Crash of a Beechcraft 65-A90 King Air in Dillingham: 11 killed

Date & Time: Jun 21, 2019 at 1822 LT
Type of aircraft:
Operator:
Registration:
N256TA
Flight Phase:
Survivors:
No
Schedule:
Dillingham - Dillingham
MSN:
LJ-256
YOM:
1967
Crew on board:
1
Crew fatalities:
Pax on board:
10
Pax fatalities:
Other fatalities:
Total fatalities:
11
Captain / Total flying hours:
1086
Captain / Total hours on type:
214.00
Aircraft flight hours:
15104
Aircraft flight cycles:
24569
Circumstances:
On June 21, 2019, about 1822 Hawaii-Aleutian standard time, a Beech King Air 65-A90 airplane, N256TA, impacted terrain after takeoff from Dillingham Airfield (HDH), Mokuleia, Hawaii. The pilot and 10 passengers were fatally injured, and the airplane was destroyed. The airplane was owned by N80896 LLC and was operated by Oahu Parachute Center (OPC) LLC under the provisions of Title 14 Code of Federal Regulations (CFR) Part 91 as a local parachute jump (skydiving) flight. Visual meteorological conditions prevailed at the time of the accident. OPC had scheduled five parachute jump flights on the day of the accident and referred to the third through fifth flights of the day as “sunset” flights because they occurred during the late afternoon and early evening. The accident occurred during the fourth flight. The accident pilot was the pilot-in-command (PIC) for each of the OPC flights that departed on the day of the accident. The pilot and 8 of the 10 passengers initially boarded the airplane. These eight passengers comprised three OPC tandem parachute instructors, three passenger parachutists, and two OPC parachutists performing camera operator functions. The pilot began to taxi the airplane from OPC’s location on the airport. According to a witness (an OPC tandem instructor who was not aboard the accident flight), the two other passengers—solo parachutists who had been on the previous skydiving flight and were late additions to the accident flight—“ran out to the airplane and were loaded up at the last minute.” The pilot taxied the airplane to runway 8 about 1820, and the airplane departed about 1822. According to multiple witnesses, after the airplane lifted off, it banked to the left, rolled inverted, and descended to the ground. One witness stated that, before impact, the airplane appeared to be intact and that there were no unusual noises or smoke coming from the airplane. A security camera video showed that the airplane was inverted in a 45° nose-down attitude at the time of impact. The airplane impacted a grass and dirt area about 630 ft northeast of the departure end of the runway, and a postcrash fire ensued. The airplane was not equipped, and was not required to be equipped, with a cockpit voice recorder or a flight data recorder. The accident flight was not detected by radar at the Federal Aviation Administration’s (FAA) Hawaii Control Facility, which was the air traffic control (ATC) facility with jurisdiction of the airspace over HDH. The FAA found no audio communications between the accident airplane and ATC on the day of the accident.
Probable cause:
The National Transportation Safety Board determines that the probable cause of this accident was the pilot’s aggressive takeoff maneuver, which resulted in an accelerated stall and subsequent loss of control at an altitude that was too low for recovery.
Contributing to the accident were
1) the operation of the airplane near its aft center of gravity limit and the pilot’s lack of training and experience with the handling qualities of the airplane in this flight regime;
2) the failure of Oahu Parachute Center and its contract mechanic to maintain the airplane in an airworthy condition and to detect and repair the airplane’s twisted left wing, which reduced the airplane’s stall margin; and
3) the Federal Aviation Administration’s (FAA) insufficient regulatory framework for overseeing parachute jump operations. Contributing to the pilot’s training deficiencies was the FAA’s lack of awareness that the pilot’s flight instructor was providing substandard training.
Final Report:

Crash of a PZL-Mielec AN-2R near Rodina: 2 killed

Date & Time: Jun 20, 2019 at 1000 LT
Type of aircraft:
Operator:
Registration:
UP-A0116
Flight Phase:
Survivors:
Yes
Schedule:
Rodina - Rodina
MSN:
1G232-38
YOM:
1989
Location:
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
The crew was engaged in a spraying mission on behalf of Rodina Agrofirm and completed five rotations in the morning. After refueling with chemicals, the airplane took off from an airfield located about 10 km from the village of Rodina. Shortly after takeoff, it collided with the wooden pillar of an electric power line, lost height and crashed in flames 100 metres further. The captain was killed while two other occupants were seriously injured. The following day, the copilot died from his injuries.

Crash of a Cessna S550 Citation II in Indianapolis: 2 killed

Date & Time: May 22, 2019 at 1243 LT
Type of aircraft:
Operator:
Registration:
N311G
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Indianapolis - Minden
MSN:
550-0041
YOM:
1985
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
3530
Circumstances:
The pilot was conducting a personal cross-country flight in a turbofan-powered airplane. Shortly after departure, the airplane entered a witness-estimated 90° left bank with the nose parallel to the horizon; as the airplane began to roll out of the turn, the nose remained at or below the horizon before it dropped and the airplane impacted the ground. Flight track data revealed that, shortly after departure, the airplane's ground speed immediately began decreasing from its maximum of 141 knots during takeoff and continued decreasing until the last recorded data point, which showed that the airplane had a ground speed of 100 knots. The surface wind reported about 10 minutes before the accident was from 170° at 9 knots, gusting to 14 knots, which resulted in a 1- to 2-knot tailwind component. Given this information and the airplane's configuration at the time of the accident, the airplane's indicated airspeed (IAS) would have been between about 86 and 93 knots. The airplane's stall speed was calculated to be 100 knots IAS (KIAS) with a bank angle of 45° and 118 KIAS with a bank angle of 60°. Thus, the pilot failed to maintain airspeed or accelerate after departure, which resulted in an aerodynamic stall A pilot who had flown with the accident pilot twice before the accident reported that, during these flights, the pilot had flown at reduced power settings and slower-than-normal airspeeds. During the flight 1 year before the accident, he reached over and pushed the power levers forward himself. He also stated that every time he had flown with the pilot, he was "very behind the airplane." Postaccident examination of the engines revealed no signs of preimpact mechanical failures or malfunctions that would have precluded normal operation, and both engines exhibited circumferential rub marks on all rotating stages, blade tip bending opposite the direction of rotation, and debris ingestion through the gas path, indicating that the engine had power at impact. Further, the right engine full authority digital electronic control (FADEC) nonvolatile memory recorded no faults. (The left engine FADEC could not be downloaded due to damage.) The Airplane Flight Manual stated that the pilot must, in part, advance the throttle lever to the maximum takeoff detent for the FADEC's nonvolatile memory to record a logic trend snapshot 2 seconds after takeoff. The lack of a FADEC logic trend snapshot is consistent with the pilot not fully advancing the throttles during the takeoff and initial climb and is likely why he did not attain or maintain sufficient airspeed. The flight track data, pilot witness account, and airplane damage are consistent with the pilot failing to fully advance the power levers while maneuvering shortly after takeoff, which led to his failure to maintain sufficient airspeed and resulted in the exceedance of the airplane's critical angle of attack and a subsequent aerodynamic stall.
Probable cause:
The pilot's failure to fully advance the power levers during the takeoff and initial climb, which led to his failure to maintain sufficient airspeed and resulted in the exceedance of the airplane's critical angle of attack and a subsequent aerodynamic stall.
Final Report:

Crash of a Cessna 208 Caravan I in the Dry Tortugas National Park

Date & Time: Apr 23, 2019 at 1200 LT
Type of aircraft:
Operator:
Registration:
N366TA
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Dry Tortugas - Key West
MSN:
208-0249
YOM:
1996
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
2407
Captain / Total hours on type:
27.00
Aircraft flight hours:
9506
Circumstances:
The pilot landed the seaplane into an easterly wind, then noticed that the surface wind was greater than forecast. Unable to taxi to the beaching location, he elected to return to his destination. He maneuvered the airplane into the wind and applied takeoff power. He described the takeoff run as "bumpy" and the water conditions as "rough." The pilot reported that the left float departed the airplane at rotation speed, and the airplane subsequently nosed into the water. The pilot and passengers were assisted by a nearby vessel and the airplane subsequently sank into 50 ft of water. Inclement sea and wind conditions prevented recovery of the wreckage for 52 days, and the wreckage was stored outside for an additional 13 days before recovery by the salvage company. Extensive saltwater corrosion prevented metallurgical examination of the landing gear components; however, no indication of a preexisting mechanical malfunction or failure was found.
Probable cause:
The pilot's decision to attempt a takeoff in rough sea conditions, resulting in damage to the floats and the sinking of the seaplane.
Final Report:

Crash of a Beechcraft B60 Duke in Fullerton: 1 killed

Date & Time: Apr 18, 2019 at 1951 LT
Type of aircraft:
Registration:
N65MY
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Fullerton - Heber City
MSN:
P-314
YOM:
1975
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
380
Captain / Total hours on type:
87.00
Aircraft flight hours:
5419
Circumstances:
The pilot began the takeoff roll in visual meteorological conditions. The airplane was airborne about 1,300 ft down the runway, which was about 75% of the normal ground roll distance for the airplane’s weight and the takeoff environment. About 2 seconds after rotation, the airplane rolled left. Three seconds later, the airplane had reached an altitude of about 80 ft above ground level and was in a 90° left bank. The nose then dropped as the airplane rolled inverted and struck the ground in a right-wing-low, nose-down attitude. The airplane was destroyed. Postaccident examination did not reveal any anomalies with the airframe or engines that would have precluded normal operation. The landing gear, flap, and trim positions were appropriate for takeoff and flight control continuity was confirmed. The symmetry of damage between both propeller assemblies indicated that both engines were producing equal and high amounts of power at impact. The autopsy revealed no natural disease was present that could pose a significant hazard to flight safety. Review of surveillance video footage from before the accident revealed that the elevator was in the almost full nose-up (or trailing edge up) position during the taxi and the beginning of the takeoff roll. Surveillance footage also showed that the pilot did not perform a preflight inspection of the airplane or control check before the accident flight. According to the pilot’s friend who was also in the hangar, as the accident pilot was pushing the airplane back into his hangar on the night before the accident, he manipulated and locked the elevator in the trailing edge up position to clear an obstacle in the hangar. However, no evidence of an installed elevator control lock was found in the cabin after the accident. The loss of control during takeoff was likely due to the pilot’s use of an unapproved elevator control lock device. Despite video evidence of the elevator locked in the trailing edge up position before the accident, an examination revealed no evidence of an installed control lock in the cabin. Therefore, during the night before the accident, the pilot likely placed an unapproved object between the elevator balance weight and the trailing edge of the horizontal stabilizer to lock the elevator in the trailing edge up position. The loss of control was also due to the pilot’s failure to correctly position the elevator before takeoff. The pilot’s friend at the hangar also reported that the pilot was running about one hour late; the night before, he was trying to troubleshoot an electrical issue in the airplane that caused a circuit breaker to keep tripping, which may have become a distraction to the pilot. The pilot had the opportunity to detect his error in not freeing the elevator both before boarding the airplane and again while in the airplane, either via a control check or detecting an anomalous aft position of the yoke. The pilot directed his attention to the arrival of a motorbike in the hangar alley shortly after he pulled the airplane out of the hangar, which likely distracted the pilot and further delayed his departure. He did not conduct a preflight inspection of the airplane or control check before the accident flight, due either to distraction or time pressure.
Probable cause:
The pilot’s use of an unapproved elevator control lock device, and his failure to remove that device and correctly position the elevator before flight, which resulted in a loss of control during takeoff. Contributing to the accident was his failure to perform a preflight inspection and control check, likely in part because of distractions before boarding and his late departure time.
Final Report:

Crash of a Britten Norman BN-2B-27 Islander in Puerto Montt: 6 killed

Date & Time: Apr 16, 2019 at 1050 LT
Type of aircraft:
Registration:
CC-CYR
Flight Phase:
Survivors:
No
Site:
Schedule:
Puerto Montt - Ayacara
MSN:
2169
YOM:
1983
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
6
Captain / Total flying hours:
1414
Captain / Total hours on type:
437.00
Aircraft flight hours:
22330
Circumstances:
The twin engine airplane departed Puerto Montt-Marcel Marchant (La Paloma) Airport Runway 01 at 1050LT on a charter flight to Ayacara, carrying five passengers and one pilot. About 36 seconds after takeoff, while climbing, the pilot declared an emergency. The airplane entered a left turn then stalled and crashed onto a house located in a residential area, about 450 metres from the runway end, bursting into flames. The houses and the airplane were destroyed by a post crash fire and all six occupants were killed. One person in the house was injured.
Probable cause:
Loss of control of the airplane in flight, during a left turn, due to the failure of the right engine (n°2) during takeoff, caused by a fuel exhaustion.
The following contributing factors were identified:
- Failure of the pilot to comply with the pre takeoff checklist,
- Failure of the pilot to check the fuel selector switch and the fuel quantity prior to start the engines,
- Failure of the pilot to feather the propeller of the right engine (n°2) during an emergency situation,
- Failure of the pilot to bring the flaps to the neutral position during an emergency situation,
- Decrease of the speed and altitude of the airplane,
- Increase bank of the wing during a left turn.
Final Report:

Crash of a Let L-410UVP-E20 in Lukla: 3 killed

Date & Time: Apr 14, 2019 at 0907 LT
Type of aircraft:
Operator:
Registration:
9N-AMH
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Lukla - Manthali
MSN:
13 29 14
YOM:
2013
Flight number:
GO802D
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
15652
Captain / Total hours on type:
3558.00
Copilot / Total flying hours:
865
Copilot / Total hours on type:
636
Aircraft flight hours:
4426
Aircraft flight cycles:
5464
Circumstances:
On 14 April 2019, around 0322Hrs, Aircraft Industries' L410UPV-E20, registration 9NAMH, owned and operated by Summit Air Pvt. Ltd. met with an accident at Tenzing-Hillary Airport, Lukla when it veered right and excurred the runway during take-off roll from runway 24. The aircraft first collided with Manang Air's helicopter, AS350B3e, registration 9N-ALC, with its rotor blade running on idle power and then with Shree Airlines' helicopter, AS350B3e, registration 9N-ALK just outside the inner perimeter fence of the aerodrome into the helipad before coming to a stop. The PIC and Cabin Crew of 9N-AMH survived the accident, whereas the Co-pilot and one security personnel on ground were killed on the spot. One more security personnel succumbed to injury later in hospital during the course of treatment. 9N-AMH and 9N-ALC both were substantially damaged by impact forces. There was no post-crash fire. Prior to the accident the aircraft had completed 3 flights on Ramechhap-Lukla-Ramechhap sector. According to PIC, he was in the left seat as the pilot monitoring (PM) and the co-pilot, in the right seat was the pilot flying (PF). According to CCTV footages, the aircraft arrived at the apron from VNRC to VNLK at 0315Hrs and shut its LH engine. The PIC started the LH engine at about 0318 Hrs after unloading cargo and passengers. At 0322:30 Hrs, the PIC aligned the aircraft with the runway at the runway threshold 24 and then handed over the controls to the co-pilot for the take-off roll. The take-off roll commenced at 0322:50 Hrs. CCTV footage captured that within 3 seconds the aircraft veered right and made an excursion. The aircraft exited the runway and travelled about 42.8 ft across the grassy part on right side of runway 24, before striking the airport inner perimeter fence. It then continued to skid for about 43 ft, into the upper helipad, crashing into 9N-ALC. Eye witnesses statements, CCTV footages and initial examination of the wreckage showed that rotor blades of helicopter 9N-ALC were on idle when RH wing of the aircraft swept two security personnel (on ground) before slashing its rotor shaft. The moving rotors cut through the cockpit on the right side slaying the Co-pilot immediately. The helicopter toppled onto the lower helipad 6 ft below. The LH wing of the aircraft broke the skid of helicopter 9NALK and came to a halt with toppled 9N-ALC beneath its RH main wheel assembly. Due to 2impact, 9N-ALK shifted about 8 ft laterally and suffered minor damages. There was no post-crash fire. The PIC switched off the battery and came out of the aircraft through emergency exit along with the cabin crew. The captain of the helicopter 9N-ALC was rescued immediately. 9N-ALC's crew sustained a broken tail-bone whereas 9N-ALK's crew escaped without sustaining major injuries. All three deceased were Nepalese citizens. Aircraft 9N-AMH and helicopter 9N-ALC were substantially damaged while the helicopter 9N-ALK endured partial damages.
Probable cause:
The commission concluded that the probable cause of the accident was aircraft's veering towards right during initial take-off roll as a result of asymmetric power due to abrupt shifting of right power lever rearwards and failure to abort the takeoff by crew. There were not enough evidences to determine the exact reason for abrupt shifting of the power lever.
Contributing Factors:
1. Failure of the PF(being a less experienced co-pilot) to immediately assess and act upon the abrupt shifting of the right power lever resulted in aircraft veering to the right causing certain time lapse for PIC to take controls in order to initiate correction.
2. PIC's attempted corrections of adding power could not correct the veering. Subsequently, application of brakes resulted in asymmetric braking due to the position of the pedals, and further contributed veering towards right.
Final Report:

Crash of a Boeing 737 MAX 8 near Debre Zeit: 157 killed

Date & Time: Mar 10, 2019 at 0844 LT
Type of aircraft:
Operator:
Registration:
ET-AVJ
Flight Phase:
Survivors:
No
Schedule:
Addis Ababa – Nairobi
MSN:
62450/7243
YOM:
2018
Flight number:
ET302
Country:
Region:
Crew on board:
8
Crew fatalities:
Pax on board:
149
Pax fatalities:
Other fatalities:
Total fatalities:
157
Captain / Total flying hours:
8122
Captain / Total hours on type:
1417.00
Copilot / Total flying hours:
361
Copilot / Total hours on type:
207
Aircraft flight hours:
1330
Aircraft flight cycles:
382
Circumstances:
On March 10, 2019, at 05:38 UTC, Ethiopian Airlines flight 302, Boeing 737-8(MAX), ET-AVJ, took off from Addis Ababa Bole International Airport bound to Nairobi, Kenya Jomo Kenyatta International Airport. ET302 was being operated under the provisions of the Ethiopian Civil Aviation Regulations (ECARAS) as a scheduled international flight between Addis Ababa Bole International Airport (HAAB), Ethiopia and Jomo Kenyatta Int. (HKJK) Nairobi, Kenya. It departed Addis Ababa with 157 persons on board: 2 flight crew (a Captain and a First Officer), 5 cabin crew and one IFSO, 149 regular passengers. At 05:36:12 the Airplane lined up on runway 07R at field elevation of 7,656 ft with flap setting of 5 degrees and a stabilizer trim setting of 5.6 units. Both flight directors (F/D) were ON with LNAV and VNAV modes armed. At 05:37:17the F/O reported to Tower ready for takeoff and at 05:37:36ATC issued take off clearance to ET-302 and advised to contact radar on 119.7MHz. The takeoff roll and lift-off was normal, including normal values of left and right angle-of-attack (AOA). During takeoff roll, the engines stabilized at about 94% N1. Shortly after liftoff, the left Angle of Attack sensor recorded value became erroneous and the left stick shaker activated and remained active until near the end of the recording. In addition, the airspeed and altitude values from the left air data system began deviating from the corresponding right side values. The left and right recorded AOA values began deviating. Left AOA decreased to 11.1° then increased to 35.7° while the right AOA indicated 14.94°. Then after, the left AOA value reached 74.5° in ¾ seconds while the right AOA reached a Maximum value of 15.3°, the difference between LH and RH AOA was59°and near the end of the recording it was 490. At 05:39:30, the radar controller identified ET-302 and advised to climb FL 340 and when able to turn right direct to RUDOL. At 5:39:51, the selected heading increased from 072° to 197°. After the flaps were fully retractedthe1stautomatic nose-down trim activated and engaged for 9 seconds positioning the stabilizer trim to 2.1 units. The pilot flying pulled to pitch up the Airplane with a force more than 90lbs. He then applied electric trim-up inputs. Five seconds after the end of these inputs a second automatic nose-down trim activated. At 5:40:22, the second automatic nose-down trim activated. Following nose-down trim activation GPWS DON’T SINK sounded for 3 seconds and “PULL UP” also displayed on PFD for 3 seconds. At 05:40:43, approximately five seconds after the end of the crew manual electrical trim up inputs, a third automatic trim nose-down was recorded but with no associated movement of the stabilizer. At 05:40:50, the captain told the F/O: “advise we would like to maintain one four thousand. We have a flight control problem”. The F/O complied and the request was approved by ATC. Following the approval of the ATC, the new target altitude of 14,000ft was set on the MCP. The Captain was unable to maintain the flight path and requested to return back to the departure airport. At 05:43:21, approximately five seconds after the last main electric trim up input, an automatic nose-down trim activated for about 5s. The stabilizer moved from 2.3 to 1 unit. The rate of climb decreased followed by a descent in 3s after the automatic trim activation. One second before the end of the automatic trim activation, the average force applied by the crew decreased from 100 lbs to 78 lbs in 3.5 seconds. In these 3.5 seconds, the pitch angle dropped from 0.5° nose up to -7.8° nose down and the descent rate increased from -100 ft/min to more than -5,000 ft/min. Following the last automatic trim activation and despite calculated column force of up to 110lbs, the pitch continued decreasing. The descent rate and the airspeed continued increasing between the triggering of the 4th automatic trim activation and the last recorded parameter value. At the end of the flight, Computed airspeed values reached 500Kt, Pitch values were greater than 40° nose down and descent rate values were greater than 33,000 ft/min. Finally, both recorders stopped recording at around 05 h 43 min 44s. At 05:44 The Airplane impacted terrain 28 NM South East of Addis Ababa near Ejere (located 8.8770 N, 39.2516 E.) village at a farm field and created a crater approximately 10 meters deep (last Airplane part found) with a hole of about 28 meters width and 40 meters length. Most of the wreckage was found buried in the ground; small fragments of the Airplane were found scattered around the site in an area by about 200 meters width and 300 meters long. The damages to the Airplane were consistent with a high energy impact. All 157 persons on board: 2 flight crew (a Captain and a First Officer), 5 cabin crew and one IFSO, 149 regular passengers were fatally injured.
Probable cause:
Repetitive and uncommanded airplane-nose-down inputs from the MCAS due to erroneous AOA input, and its unrecoverable activation system which made the airplane dive with the rate of -33,000 feet per minute close to the ground was the most probable cause of the accident.
The following contributing factors were identified:
1. The MCAS design relied on a single AOA sensor, making it vulnerable to erroneous input from the sensor;
2. During the design process, Boeing failed to consider the potential for uncommanded activation of MCAS, but assumed that pilots would recognize and address it through normal use of the control column, manual electric trim, and the existing Runaway Stabilizer NNC. The OMB and Emergency AD issued after the Lion Air accident included additional guidance but did not have the intended effect of preventing another MCAS-related accident;
3. While Boeing considered the possibility of uncommanded MCAS activation as part of its FHA, it did not evaluate all the potential alerts and indications that could accompany a failure leading to an uncommanded MCAS;
4. The MCAS contribution to cumulative AOA effects was not assessed;
5. The combined effect of alerts and indications that impacted pilot’s recognition and procedure prioritization were not evaluated by the Manufacturer;
6. Absence of AOA DISAGREE warning flag on the flight display panels (PFD);
7. The B737 MAX Crew difference CBT training prepared by Boeing and delivered to Pilots did not cover the MCAS system;
8. Failure by the manufacturer to design simulator training for pilots with regards to safety critical systems like MCAS with catastrophic consequences during undesired activation.
9. The manufacturer failed to provide procedures regarding MCAS operation to the crew during training or in the FCOM;
10. Failure by the manufacturer to address the safety critical questions raised by the airline which would have cleared out crew confusion and task prioritization;
Final Report:

Crash of a Piper PA-46-350P Malibu Mirage in Shreveport: 2 killed

Date & Time: Feb 28, 2019 at 1039 LT
Operator:
Registration:
N428CD
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Shreveport - Vernon
MSN:
46-36232
YOM:
1999
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
1393
Captain / Total hours on type:
323.00
Aircraft flight hours:
1901
Circumstances:
The instrument-rated private pilot and passenger departed into instrument meteorological conditions with a 600-ft cloud ceiling in an airplane that was about 550 lbs over gross weight. Air traffic control data showed the airplane in a climbing left turn that continued beyond the assigned heading. After reaching 1,400 ft msl, the airplane continued turning left and its altitude and speed began to vary. The airplane continued in a left spiral, completing more than two full circles, then decelerated in a right turn and rapidly descended until impact with terrain. Examination of the flight control system revealed no evidence of mechanical malfunctions and downloaded engine data indicated normal engine operation. Downloaded data from the autopilot system revealed three in-flight error codes. The first error code, which likely occurred about 1 minute after takeoff, would have resulted in the autopilot, if it was engaged at the time, disengaging. The subsequent error codes likely occurred during the erratic flight profile, with the autopilot disengaged. Before the accident flight, the pilot had informed a mechanic, who is also a pilot, of intermittent issues with the autopilot system and that these issues were unresolved. The mechanic had flown with the accident pilot previously and assessed his instrument flying skills as weak. The flight instructor who provided initial flight training for the turbine engine transition stated the pilot's instrument flying proficiency was poor when he was hand flying the airplane. Toxicology testing revealed that the pilot had used marijuana, and his girlfriend stated the pilot would take a marijuana gummy before bedtime to sleep more soundly. However, given that no psychoactive compounds were found in blood specimens, it is unlikely that the pilot was impaired at the time of the accident. The instrument conditions at the time of the accident, the airplane's erratic flightpath, and the pilot's reported lack of instrument proficiency when flying by hand support the likelihood that the pilot experienced spatial disorientation sometime after takeoff. In addition, given the reports of the intermittently malfunctioning autopilot that had not been fixed, it is likely the pilot experienced an increased workload during a critical phase of flight that, in combination with spatial disorientation, led to the pilot's loss of airplane control.
Probable cause:
The pilot's conduct of a departure into instrument meteorological conditions (IMC), which resulted in spatial disorientation and subsequent loss of airplane control. Contributing to the accident was the pilot's poor instrument flying skills and his decision to depart into IMC with an unresolved autopilot maintenance issue.
Final Report:

Crash of a Cessna 414A Chancellor in Yorba Linda: 5 killed

Date & Time: Feb 3, 2019 at 1345 LT
Type of aircraft:
Operator:
Registration:
N414RS
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Fullerton – Minden
MSN:
414A-0821
YOM:
1981
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
10235
Aircraft flight hours:
9610
Circumstances:
The commercial pilot departed for a cross-country, personal flight with no flight plan filed. No evidence was found that the pilot received a preflight weather briefing; therefore, it could not be determined if he checked or received any weather information before or during the accident flight. Visual meteorological conditions existed at the departure airport; however, during the departure climb, the weather transitioned to instrument meteorological conditions (IMC) with precipitation, microburst, and rain showers over the accident area. During the takeoff clearance, the air traffic controller cautioned the pilot about deteriorating weather conditions about 4 miles east of the airport. Radar data showed that, about 5 1/2 minutes after takeoff, the airplane had climbed to about 7,800 ft above ground level before it started a rapid descending right turn and subsequently impacted the ground about 9.6 miles east of the departure airport. Recorded data from the airplane’s Appareo Stratus 2S (portable ADS-B receiver and attitude heading and reference system) revealed that, during the last 15 seconds of the flight, the airplane’s attitude changed erratically with the pitch angle fluctuating between 45° nose-down and 75°nose-up, and the bank angle fluctuating between 170° left and 150° right while descending from 5,500 to 500 ft above ground level, indicative of a loss of airplane control shortly after the airplane entered the clouds. Several witnesses located near the accident site reported seeing the airplane exit the clouds at a high descent rate, followed by airplane parts breaking off. One witness reported that he saw the airplane exit the overcast cloud layer with a nose down pitch of about 60°and remain in that attitude for about 4 to 5 seconds “before initiating a high-speed dive recovery,” at the bottom of which, the airplane began to roll right as the left horizontal stabilizer separated from the airplane, immediately followed by the remaining empennage. He added that the left wing then appeared to shear off near the left engine, followed by the wing igniting. An outdoor home security camera, located about 0.5 mile north-northwest of the accident location, captured the airplane exiting the clouds trailing black smoke and then igniting. Examination of the debris field, airplane component damage patterns, and the fracture surfaces of separated parts revealed that both wings and the one-piece horizontal stabilizer and elevators were separated from the empennage in flight due to overstress, which resulted from excessive air loads. Although the airplane was equipped with an autopilot, the erratic variations in heading and altitude during the last 15 seconds of the flight indicated that the pilot was likely hand-flying the airplane; therefore, he likely induced the excessive air loads while attempting to regain airplane control. Conditions conducive to the development of spatial orientation existed around the time of the in-flight breakup, including restricted visibility and the flight entering IMC. The flight track data was consistent with the known effects of spatial disorientation and a resultant loss of airplane control. Therefore, the pilot likely lost airplane control after inadvertently entering IMC due to spatial disorientation, which resulted in the exceedance of the airplane’s design stress limits and subsequent in-flight breakup. Contributing to accident was the pilot’s improper decision to conduct the flight under visual flight rules despite encountering IMC and continuing the flight when the conditions deteriorated. Toxicology testing on specimens from the pilot detected the presence of delta-9-tetrahydrocanninol (THC) in heart blood, which indicated that the pilot had used marijuana at some point before the flight. Although there is no direct relationship between postmortem blood levels and antemortem effects from THC, it does undergo postmortem redistribution. Therefore, the antemortem THC level was likely lower than detected postmortem level due to postmortem redistribution from use of marijuana days previously, and it is unlikely that the pilot’s use of marijuana contributed to his poor decision-making the day of the accident. The toxicology testing also detected 67 ng/mL of the sedating antihistamine diphenhydramine. Generally, diphenhydramine is expected to cause sedating effects between 25 to 1,120 ng/mL. However, diphenhydramine undergoes postmortem redistribution, and the postmortem heart blood level may increase by about three times. Therefore, the antemortem level of diphenhydramine was likely at or below the lowest level expected to cause significant effects, and thus it is unlikely that the pilot’s use of diphenhydramine contributed to the accident.
Probable cause:
The pilot’s failure to maintain airplane control after entering instrument meteorological conditions (IMC) while climbing due to spatial disorientation, which resulted in the exceedance of the airplane’s design stress limits and subsequent in-flight break-up. Contributing to accident was the pilot's improper decision to conduct the flight under visual flight rules and to continue the flight when conditions deteriorated.
Final Report: