Beechcraft 60 Duke

Private American

The commercial pilot was relocating the multiengine airplane following the completion of an extensive avionics upgrade, which also included the installation of new fuel flow transducers. As the pilot neared the destination airport, he reported over the common traffic advisory frequency that he had "an engine out [and] smoke in the cockpit." Witnesses observed and airport surveillance video showed fire emanating from the airplane's right wing. As the airplane turned towards the runway, it entered a rightrolling descent and impacted the ground near the airport's perimeter fence. The right propeller was found feathered. Examination of the right engine revealed evidence of a fire aft of the engine-driven fuel pump. The fuel pump was discolored by the fire. The fire sleeves on both the fuel pump inlet and outlet hoses were burned away. The fuel outlet hose from the fuel pump to the flow transducer was found loose. The reason the hose was loose was not determined. It is likely that pressurized fuel sprayed from the fuel pump outlet hose and was ignited by the hot turbocharger, which resulted in the inflight fire.

Roberto Decena

The pilot was performing a personal cross-country flight. While en route to the intended destination, the pilot contacted air traffic control to report that the airplane was having a fuel pump issue and requested to divert to the nearest airport. The pilot stated that the request was only precautionary and did not declare an emergency during the flight; he provided no further information about the fuel pump. As the airplane approached the diversion airport, witnesses observed the airplane flying low and rolling to the left just before impacting terrain, after which a postcrash fire ensued. An examination of the airframe revealed no preimpact mechanical malfunctions or failures that would have precluded normal operation. A postaccident examination and review of recorded data indicated that the left engine was secured and in the feather position, and that the right engine was operating at a high RPM setting. The left engine-driven fuel pump was found fractured. Further examination of the fuel pump revealed fatigue failure of the pressure relief valve. The fatigue failure initiated in upward bending on one side of the valve disk and progressed around both sides of the valve stem. As the cracks grew, the stem separated from the disk on one side and began to tilt in relation to the disk and the valve guide due to the non-symmetric support, which caused the lower end of the stem to rub against the valve guide, creating wear marks. The increasing stem tilt would have impinged against the valve guide, and the valve might have begun to stick in the closed position. If the valve were stuck in the closed position, it would not be able to open, and the outlet fuel pressure could rise above the set point pressure. Because the pump was driven by the engine, there would not be a way for the pilot to shut it off, disconnect it, or bypass it. Instead, the fuel pressure would continue to rise until the valve were to unstick. Thus, the pilot was likely experiencing variable fuel pressure as the valve became stuck and unstuck. Examination of the spring seat and the diaphragm plate, which were in contact with each other in the fuel pump assembly, revealed wear marks on the surface of each component, with one mark on the diaphragm plate and two wear marks on the spring seat. The two wear marks on the spring seat were distinct features separated by material with no wear indications in between. The only way that these wear marks could have occurred were if the spring seat was separated from the diaphragm plate and reinstalled in a different orientation. Thus, it is likely that the pilot had encountered a fuel pump problem before the accident flight and that someone tried to troubleshoot the problem. The last radar data point indicated that the airplane was traveling at a groundspeed of about 98 knots, and had passed north of the airport, traveling to the southwest. The minimum control speed for the airplane with single-engine operation was 88 knots. However, it is likely that if the pilot initiated a left turn back toward the airport, that the right engine torque and the 14 knot wind with gusts to 24 knots would have necessitated a higher speed. Because appropriate control inputs and airspeed were not maintained, the airplane rolled in the direction of the feathered engine (due to the left fuel pump problem), resulting in a loss of control. The pilot's toxicology report was positive for cetirizine, sumatriptan, gabapentin, topiramate, and duloxetine. All of these drugs act in the central nervous system and can be impairing alone or in combination. Although this investigation could not determine the reason(s) for the pilot's use of these drugs, they are commonly used to treat chronic pain syndromes or seizures. It is likely that the pilot was experiencing some impairment because of multiple impairing medications and was unable to successfully respond to the in-flight urgent situation and safely land the airplane.

KMA Technology Solutions

The pilot began the takeoff roll in visual meteorological conditions. The airplane was airborne about 1,300 ft down the runway, which was about 75% of the normal ground roll distance for the airplane’s weight and the takeoff environment. About 2 seconds after rotation, the airplane rolled left. Three seconds later, the airplane had reached an altitude of about 80 ft above ground level and was in a 90° left bank. The nose then dropped as the airplane rolled inverted and struck the ground in a right-wing-low, nose-down attitude. The airplane was destroyed. Postaccident examination did not reveal any anomalies with the airframe or engines that would have precluded normal operation. The landing gear, flap, and trim positions were appropriate for takeoff and flight control continuity was confirmed. The symmetry of damage between both propeller assemblies indicated that both engines were producing equal and high amounts of power at impact. The autopsy revealed no natural disease was present that could pose a significant hazard to flight safety. Review of surveillance video footage from before the accident revealed that the elevator was in the almost full nose-up (or trailing edge up) position during the taxi and the beginning of the takeoff roll. Surveillance footage also showed that the pilot did not perform a preflight inspection of the airplane or control check before the accident flight. According to the pilot’s friend who was also in the hangar, as the accident pilot was pushing the airplane back into his hangar on the night before the accident, he manipulated and locked the elevator in the trailing edge up position to clear an obstacle in the hangar. However, no evidence of an installed elevator control lock was found in the cabin after the accident. The loss of control during takeoff was likely due to the pilot’s use of an unapproved elevator control lock device. Despite video evidence of the elevator locked in the trailing edge up position before the accident, an examination revealed no evidence of an installed control lock in the cabin. Therefore, during the night before the accident, the pilot likely placed an unapproved object between the elevator balance weight and the trailing edge of the horizontal stabilizer to lock the elevator in the trailing edge up position. The loss of control was also due to the pilot’s failure to correctly position the elevator before takeoff. The pilot’s friend at the hangar also reported that the pilot was running about one hour late; the night before, he was trying to troubleshoot an electrical issue in the airplane that caused a circuit breaker to keep tripping, which may have become a distraction to the pilot. The pilot had the opportunity to detect his error in not freeing the elevator both before boarding the airplane and again while in the airplane, either via a control check or detecting an anomalous aft position of the yoke. The pilot directed his attention to the arrival of a motorbike in the hangar alley shortly after he pulled the airplane out of the hangar, which likely distracted the pilot and further delayed his departure. He did not conduct a preflight inspection of the airplane or control check before the accident flight, due either to distraction or time pressure.

Henry Leasing Company

The commercial pilot and three passengers departed on a cross-country flight in a twin-engine airplane. As the flight neared the destination airport, the pilot canceled his instrument flight rules (IFR) clearance. The approach controller transferred the flight to the tower controller, and the pilot reported to the tower controller that the airplane was about 2 miles from the airport. However, the approach controller contacted the tower controller to report that the airplane was 200 ft over a nearby joint military airport at the time. GPS data revealed that, when pilot reported that the airplane was 2 miles from the destination airport, the airplane's actual location was about 10 miles from the destination airport and 2 miles from the joint military airport. The airplane impacted a remote wooded area about 8 miles northwest of the destination airport. At the time of the accident, thunderstorm cells were in the area. A review of the weather information revealed that the pilot's view of the airport was likely obscured because the airplane was in an area of light precipitation, restricting the pilot's visibility. A review of airport information noted that the IFR approach course for the destination airport passes over the joint military airport. The Federal Aviation Administration chart supplement for the destination airport noted the airport's proximity to the other airport. However, it is likely that the pilot mistook the other airport for the destination airport due to reduced visibility because of weather. The accident circumstances were consistent with controlled flight into terrain. The ethanol detected in the pilot's blood specimens but not in his urine specimens was consistent with postmortem bacteria production. The carbon monoxide and cyanide detected in the pilot's blood specimens were consistent with inhalation after the postimpact fire.

Mike %26 Mayo Partners

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.

David B. Mutchler

The private pilot, who had recently purchased the airplane, and the flight instructor were conducting an instructional flight in the multi-engine airplane to meet insurance requirements. Radar data for the accident flight, which occurred on the second day of 2 days of training, showed the airplane maneuvering between 1,000 ft and 1,200 ft above ground level (agl) just before the accident. The witness descriptions of the accident were consistent with the airplane transitioning from slow flight into a stall that developed into a spin from which the pilots were unable to recover before the airplane impacted terrain. Examination of the wreckage did not reveal evidence of any preexisting mechanical malfunctions or anomalies that would have precluded normal operation of the airplane. After the first day of training, the pilot told friends and fellow pilots that the instructor provided non-standard training that included stall practice that required emergency recoveries at low airspeed and low altitude. The instructor used techniques that were not in keeping with established flight training standards and were not what would be expected from an individual with his extensive background in general aviation flight instruction. Most critically, the instructor used two techniques that introduced unnecessary risk: increasing power before reducing the angle of attack during a stall recovery and introducing asymmetric power while recovering from a stall in a multi-engine airplane; both techniques are dangerous errors because they can lead to an airplane entering a spin. At one point during the first day of training, the airplane entered a full stall and spun before control was regained at very low altitude. The procedures performed contradicted standard practice and Federal Aviation Administration guidance; yet, despite the pilot's experience in multi-engine airplanes and in the accident airplane make and model, he chose to continue the second day of training with the instructor instead of seeking a replacement to complete the insurance check out. The spin encountered on the accident flight likely resulted from the stall recovery errors advocated by the instructor and practiced on the prior day's flight. Unlike the previous flight, the accident flight did not have sufficient altitude for recovery because of the low altitude it was operating at, which was below the safe altitude required for stall training (one which allows recovery no lower than 3,000 ft agl).

Private Paraguayan

The twin engine airplane was completing a flight to Asunción, carrying one passenger and one pilot. En route, the pilot encountered an unexpected situation and was forced to attempt an emergency landing. Upon landing on a dirt road, the aircraft lost its undercarriage and slid for few dozen metres before coming to rest with its right wing torn off. Both occupants were injured and the aircraft was destroyed.

Sky Hub Aviation

The twin engine aircraft departed Bogotá-El Dorado on a short flight to Bogotá-Guaymaral Airport, carrying three passengers and one pilot. Three minutes after takeoff from runway 13L, while climbing to a height of 200 feet in VFR conditions, the airplane entered a left turn then descended into the ground and crashed into several houses located in the district of Engativá, near the airport, bursting into flames. The aircraft as well as several houses and vehicles were destroyed. All four occupants as well as five people on the ground were killed. Thirteen others were injured, seven seriously.

Frank Leroy Bell

The pilot reported that he had added fuel at the previous fuel stop and that he was using a fuel totalizer to determine the quantity of fuel onboard. After climbing to a cruise altitude of 14,000 feet above ground level, he discovered that the fuel mixture control was frozen and that he was unable to lean the mixture to a lower fuel flow setting. The pilot reported that because of the increased fuel consumption, he briefly considered an en route stop for additional fuel but decided to continue. During descent, the airplane experienced a complete loss of power in both engines, and the pilot made an emergency off-field, gear-up landing about 7 miles from the destination. The airplane impacted terrain and thick scrub trees, which resulted in substantial damage to both wings, both engine mounts, and the fuselage. A postaccident examination found that only a trace of fuel remained. The pilot also reported that there was no mechanical malfunction or failure and that his inadequate fuel management was partly because he had become overconfident in his abilities after 50 years of flying.

Patrick R. Porter

Several witnesses observed the airplane before and during its takeoff roll on the morning of the accident. One witness observed the airplane for the entire event and stated that the run-up of the engines sounded normal. During the takeoff roll, the acceleration of the airplane appeared a little slower but the engines continued to sound normal. Directional control was maintained, and at midfield, the airplane had still not rotated. As the airplane continued down the 5,132-foot-long runway, it did not appear to be accelerating, and, about 100 yards from the end of the runway, it appeared that it was not going to stop. The airplane maintained contact with the runway and turned slightly right before it overran the end of the runway. The airplane was subsequently destroyed by impact forces and a postaccident fire. The wreckage was located at the bottom of a deep gully off the end of the runway. Postaccident examination of the area at the end of the runway revealed two distinct tire tracks, both of which crossed the asphalt and dirt overrun of 175 feet. A review of the airplane's weight and balance and performance data revealed that it was within its maximum gross takeoff weight and center of gravity limits. At the time of the accident, the density altitude was calculated to be 7,100 feet; the airport's elevation is 4,830 feet. For the weight of the airplane and density altitude at the time of the accident, it should have lifted off 2,805 feet down the runway; the distance to accelerate to takeoff speed and then to safely abort the takeoff and stop the airplane was calculated to be 4,900 feet. It is unknown whether the pilot completed performance calculations accounting for the density altitude. All flight control components were accounted for at the accident site. Although three witnesses indicated that the engines did not sound right at some point during the runup or takeoff, examination of the engine and airframe revealed no evidence of any preexisting mechanical malfunctions or failures that would have precluded normal operation. Propeller signatures were consistent with rotational forces being applied at the time of impact. No conclusive evidence was found to explain why the airplane did not rotate or why the pilot did not abort the takeoff once reaching the point to safely stop the airplane.

William B. Harris

The air traffic controller had cleared the flight for the instrument approach and the pilot acknowledged the clearance. Radar data depicted the airplane turning toward the final approach course and then continuing the turn 180 degrees before disappearing from radar at 11,200 feet. The wreckage was located at an elevation of 10,725 feet. Examination of the terrain and ground scars indicated the airplane impacted terrain in a nose down, right turn. Impact forces and a postimpact fire resulted in substantial damage to the airplane. Examination of the airplane, engines, and de-icing systems revealed no mechanical anomalies. Weather at the time of the accident was depicted as overcast skies, reduced visibility, with snow showers in the area. An icing probability chart depicted a probability of moderate rime and mixed icing. Both AIRMETs and SIGMENTs advised of moderate icing between the freezing level and flight level 220 and occasional severe rime and mixed icing below 16,000 feet. During his weather briefing, the pilot stated that he was aware of the adverse weather conditions.

Joseph S. Konicki

The pilot was receiving instruction and an instrument proficiency check (IPC) from a flight instructor. Following an hour of uneventful instruction, the IPC was initiated. During the first takeoff of the IPC, the pilot was at the flight controls, and the flight instructor controlled the throttles. Although the pilot normally set about 40 inches of manifold pressure for takeoff, the flight instructor set about 37 inches, which resulted in a longer than expected takeoff roll. Shortly after takeoff, at an altitude of less than 100 feet, with the landing gear extended, the flight instructor retarded the left throttle at 83 to 85 knots indicated airspeed; 85 knots was the minimum single engine control speed for the airplane. The pilot attempted to advance the throttles, but was unable since the flight instructor’s hand was already on the throttles. The airplane veered sharply to the left and rolled. The pilot was able to level the wings just prior to the airplane colliding with trees and terrain. The pilot reported that procedures for simulating or demonstrating an engine failure were never discussed. Although the flight instructor’s experience in the accident airplane make and model was not determined, he reported prior to the flight that he had not flown that type of airplane recently. The flight instructor was taking medication for type II diabetes. According to his wife, the flight instructor had not experienced seizures or a loss of consciousness as a result of his medical condition.

John M. White

The multiengine airplane was at an altitude of 6,000 feet when it experienced a catastrophic right engine failure, approximately 15 minutes after takeoff. The pilot elected to return to his departure airport, which was 30 miles away, instead of diverting to a suitable airport that was located about 10 miles away. The pilot reported that he was not able to maintain altitude and the airplane descended until it struck trees and impacted the ground, approximately 3 miles from the departure airport. The majority of the wreckage was consumed by fire. A 5 1/2 by 6-inch hole was observed in the top right portion of the crankcase. Examination of the right engine revealed that the No. 2 cylinder separated from the crankcase in flight. Two No. 2 cylinder studs were found to have fatigue fractures consistent with insufficient preload on their respective bolts. In addition, a fatigue fracture was observed on a portion of the right side of the crankcase, mostly perpendicular to the threaded bore of the cylinder stud. The rear top 3/8-inch and the front top 1/2-inch cylinder hold-down studs for the No. 2 cylinder exceeded the manufacturer's specified length from the case deck by .085 and .111 inches, respectively. The airplane had been operated for about 50 hours since its most recent annual inspection, which was performed about 8 months prior the accident. The right engine had been operated for about 1,425 hours since it was overhauled, and about 455 hours since the No. 2 cylinder was removed for the replacement of six cylinder studs. It was not clear why the pilot was unable to maintain altitude after the right engine failure; however, the airplane was easily capable of reaching an alternate airport had the pilot elected not to return to his departure airport.

Nestor Aviation %26 Aerobatics

The pilot reported that he planned to fly a round trip cross-country flight. Prior to takeoff, he ascertained the quantity of fuel on board based upon the airplane's fuel totalizer gauge indication, which indicated 89 gallons. The flight to the destination was uneventful, and upon landing, 20 gallons of fuel was purchased. Thereafter, the pilot departed for the return flight back to his originating airport. According to the pilot, on takeoff the fuel tank gauges indicated the tanks were between 1/3 and 1/4 full. While cruising, the pilot contacted an air traffic control facility and notified them that he had lost power in one engine. About 5 minutes later, the pilot broadcasted that both engines were without power. Unable to reach the nearest airport, the pilot landed on soft, uneven terrain. During rollout, the airplane nosed over and was substantially damaged. The calculated post accident fuel burn-off for the round trip flight was about 106 gallons. During the post accident inspection, an FAA inspector reported finding an estimated 2 gallons of fuel in one tank. The other tank was dry. No fuel was observed in the main fuel lines to the engines, and no mechanical malfunctions were reported by the pilot.

AvWerks

According to a witness, prior to arriving in the run-up area the pilot lowered the airplane's flaps. After the right flap fully extended, the flap key on the drive shaft inside the 90-degree drive assembly adapter fractured, in overload, in the direction of flap extension. Before takeoff, the pilot raised the flaps; however, with the fractured key, the right flap would have remained fully extended. The pilot could have identified this condition prior to takeoff, either visually or by means of the flap indicator, which received its input from the right flap actuator. The pilot subsequently took off, and the airplane turned left, but it is unknown at what point the pilot would have noted a control problem. The pilot climbed the airplane to 250 to 300 feet and allowed the airspeed to bleed off to where the airplane stalled and subsequently spun into the ground. Airplane manufacturer calculations revealed that the pilot should have been able to maintain control of the airplane at airspeeds over 70 knots. According to the pilot's operating handbook, the best two-engine angle of climb airspeed was 99 knots and the best two-engine rate of climb airspeed was 120 knots.

Nacional Mercantil Corretora e Representações de Algodão

The twin engine aircraft departed Montes Claros Airport at 1200LT on a flight to Goiânia, carrying one passenger and one pilot. As he started the descent to Goiânia Airport, the pilot reported the failure of the left engine and requested the permission to proceed with a direct approach to runway 32 despite the runway 14 was in use. Few seconds later, the right engine failed as well. The pilote reduced his altitude and attempted an emergency landing when the aircraft crashed in an open field located near Silvânia, about 50 km east of Goiânia Airport. On impact, the fixing points of the seat belts broke away, causing both occupants to impact the instrument panel. The aircraft was severely damaged and both occupants were killed.

Ocem Avionics

The airplane crashed into the terminal building following a loss of control on takeoff initial climb from runway 25. Witnesses reported that shortly after takeoff, the airplane banked sharply to the left, then it seemed to momentarily stabilize and commence a climb before beginning to roll to the left again. The airplane rolled to an inverted position, entered a dive, collided with the airport terminal building and exploded on impact. The entire airplane sustained severe fire and impact damage. Examination of the engines and propellers revealed no evidence of any discrepancies that would preclude normal operation. All the propeller blades displayed signatures indicative of high rotational energy at the time of impact, indicating that both propellers were rotating, not feathered, and the engines were operating at high power at the time of impact. Components of the autopilot system, specifically the pitch servo assembly and a portion of the roll servo assembly, were identified in the wreckage. The portion of the roll servo assembly found remained attached to a piece of skin torn from the airframe and consisted of the mounting bracket for the roll servo with the capstan bolted to the bracket, clearly indicating that this component had been reinstalled and strongly suggesting that the pilot reinstalled/reactivated all of the removed autopilot components the day before the accident. Maintenance personnel started an annual inspection on the airplane the month prior to the accident and found an autopilot installed in the airplane without the proper paperwork. The pilot explained to them that he designed and built the autopilot and was in the process of getting the proper paperwork for the installation of the system in his airplane. During the inspection, a mechanic found the aileron cable rubbing on the autopilot's roll servo capstan so the mechanic removed the roll servo along with the capstan. Additionally, mechanics disabled the autopilot's pitch servo and removed the autopilot control head. They were in the process of completing the inspection when the pilot asked for the airplane stating that he needed it for a trip. The pilot also asked that the airplane be returned to him without the interior installed. Two days before the accident, the airplane was returned to the pilot with the annual inspection incomplete. The autopilot control head, roll servo and capstan were returned to the pilot in a cardboard box on this date. A friend of the pilot reported that the day before the accident, the pilot completed reinstalling the seats and "other things" in order to fly the airplane the next day. It is possible that improper installation or malfunction of the autopilot resulted in the loss of control; however, the extent of damage and fragmentation of the entire airplane wreckage precluded detailed examination of the flight control and autopilot systems and hence a conclusive determination of the reason for the loss of control.

Jorge Campillo

At about the 3,000-foot marker on the 8,000-foot long runway witnesses saw the airplane at about 100 to 150-feet above the ground with the landing gear retracted when they heard a loud "bang". They said the airplane made no attempt to land on the remaining 5,000 feet of runway after the noise. The airplane continued climbing and seemed to gain a little altitude before passing the end of the runway. At that point the airplane began a right descending turn and was in a 60 to 80 degree right bank, nose low attitude when they lost sight of it. The airplane collided with the ground about 8/10 of a mile from the departure end of runway 34 in a residential area. Examination of the critical left engine found no pre-impact mechanical malfunction. Examination of the right engine found galling on all of the connecting rods. Dirt and particular contaminants were found embedded on all of the bearings, and spalling was observed on all of the cam followers. The oil suction screen was found clean, The oil filter was found contaminated with ferrous and non-ferrous small particles. The number 3 cylinder connecting rod yoke was broken on one side of the rod cap and separated into two pieces. Heavy secondary damage was noted with no signs of heat distress. Examination of the engine logbooks revealed that both engine's had been overhauled in 1986. In 1992, the airplane was registered in the Dominican Republic and the last maintenance entry indicated that the left and right engines underwent an inspection 754.3 hours since major overhaul. There were no other maintenance entries in the logbooks until the airplane was sold and moved to the United States in 2002. All three blades of the right propeller were found in the low pitch position, confirming that the pilot did not feather the right propeller as outlined in the pilot's operating handbook, under emergency procedures following a loss of engine power during takeoff.

Specialty Microwave Corporation

The pilot first reported that the engine oil temperature had dropped below what he normally observed while en route. When he tired to exercise the left propeller control, and then later tried to feather the left engine, he was unable to change the engine rpm. He then heard a pop from the right engine, and advised air traffic control (ATC), he needed to perform a landing at Bradford. He also reported a double power loss. While being radar vectored for the ILS runway 32 approach, he told ATC he was getting some power back. He was radar vectored inside of the outer marker, and broke out mid-field and high. At the departure end of the runway, he executed a right turn and during the turn, the airplane descended into trees, and a post crash fire destroyed it. A witness reported he heard backfiring when the airplane over flew the runway. When the airplane was examined, the landing gear was found down, and the wing flaps were extended 15 degrees. Neither propeller was feathered. Both engines were test run and performed satisfactorily. The left engine fuel servo was used on the right engine due to impact damage on the right engine fuel servo. The right fuel servo was examined and found to run rich. However, no problems were found that would explain a power loss, prevent the engine from running, or explain the backfiring heard by a witness. Both propellers were examined and found to be satisfactory, with an indication of more power on the left propeller than on the right propeller. The weather observation taken at 1253 included a ceiling of 1,100 feet broken, visibility 1 mile, light snow and mist. The weather observation taken at 1310 included a ceiling of 900 feet broken, visibility 3/4 mile, and light snow and mist. According to the pilot's handbook, the airplane could maintain altitude or climb on one engine, but it required the propeller to be feathered, and the landing gear and wing flaps retracted.

Private Dominican

The twin engine airplane departed Santo Domingo-Las Américas International Airport on a short flight to the Santo Domingo-Herrera Airport located downtown. Following a night takeoff, the pilot encountered a loss of power on the right engine and was unable to feather its propeller. As the propeller was windmilling, he was unable to maintain a safe altitude and elected to ditch the aircraft that crashed in the sea about 800 metres offshore. The pilot was seriously injured and the passenger was killed.

Duke Aircraft Corporation

The airplane was equipped with two experimental Engine AIR Power Systems TSIVD-427, 500-horsepower, liquid-cooled, turbocharged, V8 engines. During previous flights, the right engine lost boost then overboosted intermittently, and attempted repairs were unsuccessful. The pilot elected to fly the airplane to its home base for further troubleshooting. During cruise flight, the pilot reported an engine was surging, declared an emergency, and received vectors toward the airport. The airplane collided into a field beside the airport runway and caught fire. The airplane had a total of 8 to 10 hours of flight time at the time of the accident. Records revealed that two days after the airplane's first test flight, the pilot flew the airplane from Melbourne, Florida, to an airport 336 nm miles away, then flew it to Canada to display it at a fly-in.The FAA operating limitations for the airplane restricted its operation to flight test only, which was proposed to consist of 100 flight hours, since the installation of the modified engines. No single-engine performance data was available for this airplane. Examination of the engines and accessories revealed extensive fire and impact damage. Continuity of the crankshaft, valves, rods, and pistons was established for the right engine by manually rotating the propeller reduction control unit.

Fematic Engineering

The twin engine aircraft departed Nice-Côte d'Azur Airport on a flight to Locarno, Ticino, with four people on board. While cruising over Milan at an altitude of 10,000 feet, the pilot was invited to change his frequency and to contact Locarno Tower. Forty-six seconds later, he declared an emergency and informed ATC that he lost an engine. He was cleared to descent for a landing on either runway 35L or 35R but the aircraft continued to the north so he was later cleared to land on either runway 17L or 17R. Suddenly, the aircraft entered an uncontrolled descent then nosed down and crashed in a near vertical attitude in a wooded area located in Jerago con Orago, about 8 km northeast of Milan-Malpensa Airport. The aircraft was totally destroyed by impact forces and all four occupants were killed. There was no fire.

Mapleleaf Acquisitions

The pilot arrived at Mexia-Limestone County Airport (TX06), Mexia, Texas, sometime before 1100. Once onboard the airplane, a witness, and an acquaintance of the pilot, closed and locked the airplane's cabin door for the pilot, and walked away from the airplane. He also reported that after the engines to the airplane were started, the airplane stayed on the ramp and idled for 10 to 15 minutes. No one saw the pilot taxi to the runway, but he taxied to the north end of Runway 18 for a downwind takeoff to the south. Examination of the accident site found the wreckage oriented along a path consistent with an extended centerline of runway 18. The airplane was found along a fence line approximately 1/4 mile from the departure end of Runway 18. The airplane's track was along a 183-degree bearing, and there was a large burn area prior to and around the debris zone along the wreckage path. Examination of the cockpit revealed a 9/16-inch hex-head bolt inserted in the control lock pinhole for the control column. Under normal procedures Cockpit Check in the Duke 60 Airplane Flight Manual, for Preflight Inspection the first item listed is: 1. "Control Locks - REMOVE and STOW". In addition, under normal procedures Before Starting checklist in the Duke 60 Airplane Flight Manual, the fourth item to check is listed as: 4. "Flight Controls - FREEDOM OF MOVEMENT and PROPER RESPONSE"

XJ6 Inc.

The pilot had experienced engine problems during a flight and requested maintenance assistance from the local maintenance repair station. Before the maintenance personnel signed off and completed the repairs, the pilot refueled the airplane, and attempted an instrument flight back to the originating airport. While enroute, the pilot reported a low fuel situation, and deviated to a closer airport. During the approach, the airplane lost engine power on both engines, collided with trees, and subsequently the ground, about a half of a mile short of the intended runway. There was no fuel found in the fuel system at the accident site. No mechanical problems were discovered with the airplane during the post-accident examination. This accident was the second time the pilot had exhausted the fuel supply in this airplane.

HEDA KG

The twin engine aircraft was completing a local test flight at Halle-Oppin Airport. For unknown reasons, it belly landed and came to rest. All three occupants escaped uninjured while the aircraft was damaged beyond repair.

Corporate Aircraft Management

The pilot and passengers departed the Spirit of St. Louis Airport and flew to Springfield Regional Airport, a 50 to 60 minute flight. The fuel on board was about 25 to 30 gallons in the left wing tanks, and 75 to 80 gallons in the right wing tanks. Each engine burned about 25 to 30 gallons per hour. The airplane was not fueled prior to the return flight. About five minutes after takeoff, the airplane had reached 4,300 feet msl (3,033 feet agl) and began a 402 fpm descent. The airplane continued the descent away from the airport for about 7 nm before turning 180 degrees to the left. The airplane had descended to 2,200 feet msl (933 feet agl) and was 10 miles from the airport. The pilot reported to the controller that he had a '...partial engine failure on the left side.' The airplane impacted the ground in an inverted, vertical nose down attitude. The landing gear were down at impact. Neither propeller was feathered. The right wing, right engine, fuselage, and empennage received extensive fire damage. The left wing was consumed by fire between the nacelle and the wing root. The remaining left wing, left nacelle, and engine were not destroyed by fire. Examination of the engines and airframe did not reveal any pre-existing anomalies that prevented normal operation. The Airplane Flight Manual did not contain procedures which explained fuel cross feeding procedures in case of fuel exhaustion to a wing's fuel tanks.

Leonard Schroetlin

The pilot was cleared for the localizer runway 11 approach. The airplane impacted in an open field approximately 1 mile northeast of the airport and approximately 600 feet left of the extended centerline of the departure end of the runway. A witness saw the airplane at a low altitude, and stated 'it was foggy,' and he did not see the airplane until it was directly over his head. The witness stated that he saw the airplane for about '3 seconds,' at an altitude of 'between 50 and 100 feet above the ground,' and it did not sound like it was having 'mechanical difficulty.' The airplane turned left (north), and struck the ground with the left wing. The published missed approach called for a climbing 'right turn.' The olney airport automated weather observing system (awos) was operating and current at the time of the accident, but could only be obtained by telephone; hence atc could not provide the pilot with the current awos information. The pilot was provided the Evansville, Indiana (EVV) weather; 1,200 scattered, measured 4,500 overcast, visibility 5 miles, light rain and fog. Evansville was located approximately 20 miles southeast of Olney. The local (awos) weather was; partial obscuration, 100 feet overcast, visibility 3/4 mile.

Daniel J. Hommel

Shortly after takeoff, the pilot reported he had 'a problem...an overboost situation,' and wanted to return for landing. Instrument meteorological conditions prevailed, so the pilot was cleared for the ILS runway 26 approach. A witness saw the airplane emerge from the low overcast in a wings level descent, then pitch over to a near vertical attitude and impact a shopping center sign. The left turbocharger wastegate was found in the open (low boost) position, and the right turbocharger wastegate was found in the closed (high boost) position. The right turbocharger butterfly valve was severely eroded, the pin was missing, and the valve was free to rotate on the shaft. A hole was burnt through the right engine number 1 cylinder exhaust valve. Both propellers were in the low pitch-high rpm range. Both engines and turbochargers were original equipment and had not been overhauled in 21 years. A toxicology test showed 0.564 mcg/ml of sertraline (antidepressant) in the pilot's blood. Sertraline was not approved for use while flying an aircraft.

Richert

The twin engine aircraft departed Münster-Osnabrück Airport on a flight to Dresden, carrying four passengers and one pilot. On approach to Dresden-Klotzsche Airport by night, the pilot failed to realize his altitude was too low when the aircraft struck the chimney of a bungalow and crashed in a field located in Grossnaundorf, 13 km northeast of runway 22 threshold, bursting into flames. All five occupants were killed, among them Dietman Richert.

Edward M. Malone

The pilot departed Knoxville on a local pleasure flight to the Gatlinburg area. A few minutes into the flight, the pilot requested the ILS approach to Knoxville. About two minutes after the initial request, he requested immediate radar vectors. The controller requested the flight's altitude, but there was no reply from the pilot. The aircraft collided with trees at the 3,500 foot level of rising terrain seven miles southwest of gatlinburg. A hiker reported hearing, the sound of the engines running until the airplane collided with trees. The hiker also stated that clouds obscured the tops of the mountains. Examination of the accident site disclosed that wreckage debris was scattered over an area 650 feet long and 75 feet wide. The wreckage examination failed to disclose a mechanical problem. Sole on board, the pilot was killed.

Mt Nebo Aviation

During climb to cruise the pilot reported a power loss on one engine and received vectors for a return to the departure airport. The pilot was subsequently cleared for the VOR-A approach and reported intercepting the inbound radial. The impact site was right of the inbound radial and short of the extended runway centerline. Weather at the airport was VFR. Post impact fire damaged the airplane. The left engine propeller was in the feather position. Visual and metallurgical examination confirmed the turbocharger shaft separated due to fatigue. The shaft contained chromium. The aircraft overhaul manual states that 'chrome plating...restoration of the shaft...are not permitted.' Metallographics revealed a microstructure of grey iron (automotive application) in the center housing. The turbocharger was overhauled and installed on the left engine in october 1989. All three occupants were killed.

United Seafood

The aircraft registered N911SG arrived in Oulu on a private flight from Bremerhaven, Germany (EDWB) on 20 December 1994, with the intention to continue the flight to Murmansk, Russia (ULMM). Landing time at Oulu airport was 15.03. The aircraft had one passenger in addition to the pilot-in-command and a representative of the operator company, who had been marked as a crew member. After the landing the pilot-in-command contacted air traffic control by radio and told that the aircraft needed refuelling, without mentioning the fuel type required. The ATC officer transmitted the information by telephone to the fuel company, saying that the aircraft would take JET. According to the delivery receipt, the aircraft was refuelled with 664 litres of jet fuel, JET A-1, whereas the proper fuel type for the aircraft would have been AVGAS 100LL. The aircraft was refuelled on a stand situated in front of the terminal building. The fuel was delivered by a tanker car used only for JET A-1 refuelling and equipped with labels clearly indicating the fuel type. The representative of the aircraft operator/possessor company, who had been registered as a crew member in the aircraft log book, was present during refuelling, and the tanks were filled up according to his instructions on the quantity of fuel needed. He also accepted the fuel sample presented to him and signed the delivery receipt. He paid for the fuel in cash. The fuel tanks had not been marked with the minimum fuel grade of aviation gasoline used, as provided for in the airworthiness requirements. The filling orifices were equipped with restrictors in order to prevent jet fuel nozzles from going in and thus to prevent incorrect refuelling. The tanker car replenishment nozzle had been manufactured with an expansion, which had been shaped and dimensioned to fulfil the requirements set for jet fuel nozzles in different standards. The expansion is intended to prevent jet fuel nozzles from fitting into the orifices of aviation gasoline tanks. However, after the expansion the nozzle tip had been shaped as a Camlock coupling, which was smaller in dimension than the expansion and thus fitted into the reduced filling orifices, making it possible to fill the aviation gasoline tanks with jet fuel. During refuelling, the pilot-in-command visited meteo and paid for the landing. The aircraft had an IFR flight plan drawn up by the pilot-in-command for the continued flight from Oulu to Murmansk. According to the plan, flight time was one hour and 35 minutes, alternate aerodrome Ivalo (EFIV) and endurance 5 hours. The aircraft left for this planned flight from Oulu, runway 30, at 16.19. It had been cleared to Murmansk and to climb after take-off to FL 160 with a right turn. According to the ATC officer who had monitored the take-off, the gradient of climb was rather low. Four minutes after take-off the ATC officer gave the departure time to the aircraft and asked the crew to change over to Rovaniemi Area Control Centre radio frequency. The crew acknowledged the frequency. Without contacting Rovaniemi ACC the crew called again at Oulu ATC frequency at 4 min 47 sec after take-off, stating that they wanted to return to the airport because they were having some problems. The ATC officer cleared the aircraft to call on final 12. Approximately 10 seconds after this transmission the ATC officer asked whether any emergency equipment was needed, and the answer was negative. At 16.25.25, when the ATC officer asked if the crew had the field in sight, the crew confirmed this and reported that their DME distance was 6 nm. At 16.26.11 the crew called mayday, stating that both engines were stopping. At 16.26.38 the mayday call was repeated and emergency landing reported. Rovaniemi ACC monitored the aircraft by radar, and the last reliable radar contact was established at 16.26.30. On the basis of recorded radar data, the crash site was estimated to be approximately 1 NM from Laanila NDB, in the direction of 60°. Rescue units found the aircraft in a forest at 17.06. It had struck into trees, turned upside down and been destroyed. The aircraft door was shut and the occupants were still inside. The passenger on the back seat had been thrown away from his seat and was found dead at the accident site. The pilot-in-command was on the left front seat, seriously injured and unconscious, with his seat belt fastened (he died from his injuries 10 days later on December 30). The right crew seat occupant was injured but conscious, and his seat belt was fastened as well. It came out during the investigation that he was actually a passenger.

Ronald W. Garner

On Friday afternoon, July 16, 1993, at 1405 mountain daylight time, a Beech B-60, N75CX, registered to the pilot, overran the end of the runway and impacted terrain while landing at the Camas County Airport, Fairfield, Idaho. An IFR flight plan was filed for the business flight, conducted under 14 CFR 91, which departed Hermiston, Oregon at 1244, July 16, 1993. Visual meteorological conditions prevailed in the area. The private certificated pilot and passenger Peter W. VanKomen were seriously injured. Passenger Chris A. Carrow suffered minor injuries in the accident. The aircraft was destroyed in the mishap. There was no fire. Witnesses reported the pilot landed on runway 7, near the center of the 2950 feet long gravel airstrip and was unable to stop on the runway. The aircraft skidded off the east end of the runway where it impacted a ditch and dirt embankment. The Camas County Sheriff reported he examined the aircraft tire marks on the runway, which according to his measurement, started 1400 feet from the west end of the runway (See Sheriff Report). The sheriff indicated in his report that a witness, Bill Simon, stated in an interview that the pilot landed in downwind conditions, estimated to be 15 to 20 knots. Witness David Coffin, a private pilot, reported the two wind socks on the strip were fully extended, indicating the wind was blowing from west to east at a velocity in excess of 25 MPH, and gusting 30 to 35 MPH. The surface aviation weather observation, taken at Hailey, Idaho, 24 miles northeast of the accident site at 1350 MDT, July 16, 1993, was recorded as 3000 feet scattered clouds, visibility 30 miles, temperature 65 degrees F., dew point 29 degrees F., wind 210 degrees at 10 knots and altimeter 30.05 inches Hg. The density altitude at the Camas County Airport was calculated to be 6488 feet. The airport facility directory indicates the Camas County Airport has a single 2950 by 40 feet dirt runway, oriented 070 and 250 degrees. The elevation at the airport is 5058 feet above mean sea level.

James D. Huber

While climbing in moderate icing conditions after takeoff, pilot was cleared to 17,000' feet. Radar data showed aircraft climbed at an indicated airspeed (IAS) of 82 to 123 knots. A Beech safety info booklet stated that a minimum airspeed of 140 knots must be maintained in icing conditions. Climbing at reduced airspeed would have increased angle of attack and allowed ice to accumulate under the wings and aft of the de-icing boots. Aircraft climbed to 13,500 feet, descended momentarily to 13,300 feet, then continued climbing as airspeed decreased abruptly. After slowing to 60 knots ias at 13,700 feet, the aircraft entered a steep descending turn and accelerated to high speed (above VNE). An emergency was declared, stating the aircraft 'lost an engine.' Soon thereafter, radar contact was lost and the aircraft crashed. Pieces of empennage surfaces separated in flight and were found at remote location from the main wreckage. Both counterweights separated from the elevators. Post crash tests disclosed no mechanical evidence of engine malfunction. Low ceiling, fog, light rain, snow and icing conditions were reported in area. All six occupants were killed.

Kelco Aircraft Company

During takeoff from runway 22, the pilot reported that he had a problem, then there was no further communication from the aircraft. Several witnesses saw an object fall from the aircraft and one witness observed that a 'hood' had opened. The aircraft was maneuvered onto final approach to runway 36. A witness said that as the aircraft was lining up on final approach, it entered a steep bank and descended out of his sight. Subsequently, it collided with trees in a 27° descent, crashed and burned. A bag from the nose baggage compartment was found near the departure end of runway 22. No preimpact part failure or system malfunction of the aircraft was found. Before the flight, a ramp person observed the pilot servicing the left engine with oil, but he did not know if the pilot had secured the baggage door. An examination of the recovered door assembly failed to disclose a malfunction of the rear latch assembly. The forward latch assembly area was destroyed by fire. All three occupants were killed.

Automation Devices

The pilot departed on a local VFR flight at 1117. At 1154 he contacted Erie tower for landing. He then advised the tower at 1159 that he had feathered the right engine. One minute later he reported that the left engine was '...kicking out.' The aircraft stalled into a house 6 miles from the airport, and just short of the shoreline of Lake Erie. No fuel was found in the right wing. 7 gallons were drained from the left wing; no fuel was found in the left engine. Right fuel quantity c/b secured in out position by wire tie; several burned components found on back of right fuel quantity gage pc board. Most recent record of fuel purchase which could be found was for May 25, 1989. A pocket diary was found in the wreckage which contained entries of flight times and fuel quantity notations. The accident occurred at 155 Euclide Avenue, Erie, about six miles east of runway 24 threshold. Both occupants were killed. Pilot: Floyd E. Smith. Passenger: Elwood Graham.

Maurice J. Walsh III

After obtaining a weather briefing in which he was informed of thunderstorms and current sigmets for his intended route of flight, the pilot elected to depart his home airport on a personal flight. At the time of departure, witnesses indicated the presence of thunderstorms adjacent to the airport. After trying to obtain his IFR clearance from charlotte, the pilot was issued his IFR clearance when approaching Columbia, SC. The pilot had deviated around at least one thunderstorm while approaching Columbia. The pilot had been cleared to climb to his requested altitude of 17,000 feet and had reached 16,400 when the radar return was observed to indicate a descent and then was lost. Witnesses on the ground reported seeing the airplane exit the clouds in flames. The evidence indicated that the horizontal tail had separated followed by the wings and other components of the airplane. No evidence of separation due to structural weakening from heating was found. All four occupants were killed.

Awaa Aviation

The aircraft made a hard landing, ran off the right side of the runway and collided with the terrain. Subsequently, the plane erupted in flames and was destroyed, but the pilot and passengers were not injured.

RTS Service

Witnesses reported the aircraft took off and climbed to about 300 feet while in a wide left turn. According to witnesses, the wings were rocking and erratic engine sounds were noted. The aircraft was turning downwind when it abruptly pitched down, rolled left until inverted, descended and crash. Examination of the aircraft revealed no evidence of malfunction, although the left prop had less rotational damage than the right prop. Examination of aircraft records revealed the aircraft was inactive for about 9 years until it was returned to service less than a year before the accident. The aircraft accumulated about 17 hours since it was returned to service. The pilot stated to a witness before the accident that he had not done single engine operation in the aircraft. The aircraft was overloaded more than 200 lbs. All five occupants were killed.

Bahig F. Bishay

The pilot had just climbed to 2,500 feet when the right engine started to sputter. When he placed the fuel selector in crossfeed, both engines quit. The pilot elected to land in a field leading to substantial damage to the nose, wings, and tail section of the aircraft. A post crash inspection of fuel system revealed no fuel in the tanks or the fuel metering units for either engine. The pilot stated after the accident that the last time he refueled the aircraft was several weeks before and that it had been flown several times since its last refueling.

Rickey L. Newsom

The airplane was observed to approach the airport from the northwest. As it crossed the northeast end of the runway, it initiated a right turn to cross the runway about the midpoint to a position for a left downwind for landing on runway 5. Its altitude was estimated to be about 200-300 feet above the ground and the landing gear was down. The witness did not observe the airplane further. It collided with the ground about 0.4 miles from the threshold. The morning sun was about 10° above the horizon and was about 33° to the right of the runway centerline. It would have been in the pilot's face during his flight from the last departure point. The landing runway sloped upward from the landing threshold. The lower-than-normal traffic pattern, the sun's position in relation to the airplane flight path, and the runway slope could have caused the pilot to perceive his altitude as being higher than it actually was. All three occupants were killed.

Private Philippine

On final approach to Virac Airport runway 24, in poor weather conditions, the twin engine aircraft struck the slope of a mountain and crashed 12 km from the airfield. All six occupants were killed, among them the politician Moises M. Tapia.

John Gerlach

The pilot and his wife planned a 30 minutes pleasure flight to Lake Tahoe. Prior to departure the pilot failed to visually inspect the amount of fuel in the right wing tank. The tank was full. The tank's cap probably appeared to be secured when, in fact, because of a unique design characteristic, it was merely resting on top of the filler neck. Upon takeoff rotation the cap came off the filler neck and it was followed by a fuel spray. The pilot responded and stayed in a very low altitude and close-in traffic pattern. He attempted to land immediately. He lost control during the turn to final, stalled and collided with the pavement prior to reaching the threshold. Both occupants were killed.

Kachina Energy

Aircraft was destroyed during an attempted off airport emergency landing following a dual engine failure while leveling off at cruise flight. Pilot stated that left engine, then right engine surged and quit as he was leveling off at 9,000 feet msl. At the time of the engine failures the fuel totalizer was reading 60 gallons, but the aircraft fuel gauges were reading empty. Pilot broke out of overcast at 3,500 msl (about 1,200 feet agl) and was unable to find a suitable clear area to land before committing to an emergency landing in trees. Gear was down, flaps were up and neither engine was feathered at impact. Pilot stated that he knew he was out of gas when both engines quit and that he did not attempt an air start. Both occupants were seriously injured.

Commander Charter

During arrival, the pilot reported a problem with his #1 nav, but said he would try to make an ILS approach. He said he would return to Pontiac, if his ILS did not work. ARTCC cleared him for the ILS runway 32 approach and instructed him to contact Pellston radio (FSS). At 1525, he called the FSS and reported he was 20 miles south. At approximately 1534, the FSS specialist heard an aircraft fly over, but did not know if it was N24RT. He asked the pilot if he was making a missed approach. The pilot gave a negative reply and reported he was picking up the glide slope, then said he was having trouble with his #1 nav. A witness about 6 miles north and west of the airport saw the aircraft on a northerly heading at about 200 feet agl. About one minute later, the aircraft collided with trees, crashed and burned approximately 8 miles from the airport at an approximately elevation of 900 feet. The airport elevation was 720 feet. The nav equipment was too badly damaged during the accident to be tested. According to the aircraft radio log, the last VOR check was on 9/10/83. The pilot had logged 5.4 hours of instrument time during the previous 6 months, but had not logged any approaches. All five occupants were killed.

Prestress Supply

The pilot stated that he experienced a loss of power in both engines, made an emergency landing in a cow pasture, and struck a cow on landing rollout. Due to the extent of post crash fire no determination could be made as to the nature of the malfunction of the engines described by the pilot.

Scott M. Brunke

Shortly after takeoff, the left engine began to progressively lose power and was shut down. The aircrew notified Beech Tower of the problem and reported they would like to return and land. The aircraft was observed on final approach to runway 18 with the gear extended and the left prop stopped. Before landing, the aircraft began veering to the left. It crossed over the end of the airport at about 40 feet agl and 300 feet left (east) of the runway. The left wing and nose dropped and the aircraft impacted the ramp, left wing first. The aircraft then skidded across the ramp on a heading of 160° and collided with and damaged three other aircraft; a Beechcraft F33A registered N1833S; another Beechcraft 60 Duke registered N6747D and a Beechcraft 58 registered N5800B. An investigation revealed that the #2 exhaust valve lifter had become flat and the #2 exhaust valve had failed from fatigue. Both pilots escaped uninjured.

Ralph E. Phillips Consulting Engineers

At about 700 feet msl the pilot reported to Santa Monica tower that his left eng had failed. He immediately feathered the left prop and continued to climb, planning to attempt a restart before returning to land. At about 1,000 feet msl the pilot determined that the aircraft was no longer climbing. His airspeed was below the single engine best rate of climb speed and he felt a power loss in the right engine. He put the nose down and feathered the right prop. The aircraft struck the water 2,000 yards from the Santa Monica pier. Life guards were on the scene with a rescue boat when the pilot surfaced.