Marte
MSN:
1129
YOM:
2009
Location:
Ubatuba
São Paulo
Country:
Brazil
Region:
South America
Crew on board:
2
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
4500
Captain / Total hours on type:
126.00
Copilot / Total flying hours:
3200
Copilot / Total hours on type:
120
Aircraft flight hours:
1361
Circumstances:
At the beginning of the descent to Campo de Marte Airport while on a flight from Angra dos Reis, the crew reported engine problems and diverted to Ubatuba Airport. After touchdown on runway 09 which is 940 metres long, a maneuver was performed aiming at exchanging speed for altitude, causing the airplane to veer off runway and to crash in a swampy area located in the left hand side of the overshoot area. The airplane struck several trees, lost its both wings and empennage and was destroyed. Both crew members and two passengers were injured while six other passengers escaped unhurt.
Probable cause:
At the beginning of the descent to Campo de Marte Airport, a failure occurred in the aircraft's propeller pitch control system, which tended to feather the engine.
The following findings were identified:
a) the pilots held valid Aeronautical Medical Certificates (CMA);
b) the PIC held valid Single-Engine Land Airplane (MNTE) and Airplane IFR Flight (IFRA) ratings;
c) the SIC held valid Single-Engine Land-Airplane (MNTE) and Multi-Engine LandAirplane (MLTE) ratings;
d) the pilots had qualification and experience in the type of flight;
e) the aircraft had a valid Airworthiness Certificate (CA);
f) the aircraft was within the prescribed weight and balance limits;
g) the records of the airframe, engine, and propeller logbooks were up to date;
h) the meteorological conditions were compatible with the conduction of the flight;
i) on 02Oct2017, a modification was made in the approved type-aircraft project;
j) on 06Mar2018, the engine of the aircraft was replaced with a rental engine, on account of damage caused by FOD;
k) the aircraft returned to the maintenance organization responsible for the engine replacement, due to recurrent episodes of Engine NP Warning Light illumination;
l) the maintenance organization inspected the powerplant, washed the compressor, and performed a pre-flight, after which the aircraft returned to operation;
m) the aircraft took off from SDAG, bound for SBMT;
n) between engine start-up and takeoff from SDAG, there were two drops of the propeller rotation (NP) to values below 950 RPM;
o) after taking off from SDAG, the aircraft climbed to, and maintained, FL145;
p) moments after the aircraft started descent, and upon reduction of the PCL, the propeller rotation began to drop quickly and continuously;
q) the adoption of the procedures prescribed for the situation “ENGINE NP - In flight, If propeller is below 1640” had no effect;
r) the NP dropped to a minimum value of 266 RPM;
s) the crew decision was to land in SDUB;
t) after the touchdown, a maneuver was performed aiming at exchanging speed for altitude, and deviation of the aircraft to a swampy area located in the left-hand side of the overshoot area;
u) in the functional tests of the engine performed after the occurrence, one verified normal operating conditions and full response to control demands;
v) upon examination of the propeller, and measurement of the beta ring distance, one verified that the ring displacement was outside the limits specified by the manufacturer;
w) it was not possible to identify whether such discrepancy had resulted from a maintenance procedure or from the impact during the emergency landing;
x) analysis of the propeller-governor revealed that the internal components were in operating condition;
y) the aircraft sustained substantial damage, and
z) the PIC suffered serious injuries, the SIC and two of the passengers were slightly injured, while the other six passengers were not hurt.

Contributing factors:
- Training – undetermined.
Even though the PIC had undergone simulator training less than a year before the occurrence, his difficulty perceiving the characteristics of the emergency experienced in order to frame it in accordance with his simulated practice suggests deficiencies in the processes related to qualification and training. The SIC, in turn, was not required to undergo that type of training, since the occurrence airplane had a Class-aircraft classification bestowed by the regulatory agency. The training and qualification process available to him in face of the circumstances may have contributed
to his lack of ability to recognize and participate in the management of the failure with due proficiency, when one also considers the selection of procedures and his assisting role in relation to the speeds and configuration of the aircraft.

- Instruction – a contributor.
As for the SIC, considering the fact that the aircraft classification did not require simulator sessions or other types of specific training, it was possible to note that he was not sufficiently familiar with emergencies and abnormal situations, something that prevented him from giving a better contribution to the management of the situation.

- Piloting judgment – a contributor.
There was inadequate assessment of the flight parameters on the final approach, something that made the landing in SDUB unfeasible, when one considers the 940 meters of available runway.

- Aircraft maintenance – undetermined.
During the measurement of the distance of the beta ring performed in the analysis of the propeller components, one verified that the displacement of the ring was outside the limits specified by the manufacturer. It was not possible to identify whether such displacement was due to a maintenance action or the result of a ring-assembly event at the time of propeller replacement. However, such discrepancy may have resulted from the impact of the propeller blades during the emergency landing. Furthermore, the aircraft was subject to inspection of the failure related to the ENGINE
NP warning light illumination prior to the accident. Given the fact that such illumination was intermittent, and the investigation could not identify the reasons for the warning, the aircraft was released for return to flight without in-depth investigation as to the root cause and possible implications of a failure related to the inadvertent drop in RPM.

- Memory – undetermined.
Although the PIC had undergone training in a class D aircraft-simulator certified by the manufacturer, it was not possible to verify the necessary association between the trained procedures and his performance in joining the traffic pattern and landing with a powerless aircraft in emergency. Furthermore, since the PIC frequently landed in the location selected for the emergency landing attempt, it is likely that he sought to match such emergency approach with those normally performed, in which he could count both on the “aerodynamic brake” condition with the propeller at IDLE and on the use of the reverse.

- Perception – a contributor / undetermined.
There was not adequate recognition, organization and understanding of the stimuli related to the condition of propeller feathering, which led to a lowering of the crew’s situational awareness.
Such reduction of the situational awareness made it difficult to assess the conditions under which the emergency could be managed, as the crew settled on the idea of landing in SDUB, without observing the condition of the airfield, meteorology, distance necessary for landing without control the engine, best glide speed, approach, and aircraft configuration.

- Decision-making process – a contributor / undetermined.
Since the first decisions made for identification of the emergency condition, it was not possible to verify the existence of a well-structured decision-making process contemplating appropriate assessment of the scenario and available alternatives. Objective aspects related to the SDUB runway, such as runway length and obstacles, the actual condition of the aircraft at that time, or contingencies, were not considered.

- Support systems – a contributor.
The Aircraft Manual and the QRH did not clearly contemplate the possibility of propeller feathering in flight, making it difficult for the pilots to identify the abnormal condition, and making it impossible for them to adopt appropriate and sufficient procedures for the correct management of the emergency. Considering the possibility that the application of the “ENGINE NP - In Flight”
emergency procedure prescribed by the QRH would not achieve the desired effect, there were no further instructions as to the next actions to be taken, leaving to the crew a possible
interpretation and selection of another procedure of the same publication.

- Managerial oversight – undetermined.
As for the maintenance workshop responsible for the tasks of engine replacement, together with adjustment of the propeller and its components: in the inspection at the request of the pilots after an event of ENGINE NP warning light illumination, the maintenance staff released the aircraft for return to operation. The investigation committee raised the possibility that the supervision of the services performed, by allowing the release of the aircraft, was not sufficient to guarantee mitigation of the risks related to the aircraft operation with the possibility of an intermittent recurrence of the failure.
Final Report:

Crash of a Cessna 402B in Tanner-Hiller

Date & Time: Apr 26, 2018 at 1715 LT
Type of aircraft:
Cessna 402
Operator:
AC Research Inc.
Registration:
N87266
Flight Phase:
Landing (descent or approach)
Flight Type:
Private
Survivors:
Yes
Site:
Airport (less than 10 km from airport)
Schedule:
Keene - Tanner-Hiller
MSN:
402B-1097
YOM:
1976
Location:
Tanner-Hiller
Massachusetts
Country:
United States of America
Region:
North America
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
330
Aircraft flight hours:
9193
Circumstances:
The private pilot was conducting a local, personal flight. The pilot reported that he checked the weather conditions at three local airports before the flight but stated that he did not trust the wind reports. He added that he did not get a preflight weather briefing. Once at the destination airport, he conducted two go-arounds due to gusting wind conditions. During the third attempted landing, he made a steep approach at a normal approach speed and flared the airplane about midway down the 3,000-ft-long runway. The airplane floated down the runway for much longer than the pilot expected before touching down. Despite applying maximum braking, there was insufficient remaining runway to stop, and the airplane skidded off the runway, impacted trees, and subsequently caught fire, which resulted in substantial damage to the airframe. The wind conditions reported at an airport located about 13 miles away included a tailwind of 16 knots, gusting to 27 knots. Given the tailwind conditions reported at this airport and the pilot's description of the approach and landing, it is likely that the pilot conducted the approach to the runway in a tailwind that significantly increased the airplane's groundspeed, which resulted in a touchdown with insufficient runway remaining to stop the airplane, even with maximum braking.
Probable cause:
The pilot's improper decision to land with a tailwind, which resulted in a touchdown with insufficient runway remaining to stop the airplane.
Final Report:

Crash of a Cessna 525 CJ1 in Crozet: 1 killed

Date & Time: Apr 15, 2018 at 2054 LT
Type of aircraft:
Cessna 525 CitationJet CJ1
Operator:
Augusta Aviation LLC
Registration:
N525P
Flight Phase:
Flight
Flight Type:
Private
Survivors:
No
Site:
Plain, Valley
Schedule:
Rchmond - Weyers Cave
MSN:
525-0165
YOM:
1996
Location:
Crozet
Virginia
Country:
United States of America
Region:
North America
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
737
Captain / Total hours on type:
165.00
Aircraft flight hours:
3311
Circumstances:
The instrument rated private pilot was drinking alcohol before he arrived at the airport. Before the flight, he did not obtain a weather briefing or file an instrument flight rules flight plan for the flight that was conducted in instrument meteorological conditions. The pilot performed a 3-minute preflight inspection of the airplane and departed with a tailwind (even though he had initially taxied the airplane to the runway that favored the wind) and without communicating on the airport Unicom frequency. After departure, the airplane climbed to a maximum altitude of 11,500 feet mean sea level (msl), and then the airplane descended to 4,300 ft msl (which was 1,400 ft below the minimum safe altitude for the destination airport) and remained at that altitude for 9 minutes. Afterward, the airplane began a descending left turn, and radar contact was lost at 2054. The pilot did not talk to air traffic control during the flight and while operating in night instrument meteorological conditions. During the flight, the airplane flew through a line of severe thunderstorms with heavy rain, tornados, hail, and multiple lightning strikes. Before the airplane's descending left turn began, it encountered moderate-to-heavy rain. The airplane's high descent rate of at least 6,000 ft per minute and impact with a mountain that was about 450 ft from the last radar return, the damage to the airplane, and the distribution of the wreckage were consistent with a loss of control and a high-velocity impact. Examination of the airplane revealed no evidence of any preimpact mechanical anomalies. Based on the reported weather conditions at the time the flight, the pilot likely completed the entire flight in night instrument meteorological conditions. His decision to operate at night in an area with widespread thunderstorms and reduced visibility were conducive to the development of spatial disorientation. The airplane's descending left turn and its high-energy impact were consistent with the known effects of spatial disorientation. The pilot was not aware of the conditions near and at the destination airport because he failed to obtain a weather briefing and was not communicating with air traffic control. Also, the pilot's decision to operate an airplane within 8 hours of consuming alcohol was inconsistent with the Federal Aviation Administration's regulation prohibiting such operations, and the level of ethanol in the pilot's toxicology exceeded the level allowed by the regulation. Overall, the pilot's intoxication, combined with the impairing effects of cetirizine, affected his judgment; contributed to his unsafe decision-making; and increased his susceptibility to spatial disorientation, which resulted in the loss of control of the airplane.
Probable cause:
The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The pilot's loss of control while operating in night instrument meteorological conditions as a result of spatial disorientation. Contributing to the accident was the pilot's decision to operate
an airplane after consuming alcohol and his resulting intoxication, which degraded the pilot's judgment and decision-making.
Final Report:

Crash of a Cessna 401 in Pelagiada

Date & Time: Apr 1, 2018 at 1415 LT
Type of aircraft:
Cessna 401
Operator:
Registration:
RA-1272G
Flight Phase:
Flight
Flight Type:
Private
Survivors:
Yes
Site:
Plain, Valley
Schedule:
Pelagiada - Pelagiada
MSN:
401-0112
YOM:
1968
Location:
Pelagiada
Stavropol Krai
Country:
Russia
Region:
Asia
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
5672
Captain / Total hours on type:
150.00
Aircraft flight hours:
5100
Circumstances:
Few minutes after takeoff from Pelagiada, the pilot informed ATC about the failure of the right engine while the left engine lost power. The pilot completed an emergency belly landing in an open field located near Pelagiada, about 20 km north of Stavropol. The aircraft was damaged beyond repair and the pilot escaped uninjured.
Probable cause:
The failure of the right engine is most likely due to an interruption in the fuel supply due to the presence of dirt in the fuel filter. The left engine lost power presumably due to wear on the cylinders and pistons that had exceeded their life limit. A lack of an effective check of the fuel filters and the life of the various components of the left engines remains contributing factors.
Final Report:

Crash of a Piper PA-31P Pressurized Navajo in Laredo: 2 killed

Date & Time: Mar 8, 2018 at 1038 LT
Type of aircraft:
Piper PA-31-310 Navajo
Operator:
Robert R. Marshall
Registration:
N82605
Flight Phase:
Takeoff (climb)
Flight Type:
Private
Survivors:
No
Site:
Airport (less than 10 km from airport)
Schedule:
Laredo - Laredo
MSN:
31P-7730010
YOM:
1977
Location:
Laredo
Texas
Country:
United States of America
Region:
North America
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
4243
Copilot / Total flying hours:
194
Aircraft flight hours:
3185
Circumstances:
The commercial pilot and passenger, who held a student certificate, departed runway 18R for a local flight in a multi-engine airplane. The pilot held a flight instructor certificate for single-engine airplane. Just after takeoff, the tower controller reported to the pilot that smoke was coming from the left side of the airplane. The pilot acknowledged, stating that they were going to "fix it," and then entered a left downwind for runway 18R, adding that they didn't need any assistance. The controller subsequently cleared the airplane to land on runway 18L, which the pilot acknowledged. Two witnesses reported seeing the smoke come from the left engine. Still images taken from airport security video show the airplane before making the turn to land with white smoke trailing and the landing gear down. The airplane was then seen in a steep left turn to final approach exceeding 90° of bank, before it impacted terrain, just short of the runway in a near vertical attitude. A postcrash fire ensued. The examination of the wreckage found that the left engine's propeller was not being driven by the engine at the time of impact. The left propeller was not in the feathered position and the landing gear was found extended. The damage to the right engine propeller blades was consistent with the engine operating at high power at impact. The examination of the airframe and engines revealed no evidence of preimpact anomalies; however, the examinations were limited by impact and fire damage which precluded examination of the hoses and lines associated with the engines. The white smoke observed from the left side of the airplane was likely the result of an oil leak which allowed oil to reach the hot exterior surfaces of the engine; however, this could not be verified due to damage to the engine. There was no evidence of oil starvation for either engine. Both the extended landing gear and non-feathered left propeller would have increased the drag on the airplane. Because the pilot's operating procedures for an engine failure in a climb call for feathering the affected engine and raising the landing gear until certain of making the field, it is unlikely the pilot followed the applicable checklists in response to the situation. Further, the change from landing on runway 18R to 18L also reduced the radius of the turn and increased the required angle of bank. The increased left banked turn, the right engine operating at a high-power setting, and the airplane's increased drag likely decreased the airplane airspeed below the airplane's minimum controllable airspeed (Vmc), which resulted in a loss of control.
Probable cause:
An engine malfunction for undetermined reasons and the subsequent loss of control, due to the pilot's improper decision to maneuver the airplane below minimum controllable airspeed and his improper response to the loss of engine power.
Final Report:

Crash of a Beechcraft B60 Duke near Ferris

Date & Time: Mar 1, 2018 at 1100 LT
Type of aircraft:
Beechcraft 60 Duke
Operator:
Mike & Mayo Partners
Registration:
N77MM
Flight Phase:
Flight
Flight Type:
Private
Survivors:
Yes
Site:
Plain, Valley
Schedule:
Addison – Mexia
MSN:
P-587
YOM:
1982
Location:
Ferris
Texas
Country:
United States of America
Region:
North America
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
6400
Captain / Total hours on type:
2200.00
Aircraft flight hours:
2210
Circumstances:
The pilot in the multi-engine, retractable landing gear airplane reported that, during an instrument flight rules cross-country flight, about 5,000 ft above mean sea level, the left engine surged several times and he performed an emergency engine shutdown. Shortly afterward, the right engine lost power. During the emergency descent, the airplane struck treetops, and landed hard in a field with the landing gear retracted. The airplane sustained substantial damage to both wings, the engine mounts, and the lower fuselage. The pilot reported that he had requested 200 gallons of fuel from his home airport fixed base operator, but they did not fuel the airplane. The pilot did not check the fuel quantity during his preflight inspection. According to the Federal Aviation Administration Airplane Flying Handbook, Chapter 2, page 2-7, pilots must always positively confirm the fuel quantity by visually inspecting the fuel level in each tank. The pilot reported that there were no mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause:
The pilot's improper preflight inspection of the fuel level, which resulted in a loss of engine power due to fuel exhaustion. Contributing to the accident was the pilot's failure to lower the landing gear before the emergency landing.
Final Report:

Crash of a Quest Kodiak 100 off Georgetown: 2 killed

Date & Time: Feb 27, 2018 at 1925 LT
Type of aircraft:
Quest Kodiak 100
Operator:
Pegasus of Montana
Registration:
N969TB
Flight Phase:
Landing (descent or approach)
Flight Type:
Private
Survivors:
No
Site:
Lake, Sea, Ocean, River
Schedule:
Welaka - Welaka
MSN:
100-0173
YOM:
2016
Location:
Georgetown
Florida
Country:
United States of America
Region:
North America
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
3400
Aircraft flight hours:
68
Circumstances:
The private pilot and pilot-rated passenger were returning to the airport in night visual meteorological conditions with a cloud ceiling about 1,500 ft above ground level. Radar data indicated that the airplane overflew the airport and completed a 360° descending right turn and overflew the airport again before entering an approximate 180° left climbing turn toward and over an unlighted area within a denselywooded national forest. The airplane continued the left turn and entered a descent to impact in a river about 1 mile from the airport. All major components of the airplane were recovered from the river except the outboard section of the left wing and the left aileron. An examination of the airframe and engine revealed no mechanical malfunctions or failures that would have precluded normal operation. Because each of the two pilots onboard would have been capable of safely landing the airplane, it is unlikely that an acute event from either occupant's heart disease contributed to the accident. The night conditions, which included overcast clouds that would have obscured the nearly full moon, and the pilots' maneuvering for landing over an area devoid of cultural lighting provided conditions conducive to the development of spatial disorientation. It is likely that the pilots experienced a "black hole" illusion while maneuvering to align with the runway for landing, which resulted in an uncontrolled descent and impact with water.
Probable cause:
The pilots' spatial disorientation while maneuvering for landing in night conditions over unlighted terrain, which resulted in an uncontrolled descent and impact with water.
Final Report:

Crash of a Cessna 441 Conquest II in Rossville: 3 killed

Date & Time: Feb 22, 2018 at 1939 LT
Type of aircraft:
Cessna 441 Conquest
Operator:
Registration:
N771XW
Flight Phase:
Flight
Flight Type:
Private
Survivors:
No
Site:
Plain, Valley
Schedule:
Eagle Creek Airpark - Green Bay
MSN:
441-0065
YOM:
1978
Location:
Rossville
Indiana
Country:
United States of America
Region:
North America
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
2248
Captain / Total hours on type:
454.00
Aircraft flight hours:
6907
Circumstances:
The airline transport pilot and two passengers departed in the twin-engine, pressurized airplane on a business flight in night instrument meteorological conditions. Shortly after takeoff, the airplane began to deviate from its assigned altitude and course. The controller queried the pilot, who responded that the airplane was "… a little out of control." After regaining control of the airplane, the pilot reported that he had experienced a "trim issue." The airplane continued on course and, about 13 minutes later, the pilot again reported a trim malfunction and said that he was having difficulty controlling the airplane. The flight's heading and altitude began to deviate from the course for the last 8 minutes of radar data and became more erratic for the last 2 minutes of radar data; radar and radio communication were subsequently lost at an altitude of about 18,300 ft in the vicinity of the accident site. Several witnesses reported hearing the airplane flying overhead. They all described the airplane as being very loud and that the engine sound was continuous up until they heard the impact. The airplane impacted a field in a relatively level attitude at high speed. The wreckage was significantly fragmented and the wreckage path extended about 1/4 mile over several fields. Examination of the available airframe and engine components revealed no anomalies that would have precluded normal operation of the airplane. The accident airplane was equipped with elevator, rudder, and aileron trim systems; however, not all components of the trim system and avionics were located or in a condition allowing examination. Although the airplane was equipped with an electric elevator trim and autopilot that could both be turned off in an emergency, the investigation could not determine which trim system the pilot was reportedly experiencing difficulties with. It is likely that the pilot was unable to maintain control of the airplane as he attempted to address the trim issues that he reported to air traffic control.
Probable cause:
An in-flight loss of control for reasons that could not be determined based on the available evidence.
Final Report:

Crash of a Socata TBM-700 in Evanston: 2 killed

Date & Time: Feb 18, 2018 at 1505 LT
Type of aircraft:
Socata TBM-700
Operator:
William E. Patterson
Registration:
N700VX
Flight Phase:
Landing (descent or approach)
Flight Type:
Private
Survivors:
No
Site:
Airport (less than 10 km from airport)
Schedule:
Tulsa – Evanston
MSN:
118
YOM:
1997
Location:
Evanston-Uinta County
Wyoming
Country:
United States of America
Region:
North America
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
4154
Captain / Total hours on type:
100.00
Aircraft flight hours:
3966
Circumstances:
The commercial pilot was conducting an instrument approach following a 3.5-hour cross-country instrument flight rules (IFR) flight in a single-engine turboprop airplane. About 1.6 miles from the runway threshold, the airplane began a climb consistent with the published missed approach procedure; however, rather than completing the slight left climbing turn toward the designated holding point, the airplane continued in an approximate 270° left turn, during which the airplane's altitude varied, before entering a descending right turn and impacting terrain. Tree and ground impact signatures were consistent with a 60° nose-low attitude at the time of impact. No distress calls were received or recorded from the accident flight. A postimpact fire consumed a majority of the cockpit and fuselage. Weather information for the time of the accident revealed that the pilot was operating in IFR to low IFR conditions with gusting surface winds, light to heavy snow, mist, cloud ceilings between 700 and 1,400 ft above ground level with clouds extending through 18,500 ft, and the potential for low-level wind shear and clear air turbulence. The area of the accident site was under AIRMETs for IFR conditions, mountain obscuration, moderate icing below 20,000 ft, and moderate turbulence below 18,000 ft. In addition, a winter storm warning was issued about 6 hours before the flight departed. Although the pilot received a weather briefing about 17 hours before the accident, there was no indication that he obtained updated weather information before departure or during the accident flight. Examination of the airframe and engine did not reveal any preimpact anomalies that would have precluded normal operation; however, the extent of the fire damage precluded examination of the avionics system. The airplane was equipped with standby flight instruments. An acquaintance of the pilot reported that the pilot had experienced an avionics malfunction several months before the accident during which the airplane's flight display went blank while flying an instrument approach. During that occurrence, the pilot used ForeFlight on his iPad to maneuver back to the northeast and fly the approach again using his own navigation. During the accident flight, the airplane appeared to go missed approach, but rather than fly the published missed approach procedure, the airplane also turned left towards to northeast. However, it could not be determined if the pilot's actions were an attempt to fly the approach using his own navigation or if he was experiencing spatial disorientation. The restricted visibility and turbulence present at the time of the accident provided conditions conducive to the development of spatial disorientation. Additionally, the airplane's turning flight track and steep descent profile are consistent with the known effects of spatial disorientation.
Probable cause:
The pilot's loss of control due to spatial disorientation.
Final Report:

Crash of a Cessna 340 in Bartow: 5 killed

Date & Time: Dec 24, 2017 at 0717 LT
Type of aircraft:
Cessna 340
Operator:
Aviation Transportation
Registration:
N247AT
Flight Phase:
Takeoff (climb)
Flight Type:
Private
Survivors:
No
Site:
Airport (less than 10 km from airport)
Schedule:
Bartow – Key West
MSN:
340-0214
YOM:
1973
Location:
Bartow
Florida
Country:
United States of America
Region:
North America
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
1600
Aircraft flight hours:
1607
Circumstances:
The instrument-rated private pilot and four passengers boarded the multiengine airplane inside a hangar. The pilot then requested that the airplane be towed from the hangar to the ramp, since he did not want to hit anything on the ramp while taxiing in the dense fog. Witnesses heard the pre-takeoff engine run-up toward the end of the runway but could not see the airplane as it departed; the engines sounded normal during the run-up and takeoff. A witness video recorded the takeoff but the airplane was not visible due to the dense fog. During the takeoff roll the airplane's tires chirped, which is consistent with the wheels touching down on the runway with a side load. The video ended before the accident occurred. The witnesses stated that the takeoff continued and then they heard the airplane impact the ground and saw an explosion. The weather conditions at the time of the accident included visibility less than 1/4 mile in fog and an overcast ceiling at 300 ft above ground level. The airplane's weight at the time of the accident was about 105 lbs over the maximum takeoff weight, which exceeded the center of gravity moment envelope. The excess weight would have likely extended the takeoff roll, decreased the climb rate, and increased the amount of elevator pressure required to lift off of the runway. A majority of the airplane was consumed by postcrash fire. The ground impact marks and wreckage distribution were consistent with the airplane rolling left over the departure end of the runway and impacting the ground inverted in a nearly vertical, nose-low attitude. Examination of the engines revealed operating signatures consistent with takeoff power at the time of impact. The elevator trim tab and actuator were found beyond their full up travel limits and the trim cable exhibited tension overload separations near the actuator. It is likely that, when the cable separated in overload, the chain turned the sprocket and extended the actuator rod beyond full travel. No anomalies were observed with the airframe, engines, or cockpit instrumentation that would have precluded normal operation. The investigation was unable to determine the status of the autopilot during the accident takeoff. Based on the evidence it's likely that when the airplane entered instrument meteorological conditions the pilot experienced spatial disorientation, which resulted in a loss of control and descent into terrain.
Probable cause:
The pilot's loss of control due to spatial disorientation during takeoff in instrument meteorological conditions.
Final Report:
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