Texas

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.

On February 23, 2019, at 1239 central standard time, Atlas Air Inc. (Atlas) flight 3591, a Boeing 767-375BCF, N1217A, was destroyed after it rapidly descended from an altitude of about 6,000 ft mean sea level (msl) and crashed into a shallow, muddy marsh area of Trinity Bay, Texas, about 41 miles east-southeast of George Bush Intercontinental/Houston Airport (IAH), Houston, Texas. The captain, first officer (FO), and a nonrevenue pilot riding in the jumpseat died. Atlas operated the airplane as a Title 14 Code of Federal Regulations Part 121 domestic cargo flight for Amazon.com Services LLC, and an instrument flight rules flight plan was filed. The flight departed from Miami International Airport (MIA), Miami, Florida, about 1033 (1133 eastern standard time) and was destined for IAH. The accident flight’s departure from MIA, en route cruise, and initial descent toward IAH were uneventful. As the flight descended toward the airport, the flight crew extended the speedbrakes, lowered the slats, and began setting up the flight management computer for the approach. The FO was the pilot flying, the captain was the pilot monitoring, and the autopilot and autothrottle were engaged and remained engaged for the remainder of the flight. Analysis of the available weather information determined that, about 1238:25, the airplane was beginning to penetrate the leading edge of a cold front, within which associated windshear and instrument meteorological conditions (as the flight continued) were likely. Flight data recorder data indicated that, during the time, aircraft load factors consistent with the airplane encountering light turbulence were recorded and, at 1238:31, the airplane’s go-around mode was activated. At the time, the accident flight was about 40 miles from IAH and descending through about 6,300 ft msl toward the target altitude of 3,000 ft msl. This location and phase of flight were inconsistent with any scenario in which a pilot would intentionally select go-around mode, and neither pilot made a go-around callout to indicate intentional activation. Within seconds of go-around mode activation, manual elevator control inputs overrode the autopilot and eventually forced the airplane into a steep dive from which the crew did not recover. Only 32 seconds elapsed between the go-around mode activation and the airplane’s ground impact.

The pilot was conducting a personal cross-country flight with one passenger in his twin-engine airplane. There was no record that the pilot received a weather briefing before the accident flight. While en route to the destination, the pilot was in contact with air traffic control and received visual flight rules flightfollowing services. About 18 miles from the destination airport, the radar service was terminated, as is typical in this geographic region due to insufficient radio and radar coverage below 7,000 ft. The airplane was heading northeast at 4,900 ft mean sea level (msl) (about 2,200 ft above ground level [agl]). About 4 minutes later, radar coverage resumed, and the airplane was 6 miles west of the airport at 4,100 ft msl (1,400 ft agl) and climbing to the north. The airplane climbed through 6,000 ft msl (3,300 ft agl), then began a shallow left turn and climbed to 6,600 ft msl (3,800 ft agl), then began to descend while continuing the shallow left turn ; the last radar data point showed the airplane was about 20 nm northwest of the airport, 5,100 ft msl (2,350 ft agl) on a southwest heading. The final recorded data was about 13 miles northwest of the accident site. A witness near the destination airport heard the pilot on the radio. He reported that the pilot asked about the cloud height and the witness responded that the clouds were 800 to 1,000 ft agl. In his final radio call, the pilot told the witness, "Ok, see you in a little bit." The witness did not see the airplane in the air. The airplane impacted terrain in a slightly nose-low and wings-level attitude with no evidence of forward movement, and a postimpact fire destroyed a majority of the wreckage. The damage to the airplane was consistent with a relatively flat spin to the left at the time of impact. A postaccident examination did not reveal any preimpact mechanical malfunctions or anomalies that would have precluded normal operation. A detailed examination of the cockpit instruments and other portions of the wreckage was not possible due to the fire damage. A cold front had advanced from the northeast and instrument meteorological conditions prevailed across the region surrounding the accident site and the destination airport; the cloud ceilings were 400 ft to 900 ft above ground level. The airplane likely experienced wind shear below 3,000 ft, and there was likely icing in the clouds. While moderate icing conditions were forecast for the accident site, about the time of the accident, investigators were unable to determine the amount and severity of icing the flight may have experienced. The weather conditions had deteriorated over the previous 1 to 2 hours. The conditions at the destination airport had been clear about 2 hours before accident, and visual flight rules conditions about 1 hour before accident, when the pilot departed. Based on the available evidence it is likely that the pilot was unable to maintain control of the airplane, which resulted in an aerodynamic stall and spin into terrain.

The pilot, copilot, flight attendant, and six passengers departed on a corporate flight to a private airstrip. After leveling off at flight level 280, the flight crew checked the weather conditions at nearby airports. Based on the weather information that they had, the pilot planned for a visual approach to the runway. As the airplane neared the destination, the pilot flew over the runway and entered a left downwind visual traffic pattern to check if any animals were on the runway and what the windsock on the airstrip indicated. The pilot stated that they did not see the windsock as they passed over the runway. The pilot reported that there were turbulence and wind gusts from the hills below and to the west. When the airplane was over the runway about 50 ft above ground level (agl), the pilot reduced the engine power to idle. The pilot reported the airplane then encountered wind shear; the airspeed dropped rapidly, and the airplane was "forced down" to the runway. A representative at the airstrip reported that the airplane hit hard on landing. The pilot unlocked the thrust reversers, applied brakes, and reached to deploy the ground spoilers. As he deployed the thrust reversers, the pilot said it felt like the right landing gear collapsed. He applied full left rudder and aileron, but the airplane continued to veer to the right. The pilot tried using the tiller to steer to the left but got no response. The airplane left the side of the runway and went into the grass, which resulted in substantial damage; the right main landing gear was broken aft and collapsed under the right wing. Postaccident examinations of the airplane revealed no preimpact mechanical malfunctions or failures that would have precluded normal operation. A review of weather conditions showed surface winds out of the north to northwest at 15 kts, with some gusts up to 20 kts. There was potential for turbulence and wind shear below 5,000 ft, but there were no direct observations. The area forecast about 30 minutes after the accident called for northwesterly winds at 10 to 17 kts with a few higher gusts in the afternoon for the general area. Data from an onboard enhanced ground proximity warning system (EGPWS) revealed that the crew received a terrain alert just before the airplane crossed the runway threshold. At the time the airplane was over the runway threshold, it was 48 ft agl and in a 1,391 ft per minute rate of descent. The airplane impacted the runway 3 seconds later. Given the pilot's account, the weather information for the area, and the data from the airplane's EGPWS, it is likely that the airplane encountered wind shear while transitioning from approach to landing.

According to the copilot, before takeoff, he and the pilot had briefed that the copilot would conduct the takeoff for the planned cross-country flight and be the pilot flying and that the pilot would be the pilot monitoring. The accident flight was the copilot's first takeoff in the accident airplane with it at or near its maximum gross weight. The pilot reported that he taxied the airplane onto the runway and locked the tailwheel in place and that the copilot then took over the controls. About 13 seconds after the start of the takeoff roll, the airplane veered slightly right, and the copilot counteracted with left rudder input. The airplane then swerved left, and shortly after the pilot took control of the airplane. The airplane briefly became airborne; the pilot stated that he knew the airplane was slow as he tried to ease it back over to the runway and set it back down. Subsequently, he felt the shudder “of a stall,” and the airplane rolled left and impacted the ground, the right main landing gear collapsed, and the left wing struck the ground. After the airplane came to a stop, a postimpact fire ensued. All the airplane occupants egressed through the aft left door. Postaccident examination of the airplane revealed no evidence of any mechanical malfunctions or failures with the flight controls or tailwheel. Both outboard portions of the of the aluminum shear pin within the tailwheel strut assembly were sheared off, consistent with side load forces on the tailwheel during the impact sequence. The copilot obtained his pilot-in-command type rating and his checkout for the accident airplane about 2 months and 2 weeks before the accident, respectively. The copilot had conducted two flights in the accident airplane with a unit instructor before the accident. The instructor reported that, during these flights, he noted that the copilot had directional control issues; made "lazy inputs, similar to those for small airplanes"; tended to go to the right first; and seemed to overcorrect to the left by leaving control inputs in for too long. He added that, after the checkout was completed, the copilot could take off and land without assistance; however, he had some concern about the his reaction time to a divergence of heading on the ground. Given the evidence, it is likely the copilot failed to maintain directional control during the initial takeoff roll. It is also likely that, if the pilot, who had more experience in the airplane, had monitored the copilot's takeoff more closely and taken remedial action sooner, he may have been able to correct the loss of directional control before the airplane became briefly airborne and subsequently experienced an aerodynamic stall.

The commercial pilot and passenger, who held a student certificate, departed runway 18R for a local flight in a multi-engine airplane. The pilot held a flight instructor certificate for single-engine airplane. Just after takeoff, the tower controller reported to the pilot that smoke was coming from the left side of the airplane. The pilot acknowledged, stating that they were going to "fix it," and then entered a left downwind for runway 18R, adding that they didn't need any assistance. The controller subsequently cleared the airplane to land on runway 18L, which the pilot acknowledged. Two witnesses reported seeing the smoke come from the left engine. Still images taken from airport security video show the airplane before making the turn to land with white smoke trailing and the landing gear down. The airplane was then seen in a steep left turn to final approach exceeding 90° of bank, before it impacted terrain, just short of the runway in a near vertical attitude. A postcrash fire ensued. The examination of the wreckage found that the left engine's propeller was not being driven by the engine at the time of impact. The left propeller was not in the feathered position and the landing gear was found extended. The damage to the right engine propeller blades was consistent with the engine operating at high power at impact. The examination of the airframe and engines revealed no evidence of preimpact anomalies; however, the examinations were limited by impact and fire damage which precluded examination of the hoses and lines associated with the engines. The white smoke observed from the left side of the airplane was likely the result of an oil leak which allowed oil to reach the hot exterior surfaces of the engine; however, this could not be verified due to damage to the engine. There was no evidence of oil starvation for either engine. Both the extended landing gear and non-feathered left propeller would have increased the drag on the airplane. Because the pilot's operating procedures for an engine failure in a climb call for feathering the affected engine and raising the landing gear until certain of making the field, it is unlikely the pilot followed the applicable checklists in response to the situation. Further, the change from landing on runway 18R to 18L also reduced the radius of the turn and increased the required angle of bank. The increased left banked turn, the right engine operating at a high-power setting, and the airplane's increased drag likely decreased the airplane airspeed below the airplane's minimum controllable airspeed (Vmc), which resulted in a loss of control.

The pilot in the multi-engine, retractable landing gear airplane reported that, during an instrument flight rules cross-country flight, about 5,000 ft above mean sea level, the left engine surged several times and he performed an emergency engine shutdown. Shortly afterward, the right engine lost power. During the emergency descent, the airplane struck treetops, and landed hard in a field with the landing gear retracted. The airplane sustained substantial damage to both wings, the engine mounts, and the lower fuselage. The pilot reported that he had requested 200 gallons of fuel from his home airport fixed base operator, but they did not fuel the airplane. The pilot did not check the fuel quantity during his preflight inspection. According to the Federal Aviation Administration Airplane Flying Handbook, Chapter 2, page 2-7, pilots must always positively confirm the fuel quantity by visually inspecting the fuel level in each tank. The pilot reported that there were no mechanical malfunctions or failures with the airplane that would have precluded normal operation.

The airline transport rated pilot and passenger departed on a cross-country business flight in a twin-engine, turbo-propeller-equipped airplane in day, visual meteorological conditions. Shortly after takeoff, the airplane banked left, descended, and impacted terrain about 1/2 mile from the end of the runway. There was not a post-crash fire and fuel was present on site. A postaccident airframe examination did not reveal any anomalies that would have precluded normal operation. Examination of the left engine found signatures consistent with the engine producing power at impact. Examination of the right engine revealed rotational scoring on the compressor turbine disc/blades, and rotational scoring on the upstream side of the power vane and baffle, which indicated that the compressor section was rotating at impact; however, the lack of rotational scoring on the power turbine disc assembly, indicated the engine was not producing power at impact. Testing of the right engine's fuel control unit, fuel pump, propeller governor, and overspeed governor did not reveal any abnormities that would have accounted for the loss of power. The reason for the loss of right engine power could not be determined based on the available information.