North America

Air traffic control communications revealed that the pilot requested to take off from the departure runway so that he could perform traffic pattern work and return for a landing on the left adjacent runway. Shortly after takeoff and while departing to the west, the pilot was instructed twice to enter the left traffic pattern, with no response. Radar data showed the airplane departing the runway and remaining on runway centerline heading for the length of the flight. The airplane climbed to about 100 ft above ground level and the airplane’s groundspeed increased to 81 knots soon after departure then decreased to 70 knots before dropping off radar. Witnesses reported seeing the airplane depart the airport at a low climb rate and slow airspeed. Shortly after, the airplane flew out of view and a column of smoke was seen on the horizon. Accident site documentation identified symmetrical propeller strikes on the ground consistent with the airplane impacting the ground in a shallow, nose-up, wings level attitude. Examination of the airframe and both engines did not reveal any evidence of a preaccident mechanical failure or malfunction that would have precluded normal performance to allow for sufficient airspeed and climb rate after takeoff. Both the engines exhibited damage signatures consistent with the engines producing symmetrical power at impact. The pilot’s most recent flight in the accident airplane was 2 months before the accident. The pilot was reported to have problems with understanding the accident airplane’s avionics system; however, it is unknown if he was having these problems during the accident flight. Review of the pilot’s medical history revealed no significant medical concerns or conditions that could pose a hazard to flight.

The pilot was conducting a Part 135 on-demand cargo flight in instrument meteorological conditions. After executing a second missed approach, he informed air traffic control (ATC) of his intentions to divert to an airport located about 36 miles to the southeast. About 7 minutes after executing the second missed approach, the pilot began making unintelligible radio communications that ATC characterized as very garbled and difficult to understand, “almost hypoxic.” ATC then instructed the pilot to utilize oxygen. About 19 minutes after the second missed approach, ATC informed the pilot that the airplane had descended 1,600 ft, not following assigned course vectors or instructions and asked if everything was alright, to which no response was received. After attempting to relay communications through other airplanes in the area, an unintelligible response was received from the accident airplane. ATC then made numerous transmissions to the accident pilot urging him to utilize oxygen and open a window. No further communications were received from the accident airplane. A witness reported that he saw the airplane descend out of a low overcast cloud layer at a high rate of descent. The airplane then abruptly transitioned into a steep climb before re-entering the clouds. A few seconds later, he heard the airplane impact terrain and responded to the accident site. The sudden change in communications from the pilot indicates a possible impairment. When combined with the ATC data, the witness account, and the lack of any mechanical irregularities or malfunctions with the airplane, it is likely the pilot experienced difficulty controlling the airplane due to impairment. While the pilot was at an increased risk for an acute cardiovascular event, the extremely limited available medical evidence leaves no way to quantify that risk and no evidence regarding whether such an event occurred. As a result, whether the pilot was incapacitated by an acute medical event cannot be determined from the available medical information.

The pilot stated that, upon landing, the airplane touched down on the runway centerline with light and variable wind conditions. The pilot recalled that the touchdown felt normal but that, during the landing roll, the airplane began to veer to the right. The pilot added full left rudder, but the airplane continued to veer off the runway surface and encountered large rocks located between the runway and taxiway. A postaccident operational check of the nosewheel steering system revealed no mechanical malfunctions or anomalies that would have precluded normal operation. The left nosewheel tire was not adequately inflated and was worn to the point at which the cord was exposed; the right nosewheel tire was within tolerances. Also, one-third of the rim was absent on the left nosewheel tire outer wheel half. The available evidence precluded a determination of whether the imbalance between the nosewheel tires contributed to the control problem on the runway. It could also not be determined if the left nosewheel tire damage occurred before the touchdown or as a result of the accident sequence.

The pilot reported that, upon reaching the decision altitude on a GPS instrument approach, he saw the runway end identifier lights and continued the approach. Shortly after, the lights disappeared and then reappeared. He continued the approach and landing thinking the airplane was lined up with the runway by using the runway edge lights for reference. Upon touching down about 225 ft left of the runway, the airplane dug into snow and flipped over, which resulted in substantial damage to the wings and tail. The pilot reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation.

The pilot departed on an instrument flight rules cross-country flight with three passengers. While enroute at a cruise altitude about 6,000 ft mean sea level (msl), the pilot discussed routing and weather avoidance with the controller. The controller advised the pilot there was a gap in the line of weather showing light precipitation, and that the pilot could pass through it and then proceed on course. The controller assigned the pilot a heading, which the pilot initially acknowledged, but shortly thereafter, he advised the controller that the airplane was pointed directly at a convective cell. The controller explained that the heading would keep the pilot out of the heavy precipitation and that he would then turn the airplane through an area of light precipitation. The pilot responded, saying that the area seemed to be closing in fast, the controller acknowledged and advised the pilot if he did not want to accept that routing, he could be rerouted. The pilot elected to turn toward a gap that he saw and felt he could fly straight through it. The controller acknowledged and advised the pilot that course would take him through moderate precipitation starting in about one mile extending for about four miles; the pilot acknowledged. Radar information indicated that the airplane entered an area of heavy to very heavy precipitation, likely a rain shower updraft, while in instrument meteorological conditions, then entered a right, descending spiral and broke up in flight. Examination of the wreckage revealed no evidence of a preaccident malfunction or failure that would have prevented normal operation. The airplane was equipped with the capability to display weather radar "mosaic" imagery created from Next Generation Radar (NEXRAD) data and it is likely that the pilot was using this information to navigate around precipitation when the airplane encountered a rain shower updraft with likely severe turbulence. Due to latencies inherent in processes used to detect and deliver the NEXRAD data from the ground site, as well as the frequency of the mosaic-creation process used by the service provider, NEXRAD data can age significantly by the time the mosaic image is created. The pilot elected to navigate the hazardous weather along his route of flight based on the data displayed to him instead of the routing suggested by the controller, which resulted in the penetration of a rain shower updraft, a loss of airplane control, and a subsequent inflight breakup.

The pilot reported that he and the copilot were conducting an instrument approach to the runway in a business jet. He noted that the weather conditions included fog and mist. After touching down about 1,500 ft down the 7,300-ft-long runway, he engaged the thrust reversers and applied the brakes gradually because the runway was "slippery." As the airplane approached the end of the runway, he applied full braking, but the airplane departed the end of the runway and impacted a ditch, which resulted in the forward landing gear breaking and the airplane nosing down. The copilot corroborated the pilot's statement. The fuselage was substantially damaged. The pilot reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation.

The pilot was receiving a checkride from a designated pilot examiner for his single-pilot type rating in a turbine airplane. After a series of maneuvers, emergencies, and landings, the examiner asked the pilot to complete a no-flap landing. The pilot reported that he performed the Before Landing checklist with no flaps and believed that he had put the gear down. During touchdown, the pilot felt a "thump" and thought a tire had blown; however, he saw that the landing gear handle was in the "up" position, and he noted that the landing gear warning horn did not sound because he had performed a no-flaps landing. The examiner confirmed that the landing gear handle was in the "up" position. The pilot reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation. A Federal Aviation Administration inspector who examined the airplane reported that the landing gear handle was in the "up" position and that the fuselage had sustained substantial damage. The landing gear was lowered and locked into place without issue after the airplane was lifted from the runway.

The pilot and two passengers departed on an instrument flight rules cross-country flight in night instrument meteorological conditions (IMC). The pilot was instructed by air traffic control to climb to 12,000 ft, and then cleared to climb to FL230. The pilot reported to the controller that the airplane encountered freezing drizzle and light rime icing during the climb from 6,500 ft to 8,000 ft mean sea level (msl). As the airplane climbed through 11,600 ft msl, the pilot reported that they had an issue with faulty deicing equipment and needed to return to the airport. The controller instructed the pilot to descend and cleared the airplane back to the airport. When asked by the controller if there was an emergency, the pilot stated that they “blew a breaker,” and were unable to reset it. As the controller descended the airplane toward the airport, the pilot reported that they were having issues with faulty instruments. At this time, the airplane was at an altitude of about 4,700 ft. The controller instructed the pilot to maintain 5,000 ft, and the pilot responded that he was “pulling up.” There was no further communication with the pilot. Review of the airplane’s radar track showed the airplane’s departure from the airport and the subsequent turn and southeast track toward its destination. The track appeared as a straight line before a descending, right turn was observed. The turn radius decreased before the flight track ended. The airplane impacted terrain in a right-wing-low attitude. The wreckage was scattered and highly fragmented along a path that continued for about 570 ft. Examination of the wreckage noted various pieces of the flight control surfaces and cables in the wreckage path. Control continuity could not be established due the fragmentation of the wreckage; however, no preimpact anomalies were found. Examination of the left and right engines found rotational signatures and did not identify any pre-impact anomalies. A review of maintenance records noted two discrepancies with the propeller deice and surface deice circuit breakers, which were addressed by maintenance personnel. Impact damage and fragmentation prevented determination of which circuit breaker(s) the pilot was having issues with or an examination of any deicing systems on the airplane. The radio transmissions and transponder returns reflected in the radar data indicate that the airplane’s electrical system was operational before the accident. It is likely that the pilot’s communications with the controller and attempted troubleshooting of the circuit breakers introduced distractions from his primary task of monitoring the flight instruments while in IMC. Such interruptions would make him vulnerable to misleading vestibular cues that could adversely affect his ability to effectively interpret the instruments and maintain control of the airplane. The pilot’s report of “faulty instruments” during a decreasing radius turn and his initial distraction with the circuit breakers and radio communications is consistent with the effects of spatial disorientation.

While on an instructional flight in icing and instrument meteorological conditions (IMC), the pilots indicated that they were having instrumentation difficulties to air traffic control. They initially reported a problem with the autopilot, then a navigational issue, which they later indicated were resolved, and finally they reported it was a problem with the left side attitude indicator. After air traffic control cleared them to their destination, the airplane entered a descending left turn, which continued into a 360° descending turn. An inflight breakup resulted, with the wreckage being scattered over 7,000 ft of wooded terrain. Examination of the engines revealed there were no anomalies that would have precluded normal operation prior to the accident. Control cable continuity was established from the flight controls in the cockpit to all flight control surfaces through multiple overload failures. The pitot-static system was examined, and no blockages were noted. Since there was rotational scoring noted on the vertical gyro and the directional gyro, it’s likely they were operating at the time of the accident. Furthermore, the left side attitude indicator examination revealed that there were no anomalies with the instrument. Examination of the deice valves for the deicing boots revealed that the left wing deice valve did not operate. Corrosion was visible in all three valves and it could not be determined if the corrosion was a result of postimpact environmental exposure. Furthermore, since the cockpit switch positions were compromised in the accident, it could not be determined if the pilots were operating the deicing system at the time of the accident. However, most of the pilot reports (PIREPs) in the area indicated light icing and the airplane performed a 6,000 ft per minute climb just before the loss of control. Given this information, it is unlikely the icing conditions made the airplane uncontrollable. A review of the pilots’ flight experience revealed that the pilot in the left seat did not hold a type rating for the accident airplane model but was scheduled to attend flight training to obtain such a type rating. The pilot in the right seat, who also held a flight instructor certificate, did hold a type rating for the airplane. Given that the remarks section of the filed flight plan described the flight as a “training flight” and the left-seat pilot’s plan to obtain a type rating for the accident airplane model, it is likely the pilot in the left seat was the flying pilot for the majority of the flight. Although the right-seat pilot's autopsy noted coronary artery disease, the condition was poorly described. The circumstances of the accident are not consistent with sudden physical impairment or incapacitation; therefore, it is unlikely it contributed to the event. Toxicology testing identified diphenhydramine, which can cause significant sedation, in the right-seat pilot’s blood. However, the level present at the time of the accident was too low to quantify. Therefore, it is unlikely effects from diphenhydramine contributed to the accident. Prior to entering the descending right turn, air traffic control noted that the airplane was not following assigned headings and altitudes and the pilots’ reported having autopilot problems. Subsequently, the pilots’ reported they were using the right attitude indicator as they had difficulties with the left-side indicator. Information was insufficient to evaluate whether the reported difficulties were the result of a malfunction of the autopilot or the pilots’ management of the autopilot system. However, the reported difficulties likely increased the pilots’ workload, may have diverted their attention while operating in IMC and icing conditions, resulting in task saturation, and may have increased their susceptibility to spatial disorientation. It is also possible that the onset of spatial disorientation was the beginning of the pilots’ difficulties maintaining the airplane’s flight track and what they perceived to be an instrumentation problem. Regardless, since the left seat pilot was not rated to fly the airplane, the right seat pilot’s workload would have increased by having to diagnose the issue, assess the situation, and maintain positive airplane control. The airplane’s track data are consistent with the known effects of spatial disorientation, leading to an inflight loss of control and subsequent inflight breakup.

While the pilot was on a visual approach to the airport and descending over water on the left base leg, about 100 ft above the water's surface, the airplane entered instrument meteorological conditions with no forward visibility. The pilot looked outside his left window to gauge the airplane's altitude and saw "black waves of water approaching extremely rapidly." He tried to pull back on the yoke to initiate a climb, but the nosewheel contacted the water. Subsequently, the airplane nosed over and came to rest inverted in the water. The pilot reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation.