Wisconsin

The airplane was destroyed after an attempted landing following a reported partial power loss of the left engine while en route. The flight did not divert to the closest airport located about 27 nautical miles to the southwest while at an altitude of about 15,900 feet. This airport was a controlled field equipped with airport rescue and fire fighting (ARFF), and its longest runway was 9,005 feet. The flight diverted to the departure airport located about 93 nautical miles to the north. This airport was an uncontrolled field not equipped with ARFF, and its longest runway was 5,000 feet. No emergency was declared. The airplane was reported by a witness to be too high and too fast to land on runway 34 at the airport. The winds were from 140 degrees at 6 knots. The wreckage distribution was consistent with an impact resulting from a Vmc (minimum control speed with the critical engine inoperative) roll to the left. The pilot received a checkout from the right seat in the accident airplane by the airplane owner. The checkout was about 20 minutes in duration and did not include any single-engine flight maneuvers or emergency procedures. The owner did not hold a certified flight instructor certificate. The pilot had stopped flying for 12 years and just began giving flight instruction and flying in single-engine airplanes about a year prior to the accident. The pilot's recent multiengine flight experience was limited to a couple of non-revenue flights within the past year while seated in the right seat of a King Air. The King Air was used for commercial charter work which would involve one or two landings per flight. One landing was made on the day prior to the accident. The accident pilot asked the King Air pilot to accompany him along on the accident flight; the King Air pilot declined. A multiengine commercial rated pilot-rated passenger, who the accident pilot knew, was seated in the right front seat. Examination of the airplane's supplemental type certificate (STC) revealed that the airplane had undergone numerous inspections by different maintenance personnel. The left engine's variable absolute pressure controller had safety wire around its control arm, which precluded its normal operation and a pressure relief valve that was not called for in the STC drawings. At the time of issuance, Federal Regulation's did not require STC instructions for continued airworthiness. Reliance on the airplane and engine maintenance manuals would not have provided enough information for continued airworthiness in accordance with the STC and could have yielded a setting exceeding those for which the STC parts were originally certificated to and thus increasing Vmc speed. Examination of the left engine revealed a cylinder head separation on the number six cylinder assembly, which had accumulated an estimated time since installation of 240 hours. Visual inspection of the assembly revealed the presence of some undecipherable characters in its parts numbering. A cylinder head separation from another airplane was also examined. This cylinder assembly accumulated about 270 hours since installation. Both cylinder assembly examinations revealed the presence of additional material on the cylinder barrel threads and fatigue fracture on the cylinder head.

At 1623:41, the pilot requested taxi clearance. The Green Bay (GRB) tower (ATCT) told the pilot to taxi to runway 18. At 1626:47 the pilot said that he was ready for takeoff. The ATCT local controller (LC) told the pilot, "proceed on course, cleared for takeoff". At 1627:33, radar showed the airplane began to accelerate down runway 18. At 1628:17 the LC told the pilot to contact departure control. The pilot responded, "ah papa charlie we have a little problem here we're going to have to come back." The LC asked the pilot, "what approach would you like?" The pilot responded, "like to keep the vis." At 1628:35, the LC asked the pilot, "like the contact approach that what you're saying?" There was no response from the pilot. At 1628:50, GRB radar showed the airplane on a heading of 091 degrees, at an altitude of 855 feet msl (160 feet agl), and at an airspeed of 206 knots. The airplane was 1.28 miles southeast of the airport radar. Radar contact with the airplane was lost at 1628:55. A witness to the accident said, "It was snowing moderately at that time. The road was wet but not slippery. Crossing the intersection of Morning Glory Rd. & Main St., I noted a white private jet flying from the south. It was flying at approximately a 75-80 degree angle perpendicular to the ground with its left wing down & teetering slightly." The witness said, "It then crossed Main Street with the lower wing tip approximately 20 to 30 feet above the power wires. The plane became more perpendicular to the ground at a 90 degree angle with the left wing down & (and) lost altitude crashing into the Morning Glory Dairy warehouse building." An examination of the airplane revealed no anomalies. At 1638, GRB weather was reported as ceilings of 200 feet broken, 800 feet overcast, visibility 1/2 statute mile with snow and fog, temperature 32 degrees F, dew point 32 degrees F, winds 120 degrees at 3 knots, and an altimeter setting of 29.99 inches Hg. Witnesses at the FBO said the pilot arrived to pick up the airplane after 1600. The pilot was briefed by the mechanic as he did his walk around inspection of the airplane. The pilot then
got into the airplane. The airplane was towed out and the tow bar removed. About two minutes later, the engines started. Less than five minutes after the engines started, the airplane taxied. The NTSB Audio Laboratory reviewed radio communications between ATCT and the pilot to determine from the speech evidence the pilot's level of psychological stress and workload. The examination indicated the pilot's speech characteristics were consistent with an increased stress/workload that might accompany a developing emergency. Referring to the pilot's final transmissions, "His unusually long reaction time suggests that he was distracted by competing cockpit priorities and/or was having a difficult time determining his answer, while his fast speech and microphone keying provide further evidence of an urgency to return to other cockpit activities." The report states that the pilot's statements remained rational and showed good word choice and grammar. "These factors, along with the relatively small change in fundamental frequency, suggest that the pilot did not reach an extreme level of stress."

During the activation of the crew oxygen system a fire erupted which consumed the entire pressure vessel. Representatives from the National Aeronautics and Space Administration's (NASA) Johnson Space Center (JSC), White Sands Testing Facility (WSTF), Las Cruces, New Mexico, examined the retained oxygen system components. Examination of these components revealed that the fire's initiation location was the first stage pressure reducer located in the oxygen regulator assembly.

At 1400 cst, modified Douglas DC-3C/BT-67R, TZ-389, and Beech A36, N3657A, began formation flight to get DC-3 flying time and for the 2nd occupant of the A36 to get aerial photos of the DC-3. A witness saw the airplanes at 500 feet to 700 feet agl, "flying close together heading north." He said "the big plane (DC-3) was flying straight and level. The little plane (A36) was just to the west of the big plane. The little plane then hit the big plane near the middle." After impact, pieces of acft were seen falling. Another witness saw the DC-3 heading north and the A36 circling it above and below. On its last pass, the A36 circled behind the DC-3, then crossed over the top and hitting the top of the DC-3. About 5 seconds after impact, the DC-3 gently rolled/turned westbound (apparently descending and gaining airspeed); the left wing then came off, followed by the right wing about 2 seconds later. Parts of the A36 empennage were found 3590 to 4,910 feet from the main wreckage. There was evidence that during impact, the DC-3 elevator and rudder controls were severed. No preimpact anomalies were found. At 1445 cst, an AIRMET had been issued, forecasting light to moderate turbulence below 8,000 feet msl. Toxicology tests of the DC-3 copilot's blood showed 0.127 mcg/ml amitriptyline (a prescription antidepressant with sedative side effects), 0.039 mcg/ml nortriptyline (metabolite of amitriptyline), and an undetermined amount of ephedrine and phenylpropanolamine (over-the-counter medications used in cold preparations, diet aids and stimulants).

There were five recorded transmissions of conversations from one of the pilots aboard the accident airplane and the Fort Dodge, Iowa AFSS; one on 12/27 and four on 12/28. The weather forecast for icing included wording such as '...moderate to isolated severe icing from seven thousand downward for your entire route of flight....' The pilot stated that he received 'Full Flight Service briefings...' and also indicated that he spoke to flight watch prior to takeoff. While executing the ILS approach to the destination airport, the pilot was unable to maintain the proper glidepath even with the application of full power. The pilot maintained marginal control of the airplane during the descent until impact with trees and the terrain about 10 miles west of the destination airport. The pilot and passengers reported 'vibration' and 'shudder' of the airplane prior to the impact. One passenger reported that she saw ice forming on the left 'rear' wings. Persons on the ground reported severe icing conditions around the time of the accident.

Prior to takeoff from a private turf airstrip (1400'x 90'), the pilot adjusted the left engine's fuel pump. On takeoff roll the left engine began surging. The pilot continued the takeoff. The pilot lifted off at approximately 1000' and pulled back on the yoke to get over the trees on the left side of the airstrip. The airplane drifted to the left. The pilot said he stalled the airplane and should have pushed the yoke forward to gain airspeed. The Pilot Operating Handbook indicted a takeoff roll of approximately 2,500 feet was needed on a dry paved surface.

The airplane was circling to land on runway 22 after executing a VOR/DME approach. The airplane impacted the ground approximately one quarter mile northeast of the runway 22 threshold. The wreckage path covered a distance of approximately 350 feet. Control continuity was established. Airframe, engine and navaid examination revealed no abnormalities. The left wing and horizontal stabilizer leading edges had approximately one-eighth inch of rime ice adhering to their leading edges. Two witnesses reported seeing the airplane rolling from the left to the right. The Eagle River AWOS was not available on a VHF radio frequency, due to radio frequency congestion at the O'Hare International Airport, Chicago, Illinois.

The single engine airplane departed with two pilots, two passengers, baggage and equipment. At takeoff, the airplane was 955 pounds over the maximum allowable gross weight, and 2 inches beyond the aft c.g. Limit. After 4 hours of flying, the pilot elected to divert to another airport, due to icing conditions. During the descending left turn from base leg to final approach to runway 22, the airplane dropped, struck the ground, and slid 250 feet. The wings were separated from the airplane during the ground slide by two trees. A satisfactory postaccident engine run was completed. The airplane was calculated to be about 600 pounds over the maximum landing weight, and 2 inches beyond the aft c.g. Limit. The air induction lever was in the primary position, and not the required alternate position for icing conditions. The propeller and stall warning heat switches were off. The airplane had been flying in light freezing rain, which the poh stated should be avoided. Severe mixed icing was reported 25 miles northwest of the airport. Winds at the airport were from 150 degrees at 10 knots, gusting to 16 knots. Both pilots were killed and both passengers were seriously injured.

The pilot of a twin-engine cargo airplane shut down the left engine and feathered the propeller due to a loss of engine oil. The FAA ARTCC handling the flight vectored the airplane toward a VOR. Due to the airplane's altitude and distance from the center's radar, the pilot of the airplane had to perform a full instrument approach procedure. The airplane maintained its enroute assigned altitude until passing the VOR outbound. Ntap readouts show the airplane descending throughout the procedure turn and inbound leg of the approach. The airplane's last radar contact was 300 feet below the inbound altitude for the approach while outside the final approach fix. The airplane collided with trees and terrain approximately 2 1/4 miles from the airport. The VOR is 5.5 miles from the airport. The on-scene investigation revealed the left engine's propeller had been feathered, its number nine cylinder mounting studs on the engine's case were crushed downward or were broken off at the case's surface, and the landing gear had been extended. The pilot, sole on board, was killed.

The crew discussed touch-and-go landings as they walked out to board. The captain occupied the right seat to allow the copilot to fly the short repositioning flight from the left. The airplane lifted off prematurely and remained in ground effect. Roll attitude vacillated slightly before onset of a rapid right roll to inverted at ground impact. The engines continued to run after impact; both were selected to high power. No material or mechanical discrepancy was found which diminished power or aircraft control. Both occupants were killed.