Texas

The pilot reported that, before the flight, the airplane was fueled with 140 gallons of Jet A fuel. Shortly after takeoff, both engines lost total power. Because the airplane had insufficient altitude to return to the airport, the pilot executed a forced landing to a field and the left wing sustained substantial damage. A postcrash fire ensued. The investigation determined that the airplane was inadvertently fueled with Jet A fuel rather than AVGAS, which was required for the airplane’s reciprocating engines. The line service worker who fueled the airplane reported that there were no decals at the airplane fuel ports; however, postaccident examination of the airplane found that a decal specifying AVGAS was present at the right-wing fuel port. The investigation could not determine whether the same or a similar decal was present at the left-wing fuel port because the left wing was partially consumed during the postimpact fire.

A Cessna 208B airplane collided with a powered paraglider during cruise flight at 5,000 feet mean sea level (msl) in Class E airspace. Based on video evidence, the powered paraglider operator impacted the Cessna’s right wing leading edge, outboard of the lift strut attachment point. The outboard 10 ft of the Cessna’s right wing separated during the collision. The Cessna impacted terrain at high vertical speed in a steep nose-down and inverted attitude. The powered paraglider operator was found separated from his seat style harness. The paraglider wing, harness, and emergency parachute were located about 3.9 miles south of the Cessna’s main wreckage site. Based on video evidence and automatic dependent surveillance-broadcast (ADS-B) data, the Cessna and the powered paraglider converged with a 90° collision angle and a closing speed of about 164 knots. About 8 seconds before the collision, the powered paraglider operator suddenly turned his head to the right and about 6 seconds before the collision, the powered paraglider maneuvered in a manner consistent with an attempt to avoid a collision with the converging Cessna. Research indicates that about 12.5 seconds can be expected to elapse between the time that a pilot sees a conflicting aircraft and the time an avoidance maneuver begins. Additionally, research suggests that general aviation pilots may only spend 30-50% of their time scanning outside the cockpit. About 8 seconds before the collision (when the powered paraglider operator’s head suddenly turned to the right), the Cessna would have appeared in the powered paraglider operator’s peripheral view, where research has demonstrated visual acuity is very poor. Additionally, there would have been little apparent motion because the Cessna and the powered paraglider were on a collision course. Under optimal viewing conditions, the powered paraglider may have been recognizable to the Cessna pilot about 17.5 seconds before the collision. However, despite the powered paraglider’s position near the center of his field of view, the Cessna pilot did not attempt to maneuver his airplane to avoid a collision. Further review of the video evidence revealed that the powered paraglider was superimposed on a horizon containing terrain features creating a complex background. Research suggests that the powered paraglider in a complex background may have been recognizable about 7.4 seconds before the collision. However, the limited visual contrast of the powered paraglider and its occupant against the background may have further reduced visual detection to 2-3 seconds before the collision. Thus, after considering all the known variables, it is likely that the Cessna pilot did not see the powered paraglider with sufficient time to avoid the collision. The Cessna was equipped with a transponder and an ADS-B OUT transmitter, which made the airplane visible to the air traffic control system. The operation of the powered paraglider in Class E airspace did not require two-way radio communication with air traffic control, the use of a transponder, or an ADS-B OUT transmitter and therefore was not visible to air traffic control. Neither the Cessna nor the powered paraglider were equipped with ADS-B IN technology, cockpit display of traffic information, or a traffic alerting system. Postmortem toxicological testing detected the prescription antipsychotic medication quetiapine, which is not approved by the Federal Aviation Administration (FAA), in the Cessna pilot’s muscle specimen but the test results did not provide sufficient basis for determining whether he was drowsy or otherwise impaired at the time of the collision (especially in the absence of any supporting details to suggest quetiapine use). Testing also detected ethanol at a low level (0.022 g/dL) in the Cessna pilot’s muscle specimen, but ethanol was not detected (less than 0.01 g/dL) in another muscle specimen. Based on the available results, some, or all of the small amount of detected ethanol may have been from postmortem production, and it is unlikely that ethanol effects contributed to the accident. The Cessna pilot likely did not have sufficient time to see and avoid the powered paraglider (regardless of whether he was impaired by the quetiapine) and, thus, it is unlikely the effects of quetiapine or an associated medical condition contributed to the accident.

The captain (who was the pilot flying) initiated the takeoff roll, and the airplane accelerated normally. According to the cockpit voice recorder (CVR) transcript, the first officer made the “V1” and then “rotate” callouts. According to the captain (in a postaccident interview), when he pulled back on the control column to rotate the airplane, “nothing happened,” and the control column felt like it “was in concrete” and “frozen.” The CVR captured that the first officer subsequently made the “V2” callout, then the captain said “come on” in a strained voice. Both pilots recalled in postaccident interviews that they both attempted to pull back on the controls, but the airplane did not rotate. The CVR captured that the first officer called out “abort.” The first officer pulled the thrust levers to idle and applied the brakes, and the captain deployed the thrust reversers. (See “Execution of Rejected Takeoff” for more information.) The airplane overran the departure end of the runway and continued through the airport perimeter fence and across a road, striking electrical distribution lines and trees before coming to rest in a pasture, where a postcrash fire ensued. The pilots, two additional crewmembers, and all passengers evacuated the airplane. Two passengers received serious injuries, and one received a minor injury. The airplane was totally destroyed by a post crash fire.

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.