California

Earlier on the day of the accident, the flight crew had conducted a patient transfer from a remote airport to another nearby airport. Following the patient transfer, the flight crew departed under night conditions to return to their home base. Review of air traffic control (ATC) communication, as well as cockpit voice recorder (CVR) recordings, showed that the flight crew initially was cleared on the RNAV (GPS) runway 17 instrument approach. The approach plate for the instrument approach stated that circling to runway 27R and 35 was not authorized at night. Following the approach clearance, the flight crew discussed their intent to cancel the approach and circle to land on runway 27R. Additionally, the flight crew discussed with each other if they could see the runway. Once the flight crew established visual contact with the runway, they requested to squawk VFR, then the controller cleared them to land on runway 17. The flight crew then requested to land on runway 27. The controller asked the pilot if they wanted to cancel their instrument flight rules (IFR) flight plan, to which the pilot replied, “yes sir.” The controller acknowledged that the IFR cancellation was received and instructed the pilot to overfly the field and enter left traffic for runway 27R and cleared them to land. Shortly after, the flight crew asked the controller if the runway lights for runway 27R could be increased; however, the controller informed them that the lights were already at 100 percent. Just before the controller’s response, the copilot, who was the pilot flying, then asked the captain “where is the runway.” As the flight crew maneuvered to a downwind leg, the captain told the copilot not to go any lower; the copilot requested that the captain tell him when to turn left. The captain told him to turn left about 10 seconds later. The copilot stated, “I see that little mountain, okay” followed by both the captain and co-pilot saying, “woah woah woah, speed, speed” 3 seconds later. During the following 5 seconds, the captain and copilot both stated, “go around the mountain” followed by the captain saying, “this is dicey” and the co-pilot responding, “yeah it’s very dicey.” Shortly after, the captain told the copilot “here let me take it on this turn” followed by the co-pilot saying, “yes, you fly.” The captain asked the copilot to watch his speed, and the copilot agreed. About 1 second later, the copilot stated, “speed speed speed, more more, more more, faster, faster… .” Soon after, the CVR indicated that the airplane impacted the terrain. Automatic dependent surveillance – broadcast (ADS-B) data showed that at the time the flight crew reported the runway in sight, they were about 360 ft below the instrument approach minimum descent altitude (MDA), and upon crossing the published missed approach point they were 660 ft below the MDA. The data showed that the flight overflew the destination airport at an altitude of about 775 ft mean sea level (msl), or 407 ft above ground level (agl), and entered a left downwind for runway 27R. While on the downwind leg, the airplane descended to an altitude of 700 ft msl, then ascended to an altitude of 950 ft msl while on the base leg. The last recorded ADS-B target was at an altitude of 875 ft msl, or about 295 ft agl.

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.

The pilot was on a cross-country flight, receiving vectors for an instrument approach while in instrument meteorological conditions (IMC). The approach controller instructed the pilot to descend to 2,800 ft mean sea level (msl) until established on the localizer, and subsequently cleared the flight for the instrument landing system (ILS) approach to runway 28R, then circle to land on runway 23. About 1 minute later, the controller told the pilot that it looked like the airplane was drifting right of course and asked him if he was correcting back on course. The pilot responded “correcting, 22G.” About 9 seconds later, the pilot transmitted “SoCal, is 22G, VFR runway 23” to which the controller told the pilot that the airplane was not tracking on the localizer and subsequently canceled the approach clearance and instructed the pilot to climb and maintain 3,000 ft. As the pilot acknowledged the altitude assignment, the controller issued a low altitude alert, and provided the minimum vectoring altitude in the area. The pilot acknowledged the controller’s instructions shortly after. At this time, recorded advanced dependent surveillance-broadcast (ADS-B) data showed the airplane on a northwesterly heading at an altitude of 2,400 ft msl. Over the course of the following 2 minutes, the controller issued multiple instructions for the pilot to climb to 4,000 ft, which the pilot acknowledged; however, ADS-B data showed that the airplane remained between 2,500 ft and 3,500 ft. The controller queried the pilot about his altitude and the pilot responded, “2,500 ft, 22G.” The controller subsequently issued a low altitude alert and advised the pilot to expedite the climb to 5,000 ft. No further communication was received from the pilot despite multiple queries from the controller. ADS-B data showed that the airplane had begun to climb and reached a maximum altitude of 3,500 ft before it began a descending right turn. The airplane remained in the right descending turn at a descent rate of about 5,000 ft per minute until the last recorded target at 900 ft msl, located about 1,333 ft northwest of the accident site. The airplane and two houses were destroyed. The pilot and the driver of a UPS truck were killed. Two other people on the ground were injured.

The captain and first officer (FO) departed on a non-revenue flight operating under instrument flight rules with four passengers bound for Truckee, California. Most of the flight was uneventful. During the descent, air traffic control (ATC) told the flight crew to expect the area navigation (RNAV [GPS]) approach for runway 20. The captain (pilot flying [PF]) stated and the FO (pilot monitoring [PM]) calculated and confirmed that runway 20 was too short for the landing distance required by the airplane at its expected landing weight. Instead of making a request to ATC for the straight-in approach to runway 11 (the longer runway), the captain told the FO they could take the runway 20 approach and circle to land on runway 11, and the FO relayed this information to ATC. ATC approved, and the flight crew accepted the circle-to-land approach. Although the descent checklist required that the flight crew brief the new circle-to-land approach, and the flight crew’s acceptance of the new approach invalidated the previous straight-in approach brief, they failed to brief the new approach. ATC instructed the flight crew to hold, but the captain was slow in complying with this instruction, so the FO started the turn to enter the holding pattern and then informed ATC once they were established in the hold. About 20 seconds later, ATC cleared them for the approach. Before the FO confirmed the clearance, he asked the captain if he was ready for the approach, and the captain stated that he was. The FO subsequently commented that they had too much airspeed at the beginning of the approach and then suggested a 360° turn to the captain, but the captain never acknowledged the excessive airspeed and refused the 360° turn. After the FO visually identified the airport, he told the captain to make a 90° right turn to put the airplane on an approximate heading of 290°, which was parallel to runway 11 and consistent with the manufacturer’s operating manual procedures for the downwind leg of the circling approach. However, the FO instructed the captain to roll out of the turn prematurely, and the captain stopped the turn on a heading of about 233° magnetic, which placed the airplane at an angle 57° left of the downwind course parallel with runway 11. As a result of the early roll-out, the flight crew established a course that required an unnecessarily tight turning radius. When they started the turn to final, the airplane was still about 1.3 nautical miles (nm) from the maximum circling radius that was established for the airplane’s approach category. The FO also deployed flaps 45° after confirming with the captain (the manufacturer’s operating manual procedures for the downwind leg called for a flaps setting of 30°, but the manufacturer stated that a flight crew is not prohibited from a flaps 45° configuration if the approach remains within the limitations of the airplane’s flight manual). The airplane’s airspeed was 44 kts above the landing reference speed (Vref) of 118 kts that the flight crew had calculated earlier in the flight; the FO told the captain, “I’m gonna get your speed under control for you.” The FO likely reduced the throttles after he made this statement, as the engine fan speeds (N1) began to decrease from about 88% to about 28%, and the airplane began to slow from 162 kts. After the FO repeatedly attempted to point out the airport to the captain, the captain identified the runway; the captain's difficulty in finding the runway might have been the result of reduced visibility in the area due to smoke. The FO continuously reassured and instructed the captain throughout the circle-to-land portion of the approach. On the base leg to the runway and about 25 seconds before impact with the ground, the FO started to repeatedly ask for control of the airplane, but neither flight crewmember verbalized a positive transfer of control as required by the operator’s general operating manual (GOM); we could not determine who had control of the airplane following these requests. As the airplane crossed the runway extended centerline while maneuvering toward the runway, the FO noted that the airplane was too high. One of the pilots (recorded flight data did not indicate which) fully deployed the flight spoilers, likely to increase the airplane's sink rate. (The flight spoilers are deployed using a single control lever accessible to both pilots.) The airspeed at the time was 135 kts, 17 kts above the Vref based on the erroneous basic operating weight (BOW) programmed into the airplane’s flight management system (FMS). About 7 seconds later, the left bank became steeper, and the stall protection system (SPS) stick shaker and stick pusher engaged. The captain asked the FO, “What are you doing,” and the FO again asked the captain multiple times to “let [him] have the airplane.” The stick shaker and stick pusher then briefly disengaged before engaging again. The airplane then entered a rapid left roll, consistent with a left-wing stall, and impacted terrain. A postcrash fire consumed most of the wreckage. All six occupants, four passengers and two pilots, were killed.

Before taking off, the pilot canceled an instrument flight rules (IFR) flight plan that she had filed and requested a visual flight rules (VFR) on-top clearance, which the controller issued via the Monterey Five departure procedure. The departure procedure included a left turn after takeoff. The pilot took off and climbed to about 818 ft then entered a right turn. The air traffic controller noticed that the airplane was in a right-hand turn rather than a left-hand turn and issued a heading correction to continue a right-hand turn to 030o , which the pilot acknowledged. The airplane continued the climbing turn for another 925 ft then entered a descent. The controller issued two low altitude alerts with no response from the pilot. No further radio communication with the pilot was received. The airplane continued the descent until it contacted trees, terrain, and a residence about 1 mile from the departure airport. Review of weather information indicated prevailing instrument meteorological conditions (IMC) in the area due to a low ceiling, with ceilings near 800 ft above ground level and tops near 2,000 ft msl. Examination of the airframe and engines did not reveal any anomalies that would have precluded normal operation. The airplane’s climbing right turn occurred shortly after the airplane entered IMC while the pilot was acknowledging a frequency change, contacting the next controller, and acknowledging the heading instruction. Track data show that as the right-hand turn continued, the airplane began descending, which was not consistent with its clearance. Review of the pilot’s logbook showed that the pilot had not met the instrument currency requirements and was likely not proficient at controlling the airplane on instruments. The pilot’s lack of recent experience operating in IMC combined with a momentary diversion of attention to manage the radio may have contributed to the development of spatial disorientation, resulting in a loss of airplane control.

The non-instrument-rated pilot departed on a cross-country flight. Radar track data revealed the airplane traveled on a relatively straight course to the northeast for about 32 minutes. Near the end of the flight track data, the track showed an increasingly tight left spiraling turn near the accident site. The airplane impacted steep sloping terrain, and a postimpact fire ensued. As a result of the impact, the airplane was segmented into several sections. Examination of the wreckage revealed no evidence of mechanical malfunction or failures that would have precluded normal operation. The attitude indicator instrument was disassembled, and the vacuum-powered rotor and housing revealed rotational scoring damage, indicating the instrument vacuum system was operational at the time of the accident. The investigation found no evidence indicating the pilot checked the weather or received weather information before departure. The surrounding weather reporting stations near the accident site reported wind conditions with peak gusts up to 47 knots around the time of the accident. The pilot likely encountered mountain wave activity with severe turbulence, which resulted in loss of control of the airplane and impact with terrain. Contributing to the accident was the pilot’s failure to obtain a preflight weather briefing, which would have alerted him to the presence of hazardous strong winds and turbulent conditions. Postmortem toxicology testing of the pilot’s lung and muscle tissue samples detected several substances that are mentally and physically impairing individually and even more so in combination for performing hazardous and complex tasks. However, blood concentrations are needed to determine the level of impairment, and no blood samples for the pilot were available. While the pilot was taking potentially impairing medications and likely had conditions that would influence decision making and reduce performance, without blood concentrations, it was not possible to determine whether the potentially impairing combination of medications degraded his ability to safely operate the airplane.

The flight crew was conducting a flight with two passengers and one flight attendant onboard the multiengine jet airplane. The flight crew later stated that at rotation speed, the captain applied back pressure to the control yoke; however, the nose did not rotate to a takeoff attitude. The captain attempted to rotate the airplane once more by relaxing the yoke then pulling it back again, and, with no change in the airplane’s attitude, he made the decision to reject the takeoff by retarding the thrust levers and applying maximum braking. The airplane overran the end of the runway onto a gravel pad where the landing gear collapsed. Continuity was confirmed from the flight controls to the control surfaces. No mechanical anomalies with the engines or airplane systems were noted during the investigation that would have precluded normal operation. A review of performance data indicated that the flight crew attempted to takeoff with the airplane 2,975 lbs over the maximum takeoff weight (MTOW), a center of gravity (CG) close to the most forward limit, and an incorrect stabilizer trim setting. The digital flight data recorder (DFDR) data indicated that the captain attempted takeoff at a rotation speed 23 knots (kts) slower than the calculated rotation speed for the airplane at maximum weight. Takeoff performance showed the departure runway was 575 ft shorter than the distance required for takeoff at the airplane’s weight. The captain, who was the pilot flying, did not hold any valid pilot certificates at the time of the accident because they had been revoked 2 years prior due to his falsification of logbook entries and records. Additionally, he had never held a type rating for the accident airplane and had started, but not completed, training in the accident airplane model before the accident. The first officer had accumulated about 16 hours of flight experience in the make and model of the airplane and was not authorized to operate as pilot-in-command. The airplane’s flight management system (FMS) data were not recovered; therefore, it could not be determined what data the flight crew entered into the FMS that allowed the airspeed numbers to be generated. The investigation revealed that had the actual performance numbers been entered, a “FIELD LIMITED” amber message would have illuminated warning the crew that the MTOW was exceeded, and airspeed numbers would not have been generated. Therefore, it is likely that the crew entered incorrect data into the FMS either by manually entering a longer runway length and/or decreased the weight of the fuel, passengers, and/or cargo.

While the airplane was in cruise flight and being flown by the copilot, the left engine fuel pressure fluctuated, which was followed by a brief loss of engine power. Concerned that the airplane might have a failed engine-driven fuel pump, the pilot turned the boost pumps to high and asked the passenger (the airplane’s mechanic) to open the fuel cross-feed valve. As the airplane approached its intended destination, both fuel pressure needles began to fluctuate. The pilot assumed that fuel starvation to the engines was occurring and decided to make an off-airport landing to a field behind their airplane’s position due to residential areas located between the airplane’s location and the airport. The pilot stated that he took control of the airplane from the copilot and initiated a right turn toward the field, and that, shortly afterward, both engines lost total power. During the landing roll, the pilot observed a ditch in front of the airplane and was able to get the airplane airborne briefly to avoid the first ditch; however, he was not able to avoid a second, larger ditch. Subsequently, the airplane struck the second ditch, became airborne, and impacted the ground, which resulted in substantial damage to the fuselage. Recovery company personnel reported that, during recovery of the wreckage, about 1 gallon of fuel was removed from the two forward and the two aft wing fuel tanks. Postaccident examination of the airplane revealed no evidence of any pre-existing anomalies that would have precluded normal operation of either engine except that all four main fuel tank fuel gauges displayed erroneous indications after each tank was filled with water. No leaks were observed throughout the fuel system. The airplane was last refueled on the day before the accident with 497.7 gallons. When the airplane was last refueled, the fuel tanks were reportedly filled to about 3 inches below the fuel filler neck. The investigation could not determine, based on the available evidence for this accident, how much of the airplane’s fuel load (maximum capacity was 670 gallons) the airplane had onboard after it was refueled. Additionally, the pilot reported that he commonly used a fuel burn rate of 150 gallons per hour for flight planning purposes; that figure included takeoff fuel burn. Recorded automatic dependent surveillance broadcast data showed that the airplane had flown for 4 hours 1 minute since refueling and included six takeoffs and five landings (but did not include taxi times). As part of the investigation, the pilot estimated that 485.9 gallons of fuel had been used since the last refueling. However, on the basis of the pilot’s initial planned fuel load and recorded flight times, the airplane would have used about 600 gallons of fuel. The pilot later submitted an estimated fuel burn for the flights since refueling of 485.9 gallons. The flight manual did not have fuel burn references for the exact power settings and altitudes flown; thus, the hourly fuel burn could not be determined. The pilot, copilot, and passenger did not visually verify the fuel levels in all four main fuel tanks before the accident flight. The pilot also underestimated the amount of fuel that would be used for the planned flights. As a result, fuel exhaustion occurred, which led to a total loss of engine power.

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.

The pilot departed on a local flight with two passengers. Several witnesses reported that they heard the airplane’s engine backfiring and sputtering and subsequently heard the engine quit. The surviving passenger, who was seated in the front right seat, stated that the engine lost power and there was nowhere to land. The airplane subsequently impacted heavily wooded terrain about 1 mile from the departure airport. Postaccident examination of the engine revealed that the No. 7 cylinder intake valve was stuck open. The No. 2 cylinder front spark plug was defective, and the Nos. 2- and 4-cylinders’ ignition wires were frayed, worn, and displayed arcing, which likely led to erratic operation or a lack of ignition in these two cylinders. The culmination of these issues most likely led to the engine running rough, backfiring, and subsequently losing total power. An annual inspection was accomplished on the airframe and engine about 2 months before the
accident. General maintenance practices and the inspection should have identified the anomalies that were found during the postaccident engine examination.