Private

Before departing on the flight, the pilot of the turbo-propeller-equipped, single-engine airplane and student pilot-rated passenger seated in the right front seat of the airplane attempted to enter a flight plan into the airplane’s integrated flight management system. They ultimately did not complete this task prior to takeoff with the pilot remarking, “we’ll get to it later.” The pilot subsequently departed and climbed into instrument meteorological conditions (IMC) without an instrument flight rules (IFR) flight plan. After entering IMC, he contacted air traffic control and asked for visual flight rules (VFR) flight following services and an IFR clearance to the destination airport. From shortly after when the airplane leveled after takeoff through the final seconds of the flight, the pilot attempted to program, delete, reprogram, and activate a flight plan into the airplane’s flight management system as evidenced by his comments recorded on the airplane’s cockpit voice recorder (CVR). After departing, the pilot also attempted to navigate around restricted airspace that the airplane had flown into. The CVR audio showed that during the final 10 minutes of the flight, the pilot was unsure of the spelling of the fix he should have been navigating to in order to begin the instrument approach at the destination airport, and more generally expressed frustration and confusion while attempting to program the integrated flight management system. As the pilot continued to fixate on programming the airplane’s flight management system and change the altimeter setting, the airplane’s pitch attitude increased to 10° nose up, while the airspeed had decayed to 109 knots. As a result of his inattention to this airspeed decay, the stall warning system activated and the autopilot disconnected. During this time the airplane began climbing and turning to the right and then to the left before entering a steep descending right turn that continued until the airplane impacted the ocean. For the final 2 and 1/2 minutes of the flight, the pilot was provided with stall warnings, stick shaker activations, autopilot disconnect warnings, and terrain avoidance warning system alerts. The airplane impacted the ocean about 3 miles from the coast. Examination of the recovered sections of the airplane did not reveal evidence of any mechanical failures or malfunctions of the airframe or engine that would have precluded normal operation. The instrument meteorological conditions present in the area at the time of the accident were conducive to the development of spatial disorientation. The airplane’s erratic flight track in the final 2 minutes of flight, culminating in the final rapidly descending right turn, were consistent with the known effects of spatial disorientation. It is likely that the pilot’s inadequate preflight planning, and his subsequent distraction while he unsuccessfully attempted to program the airplane’s flight management system during the flight resulted in his failure to adequately monitor the airplane’s speed. This led to the activation of the airplane’s stall protection and warning systems as the airplane approached and entered an aerodynamic stall. The resulting sudden deactivation of the autopilot, combined with his inattention to the airplane’s flight attitude and speed, likely surprised the pilot. Ultimately, the pilot failed to regain control of the airplane following the aerodynamic stall, likely due to spatial disorientation. The pilot had a history of mantle cell lymphoma that was in remission and his maintenance treatment with a rituximab infusion was over 60 days prior to the accident. The pilot also had a history of back pain and had received steroid injections and nonsteroidal anti-inflammatory drugs. By self-report, he had taken oxycodone for pain management; it is unknown how frequently he used this medication or if he had used the medication on the day of the accident. While oxycodone can result in fatigue and dizziness, and may interfere with reaction time, given the information from the CVR, it could not be determined if the pilot had these side effects. A few weeks prior to the accident, the pilot reported having COVID-19 and receiving a 5-day treatment course of hydroxychloroquine and ivermectin. While there are some impairing side effects associated with the use of those medications, enough time had elapsed that no adverse effects would be expected. There is an increased risk of a sudden incapacitating cardiovascular event such as a dysrhythmia, stroke, or pulmonary embolism in people who have recovered from their COVID-19 infection. The risk is slight for those not hospitalized for the infection. The pilot did not have an underlying cardiovascular disease that would pose an increased risk for a sudden incapacitating event and the CVR did not provide evidence of a sudden incapacitating event occurring. Thus, it could not be determined if the pilot’s medical conditions of mantle cell lymphoma, back pain, and recent history of COVID-19 and the medications used to treat these conditions, including rituximab, oxycodone, hydroxychloroquine, and ivermectin, were contributing factors to this accident.

The airplane had recently undergone an annual inspection, and the pilot planned to fly the airplane back to his home base. After receiving clearance from air traffic control, the pilot proceeded to take off. The airplane accelerated and reached a peak groundspeed of 81 kts about 2,075 ft down the 4,097-ft runway. Once airborne, the airplane drifted slightly to the right and the pilot radioed an urgent need to return to the airport. The controller cleared the airplane to land and no further transmissions were received from the accident airplane. The airplane’s flight path showed that it slowed before turning back toward the left and the airplane’s speed continued to decrease throughout the remainder of the data. The final data point recorded the airplane at a groundspeed of 45 kts. The groundspeed would equate to 60 kts airspeed when considering the 15-kt headwind. The stall speed chart for the airplane listed the minimum stall speed for any configuration as 64 kts. Postaccident examinations of the airframe and engine revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation. External and internal engine damage indicated that the engine was producing power at the time of impact, but the amount of power output could not be determined. Based on the available information, the pilot perceived an urgent need to return the airplane to the airport; however, due to the amount of damage from the impact and postimpact fire, the reason that the pilot was returning to the airport could not be determined. Stall speed information for the airplane, the recorded winds, and flight track data, indicated that the airplane encountered an aerodynamic stall before impacting the ground near the departure end of the runway. Since the airplane stalled and impacted the ground before reaching the perimeter of the airport, the pilot may not have had sufficient altitude to execute a forced landing to the empty field off the departure end of the runway.

En route, the pilot encountered engine problems and elected to make an emergency landing on a motorway. Upon landing, the aircraft impacted the road bank, lost its left wing and came to rest. All six occupants evacuated with minor injuries and the aircraft was damaged beyond repair.

After landing at Brasília-Nelson Piquet Airport, the single engine airplane went out of control and veered off runway. It went down into a ravine and came to rest into trees. All five occupants evacuated safely while the aircraft was destroyed. The pilot reported he encountered strong winds upon landing.

Following an uneventful flight from Oxford-Kidlington Airport, the airplane landed at night on runway 27 at Heraklion-Nikos Kazantzakis Airport. After touchdown, the nose gear failed and the airplane slid for few dozen metres before coming to rest. All seven occupants evacuated safely and the airplane was later considered as damaged beyond repair.

The pilot was conducting a solo night cross-country flight in low visibility through mountainous terrain. The pilot was then cleared by an air traffic controller to conduct a RNAV (GPS)-E instrument approach into the destination airport. After passing the final approach fix and before the missed approach point, the pilot, for an unknown reason, executed a left turn, consistent with the missed approach procedure. During the turn toward the holding waypoint, the airplane did not climb. Shortly thereafter, the airplane impacted steep rising terrain The local weather at the time of the accident indicated a cloud ceiling of 1,200 ft above ground level and 1 statute mile visibility, which was below the weather minimums for the approach. Data retrieved from the onboard avionics revealed that although the pilot flew the published route in accordance with the instrument approach procedure, the minimum required altitudes were not adhered to. A review of the ForeFlight weather briefing data indicated that a route weather briefing had been generated by the pilot with the filing of the instrument flight rules (IFR) flight plan. While no weather imagery was reviewed during the period, the pilot had checked METARs for the destination and another nearby airport before departure and viewed the RNAV (GPS)-E approach procedure at the destination airport. A review of the data that was presented to the pilot indicated that visual flight rules conditions prevailed at the destination with light snow in the vicinity at the time it was generated. Based on the preflight weather briefing the pilot obtained, he was likely unaware of the IFR conditions and below minimum weather conditions at the destination until he descended into the area and obtained the current local weather during the flight. It is probable that, based upon the weather and flight track information, as the pilot was on the instrument approach, he became aware of the below minimum weather conditions and elected to initiate the missed approach, as evident by the turn away from the airport similar to the missed approach procedure and the flaps and landing gear being in transition. This investigation was unable to determine why the missed approach procedure was prematurely initiated and why the airplane failed to climb. Additionally, there were no preimpact mechanical malfunctions or anomalies found during a postaccident examination that would have precluded normal operation.

The airplane was departing into instrument meteorological conditions using a standard instrument departure. The takeoff instructions consisted of making a climbing right turn direct to a nondirectional beacon. After departing, the pilot made a radio communication to an air traffic controller asking if he will tell him when to turn. The controller replied that he would not be calling his turn and that the pilot should fly the departure as published making a climbing right turn to overfly the approach end of the runway. The pilot acknowledged the communication, which was his last transmission. The airplane made a 360° turn and descended below the cloud layer. The airplane then climbed back into the cloud layer and made an inverted loop, descending into the ground in a near-vertical attitude. A postaccident examination of the airplane revealed no evidence of preimpact mechanical malfunctions or failures. Recorded audio of the airplane before the accident was consistent with the engines operating. The signatures on both propellers were consistent with one another and consistent with the engines operating at a similar rpm. The pilot was qualified and recently underwent recurrent training. The reasons the pilot became spatially disoriented could not definitely determined. The pilot left the anti-collision lights on while in the clouds, which may have resulted in him having flicker vertigo.

While on final approach, the airplane gradually slowed to near its stall speed. About 600 ft beyond the last recorded data, the airplane impacted the ground in a nose-down attitude that was consistent with a stall. Postaccident examination revealed no preaccident mechanical failures or malfunctions that would have contributed to the accident. Witnesses near the accident site reported very heavy sleet with low visibility conditions, whereas a witness located near the final approach flightpath, about 2 miles before the accident site observed the airplane fly by below an overcast cloud layer with no precipitation present. Based on the witness accounts and weather data, the airplane likely entered a lake effect band of heavy sleet during the final portion of the flight. The airplane was modified with 5-bladed propellers, and other pilots reported it would decelerate rapidly, especially when the speed/propeller levers were moved to the high rpm (forward) position. The pilot usually flew a larger corporate jet and had not flown the accident airplane for 8 months. The passenger was a student pilot with an interest in becoming a professional pilot. The pilot’s poor airspeed control on final approach was likely influenced by a lack of recency in the turboprop airplane. The workload of inflight deicing tasks may have also contributed to the poor airspeed control. The aerodynamic effects of the heavy sleet that was encountered near the accident site likely contributed to the stall to some degree.

The captain (who was the pilot flying) initiated the takeoff roll, and the airplane accelerated normally. According to the cockpit voice recorder (CVR) transcript, the first officer made the “V1” and then “rotate” callouts. According to the captain (in a postaccident interview), when he pulled back on the control column to rotate the airplane, “nothing happened,” and the control column felt like it “was in concrete” and “frozen.” The CVR captured that the first officer subsequently made the “V2” callout, then the captain said “come on” in a strained voice. Both pilots recalled in postaccident interviews that they both attempted to pull back on the controls, but the airplane did not rotate. The CVR captured that the first officer called out “abort.” The first officer pulled the thrust levers to idle and applied the brakes, and the captain deployed the thrust reversers. (See “Execution of Rejected Takeoff” for more information.) The airplane overran the departure end of the runway and continued through the airport perimeter fence and across a road, striking electrical distribution lines and trees before coming to rest in a pasture, where a postcrash fire ensued. The pilots, two additional crewmembers, and all passengers evacuated the airplane. Two passengers received serious injuries, and one received a minor injury. The airplane was totally destroyed by a post crash fire.

The pilot stated that the departure started normally but that, after becoming airborne, the airplane controls were not responding to his inputs as expected. The airplane continued to pitch up in a nose-high attitude and he was unable to push the control yoke forward, which he described as feeling like he was “stretching” cables with forward pressure. With the airplane’s pitch uncontrollable, he elected to make a rapid maneuver toward an unpopulated area. The airplane descended into trees; after coming to a stop, a fire erupted. A postaccident examination of the flight control system revealed no definitive evidence of preimpact mechanical malfunctions or failures. Because the elevator system was extensively damaged and was partially consumed by fire, the investigation was not able to determine the cause of the pitch control anomaly. The airplane’s weight and center of gravity (CG) could not be confirmed. The burned remains of items found in the airplane could not be identified and the location of those items at impact could not be confirmed.