Contributor - Safety

David Jack Kenny

<h2>Preliminary Reports</h2>

 


Phenom 100 Stalls Onto Runway

 


Embraer EMB-500, February 8, 2021, Le Bourget Airport, Paris, France – The three occupants suffered minor injuries when the Maltese-registered charter jet stalled onto Paris-Le Bourget Airport’s Runway 27, collapsing all three legs of the landing gear.&nbsp;The light jet slid off the left side of the runway, igniting a fire that was quickly suppressed by the airport rescue and firefighting crew.&nbsp;The flight had arrived from Venice’s Marco Polo Airport.

 


No Injuries After Falcon Aborts Takeoff

 


Falcon 900EX, February 13, 2021, Montgomery-Gibbs Executive Airport, San Diego, California – Two passengers and three crew members evacuated the aircraft without injury after it ran off the end of the runway following an aborted takeoff.&nbsp;The Part 91 flight was intended to proceed to Hawaii’s Kona Airport, but the pilots reported that the flight controls failed to raise the nose when the jet reached rotation speed. The crew immediately aborted the takeoff, but the airplane continued off the runway, coming to rest about 560 feet beyond.

 


Seven Fatalities in Nigerian King Air Crash

 


Beechcraft B300 King Air 350i, February 21, 2021, Abuja International Airport, Nigeria – A King Air 350i operated by the Nigerian Air Force crashed while attempting to return to the Abuja Airport following a reported engine failure after takeoff.&nbsp;Much of the aircraft was destroyed by a post-crash fire, and none of the seven persons on board survived.&nbsp;As of this writing, the identities of the victims had not been released.

 


The flight was bound for Minna, 68 miles to the northwest, to help rescue 42 victims of a mass kidnapping.&nbsp;Nine minutes after the initial report of an engine failure, the King Air went down in scrubland just outside the airport’s perimeter fence under the final approach course to Runway 22, narrowly missing warehouses and makeshift settlements in the vicinity.&nbsp;Textron Aviation and the NTSB have been enlisted as parties to the investigation.

 


R66 Lost Off Kodiak Island

 


Robinson R66, March 2, 2021, near Kodiak, Alaska – The helicopter is presumed to have been destroyed and its solo pilot killed after it disappeared over open ocean on a flight from Anchorage to Kodiak.&nbsp;Its Spidertracks trace ended south of the Barron Islands about 70 miles north of Kodiak.&nbsp;No emergency locator transmitter signal was received.&nbsp;A two-day search by the Coast Guard located only “minimal debris believed to be from the helicopter,” including an inflated yellow pop-out float.&nbsp;Several days later, parts of the helicopter’s fuselage, skids, and float were found on a beach near Afognak Island.

 


The pilot was the owner of Kodiak Helicopters, which owned and operated the R66.&nbsp;A company pilot told investigators that the owner had him cancel any scheduled charter flights so he could take the helicopter for a few days to be in Kodiak with his family when a local news story concerning him broke.&nbsp;He said the accident pilot “seemed distracted and not himself.”&nbsp;The Anchorage Daily News subsequently reported that a week earlier he’d resigned as head of the Alaska Native Tribal Health Consortium following charges of sexual misconduct, accusations the pilot denied.

 


<h2>Final Reports</h2>

 


Questionable Flight Planning Leads to Fuel Exhaustion

 


Piper PA-42, March 31, 2017, Sorocaba, Brazil – The pilot’s inflight decision to skip an intermediate stop while flying at a lower-than-optimal altitude without setting power for maximum economy led to a dual loss of engine power on final approach.&nbsp;The airplane was destroyed and the pilot and passenger killed when it went down just one kilometer (0.62 miles) from the Sorocaba airport.&nbsp;The landing gear was extended.&nbsp;Cavitation in the fuel pumps’ gear bushings and discoloration of the gear teeth from overheating indicated that the pumps had been run dry.&nbsp;There was no post-impact fire and no blighting of vegetation at the accident site.

 


The flight departed Manaus on a flight plan to Barra do Garças with a full load of fuel (3,752 pounds usable). En route, the pilot amended his destination to Sorocaba, 532 nm further away, and continued at an altitude of 13,500 feet and his filed airspeed of 220 knots.&nbsp;CENIPA investigators determined that the use of economy cruise power would have slowed the airplane to 202 knots but allowed the flight to be completed with a 30-minute fuel reserve.&nbsp;Using normal cruise power at FL250, the flight would have arrived with a reserve of one hour 15 minutes, but using normal cruise power at 13,500 feet would have required 4,175 pounds of fuel, 363 more than its capacity.

 


The choice of the lower altitude has not been explained.&nbsp;While the aircraft’s logbooks did not record any deficiencies in its pressurization system, they were out of date, with no entries since its previous inspection in August 2016.

 


Partial-power Climb Caused Departure Stall

 


Cessna 550, May 22, 2019, Indianapolis, Indiana – Physical evidence corroborated by witness testimony showed that the pilot’s failure to use full power during and after takeoff caused airspeed to decay, resulting in a fatal low-altitude stall.&nbsp;The 75-year-old airline transport pilot and his only passenger were killed when the jet crashed into a flooded cornfield half a mile northeast of the Indianapolis Regional Airport.&nbsp;About 80 percent&nbsp;of the wreckage was consumed by a post-impact fire.

 


Aggregated flight track data showed that the Citation's airspeed began decreasing from a maximum of 141 knots as it climbed through 163 feet agl; the last radar hit came at 263 feet agl and a groundspeed of 100 knots on a heading of 346 degrees.&nbsp;Surface winds were from 170 degrees at 9 knots gusting to 14, implying that its airspeed was between 86 and 93 knots.&nbsp;A witness on the ground reported seeing the jet roll to an estimated 90-degree bank with its nose parallel to the horizon; its nose stayed at or below the horizon as the wings rolled level, then dropped until the airplane hit the ground.&nbsp;The manufacturer calculated that at its estimated weight of 14,500 pounds, stall speed would be 100 knots at 45 degrees of bank and 118 knots in a 60-degree bank.

 


The non-volatile memory in the right engine’s Fadec&nbsp;recorded no faults but also never began recording a logic trend snapshot, which requires the throttle lever angle to be set to full takeoff power for at least two seconds after the weight-on-wheels switch opens.&nbsp;(Damage precluded downloading the left engine’s Fadec&nbsp;data.)&nbsp;A witness who’d flown with the pilot twice in the Citation, most recently the day before the accident, reported that on both occasions he was “very behind the airplane,” pulling the power levers back early and flying at slower-than-normal airspeeds while maintaining that the jet “flew like a [Cessna]&nbsp;172.” The NTSB accordingly attributed the accident to “The pilot’s failure to fully advance the power levers during the takeoff and initial climb...”

 


Multiple Factors Led to B.C. CFIT

 


Cessna 208 floatplane, July 26, 2019, Addenbroke Island, British Columbia, Canada – Fatigue and group dynamics may have contributed to the pilot’s choice to continue flying into reduced visibility under low ceilings.&nbsp;The pilot and three passengers were killed and four other passengers suffered serious injuries when their float-equipped Cessna Caravan hit a forested hillside on Addenbroke Island at an elevation of 490 feet.&nbsp;One other passenger escaped with minor injuries.&nbsp;The flight was one of four company aircraft that departed to the north-northwest from Vancouver Harbour Water Aerodrome, three carrying passengers to a fishing lodge and the fourth to a research station nearby.&nbsp; All were initially delayed for weather but eventually took off despite consistent reports of conditions below VFR minima along the last 75 miles of the route.

 


The accident flight was scheduled to depart first at 0730 but actually took off third, more than two hours later.&nbsp; It maintained 4,500 feet for the first hour, then slowly descended to 1,300 feet.&nbsp; Seventeen minutes later it began another gradual descent, this time to 330 feet over the ocean just offshore.&nbsp; A returning company aircraft that entered Fitz Hugh Sound southbound descended to 170 feet over the water after entering an area of heavy rain.&nbsp; Its pilot was in radio contact with the accident pilot and they agreed to stay on opposite sides of the channel.&nbsp; The accident pilot altered course slightly to the east and descended to 230 feet as the airplanes passed one another at a distance of about 2 nm.&nbsp; The accident airplane then turned 25 degrees to the west and began a gradual climb.&nbsp; Less than two minutes later, it struck trees in straight and level flight.

 


Reports and camera footage from lighthouses near the site showed visibilities varying from 15 statute miles to as little as 1/8 mile in rain and fog.&nbsp; Interviews with other company pilots and cell phone records from the accident flight led TSB investigators to conclude that the pilot was likely using the autopilot well below its certificated en-route minimum of 800 feet agl, and had disabled the Garmin G1000’s obstruction warning and synthetic vision systems.&nbsp;The pilot, who had a second job, had worked 27 of the past 28 days, including 83.5 hours the preceding week on a schedule conducive to circadian rhythm disruption, with less than five hours sleep on at least one night.

 


The TSB also noted that while company pilots made individual go/no-go decisions, those for multiple-aircraft charters “are made either explicitly and/or implicitly as a group,” as are decisions to continue or turn back.&nbsp;Groups comprised of individuals with widely varying levels of seniority can be susceptible to conformity or compliance biases.&nbsp;In this case, the first (successful) flight was made by the company’s operations manager, who reported conditions to the others.

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