code

GA

Crash of a Lockheed 12A Electra Junior in Jackson

Date & Time: Jun 17, 2024 at 2000 LT
Type of aircraft:
Operator:
Registration:
N2072
Flight Type:
Survivors:
Yes
MSN:
1208
YOM:
1936
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
After landing on the grassy runway 36 at Jackson-Seven Lakes Airfield, the twin engine airplane went out of control, veered off runway to the left and came to rest against a tree. All three occupants were injured and the airplane was damaged beyond repair. It was officially registered N2072 and the registration NC2072 was on the fuselage.

Crash of an Embraer EMB-545 Praetor 500 in Brunswick

Date & Time: Sep 21, 2023 at 1436 LT
Operator:
Registration:
N434FX
Survivors:
Yes
Schedule:
White Plains – Brunswick
MSN:
550-10073
YOM:
2020
Crew on board:
2
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
10900
Captain / Total hours on type:
1872.00
Copilot / Total flying hours:
16686
Copilot / Total hours on type:
306
Aircraft flight hours:
2863
Circumstances:
On September 21, 2023, about 1436 eastern daylight time, an Embraer SA EMB-525, N434FX, operated by Flexjet LLC, was substantially damaged when it was involved in an accident near St. Simons Island, Georgia. The pilot, copilot and six passengers were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91K fractional flight. The flight departed Westchester County Airport (HPN), White Plains, New York at 1239, destined for St. Simons Island Airport (SSI), St. Simons Island, Georgia. According to the pilot, the departure and en route phases of the flight were uneventful. During the arrival phase into SSI they elected to fly the RNAV (GPS) Runway 4 approach to allow them to be better aligned and setup for the landing. Checklists and callouts were conducted, and the approach was stable. After the 500 ft stable callout was made the airplane crossed over a small section of trees and rose slightly. The airplane then began to porpoise slightly when it was about 100 to 150 ft above mean sea level. The pilot tried to make corrections, but the airplane was not responding to his control inputs. The airplane then landed hard and slid along the runway, coming to rest in the grass off of runway 4. After the airplane came to rest, they evacuated the passengers safely and powered down the airplane. According to the copilot, the flight from HPN to SSI was uneventful until the final few seconds. When they were cleared for the approach, the pilot configured the airplane, slowed appropriately, and selected “Flaps 3” for the landing. The checklists were completed, and they had the runway in sight when they were 10 miles from the airport. No other traffic was identified as being in the airport traffic pattern and they prepared to land. The copilot made the “500’, Stabilized, 20 knot of headwind” callout at approximately 500 ft’. As the airplane crossed above the airport property, it began to pitch rapidly up and down. The copilot then looked over at the pilot’s hand on the control side sick and he could see him moving it back and forth excessively. He then said something along the lines of “Take it easy there,” and the pilot replied that the airplane was not responding. At that point the airplane was “maybe 50 ft” above the runway. The airplane touched down hard, prior to the runway threshold, on centerline, bounced and then touched down again. The airplane was listing to the right and skidding on the runway while slowly drifting to the right. The airplane slid off the runway and onto the grass where it hit a concrete sign base before it came to rest on the grass. Prior to opening the main cabin door, the copilot realized that both engines were still running. He then asked the pilot to shut down engines so that he could open the door to deplane the passengers. The copilot observed fuel gushing from the belly of the airplane when he exited. Examination of the accident site and airplane revealed that the airplane was substantially damaged. Both main landing gear were damaged, and the struts had punctured the top of the wings. During the impact sequence the airplane skidded down runway 4 for approximately 2,531 ft, then departed the right side of the runway, shearing off eight runway lights, one taxiway light, and destroying the taxiway A4 directional sign. The right main landing gear separated from the airplane and the leading edge of the right wing was damaged consistent with the impact with the taxiway sign. The airplane then went across taxiway A4, coming to rest between runway 4, taxiway A, and taxiway A4. The total distance from the airplane’s touchdown to where the airplane came to rest was approximately 3,083 ft. The reported wind at SSI about the time of the accident was from 050° at 13 knots, gusting to 23 knots. According to Federal Aviation Administration (FAA) and pilot records, the pilot held an airline transport pilot certificate, with a rating for airplane multi engine land, and commercial privileges for airplane single engine land and single engine sea. He also held type ratings on the BE-300, BE-400, CE-560XL, CE-650, CL-600, EMB-550, HS-125, and MU-300. His most recent FAA firstclass medical certificate was issued on June 13, 2023. He reported that he had accrued approximately 10,900 total flight hours, with 1,872 hours in the airplane make and model. According to FAA and pilot records, the copilot held an airline transport pilot certificate with a rating for airplane multi engine land, and commercial privileges for airplane single engine land. He also held type ratings on the A-310, A-320, B-757, B-767, DC-9, DC-10, EMB-550, and LR-JET. His most recent FAA first-class medical certificate was issued on June 13, 2023. He reported that he had accrued approximately 16,686 total flight hours, with 306 hours in the airplane make and model. According to FAA and maintenance records, the airplane was manufactured in 2020. The airplane’s most recent continuous airworthiness inspection was completed on April 11, 2023, at 2,863 total hours of operation.

Crash of a Cessna 340 in Covington: 2 killed

Date & Time: Apr 21, 2022 at 1844 LT
Type of aircraft:
Operator:
Registration:
N84GR
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Covington - Covington
MSN:
340-0178
YOM:
1973
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
0
Captain / Total hours on type:
0.00
Copilot / Total flying hours:
3148
Copilot / Total hours on type:
0
Aircraft flight hours:
7581
Circumstances:
The student pilot, who was the new owner of the multi-engine airplane, and a private pilot flew commercially to Lubbock, Texas, utilized a ride-hailing service to drive to Portales, New Mexico; they met with the former owner of the airplane to finalize the purchase of the airplane and flew it back to Georgia the same day. The next day, the student pilot commenced flight training with the private pilot who offered to provide flight instruction to the student pilot in the student pilot’s newly acquired multi-engine airplane, even though he did not possess a flight instructor’s rating or a multi-engine airplane rating. Radar data showed that the track of the accident airplane's route consisted of their departure airport, a midway stop, and the third leg of the flight, where it crashed during the approach to their destination airport. Witnesses observed a sharp right turn before the airplane’s spiraling descent and impact with terrain and unoccupied semi-trailers. Surveillance footage from a parking lot security camera captured the airplane in a right spiral turn just before the accident. The airplane was destroyed by impact forces and the postimpact fire. The postaccident examination of the airframe, engines, and propellers revealed no anomalies that would preclude normal engine and airplane performance. Additionally, a review of the maintenance logbook revealed that the airplane was overdue for its annual maintenance inspection; no special flight permit (ferry permit) was obtained from the Federal Aviation Administration (FAA) for its return flight to Georgia. Toxicological testing of the student pilot revealed the presence amphetamine, a prescription Schedule II controlled substance that may result in cognitive deficits that pose a risk to aviation safety; however, its effect, if any on the accident flight could not be determined. It is likely that the private pilot’s failure to maintain aircraft control was exacerbated by his lack of a multi-engine airplane rating, his lack of a flight instructor rating, and his poor decision making.
Probable cause:
The private pilot’s loss of control in flight, which resulted in a collision with terrain. Contributing to the accident was the student pilot’s decision to obtain flight instruction from the private pilot and the private pilot's insufficient qualifications to fly or to provide flight instruction in a multi-engine airplane.
Final Report:

Crash of a Dassault Falcon 20CC in Thomson: 2 killed

Date & Time: Oct 5, 2021 at 0544 LT
Type of aircraft:
Registration:
N283SA
Flight Type:
Survivors:
No
Schedule:
Lubbock - Thomson
MSN:
83
YOM:
1967
Flight number:
PKW887
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
11955
Captain / Total hours on type:
1665.00
Copilot / Total flying hours:
10908
Copilot / Total hours on type:
1248
Aircraft flight hours:
18798
Circumstances:
The captain and first officer were assigned a two-leg overnight on-demand cargo flight. The flight crew were accustomed to flying night cargo flights, had regularly flown together, and were experienced pilots. The first leg of the trip was uneventful and was flown by the captain; however, their trip was delayed 2 hours and 20 minutes at the intermediate stop due to a delay in the freight arriving. The flight subsequently departed with the first officer as the pilot flying. While enroute, about forty minutes from the destination, the flight crew asked the air traffic controller about the NOTAMs for the instrument landing system (ILS) instrument approach procedure at the destination. The controller informed the flight crew of two NOTAMs: the first pertained to the ILS glidepath being unserviceable and the second applied to the localizer being unserviceable. When the controller read the first NOTAM, he stated he did not know what “GP” meant, which was the abbreviation for the glideslope/glidepath on the approach. The controller also informed the flight crew that the localizer NOTAM was not in effect until later in the morning after their expected arrival, which was consistent with the published NOTAM. The flight crew subsequently requested the ILS approach and when the flight was about 15 miles from the final approach fix, the controller cleared the flight for the ILS or localizer approach, to which the captain read back that they were cleared for the ILS approach. As the flight neared the final approach fix, the captain reported that they had the airport in sight; he cancelled the instrument flight rules flight plan, and the flight continued flying towards the runway. The airplane crossed the final approach fix off course, high, and fast. The cockpit voice recorder (CVR) transcript revealed that the captain repeatedly instructed the first officer to correct for the approach path deviations. Furthermore, the majority of the approach was conducted with a flight-idle power setting and no standard altitude callouts were made during the final approach. Instead of performing a go-around and acknowledging the unstable approach conditions, the captain instructed the first officer to use the air brakes on final approach to reduce the altitude and airspeed. Shortly after this comment was made, the captain announced that they were low on the approach and a few seconds later the captain announced that trees were observed in their flight path. The CVR captured sounds consistent with power increasing; however, the audible stall warning tone was also heard. Subsequently, the airplane continued its descent and impacted terrain about .70 nautical mile from the runway. The airplane was destroyed by impact forces and both occupants were killed.
Probable cause:
The flight crew’s continuation of an unstable dark night visual approach and the captain’s instruction to use air brakes during the approach contrary to airplane operating limitations, which resulted in a descent below the glide path, and a collision with terrain. Contributing to the accident was the captain’s poor crew resource management and failure to take over pilot flying responsibilities after the first officer repeatedly demonstrated deficiencies in flying the airplane, and the operator’s lack of safety management system and flight data monitoring program to proactively identify procedural non-compliance and unstable approaches.
Final Report:

Crash of a Piper PA-31T Cheyenne near Eatonton: 5 killed

Date & Time: Jun 5, 2020 at 1520 LT
Type of aircraft:
Registration:
N135VE
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Williston – New Castle
MSN:
31-7520024
YOM:
1975
Crew on board:
2
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
2000
Copilot / Total flying hours:
15
Aircraft flight hours:
7749
Circumstances:
Before the personal instrument flight rules flight began, the pilot obtained a preflight weather briefing that indicated that instrument meteorological conditions, convective activity, and moderate-to-severe icing conditions would be occurring along the route of flight. According to track data, while the pilot was navigating to avoid weather, the pilot was using the autopilot for maneuvering. After the pilot reported to air traffic control that the airplane would be turning direct to its destination, the performance analysis of track data showed that the airplane began a slight left turn with a bank angle of about 10°, which was consistent with the intended route of flight. However, the turn then reversed, and the airplane began banking to the right, reaching about 120° right wing down during the next 70 seconds and showing a slow oscillation in pitch attitude. Satellite imagery showed that the airplane was likely in instrument meteorological conditions when it began a rapid descent, and the airplane’s descent rate was about 7,000 feet per minute. Postaccident examination of the airplane and right engine (the left engine was not recovered) revealed no evidence of any preimpact mechanical malfunctions or failures that would have precluded normal operation. The dynamics of the airplane’s movements after the right turn began indicated that the airplane likely was not being actively controlled when it diverted from the intended flightpath. The circumstances of this accident were thus consistent with the pilot’s lack of timely recognition that the autopilot was disengaged. The available evidence for this accident precluded a determination of where the pilot’s attention was directed while navigating direct to the destination. However, the turbulence would have increased the pilot’s workload, and the restricted visibility conditions would have prevented the pilot’s use of outside cues to detect deviations in the airplane’s attitude. Also, the initial roll rates might not have been sufficient to provide reliable cues to the pilot of the developing bank, and the convective conditions would likely have made it difficult for the pilot to detect and recover from the fully developed unusual attitude.
Probable cause:
The pilot’s failure to maintain control of the airplane while maneuvering in instrument meteorological conditions, which placed the airplane in an unusual attitude from which the pilot could not recover. Contributing to the accident was the convective and turbulent weather.
Final Report:

Crash of a Cessna 402C in Hampton

Date & Time: May 9, 2020 at 1513 LT
Type of aircraft:
Operator:
Registration:
N4661N
Survivors:
Yes
Schedule:
Peachtree City - Peachtree City
MSN:
402C-0019
YOM:
1979
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
7330
Captain / Total hours on type:
11.00
Copilot / Total flying hours:
1096
Copilot / Total hours on type:
5
Aircraft flight hours:
17081
Circumstances:
According the commercial pilot and a flight instructor rated check pilot, they were conducting their first long-duration, aerial observation flight in the multiengine airplane, which was recently acquired by the operator. They departed with full fuel tanks, competed the 5-hour aerial observation portion of the flight, and began to return to the destination airport. About 15 miles from the airport, the left engine fuel warning light illuminated. Within a few seconds, the right engine stopped producing power. They attempted to restart the engine and turned the airplane toward an alternate airport that was closer. The pilots then turned on the electric fuel pump, the right engine began surging, and soon after the left engine stopped producing power. They turned both electric fuel pumps to the low setting, both engines continued to surge, and the pilots continued toward the alternate airport. When they were about 3 miles from the airport, both engines lost total power, and they elected to land on a highway. When they were a few feet above the ground, power returned briefly to the left engine, which resulted in the airplane climbing and beginning to roll. The commercial pilot pulled the yoke aft to avoid a highway sign, which resulted in an aerodynamic stall, and subsequent impact with trees and terrain. The airplane sustained substantial damage to the wings and fuselage. Although both pilots reported the fuel gauges indicated 20 gallons of fuel remaining on each side when the engines stopped producing power, the flight instructor noted that there was no fuel in the airplane at the time of the accident. In addition, according to a Federal Aviation Administration inspector who responded to the accident site, both fuel tanks were breached and there was no evidence of fuel spillage.
Probable cause:
A dual total loss of engine power as a result of fuel exhaustion.
Final Report:

Crash of a Piper PA-46-310P Malibu in Bishop: 3 killed

Date & Time: Mar 3, 2020 at 1634 LT
Registration:
N43368
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Columbia – Tuscaloosa
MSN:
46-8408028
YOM:
1984
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
1178
Circumstances:
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.
Probable cause:
The pilot’s encounter with a rain shower updraft and severe turbulence, which resulted in a loss of airplane control and an inflight breakup. Contributing to the accident was the pilot’s reliance on outdated weather information on his in-cockpit weather display.
Final Report:

Crash of a Cessna 501 Citation I/SP near Fairmount: 4 killed

Date & Time: Feb 8, 2020 at 1013 LT
Type of aircraft:
Operator:
Registration:
N501RG
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Peachtree City - Nashville
MSN:
501-0260
YOM:
1982
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
805
Copilot / Total flying hours:
5924
Copilot / Total hours on type:
55
Aircraft flight hours:
8078
Circumstances:
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.
Probable cause:
The pilots’ loss of control in flight in freezing instrument meteorological conditions due to spatial disorientation and the cumulative effects of task saturation.
Final Report:

Crash of a Cessna 560 Citation V in Atlanta: 4 killed

Date & Time: Dec 20, 2018 at 1210 LT
Type of aircraft:
Operator:
Registration:
N188CW
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Atlanta - Millington
MSN:
560-0148
YOM:
1991
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
2300
Captain / Total hours on type:
110.00
Aircraft flight hours:
6854
Circumstances:
The pilot departed on an instrument flight rules flight into instrument meteorological conditions (IMC). Radar data indicated that the airplane entered a left turn after takeoff, consistent with the pilot's instrument clearance. As the airplane climbed to an altitude about 2,410 ft above ground level, its rate of climb increased from about 3,500 ft per minute to 9,600 ft per minute, the stick shaker activated, and the airplane decelerated to about 75 knots. The airplane then entered a descending right turn and rolled inverted before impacting terrain about 1 mile from the airport. All major components of the airplane were located at the accident site, and examination of the wreckage revealed no anomalies with the airplane that would have precluded normal operation. The weather conditions about the time of the accident included an overcast cloud ceiling about 600 ft above ground level. It is likely that the pilot became spatially disoriented after entering the cloud layer, which resulted in the airplane's high rate of climb, rapid loss of airspeed, and a likely aerodynamic stall. The steep descending right turn, the airplane's roll to an inverted attitude, and the high-energy impact are also consistent with a loss of control due to spatial disorientation.
Probable cause:
The pilot's loss of airplane control due to spatial disorientation during initial climb in instrument meteorological conditions.
Final Report:

Crash of a Lockheed WC-130H Hercules in Savannah: 9 killed

Date & Time: May 2, 2018 at 1127 LT
Type of aircraft:
Operator:
Registration:
65-0968
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Savannah – Davis-Monthan
MSN:
4110
YOM:
1965
Crew on board:
5
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
9
Captain / Total hours on type:
2070.00
Copilot / Total hours on type:
9
Circumstances:
On 2 May 2018, at approximately 1127 hours local time (L), the Mishap Aircraft (MA), a WC-130H, tail number 65-0968, assigned to the Puerto Rico Air National Guard, 156th Airlift Wing (156 AW), located at Muñiz Air National Guard Base, Puerto Rico, crashed approximately 1.5 miles northeast of Savannah/Hilton Head International Airport (KSAV), Georgia. All nine members aboard the MA—Mishap Pilot 1 (MP1), Mishap Pilot 2, Mishap Navigator, Mishap Flight Engineer, and Mishap Loadmaster (collectively the “Mishap Crew (MC)”), and four mission essential personnel, Mishap Airman 1, 2, 3, and 4—perished during the accident. The MC’s mission was to fly the MA to the 309th Aerospace Maintenance and Regeneration Group at Davis-Monthan Air Force Base, Arizona (commonly referred to as the “Boneyard”), for removal from service. The MA had been at KSAV for almost a month, since 9 April 2018, to undergo prescheduled fuel cell maintenance and unscheduled work on engine number one by 156 AW maintenance personnel using the facilities of the 165th Airlift Wing. During takeoff roll, engine one revolutions per minute (RPM) fluctuated and did not provide normal RPM when MP1 advanced the throttle lever into the flight range for takeoff. Approximately eight seconds prior to aircraft rotation, engine one RPM and torque significantly decayed, which substantially lowered thrust. The fluctuation on roll and significant performance decay went unrecognized by the MC until rotation, when MP1 commented on aircraft control challenges and the MA veered left and nearly departed the runway into the grass before it achieved flight. The MA departed KSAV at approximately 1125L. As the MC retracted the landing gear, they identified the engine one RPM and torque malfunction and MP1 called for engine shutdown. However, the MC failed to complete the Takeoff Continued After Engine Failure procedure, the Engine Shutdown procedure, and the After Takeoff checklist as directed by the Flight Manual, and the MA’s flaps remained at 50 percent. Additionally, MP1 banked left into the inoperative engine, continued to climb, and varied left and right rudder inputs. At an altitude of approximately 900 feet mean sea level and 131 knots indicated air speed, MP1 input over nine degrees of left rudder, the MA skidded left, the left wing stalled, and the MA departed controlled flight and impacted the terrain on Georgia State Highway 21.
Probable cause:
The board president found, by a preponderance of the evidence, the cause of the mishap was MP1’s improper application of left rudder, which resulted in a subsequent skid below three-engine minimum controllable airspeed, a left-wing stall, and the MA’s departure from controlled flight. Additionally, the board president found, by a preponderance of the evidence, the MC’s failure to adequately prepare for emergency actions, the MC’s failure to reject the takeoff, the MC’s failure to properly execute appropriate after takeoff and engine shutdown checklists and procedures, and the Mishap Maintainers’ failure to properly diagnose and repair engine number one substantially contributed to the mishap.
Final Report: