Texas

The pilot was planning to perform a functional test of the airplane’s newly upgraded autopilot system. Automatic dependent surveillance-broadcast data showed that, after takeoff, the airplane turned east and climbed to 2,750 ft. Air traffic control information indicated that the controller cleared the pilot to operate under visual flight rules to the east of the airport. Communications between ground control, tower control, and the pilot were normal during the ground taxi, takeoff, and climb. Radio and radar communications were lost 6 minutes after takeoff, and no radio distress calls were received from the pilot. The airplane impacted wooded terrain about 3/4 mile to the east of the last recorded radar data point. Groundspeeds and headings were consistent throughout the flight with no abrupt deviations. The airplane impacted the wooded terrain in a nose-down, near-vertical flight attitude. Most of the airplane, including the fuselage, wings, and empennage, were consumed by a postimpact fire. Both engines and propellers separated from the airplane at impact with the ground. Examination of the engines revealed no preaccident failures or malfunctions that would have precluded normal operations. Both propellers showed signs of normal operation. Flight control continuity was confirmed. The elevator trim cables stop blocks were secured to the cables and undamaged. They were found against the forward stop meaning the trim tab was at full down travel (elevator leading edge full down) which indicated that the airplane was trimmed full nose up at impact. The airplane’s cabin sustained fragmentation from impact and was consumed by fire; as a result, the autopilot system could not be examined. The investigation was unable to determine why the pilot lost control of the airplane.

After a 30-minute uneventful instrument flight rules (IFR) flight, the business jet landed in the rain on the 4,311ft-long runway. The pilot reported, and runway skid marks corroborated, that the airplane touched down about 1,000 ft from the approach end of the runway. The pilot reported braking action was initially normal and the anti-skid system cycled twice before it stopped working and he was unable to slow the airplane using the emergency brakes. The airplane continued off the departure end of the runway where it traveled through wet grass and a fence before coming to rest with the landing gear collapsed. A video of the airplane during the landing roll indicated there was a significant amount of water on the runway. No mechanical anomalies were found with the brake/antiskid systems during the postaccident examination of the airplane. Marks on the runway indicated functionality of the antiskid system. Stopping performance calculations estimated the distance required to stop the airplane on the runway was about 4,127 ft. The runway length remaining after the airplane touched down was about 3,311 ft. The pilot was aware of the runway length and weather conditions prior to departure and reported that he should have not accepted the trip.

While in cruise flight at 19,000 ft mean sea level (msl), the pilot declared an emergency to air traffic control and stated that the airplane had lost engine power and that he needed to divert. The pilot elected to divert to an airport that was about 5 miles south of his position. Archived automatic dependent surveillance-broadcast data and commercially available flight track data showed that a descent was initiated from 19,000 ft and the airplane proceeded directly to, and circled around, the airport one time while descending. The last data point showed the airplane at 1,250 ft msl (about 750 ft above ground level) and about 1 mile north of the approach end of the runway. From the cruise altitude of 19,000ft until the last data point, about 12 minutes and 45 seconds had elapsed, which equated to an average descent rate of about 1,392ft per minute. Witnesses located about 1/4 mile south of the end of the runway on a miniature golf course noticed the propeller on the airplane was not turning. They stated that they saw the airplane in a “really hard” left bank; the nose of the airplane dropped, and it impacted the ground in a near vertical attitude. The airplane came to rest along a road about 200 ft south of the airport property. The airplane impacted the terrain in a nose low, near vertical attitude and sustained substantial damage to fuselage and both wings. It is likely that, based on the location of the runway, relative to the miniature golf course, the pilot initiated the left bank to avoid bystanders on the ground and inadvertently exceeded the wing’s critical angle of attack, which resulted in an aerodynamic stall. The airplane was equipped with an engine trend monitor (ETM), which captured various events concerning the accident flight, including engine start, operating limit exceedances, and power checks. The ETM captured a power check while the airplane was at 19,100 ft. About 3 minutes 32 seconds later, an engine off event was recorded. The ETM further captured a logon message, which was consistent with the power being cycled, at an altitude of 3,542 ft, 9 minutes, 52 seconds later. The ETM did not record any start attempts between the logged engine off event and when power was lost to the unit. A postaccident examination of the airframe, engine, and accessories did not reveal any mechanical malfunctions or anomalies that would have precluded normal operation. Although it cannot be determined whether a restart attempt would have been successful, the data were consistent with a restart not being attempted. Both the engine failure and power off landing checklists contained instructions for the pilot to establish the airspeed at 90 knots; however, when the winds aloft were applied to the reported groundspeeds, it was evident this did not occur. Furthermore, the power off landing checklist instructed the pilot to be about 1,500 ft above the airport on the downwind leg; however, data indicate that the airplane was about 5,000 ft above the airport on the downwind leg. The rapid descent from 5,000 ft on the downwind leg to about 750 ft above ground level on the final leg resulted in an unstabilized approach.

The instructor pilot reported that while practicing an engine-out landing in the traffic pattern, the pilot-rated student overshot the turn from base leg to final rolling out to the right of the runway centerline. The student pilot attempted to turn back toward the runway and then saw that the airplane’s airspeed was rapidly decreasing. The instructor reported that when he realized the severity of the situation it was too late to do anything. The student attempted to add power for a go-around but was unable to recover. The airplane stalled about 10 ft above the ground, impacted the ground right of the runway, and skidded onto the runway where it came to rest. Both wings and the forward fuselage were substantially damaged. Both pilots stated there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation.

Shortly after takeoff the pilot reported to the air traffic controller that he was losing engine power. The pilot then said he was going to divert to a nearby airport and accepted headings to the airport. The pilot then reported the loss of engine power had stabilized, so he wanted to return to his departure airfield. A few moments later the pilot reported that he was losing engine power again and he needed to go back to his diversion airport. The controller reported that another airport was at the pilot’s 11 o’clock position and about 3 miles. The pilot elected to divert to that airport. The airplane was at 4,500 ft and too close to the airport, so the pilot flew a 360° turn to set up for a left base. During the turn outbound, the engine lost all power, and the pilot was not able to reach the runway. The airplane impacted a field, short of the airport. The airplane’s wings separated in the accident and a small postcrash fire developed. A review of the airplane’s maintenance records revealed maintenance was performed on the day of the accident flight to correct reported difficulty moving the Power Control Lever (PCL) into reverse position. The control cables were inspected from the pilot’s control quadrant to the engine, engine controls, and propeller governor. A static rigging check of the PCL was performed with no anomalies noted. Severe binding was observed on the beta control cable (propeller reversing cable). The cable assembly was removed from the engine, cleaned, reinstalled, and rigged in accordance with manufacturer guidance. During a post-accident examination of the engine and propeller assembly, the beta control cable was found mis-rigged and the propeller blades were found in the feathered position. The beta valve plunger was extended beyond the chamfer face of the propeller governor, consistent with a position that would shut off oil flow from the governor oil pump to the constant speed unit (CSU). A wire could be inserted through both the forward and aft beta control cable clevis inspection holes that function as check points for proper thread engagement. The forward beta control cable clevis adjustment nut was rotated full aft. The swaging ball end on the forward end of the beta control cable was not properly secured between the clevis rod end and the push-pull control terminal and was free to rotate within the assembly. Before takeoff, the beta valve was in an operational position that allowed oil flow to the CSU, resulting in normal propeller control. Vibration due to engine operation and beta valve return spring force most likely caused the improperly secured swaging ball to rotate (i.e. “unthread”) forward on the beta control cable. The resulting lengthening of the reversing cable assembly allowed the beta valve to stroke forward and shut off oil flow to the propeller CSU. Without propeller servo oil flow to maintain propeller control, the propeller faded to the high pitch/feather position due to normal leakage in the transfer bearing. The reported loss of power is consistent with a loss of thrust due to the beta control cable being mis-rigged during the most recent maintenance work.

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

The pilot was conducting a cross-country flight at a cruise altitude of 10,500 ft mean sea level when the left engine lost all power. He secured the engine and elected to continue to his destination. Shortly thereafter, the right engine lost all power. After selecting an airport for a forced landing, he overflew the runway and entered the pattern. The pilot stated that on short final, after extending the landing gear, "the plane quit flying and the airspeed went to nothing." The airplane landed 200 to 300 yards short of the runway threshold, resulting in substantial damage to the wings and fuselage. During a postaccident examination, only tablespoons of fuel were drained from the left tank. Due to the position of the airplane, the right tank could not be drained; however, when power was applied to the airplane, both fuel quantity gauges indicated empty fuel tanks. Neither fuel tank was breached during the accident, and there was no discoloration present on either of the wings or engine nacelles to indicate a fuel leak; therefore, the loss of engine power is consistent with fuel exhaustion.

The airline transport pilot departed on a night cargo flight into conditions that included an overcast cloud ceiling and “hazy” visibility, as reported by another pilot. About one minute after takeoff, the pilot made a series of course changes and large altitude and airspeed deviations. Following several queries from the air traffic controller concerning the airplane’s erratic flight path, the pilot responded that he had “some instrument problems.” The pilot attempted to return to land at the departure airport, but the airplane impacted terrain after entering a near-vertical dive. The airplane was one of two in the operator’s fleet equipped with an inverter system that electrically powered the pilot’s (left side) flight instruments. Examination of the annunciator panel lighting filaments revealed that the inverter system was not powered when the airplane impacted the ground. Without electrical power from an inverter, the pilot’s side attitude indicator and horizontal situation indicator (HSI) would have been inoperative and warning flags would have been displayed over the respective instruments. The pilot had a history of poor procedural knowledge and weak flying skills. It is possible that he either failed to turn on an inverter during ground operations and did not respond to the accompanying warning flags, or he did not switch to the other inverter in the event that an inverter failed inflight. Due to impact damage, the operational status of the two inverters installed in the airplane could not be confirmed. However, the vacuum-powered flight instruments on the copilot’s (right side) were operational, and the pilot could have referenced these instruments to maintain orientation. Based on the available information, the pilot likely lost control of the airplane after experiencing spatial disorientation. The night marginal visual flight rules conditions and instrumentation problems would have been conducive to the development of spatial disorientation, and the airplane’s extensive fragmentation indicative of a high-energy impact was consistent with the known effects of spatial disorientation. Ethanol identified during toxicology testing may have come from postmortem production and based on the low levels recorded, was unlikely to have contributed to this accident. Morphine identified in the pilot’s liver could not be used to extrapolate to antemortem blood levels; therefore, whether or to what extent the pilot’s use of morphine contributed to the accident could not be determined.

The pilot reported that, during the approach and while the airplane was about 500 ft above ground level and 81 knots, he "felt the descent rate increase significantly." The pilot increased engine power, but "the high rate of descent continued," and he then increased the engine power further. A slow left roll developed, and he applied full right aileron and full right rudder to arrest the left roll. He also reduced the engine power, and the left roll stopped. The pilot regained control of the airplane, but the airplane's heading was 45° left of the runway heading, and the airplane impacted trees and then terrain. The airplane caught fire, and the pilot and passenger exited through the emergency exit. The airplane sustained substantial damage to the windscreens and fuselage. The pilot reported that there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation.

The pilot, co-pilot, and eight passengers departed on a cross-country flight in the twin-engine airplane. One witness located on the ramp at the airport reported that the airplane sounded underpowered immediately after takeoff “like it was at a reduced power setting.” Another witness stated that the airplane sounded like it did not have sufficient power to takeoff. A third witness described the rotation as “steep,” and other witnesses reported thinking that the airplane was performing aerobatics. Digital video from multiple cameras both on and off the airport showed the airplane roll to its left before reaching a maximum altitude of 100 ft above ground level; it then descended and impacted an airport hangar in an inverted attitude about 17 seconds after takeoff and an explosion immediately followed. After breaching a closed roll-up garage door, the airplane came to rest on its right side outside of the hangar and was immediately involved in a postimpact fire. Sound spectrum analysis of data from the airplane’s cockpit voice recorder (CVR) estimated that the propeller speeds were at takeoff power (1,714 to 1,728 rpm) at liftoff. About 7 seconds later, the propeller speeds diverged, with the left propeller speed decreasing to about 1,688 rpm and the right propeller speed decreasing to 1,707 rpm. Based on the airplane’s estimated calibrated airspeed of about 110 knots and the propeller rpm when the speeds diverged, the estimated thrust in the left engine decreased to near 0 while the right engine continued operating at slightly less than maximum takeoff power. Analysis of available data estimated that, 2 seconds after the propeller speed deviation, the airplane’s sideslip angle was nearly 20°. During the first 5 seconds after the propeller speed deviation, the airplane’s roll rate was about 5° per second to the left; its roll rate then rapidly increased to more than 60° per second before the airplane rolled inverted. Witness marks on the left engine and propeller, the reduction in propeller speed, and the airplane’s roll to the left suggest that the airplane most likely experienced a loss of thrust in the left engine shortly after takeoff. The airplane manufacturer’s engine-out procedure during takeoff instructed that the landing gear should be retracted once a positive rate of climb is established, and the propeller of the inoperative engine should be feathered. Right rudder should also be applied to balance the yawing moment imparted by a thrust reduction in the left engine. Examination of the wreckage found both main landing gear in a position consistent with being extended and the left propeller was unfeathered. The condition of the wreckage precluded determining whether the autofeather system was armed or activated during the accident flight. Thus, the pilot failed to properly configure the airplane once the left engine thrust was reduced. Calculations based on the airplane’s sideslip angle shortly after the propeller speed deviation determined that the thrust asymmetry alone was insufficient to produce the sideslip angle. Based on an evaluation of thrust estimates provided by the propeller manufacturer and performance data provided by the airplane manufacturer, it is likely that the pilot applied left rudder, the opposite input needed to maintain lateral control, before applying right rudder seconds later. However, by then, the airplane’s roll rate was increasing too rapidly, and its altitude was too low to recover. The data support that it would have been possible to maintain directional and lateral control of the airplane after the thrust reduction in the left engine if the pilot had commanded right rudder initially rather than left rudder. The pilot’s confused reaction to the airplane’s performance shortly after takeoff supports the possibility that he was startled by the stall warning that followed the propeller speed divergence, which may have prompted his initial, improper rudder input. In addition, the NTSB’s investigation estimated that rotation occurred before the airplane had attained Vr (rotation speed), which decreased the margin to the minimum controllable airspeed and likely lessened the amount of time available for the pilot to properly react to the reduction in thrust and maintain airplane control. Although the airplane was slightly over its maximum takeoff weight at departure, its rate of climb was near what would be expected at maximum weight in the weather conditions on the day of the accident (even with the extended landing gear adding drag); therefore, the weight exceedance likely was not a factor in the accident. Engine and propeller examinations and functional evaluations of the engine and propeller controls found no condition that would have prevented normal operation; evidence of operation in both engines at impact was found. Absent evidence of an engine malfunction, the investigation considered whether the left engine’s thrust reduction was caused by other means, such as uncommanded throttle movement due to an insufficient friction setting of the airplane’s power lever friction locks. Given the lack of callouts for checklists on the CVR and the pilot’s consistently reported history of not using checklists, it is possible that he did not check or adjust the setting of the power lever friction locks before the accident flight, which led to uncommanded movement of the throttle. Although the co-pilot reportedly had flown with the pilot many times previously and was familiar with the B-300, he was not type rated in the airplane and was not allowed by the pilot to operate the flight controls when passengers were on board. Therefore, the co-pilot may not have checked or adjusted the friction setting before the flight’s departure. Although the investigation considered inadequate friction setting the most likely cause of the thrust reduction in the left engine, other circumstances, such as a malfunction within the throttle control system, could also result in loss of engine thrust. However, heavy fire and impact damage to the throttle control system components, including the power quadrant and cockpit control lever friction components, precluded determining the position of the throttle levers at the time of the loss of thrust or the friction setting during the accident flight. Thus, the reason for the reduction in thrust could not be determined definitively. In addition to a lack of callouts for checklists on the CVR, the pilots did not discuss any emergency procedures. As a result, they did not have a shared understanding of how to respond to the emergency of losing thrust in an engine during takeoff. Although the co-pilot verbally identified the loss of the left engine in response to the pilot’s confused reaction to the airplane’s performance shortly after takeoff, it is likely the co-pilot did not initiate any corrective flight control inputs, possibly due to the pilot’s established practice of being the sole operator of flight controls when passengers were on board. The investigation considered whether fatigue from inadequately treated obstructive sleep apnea contributed to the pilot’s response to the emergency; however, the extent of any fatigue could not be determined from the available evidence. In addition, no evidence indicates that the pilot’s medical conditions or their treatment were factors in the accident. In summary, the available evidence indicates that the pilot improperly responded to the loss of thrust in the left engine by initially commanding a left rudder input and did not retract the landing gear or feather the left propeller, which was not consistent with the airplane manufacturer’s engine out procedure during takeoff. It would have been possible to maintain directional and lateral control of the airplane after the thrust reduction in the left engine if right rudder had been commanded initially rather than left rudder. It is possible that the pilot’s reported habit of not using checklists resulted in his not checking or adjusting the power lever friction locks as specified in the airplane manufacturer’s checklists. However, fire and impact damage precluded determining the position of the power levers or friction setting during the flight.