Contributor - Safety

David Jack Kenny

<h1><b>Preliminary Reports</b></h1>
<h2><b>Pilot Distraction Noted in Hawker/Mustang Collision</b></h2>
<h3>Hawker 850XP, Cessna Citation Mustang, Oct. 24, 2023, Houston</h3>
<p>Pilot distraction is being eyed as a factor in the runway collision of the two business jets at William P. Hobby Airport (KHOU) in Houston, according to details in a preliminary report recently issued on the 2023 accident.</p>
<p>At 3:20 p.m. local time, the Hawker 850XP was taking off when it collided with the landing Citation Mustang at the intersection of Runways 22 and 13R. No injuries were reported among the occupants of either aircraft. The Hawker, operating as an on-demand passenger flight destined to Waukesha, Wisconsin, sustained minor damage, while the Citation, flown under Part 91 from Atlanta, was substantially damaged.</p>
<p>The collision occurred during the Hawker’s takeoff roll, though the controller instructed the crew of the jet to line up and wait on Runway 22. The controller had cleared the Citation to land on Runway 13R. Despite attempts by the controller to get the Hawker crew to stop the airplane, they did not respond.</p>
<p>In a post-accident interview, the Hawker crew believed they were cleared for takeoff. They also reported investigating alerts during taxi and takeoff roll.</p>
<p>“As the airplane began the left turn to be perpendicular to the runway, they stated the V-speeds were no longer on the display screens,” according to the preliminary report.</p>
<p>Approximately three minutes later, the airplane had entered its takeoff roll, “when the flight data/clearance delivery controller alerted the local controller about [the Hawker] N269AA’s movement, and at 15:19:47 the local controller stated ‘November nine alpha alpha, stop, hold your position.’ There was no response from the crew of N269AA, and at 1519:53 the local controller again stated, ‘Alpha, alpha, hold your position, stop,’ to which there was still no response,” the NTSB report stated.</p>
<p>KHOU is equipped with airport surface detection equipment—Model X (ASDE-X)—to enable controllers to track aircraft movements on the ground. “The controllers noticed N269AA’s movement before the ASDE-X alert,” however, according to the report.</p>
<p>In a post-flight interview, the Hawker crew said they were investigating two alerts for pitch trim and rudder bias during the takeoff roll. The two crewmembers reported not seeing the other aircraft until about one second before the collision.</p>
<p>The pilot of the Citation reported not seeing the Hawker, but hearing a thud on impact. The Hawker took off and subsequently requested a return to the runway and were granted clearance to go around and land. Post-accident examinations showed significant damage to the left wing of the Hawker and to the tail section of the Mustang.</p>
<h2><b>Two Killed in Caravan Training Accident</b></h2>
<h3>Cessna 208B, Dec. 17, 2024, Honolulu, Hawaii</h3>
<p>Both pilots, employees of an inter-island Part 135 cargo operator, perished when the airplane crashed into an unoccupied building seconds after takeoff. ADS-B data indicate that the instructional flight lifted off from Runway 04L of the Daniel K. Inouye International Airport (PHNL) at 15:14:57 local time at a groundspeed of 91 knots. Within 10 seconds it began an unexpected left turn.</p>
<p>Footage captured by observers showed the “very aggressive” bank continuing to steepen. When the tower controller asked whether they were turning right, the crew transmitted, “We are, we have, uh, we’re out of control here.” They were cleared to land on any runway but were unable to return to the airport, striking the building in a near-vertical attitude and igniting a post-crash fire.</p>
<p>FAA records showed that both pilots held current first-class medical certificates and commercial pilot certificates with single--engine airplane and instrument ratings. One also held a multiengine rating and a flight instructor’s certificate with single-engine, multiengine, and instrument ratings.</p>
<h2><b>Numerous Casualties in Departure Crash</b></h2>
<h3>Piper PA-42-1000 Cheyenne 400LS, Dec. 22, 2024, Gramado, Rio Grande do Sul, Brazil</h3>
<p>All 10 on board were killed and 17 people on the ground were reported injured after the twin-engine turboprop crashed into buildings moments after takeoff from Runway 24 of Canela Airport (SSCN). Press reports indicate that the airplane initially hit a chimney about 3 km (1.9 miles) from the airport, then struck a residential building, a furniture store, and a mobile phone shop. Most of the ground injuries were attributed to smoke inhalation from the ensuing fires. Two women were said to have been hospitalized in critical condition with burns.</p>
<p>All nine passengers were apparently family members of the airplane’s owner and pilot, the CEO of a business recovery firm. The nearest weather observation, recorded 40 km (25 miles) to the northwest at Caxias do Sul Airport, included 6 km (3.7 miles) visibility under a 600-foot broken ceiling and another broken layer at 6,000 feet.</p>
<h1><b>Final Reports</b></h1>
<h2><b>Fatal Pitch Excursions Traced to Overlooked Pitot Cover</b></h2>
<h3>Bombardier BD-100-1A10 Challenger 300, March 3, 2023, Windsor Locks, Connecticut</h3>
<p>A series of violent pitch excursions that subjected the airframe to g-loads in excess of its maneuvering load factor limitation and ultimately caused the death of an unsecured passenger resulted from inhibition of the horizontal stabilizer trim electronic control unit’s (HSTECU) autopilot trim function, forcing the autopilot to compensate for a badly out-of-trim condition using the primary flight controls.</p>
<p>Disconnecting the autopilot in an effort to troubleshoot a cascade of crew alerting system (CAS) advisories led the jet to pitch up from 3 to 8 degrees in just one second, a 4-g acceleration, then past 20 degrees after the PIC initially pushed the nose down, then released forward pressure. The flight data recorder’s (FDR) inertial switch ended the recording when loading increased beyond 4 gs, so the full extent of the pitch event remains unknown.</p>
<p>The crew’s failure to identify the initial “RUDDER LIMITER FAULT’ warning as a no-go condition and their use of the wrong checklist while attempting to troubleshoot the problem in flight were both cited as probable causes of the accident.</p>
<p>The inhibition of the HSTECU’s autopilot trim originated from a mismatch of more than 20 knots in the speeds calculated by the airplane’s two air data computers, which registered fault codes in the HSTECU. The mismatch in turn was due to the copilot’s having overlooked the right pitot cover during his external preflight when he was interrupted by line staff. The PIC aborted the initial takeoff run after the SIC reported anomalous readings on his primary flight display, but they did not consult the “go/no-go” checklist when the rudder limiter warning illuminated.</p>
<p>Had they realized it was listed as a “no-go” condition and consulted maintenance control as required, they’d have been told to power down the aircraft to clear the fault codes and restore normal function.</p>
<p>After aborting the takeoff, the jet stopped on a taxiway where the SIC removed the pitot cover. The “RUDDER FAULT LIMIT” warning then illuminated, which the PIC unsuccessfully tried to troubleshoot. They agreed to continue the flight without checking the “go/no-go” guide or contacting maintenance control.</p>
<p>During takeoff the SIC saw that the jet’s V-speeds were no longer bugged on the airspeed indicator, so he called them out from memory. At 400 feet, the amber “MACH TRIM FAIL” warning illuminated, joined by the amber “AP STAB TRIM FAIL” when the autopilot was engaged. The PIC disengaged and reengaged the autopilot three times during the climb to cruising altitude; each time the autopilot-related messages cleared and then reappeared. The “AP HOLDING NOSE DOWN” caution also illuminated the second and third times as airspeed increased.</p>
<p>The PIC called for “the checklist” without specifying which. The SIC located the one for primary stabilizer trim failure, which seemed to address the cause of the problem, and did not examine checklists relating to the other warning messages. The first item was to move the stabilizer trim switch from “PRI” to “OFF;” when the SIC did this, the autopilot disconnected and the jet pitched up. The PIC countered by “pushing the control column forward with at least 90 lbs of force,” imposing a -2.3 g load. The 20-degree pitch-up occurred as he returned the control column to neutral.</p>
<p>Shortly after they regained control using manual trim, a passenger reported that another passenger had suffered serious injuries. She had not been wearing her seat belt although the seat belt light had been on throughout the flight. The Challenger diverted and landed at Windsor Locks 17 minutes after the upset, but the passenger died of her injuries later that day.</p>
<h2><b>ATSB Ends Ditching Investigation</b></h2>
<h3>Bell 206B, April 14, 2024, Thursday Island, Queensland, Australia</h3>
<p>On Dec. 13, 2024, the Australian Transport Safety Bureau officially discontinued its investigation into the helicopter’s ditching roughly 300 meters west of Thursday Island after an apparent engine failure. The aircraft was not recovered, and the Bureau deemed it “unlikely that further investigation would identify any systemic safety issues or important safety lessons.”</p>
<p>Shortly after takeoff, the pilot noticed “a slight surge” before the engine lost power. He performed an autorotation onto the water, and he and both passengers escaped and were rescued. The helicopter sank after about five minutes. Investigators interviewed the pilot, both passengers, and another company pilot; reviewed flight tracking data; and scrutinized the investigation report of the Queensland Police Service. Without the opportunity to examine the wreckage, no further information was available.</p>
<p><i>— </i><i>Amy Wilde</i><i>r contributed to this report.</i></p>


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