Florida

The pilot obtained multiple preflight weather briefings that resulted in him delaying the flight’s departure until the afternoon. After departure, while near his intended destination, the pilot was twice advised by air traffic controllers of adverse weather, including heavy to extreme precipitation along the intended final approach. While in visual meteorological conditions the pilot requested an RNAV approach to his destination airport. While flying towards the final approach fix at a low thrust setting the autopilot attempted to maintain 2,000 ft while pitching up and slowing to about 100 knots, causing an airspeed aural warning. The pilot applied partial thrust and while in instrument meteorological conditions the flight encountered extreme precipitation and turbulence associated with the previously reported thunderstorm. The pilot turned off the autopilot; the airplane then climbed at a rate that was well beyond the performance capability of the airplane, likely caused by updrafts from the mature thunderstorm and application of takeoff thrust. The High Electronic Stability & Protection (ESP) engaged, pitching the airplane nose-down coupled with the pilot pushing the control stick forward. The airplane then began descending followed by pitching up and climbing again. The pilot pulled the Cirrus Airframe Parachute System (CAPS) and descended under canopy into a marsh but the airplane was dragged a short distance from wind that inflated the CAPS canopy. Post accident examination of the recovered airplane revealed substantial damage to the front pressure bulkhead and to both sides of the fuselage immediately behind the front pressure bulkhead. There was no evidence of preimpact failure or malfunction of the flight controls for roll, pitch, or yaw. Data downloaded from the Recoverable Data Module (RDM) revealed no faults with the autopilot or stability protection systems until the CAPS system was activated, when those recorded faults would have been expected. Further, there were no discrepancies with the engine. Although the pilot perceived a malfunction of the autopilot at several times during the final portion of the flight, the perceived autopilot discrepancies were likely normal system responses based on the autopilot mode changes.

Following an uneventful flight from Santo Domingo-Las Américas Airport, the crew was cleared to land on runway 09 at Miami-Intl Airport. The first officer recalled that the airplane touched down smoothly on the right and then the left main landing gear and that the airplane was slightly to the right of the centerline, which he corrected after touching down. Shortly afterward, the flight crew felt a vibration on the left side of the airplane. The vibration increased, and the airplane veered to the left despite the crew’s efforts to maintain the airplane on the runway centerline. The airplane subsequently departed the paved runway surface and impacted the glideslope equipment building for runway 30, which was located to the left of runway 09, causing the nose landing gear and the right main landing gear to collapse. A post crash fire began on the right wing after the fuel tank on that wing was breached, after which the airplane came to a stop. Nevertheless, fire was quickly extinguished and all 140 occupants evacuated safely, among them four passengers were taken to Jackson Hospital.

Shortly after departure, the engine lost total power and the pilot was forced to ditch in open water; the occupants egressed and were subsequently rescued by a recreational vessel. Examination of the engine revealed a fracture hole near the n°2 cylinder, which was likely the result of the n°2 cylinder connecting rod fracturing in fatigue as a result of high heat and high stress associated with failure of the n°2 bearing. The fatigue fracture displayed multiple origins consistent with relatively high cyclic stress, which likely occurred as excessive clearances developed between the bearing and the crankshaft journal. The n°2 connecting rod bearing may have failed due to a material defect in the bearing itself or due to a disruption in the oil lubrication supply to the bearing/journal interface. Either situation can cause similar damage patterns to develop, including excessive heating and subsequent bearing failure.

The flight crew, which consisted of the pilot- and second-in-command (PIC and SIC), and a non-type-rated observer pilot, reported that during takeoff near 100 knots a violent shimmy developed at the nose landing gear (NLG). The PIC aborted the takeoff and during the abort procedure, the NLG separated. The airplane veered off the runway, and the right wing and right main landing gear struck approach lights, which resulted in substantial damage to the fuselage and right wing. The passengers and flight crew evacuated the airplane without incident through the main cabin door. Postaccident interviews revealed that following towing operations prior to the flight crew’s arrival, ground personnel were unable to get the plunger button and locking balls of the NLG’s removable pip pin to release normally. Following a brief troubleshooting effort by the ground crew, the pip pin’s plunger button remained stuck fully inward, and the locking balls remained retracted. The ground crew re-installed the pip pin through the steering collar with the upper torque link arm connected. However, with the locking balls in the retracted position, the pin was not secured in position as it should have been. Further, the ground personnel could not install the safety pin through the pip pin because the pin’s design prevented the safety pin from being inserted if the locking balls and plunger were not released. The ground personnel left the safety pin hanging from its lanyard on the right side of the NLG. The ground personnel subsequently informed their ramp supervisor of the anomaly. The supervisor reported that he informed the first arriving crewmember at the airplane (the observer pilot) that the nose pin needed to be checked. However, all three pilots reported that no ground crewmember told them about any issues with the NLG or pins. Examination of the runway environment revealed that the first item of debris located on the runway was the pip pin. Shortly after this location, tire swivel marks were located near the runway centerline, which were followed by large scrape and tire marks, leading to the separated NLG. The safety pin remained attached to the NLG via its lanyard and was undamaged. Postaccident examination and testing of the NLG and its pins revealed no evidence of preimpact mechanical malfunctions or failures. The sticking of the pip pin plunger button that the ground crew reported experiencing could not be duplicated during postaccident testing. When installed on the NLG, the locking ball mechanism worked as intended, and the pip pin could not be removed by hand. Although the airplane’s preflight checklist called for a visual check of the NLG’s torque link to ensure that it was connected to the steering collar by the pip pin and that the safety pin was installed, it is likely that none of the pilots noticed that the pip pin did not have its safety pin installed during preflight. Subsequently, during the takeoff roll, without the locking balls extended, the pip pin likely moved outward and fell from its position holding the upper torque link arm. This allowed the upper torque link arm to move freely, which resulted in the violent shimmy and NLG separation. The location of the debris on the runway, tire marks, and postaccident examination and testing support this likely chain of events. Contributing to the PIC and SIC’s omission during preflight was the ground crew’s failure to directly inform the PIC or SIC that there was a problem with the NLG pip pin. The ground crew also failed to discard the malfunctioning pip pin per the airplane’s ground handling procedures and instead re-installed the pip pin. Although the observer pilot was reportedly informed of an issue with a nose gear pin, he was not qualified to act as a required flight crewmember for the airplane and was on his cell phone when he was reportedly informed of the issue by the ramp supervisor. These factors likely contributed to the miscommunication and the PIC’s and SIC’s subsequent lack of awareness of the NLG issue.

The pilot, who was the owner of the airplane, and the pilot-rated passenger, whose maintenance facility had recently completed work on the airplane, departed on the second of two local flights on the day of the accident as requested by the pilot, since he had not flown the airplane recently. Flight track and engine monitor data indicated that, about 15 minutes after takeoff, fuel flow and engine exhaust gas temperature (EGT) values were consistent with a total loss of left engine power at an altitude about 2,500 ft. Engine power was fully restored about 4 minutes later. Between the time of the power loss and subsequent restoration, the airplane directly overflew an airport and was in the vicinity of a larger airport. It is likely that the left engine was intentionally shut down to practice one engine inoperative (OEI) procedures. Had the loss of power been unanticipated, the pilot would likely have initiated a landing at one of these airports in accordance with the airplane’s published emergency procedure, which was to land as soon as possible if engine power could not be restored; however, data indicated that engine power was restored, and the flight continued back to the departure airport. About 7.5 minutes later, about 6 nautical miles from the departure airport, engine data indicated a total loss of right engine power, followed almost immediately by a total loss of left engine power, at an altitude about 3,500 ft. A battery voltage perturbation consistent with starter engagement was recorded about 1 minute later, followed by a slight increase in left engine fuel flow; however, the data did not indicate that left engine power was fully restored during the remainder of the flight. The airplane continued in the direction of the departure airport as it descended and ultimately impacted a tree and terrain and came to rest upright. A witness saw the airplane flying toward her with the landing gear extended and stated that it appeared as though neither of the two propellers was turning. A doorbell security camera near the accident site captured the airplane as it passed overhead at low altitude. Sound spectrum analysis of the footage indicated that one engine was likely operating about 1,600 rpm while the other was operating at less than 1,000 rpm. The right propeller was found feathered at the accident site. An examination and test run of the right engine revealed no anomalies that would have precluded normal operation. The left propeller blades exhibited bending, twisting, and chordwise polishing consistent with the engine producing some power at the time of impact. Examination of the left engine and engine-driven fuel pump did not reveal any anomalies. Based on the available information, it is likely that the pilots were conducting practice OEI procedures and intentionally shut down the right engine. The loss of left engine power immediately after was likely the result of the pilot’s failure to properly identify and verify the “failed” engine before securing it, which resulted in an inadvertent shutdown of the left engine. Although partial left engine power was restored before the accident (as indicated by fuel flow values, damage to the left propeller, and sound spectrum analysis of security camera video), the left engine power available was inadequate to maintain altitude for reasons that could not be determined, and it is likely that the pilot was performing a forced landing when the accident occurred. It is also likely that the pilot’s decision to conduct intentional OEI flight at low altitude resulted in reduced time and altitude available for troubleshooting and restoration of engine power following the inadvertent shutdown of the left engine. The 67-year-old pilot was a Canadian national and had never applied for a Federal Aviation Administration medical certificate. According to the Transportation Safety Board of Canada, the pilot was issued a category 1 license with knowledge of a previous condition and knowledge of currently taking Xarelto (rivaroxabam). No acute or historical cardiovascular event was found on autopsy. Toxicology testing detected the sedating antihistamine cetirizine just below therapeutic levels in the pilot’s blood. A very low concentration of the narcotic pain medication codeine was detected in the pilot’s blood and urine; codeine’s metabolite morphine was also detected in his urine. The mood stabilizing medication lamotrigine was detected but not quantified in the pilot’s blood and urine. Thus, the pilot was taking some impairing medications and likely had a psychiatric condition that could impact decision-making and performance; however, given the circumstances of the accident, including the presence of the pilot-rated passenger to operate the airplane, the effects from the pilot’s use of cetirizine, codeine, and lamotrigine were not likely factors in this accident.

After takeoff from his home airport with about 50 gallons of fuel in each fuel tank, the pilot climbed to 7,000 ft and proceeded to his destination. When he was about halfway there, he switched from the right fuel tank to the left fuel tank. Immediately after switching fuel tanks, the engine started to sputter and lost power. The pilot switched back to the right fuel tank but there was no change. He then tried different power settings, adjusted the mixture to full rich and switched tanks again without regaining engine power. The pilot advised air traffic control (ATC) that he was having an engine problem and needed to land at the nearest airport. ATC instructed him contact the control tower at the nearest airport and cleared him to land. The pilot advised the controller that he was not going to be able to make it to the airport and that he was going to land in the water. During the water landing, the airplane came to a sudden stop. The pilot and his passenger then egressed, and the airplane sank. An annual inspection of the airplane had been completed about 2 months prior to the accident and test flights associated with the annual inspection had all been done with the fuel selector selected to the right fuel tank, and this was the first time he had selected the left fuel tank since before the annual inspection. The airplane was equipped with an engine monitor that was capable of recording engine parameters. Examination of the data revealed that around the time of the loss of engine power, exhaust gas temperature and cylinder head temperature experienced a rapid decrease on all cylinders along with a rapid decrease of turbine inlet temperature, which was indicative of the engine being starved of fuel. Examination of the wreckage did not reveal any evidence of any preimpact failures or malfunctions of the airplane or engine that would have precluded normal operation. During examination of the fuel system, the fuel selector was observed in the RIGHT fuel tank position and was confirmed to be in the right fuel tank position with low pressure air. However, when the fuel selector was positioned to the LEFT fuel tank position, continuity could not be established with low pressure air. Further examination revealed that a fuel selector valve labeled FERRY TANK was installed in the left fuel line between the factory-installed fuel selector and the left fuel tank. The ferry tank fuel selector was observed to be in the ON position, which blocked continuity from the left fuel tank to the engine. Continuity could only be established when the ferry tank fuel selector was positioned to the OFF position. With low pressure air, no continuity could be established from the ferry tank fuel line that attached to the ferry tank’s fuel selector. The ferry tank fuel selector valve was mounted between the pilot and copilot seats on the forward side of the main wing spar in the area where the pilot and copilot would normally enter and exit the cockpit. This location was such that the selector handle could easily be inadvertently kicked or moved by a person or object. A guard was not installed over the ferry tank fuel selector valve nor was the selector valve handle safety wired in the OFF position to deactivate the valve even though a ferry tank was not installed. Review of the airplane’s history revealed that about 3 years before the accident, the airplane had been used for an around-the-world flight by the pilot and that prior to the flight, a ferry tank had been installed. A review of maintenance records did not reveal any logbook entries or associated paperwork for the ferry tank installation and/or removal, except for a copy of the one-page fuel system schematic from the maintenance manual with a handwritten annotation (“Tank”), and hand drawn lines, both added to it in blue ink. A review of Federal Aviation Administration records did not reveal any record of a FAA Form 337 (Major Repair or Alteration) or a supplemental type certificate for installation of the ferry tank or the modification to the fuel system.

The copilot, who was seated in the right seat, reported that after an uneventful run-up and taxi, the pilot, who was seated in the left seat, initiated the takeoff. The airplane remained on the runway past the point at which takeoff should have occurred and the copilot observed the pilot attempting to pull back on the control yoke but it would not move. The copilot then also attempted to pull back on the control yoke but was also unsuccessful. Observing that the end of the runway was nearing, the copilot aborted the takeoff by reducing the throttle to idle and applying maximum braking. The airplane overran the runway into rough and marshy terrain, where it came to rest partially submerged in water. Postaccident examination of the airplane and flight controls found no evidence of preimpact mechanical malfunctions or failures that would have precluded normal operation. Specifically, examination of the elevator flight control rigging, in addition to functional checks of the elevator, confirmed continuity and normal function. Additionally, the flight control lock was found on the floor near the rudder pedals on the left side of the cockpit. Due to a head injury sustained during the accident, the pilot was unable to recall most of the events that transpired during the accident. The pilot did state that he typically removed the control lock during the preflight inspection and that he would place it in his flight bag. He thought that a shoulder injury may have led to the control lock missing the flight bag, and why it was found behind the rudder pedals after the accident. Review and analysis of a video that captured the airplane during its taxi to the runway showed that the elevator control position was similar to what it would be with the control lock installed. While the pilot and copilot reported that they did not observe the control lock installed during the takeoff, the position of the elevator observed on the video, the successful postaccident functional test of elevator, and the unsecured flight control lock being located behind the pilot’s rudder pedals after the accident suggest that the control anomaly experienced by the pilots may have been a result of the control lock remaining inadvertently installed and overlooked by both pilots prior to the takeoff. According to the airframe manufacturer’s preflight and before takeoff checklists, the flight control lock must be removed during preflight, prior to engine start and taxi, and the flight controls must be checked prior to takeoff. Regardless of why the elevator control would not move during the takeoff, a positive flight control check prior to the takeoff should have detected any such anomaly. It is likely that the pilot failed to conduct a flight control check prior to takeoff. Further, the pilot failed to abort the takeoff at the first indication that there was a problem. Although delayed, the copilot’s decision to take control of the airplane and abort the takeoff likely mitigated the potential for more severe injury to the occupants and damage to the airplane.

The pilot-in-command seated in the right seat was providing familiarization in the multiengine airplane to the left seat pilot during a flight to a nearby airport for fuel. Shortly after takeoff, one of the pilots reported an engine problem and advised that they were diverting to a nearby airport. A witness along the route of flight reported hearing the engines accelerating and decelerating and then popping sounds; several witnesses near the accident site reported hearing no engine sounds. The airplane impacted a building and terrain about 10 minutes after takeoff. Very minimal fuel leakage on the ground was noted and only 23 ounces of aviation fuel were collected from the airplane’s five fuel tanks. No evidence of preimpact failure or malfunction was noted for either engine or propeller; the damage to both propellers was consistent with low-to-no power at impact. Since the pilot could not have visually verified the fuel level in the center fuel tank because of the low quantity of fuel prior to the flight, he would have had to rely on fuel consumption calculations since fueling based on flight time and the airplane’s fuel quantity indicating system. Although the fuel quantity indications at engine start and impact could not be determined postaccident from the available evidence, if the fuel quantity reading at the start of the flight was accurate based on the amount of fuel required for engine start, taxi, run-up, takeoff, and then only to fly the accident flight duration of 10 minutes, it would have been reading between 8 and 10 gallons. It is unlikely that the pilot, who was a chief pilot of a cargo operation and tasked with familiarizing company pilots in the airplane, would have knowingly initiated the flight with an insufficient fuel load for the intended flight or with the fuel gauge accurately registering the actual fuel load that was on-board. Examination of the tank unit, or fuel quantity transmitter, revealed that the resistance between pins A and B, which were the ends of the resistor element inside the housing, fell within specification. When monitoring the potentiometer pin C, there was no resistance, indicating an open circuit between the wiper and the resistor element. X-ray imaging revealed that the conductor of electrical wire was fractured between the end of the lugs at the wiper and for pin C. Bypassing the fractured conductor, the resistive readings followed the position of the float arm consistent with normal operation. Visual examination of the wire insulation revealed no evidence of shorting, burning or damage. Examination of the fractured electrical conductor by the NTSB Materials Laboratory revealed that many of the individual wires exhibited intergranular fracture surface features with fatigue striations in various directions on some individual grains. It is likely that the many fatigue fractured conductor strands of the electrical wire inside the accident tank unit or fuel transmitter resulted in the fuel gauge indicating that the tanks contained more fuel than the amount that was actually on board, which resulted in inadequate fuel for the intended flight and a subsequent total loss of engine power due to fuel exhaustion. The inaccurate fuel indication would also be consistent with the pilot’s decision to decline additional fuel before departing on the accident flight. While the estimated fuel remaining since fueling (between 15 and 51 gallons) was substantially more than the actual amount on board at the start of the accident flight (between 8 and 10 gallons), the difference could have been caused by either not allowing the fuel to settle during fueling, and/or the operational use of the airplane. Ultimately, the fuel supply was likely completely exhausted during the flight, which resulted in the subsequent loss of power to both engines. Given the circumstances of the accident, the effects from the right seat pilot’s use of cetirizine and the identified ethanol in the left seat pilot, which was likely from sources other than ingestion, did not contribute to this accident.

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 owner of the airplane had purchased the airplane with the intent to resell it after repairs had been made. As part of that process, a mechanic hired by the owner had assessed the airplane’s condition, proposed the necessary repairs to the airplane’s owner, and had identified a pilot who would, once the repairs and required inspection annual inspection had been completed, fly the airplane from where it was located to where the owner resided. While the mechanic had identified a potential pilot for the relocation flight, he had not yet completed the repairs to the airplane, nor had he completed the necessary logbook entries that would have returned the airplane to service. The pilot-rated passenger onboard the airplane for the accident flight, was the pilot who had been identified by the mechanic for the relocation flight. Review of the pilot-rated passenger’s flight experience revealed that he did not possess the necessary pilot certificate rating, nor did he have the flight experience necessary to act as pilot-in-command of the complex, highperformance, pressurized, multi-engine airplane. Additionally, the owner of the airplane had not given the pilot-rated-passenger, or anyone else, permission to fly the airplane. The reason for, and the circumstances under which the pilot-rated passenger and the commercial pilot (who did hold a multi-engine rating) were flying the airplane on the accident flight could not be definitively determined, although because another passenger was onboard the airplane, it is most likely that the accident flight was personal in nature. Given the commercial pilot’s previous flight experience, it is also likely that he was acting as pilot-in-command for the flight. One witness said that he heard the airplane’s engines backfiring as it flew overhead, while another witness located about 1 mile from the accident site heard the accident airplane flying overhead. The second witness said that both engines were running, but they seemed to be running at idle and that the flaps and landing gear were retracted. The witness saw the airplane roll to the left three times before descending below the tree line. As the airplane descended toward the ground, the witness heard the engines make “two pop” sounds. The airplane impacted a wooded area about 4 miles from the departure airport, and the wreckage path through the trees was only about 75-feet long. While the witnesses described the airplane’s engines backfiring or popping before the accident, the postaccident examination of the wreckage revealed no evidence of any preimpact mechanical malfunctions or failures that would have precluded normal operation. Additionally, examination of both propeller blades showed evidence of low rotational energy at impact, and that neither propeller had been feathered in flight. Given the witness statement describing the airplane “rolling three times” before it descended from view toward the ground, it is most likely that the pilot lost control of the airplane and while maneuvering. It is also likely that the pilot’s lack of any documented previous training or flight experience in the accident airplane make and model contributed to his inability to maintain control of the airplane. Toxicology testing was performed on the pilot’s chest cavity blood. The results identified 6.7 ng/ml of delta-9-tetrahydracannabinol (THC, the active compound in marijuana) as well as 2.6 ng/ml of its active metabolite, 11-hydroxy-THC and 41.3 ng/ml of its inactive metabolite delta9-carboxy-THC. Because the measured THC levels were from cavity blood, it was not possible to determine when the pilot last used marijuana or whether he was impaired by it at the time of the flight. As a result, it could not be determined whether effects from the pilot’s use of marijuana contributed to the accident circumstances.