Missouri

Flying over Missouri in marginal weather conditions, the single engine airplane entered an uncontrolled descent at 1203LT and crashed about three minutes later in a wooded area located near Hartsburg. There was no fire. The airplane was destroyed and the pilot, sole on board, was killed. At the time of the accident, weather conditions were poor with thunderstorm activity in the area. The pilot departed Madison-Dane County on a flight to Siloam Springs-Smith Field.

Shortly after takeoff from Mosby-Midwest National Air Center Airport, the twin engine airplane collided with high tension cables and crash landed in a soybean field, bursting into flames. The airplane was destroyed by a post crash fire and the pilot, sole on board, was killed.

During a cross-country flight, the pilot initiated a descent to his intended destination. During the descent, the pilot informed air traffic control (ATC) that he could not retard power on the right engine. Later in the descent, the pilot decided to shut down the right engine. The pilot communicated his desire to land at the nearest airport to ATC, and ATC provided the pilot with the clearance to divert. Radar data showed the airplane in a steady descent toward the airport. When the airplane was at an altitude of about 2,500 ft mean sea level, the pilot contacted ATC and stated that he was trying to get the airplane under control; radar data showed the airplane in a 360° right turn at the time. The pilot contacted ATC again and stated that he was going to land on a highway. No further transmissions were received from the pilot. After the right turn, the airplane continued in a descent through 1,300 ft mean sea level, at which point radar contact was lost. A witness saw the airplane and stated that the airplane was low and slow but appeared to be in stable flight with both propellers spinning. She did not see any smoke coming from the airplane. She saw the airplane flying northeast to southwest when it suddenly descended nose first into the ground. The airplane impacted a gravel road adjacent to a 100-fttall grain silo about 1 mile from the highway and about 3.3 miles from the airport.

The private pilot reported that, immediately after takeoff in the multi-engine airplane, the right engine experienced a total loss of power. The pilot aborted the takeoff; the airplane exited the end of the runway surface, impacted rough terrain, and came to rest upright. Examination of the right engine showed that the magneto distributor drive gears were not turning. Both damaged magnetos were removed and replaced with a slave set of magnetos. The right engine was installed in an engine test cell, and subsequently started and performed normally throughout the test cell procedure. The damaged magnetos from the right engine were disassembled. Both nylon magneto distributor gears exhibited missing gear teeth and brown discoloration. A review of maintenance records showed that the right engine had been operated for about 8 years and an estimated 697 hours since the most recent magneto overhauls had been completed. According to maintenance instructions from the engine manufacturer, the magnetos should be inspected every 500 hours and should be overhauled or replaced at the expiration of five years since the last overhaul. Guidance also indicated that discoloration of the drive gear is an indication that the gear had been exposed to extreme heat and should be replaced.

The pilot reported that, shortly after takeoff, the twin-engine airplane's left front baggage door opened. He attempted to return to the airport, but the left engine lost engine power while the airplane was on the downwind leg of the traffic pattern. The airplane subsequently impacted power lines and terrain. An explosion occurred during the impact sequence, and a fire ensued that almost completely consumed the airframe. Tear down examination of the right engine revealed no anomalies. A test run of the left engine revealed no anomalies; however, due to impact and fire damage, it was not possible to fully test or examine the left engine's fuel system. The reason for the left engine’s loss of power could not
be determined.

Prior to departure, the pilot was informed that it had been raining; the roads were wet, but no mention of ice at his destination. During the approach to the destination airport, the runway appeared "wet", and a normal approach and landing was attempted. The airplane touched down at 110 knots, the pilot "then deployed lift dump and [then applied the] brakes". Unable to get braking action, the pilot tried to slide the airplane "left and right" to get traction, but could not. The airplane departed the south end of the 4,370-foot-long runway, went over the edge of an embankment and stopped next to a levee. There were no reported pre-impact malfunctions with the airplane. The Manufacturer Approved Airplane Flight Manual Supplement for Airplanes Operating on Wet and contaminated Runways; General Information Section, states operations on runways contaminated with ice or wet ice are not recommended and no operational information is provided. Using the supplement, the anticipated landing distance on a wet runway was calculated to be about 3,400 feet, the anticipated landing distance on an uncontaminated runway was calculated to be approximately 2,800 feet, and the prescribed landing speed (Vref) was determined to be about 111 knots. A braking action (runway condition) report for the private airfield's runway did not exist, nor was one required.

On June 28, 2007, about 0815 central daylight time, a Piper PA-46-500TP, N477MD, was destroyed on impact with terrain following an in-flight breakup near Wellsville, Missouri. The personal flight was operating under Title 14, Code of Federal Regulations Part 91. Visual meteorological surface conditions prevailed in the area at the time of the accident. An instrument flight rules (IFR) flight plan was on file and was activated. The pilot and two passengers sustained fatal injuries. The flight originated from the Spirit of St Louis Airport, near Chesterfield, Missouri, about 0750, and was destined for the Buffalo Municipal Airport, near Buffalo, Minnesota. About 0711, a person representing N477MD contacted Kankakee Automated Flight Service Station (AFSS) to file an IFR flight plan and obtain an abbreviated weather update. During the abbreviated weather update, the AFSS briefer advised the pilot that there was heavy rain and thunderstorm activity in Missouri along the aircraft's planned route of flight. The pilot stated that he had onboard radar for weather avoidance. About 0750, N477MD departed SUS, contacted Federal Aviation Administration (FAA) air traffic controller (ATC) on the St. Louis (Gateway) Departure frequency about 0752, and was initially cleared to climb to 4,000 feet. The Gateway controller advised of light to moderate precipitation three miles ahead of the aircraft. The pilot requested a northerly course deviation for weather avoidance, which was approved. About 0753, N477MD was cleared to climb to 10,000 feet. The controller then advised of additional areas of moderate and heavy precipitation ahead of the airplane, gave the pilot information on the location and extent of the weather areas, and suggested a track that would avoid it. The pilot responded that he saw the same areas on his onboard radar and concurred with the controller's assessment. Radar data showed that the airplane flew northwest bound, and then turned toward the west. About 0757, N477MD was instructed to resume the Ozark 3 departure procedure, and the pilot acknowledged. About 0758, the pilot was cleared again to proceed direct to Macon, Missouri (MCM) VHF omnidirectional range distance measuring equipment (VOR/DME), and two minutes later, was instructed to contact Kansas City Center (ZKC). The pilot contacted the ZKC R53 controller at 0800:47, and, after a discussion about the final requested altitude, was cleared to climb and maintain flight level 230. At 0801:42, a position relief briefing occurred and the R53 controller was replaced. The new R53 controller made no transmissions to N477MD, and was replaced by a third controller at 0806:27. The next transmission to N477MD occurred at 0812:26, when the R53 controller asked the pilot if he had been given a clearance to deviate. The flight's radar track showed that the airplane turned to the left. The pilot responded, "mike delta we've got problems uh..." The controller responded by asking the pilot if he was declaring an emergency, and made several other attempts to contact N477MD. The pilot did not respond to any of these calls, and radar contact was lost. None of the three ZKC controllers had given the pilot any weather information during the time he was controlled by ZKC. The plane crashed in an open field near Wellsville and was destroyed upon impact. All three occupants have been killed.

Shortly after takeoff the pilot experienced a loss of power on the right engine. He attempted to return to the airport to land, but determined that he was not going to reach the runway so he elected to land on a dirt field. He flew under power lines that were in his flight path and attempted to flare the airplane prior to it impacting the terrain. The airplane was equipped with Teledyne Continental GTSIO-520 engines. Post accident examination of the right engine revealed that all of the teeth on the starter adapter gear and several of the teeth on the crankshaft gear were missing. Several gear teeth and metal filings were located in the oil sump. The torsional damper to shaft gear woodruff key was sheared. The torsional damper was placed on a test bench to determine the damping time. The consecutive tests averaged a damping time of 6.9 seconds. The damping time of a new damper is min/max 1.5 to 3.125 seconds. Metallurgical examination revealed 15 starter gear teeth and 11 crankshaft gear teeth were fractured near their root. No indications of preexisting cracking were noted. At least two of the starter gear teeth and several of the crankshaft gear teeth displayed spalling and wear at the pitch line of the teeth. On June 13, 1994, Teledyne Continental issued a Mandatory Service Bulletin, MSB94-4, addressing the possible failure of the starter adapter gear and/or crankshaft gear on GTSIO-520 and GIO-550 engines. On October 31, 2005, Teledyne Continental issued revision, MSB94-4G. The service bulletin called for an inspection of the starter adapter viscous damper and shaft gear backlash every 100 hours of engine operation, and a visual inspection of the starter adapter shaft and crankshaft gear teeth for spalling, pitting, and wear, every 400 hours of engine operation. The Federal Aviation Administration (FAA) issued Airworthiness Directive (AD) 2005-20-04, effective November 1, 2005, requiring compliance with the Teledyne Continental Mandatory Service Bulletin. Maintenance records showed the mandatory service bulletin had been complied with when the right engine was overhauled and installed in March 2001. There was no indication in the maintenance records that either the mandatory service bulletin or the AD had been complied with since the engine was installed. The engine had a total time of 541.9 hours at the time of the accident. The pilot did not follow the published emergency procedures.

The airplane was operated by a company pilot. A noncompany pilot, who had not attended or completed a training course or received a checkout for Raytheon Aircraft Company Beech King Air 200 airplanes, was asked by the pilot to accompany him on the flight so that the noncompany pilot could accumulate flight time. The flight only required one pilot. While the airplane was in cruise flight (27,000 feet mean sea level), the cockpit voice recorder (CVR) recorded the sound of the windshield fracturing. The CVR transcript indicated that the company pilot was not in the cockpit when the windshield fractured because he was emptying trash in the cabin. This action showed poor judgment considering the noncompany pilot was not qualified in the airplane. Although the windshield stayed in place, the company pilot stated that “within seconds” after it fractured, he depressurized the airplane because he was unsure about the windshield’s “integrity.” However, the Beech King Air Airplane Flight Manual (AFM) states to maintain cabin pressurization in the event of a fractured windshield and further states that the airplane can continue flight for up to 25 hours with the windshield fractured. During the on-scene examinations, an unapproved document (not derived from the AFM) that contained several checklists was found on the airplane. The company pilot stated that he used this document and that it “came with the airplane.” The document did not include a checklist addressing a cracked or shattered windshield. The company pilot most likely was not aware that the airplane should not have been depressurized nor that it could operate for 25 hours after the fracture occurred and, therefore, that the fractured windshield did not present an in-flight emergency. The CVR transcript revealed that, after depressurizing the airplane, the pilots attempted to use the oxygen masks but were unable to receive any oxygen. (The pilots most likely did not turn the oxygen on once they needed it because they either forgot as a result of the emergency or because they did not have time to do so before they lost consciousness.) According to the company pilot, during his preflight inspection of the airplane, the oxygen system was functional. He stated that, after the inspection, he turned the oxygen system ready switch to the OFF position because he wanted to “save” the oxygen, which was not in accordance with the Before Start checklist in the AFM. Post accident functional testing of the oxygen system revealed normal operation. The unapproved checklists document did not include the instruction to leave the oxygen system on. Regardless, the pilot stated that he knew the approved checklist stated to leave the oxygen system on but that he still chose to turn it off. The pilot exhibited poor judgment by using an unapproved, incomplete checklists document and by knowingly deviating from approved preflight procedures. About 1 minute after the pilots tried to get oxygen, the CVR recorded the last comment by either pilot. For about the next 7 minutes until it stopped recording, the CVR recorded the sounds of increased engine propeller noise, the landing gear and overspeed warning horns, and altitude alerts indicating that the airplane had entered an uncontrolled descent. (The CVR’s 4-g impact switch was found in the open position during the on-scene examination, indicating that the airplane experienced at least 4 acceleration of gravity forces.) Further, a plot of two radar data points, recorded after the last pilot comment, showed that the airplane descended from 25,400 feet to 7,800 feet within 5 minutes. Shortly thereafter, the pilots regained consciousness and recovered from the uncontrolled descent. The airplane was substantially damaged by the acceleration forces incurred during the uncontrolled descent and subsequent recovery. Examination of the windshield revealed that a dense network of fractures was located on the inner glass ply; however, the windshield did not lose significant pieces of glass and maintained its structural integrity. Therefore, the fractures did not preclude safe continued flight. Post accident examinations revealed evidence that the fracture initiated due to a design deficiency in the glass. The manufacturer redesigned the windshield in 2001 (the accident airplane was manufactured in 1998), and no known similar fractures have occurred in the newly designed windshield. The manufacturer chose not to issue a service bulletin for a retrofit of the new windshield design in airplanes manufactured before 2001 because the fracture of one pane of glass is not a safety-of-flight issue.

The airplane impacted a fence and terrain on short final during a visual approach to runway 27. The airplane was operated as a cargo airplane with two flight crewmembers by a commercial operator certificated under 14 CFR Part 135. The flightcrew worked approximately 18.75 hours within a 24-hour period leading up to the accident performing flights listed by the operator as either 14 CFR Part 91 or 14 CFR Part 135, all of which were in the conduct of company business. Of this total, 5.9 hours involved flying conducted under 14 CFR Part 135. The flight to the accident airport was for the purposes of picking up repair parts for another company airplane that received minor damage in which the flight crew was previously piloting in the 24- hour period. They were then going to fly back to the operator's home base on the same day, which would have had an estimated flying time of 2:45 hours. The captain said he was tired and that he and the first officer had not slept at any of the stops made during the period. The captain said that the company likes for the airplanes to return to their home base. The captain said that the company prefers an option for pilots to stay overnight if tired and he has stayed overnight on previous trips but only due to maintenance related reasons. The Aeronautical Information Manual states that acute fatigue affects timing and perceptional field performance.