Cessna 500 Citation

Shelter Charter Services

The private pilot departed on an instrument flight rules flight plan in his twin-engine turbojet airplane. The flight was uneventful until the air traffic controller amended the flight plan, which required the pilot to manually enter the new routing information into the GPS. A few minutes later, the pilot told the controller that he was having problems with the GPS and asked for a direct route to his destination. The controller authorized the direct route and instructed the pilot to descend from 22,000 ft to 6,000 ft, during which time the sound of the autopilot disconnect was heard on the cockpit voice recorder (CVR). During the descent, the pilot told the controller that the airplane had a steering problem and was in the clouds. The pilot was instructed to descend the airplane to 4,100 ft, which was the minimum vectoring altitude. The airplane continued to descend, entered visual meteorological conditions, and then descended below the assigned altitude. The controller queried the pilot about the airplane's low altitude and instructed the pilot to maintain 4,100 ft. The pilot responded that he was unsure if he would be able to climb the airplane back to that altitude due to steering issues. The controller issued a low altitude warning and again advised the pilot to climb back to 4,100 ft. The pilot responded that the autopilot was working again and that he was able to climb the airplane to the assigned altitude. The controller then instructed the pilot to change to another radio frequency, but the pilot responded that he was still having a problem with the GPS. The pilot asked the controller to give him direct routing to the airport. A few minutes later, the pilot told the controller that he was barely able to keep the airplane straight and its wings level. The controller asked the pilot if he had the airport in sight, which he did not. The pilot then declared an emergency and expressed concerns related to identifying the landing runway. Afterward, radio contact between the controller and the pilot was lost. Shortly before the airplane impacted the ground, a witness saw the airplane make a complete 360° roll to the left, enter a steep 90° bank to the left, roll inverted, and enter a vertical nose-down dive. Another witness saw the airplane spiral to the ground. The airplane impacted the front lawn of a private residence, and a postcrash fire ensued.The pilot held a type rating for the airplane, but the pilot's personal logbooks were not available for review. As a result, his overall currency and total flight experience in the accident airplane could not be determined. The airplane was originally certified for operations with a pilot and copilot. To obtain an exemption to operate the airplane as a single pilot, a pilot must successfully complete an approved single-pilot exemption training course annually. The accident airplane was modified, and the previous owner was issued a single-pilot conformity certificate by the company that performed the modifications. However, there was no record indicating that the accident pilot received training under this exemption. Several facilities that have single-pilot exemption training for the accident airplane series also had no record of the pilot receiving training for single-pilot operations in the accident airplane. Therefore, unlikely that the pilot was properly certificated to act as a single-pilot. The GPS was installed in the airplane about 3.5 years before the accident. A friend of the pilot trained him on how to use the GPS. The friend said that the pilot generally was confused about how the unit operated and struggled with pulling up pages and correlating data. The friend of the pilot had flown with him several times and indicated that, if an air traffic controller amended a preprogrammed flight plan while en route, the pilot would be confused with the procedure for amending the flight plan. The friend also said the pilot depended heavily on the autopilot, which was integrated with the GPS, and that he would activate the autopilot immediately after takeoff and deactivate it on short final approach to a runway. The pilot would not trim the airplane before turning on the autopilot because he assumed that the autopilot would automatically trim the airplane, which led to the autopilot working against the mis-trimmed airplane. The friend added that the pilot was "constantly complaining" that the airplane was "uncontrollable." A postaccident examination of the airplane and the autopilot system revealed no evidence of any preimpact deficiencies that would have precluded normal operation. This information suggests that pilot historically had difficulty flying the airplane without the aid of the autopilot. When coupled with his performance flying the airplane during the accident flight without the aid of the autopilot, it further suggests that the pilot was consistently unable to manually fly the airplane. Additionally, given the pilot's previous experience with the GPS installed on the airplane, it is likely that during the accident flight the pilot became confused about how to operate the GPS and ultimately was unable to properly control of the airplane without the autopilot engaged. Based on witness information, it is likely that during the final moments of the flight the pilot lost control of the airplane and it entered an aerodynamic stall. The pilot was then unable to regain control of the airplane as it spun 4,000 ft to the ground.

Yatish Air

The commercial pilot of the jet reported that he initially requested that 100 lbs of fuel be added to both fuel tanks. During the subsequent preflight inspection, the pilot decided that more fuel was needed, so he requested that the airplane's fuel tanks be topped off with fuel. However, he did not confirm the fuel levels or check the fuel gauges before takeoff. He departed on the flight and did not check the fuel gauges until about 1 hour after takeoff. He stated that, at that time, the fuel gauges were showing about 900-1,000 lbs of fuel per side, and he realized that the fuel tanks had not been topped off as requested. He reduced engine power to conserve fuel and to increase the airplane's flight endurance while he continued to his destination. When the fuel gauges showed about 400-500 lbs of fuel per side, the low fuel lights for both wing fuel tanks illuminated. The pilot reported to air traffic control that the airplane was low on fuel and diverted the flight to the nearest airport. The pilot reported that the airplane was high and fast on the visual approach for landing. He misjudged the height above the ground and later stated that the airplane "landed very hard." The airplane's left main landing gear and nose gear collapsed and the airplane veered off the runway, resulting in substantial damage to the left wing. The pilot reported no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation.

Norjet

The pilot and 3 passengers boarded the aircraft. At 2126, the pilot obtained an IFR clearance from the CYLW ground controller for the KELOWNA SEVEN DEP standard instrument departure (SID) procedure for Runway 34. The instructions for the runway 34 KELOWNA SEVEN DEP SID were to climb to 9000 feet ASL, or to an altitude assigned by air traffic control (ATC), and to contact the Vancouver Area Control Centre (ACC) after passing through 4000 feet ASL. The aircraft was then to climb and track 330° magnetic (M) inbound to the Kelowna non-directional beacon (LW). From LW, the aircraft was to climb and track 330°M outbound for vectors to the filed or assigned route. At 2127, C-GTNG began to taxi toward Runway 34. At 2131, the CYLW tower controller cleared the aircraft to take off from the intersection of Runway 34 and Taxiway D. The pilot acknowledged the clearance and began the take-off roll on Runway 34 about 1 minute later. Radar data showed that, at 2133:41, the aircraft was 0.5 nautical miles (nm) beyond the departure end of the runway and was climbing at more than 4000 feet per minute (fpm) through 2800 feet ASL, at a climb angle of approximately 16°. In that time, it had deviated laterally by about 3° to the right of the 330°M track associated with the SID. At 2134:01, when the aircraft was 1.2 nm beyond the runway, it had climbed through 3800 feet ASL and deviated further to the right of the intended routing. The aircraft’s rate of climb decreased to about 1600 fpm, and its ground speed was 150 knots. A short time later, the aircraft’s rate of climb decreased to 600 fpm, its climb angle decreased to 2°, and its ground speed had increased to 160 knots. At 2134:22, the aircraft was 2.1 nm beyond the departure end of the runway, and it was climbing through approximately 4800 feet ASL. The aircraft had deviated about 13° to the right of the intended track, and its rate of climb reached its maximum value of approximately 000 fpm, 3 with a climb angle of about 22°. The ground speed was roughly 145 knots. At 2134:39, the aircraft was 2.7 nm beyond the departure end of the runway, passing through 5800 feet ASL, and had deviated about 20° to the right of the intended routing. The rate of climb was approximately 2000 fpm, with a climb angle of about 7°. According to the SID, the pilot was to make initial contact with the ACC after the aircraft had passed through 4000 feet ASL.Initial contact was made when the aircraft was passing through 6000 feet ASL, at 2134:42. At 2134:46, the ACC acknowledged the communication and indicated that the aircraft had been identified on radar. The aircraft was then cleared for a right turn direct to the MENBO waypoint once it was at a safe altitude, or once it was climbing through 8000 feet ASL. The aircraft was also cleared to follow the flight-planned route and climb to 10 000 feet ASL. At 2134:55, the pilot read back the clearance as the aircraft climbed through 6400 feet ASL, with a rate of climb of approximately 2400 fpm. The aircraft was tracking about 348°M at a ground speed of about 170 knots. At 2135:34, the aircraft began a turn to the right, which was consistent with the instruction from the ACC. Flying directly to the MENBO waypoint required the aircraft to be on a heading of 066°M, requiring a right turn of about 50°. At this point, the aircraft was still climbing and was passing through 8300 feet ASL. The rate of climb was about 3000 fpm. The aircraft continued the right turn and was tracking through 085°M. After reaching a peak altitude of approximately 8600 feet ASL, the aircraft entered a steep descending turn to the right, consistent with the characteristics of a spiral dive. At 2135:47, the ACC controller cleared C-GTNG to climb to FL 250. The lack of radar returns and radio communications from the aircraft prompted the controller to initiate search activities. At 2151, NAV CANADA notified first responders, who located the accident site in forested terrain at about midnight. The aircraft had been destroyed, and all of the occupants had been fatally injured.

Ed Dufresne Ministries

After climbing to and leveling at 15,000 feet, the airplane departed controlled flight, descended rapidly in a nose-down vertical dive, and impacted terrain; an explosion and postaccident fire occurred. Evidence at the accident site revealed that most of the wreckage was located in or near a single impact crater; however, the outer portion of the left wing impacted the ground about 1/2 mile from the main wreckage. Following the previous flight, the pilot reported to a maintenance person in another state that he had several malfunctioning flight instruments, including the autopilot, the horizontal situation indicator, and the artificial horizon gyros. The pilot, who was not a mechanic, had maintenance personnel replace the right side artificial horizon gyro but did not have any other maintenance performed at that time. The pilot was approved under an FAA exemption to operate the airplane as a single pilot; however, the exemption required that all equipment must be operational, including a fully functioning autopilot, flight director, and gyroscopic flight instruments. Despite the malfunctioning instruments, the pilot chose to take off and fly in instrument meteorological conditions. At the time of the loss of control, the airplane had just entered an area with supercooled large water droplets and severe icing, which would have affected the airplane's flying characteristics. At the same time, the air traffic controller provided the pilot with a radio frequency change, a change in assigned altitude, and a slight routing change. It is likely that these instructions increased the pilot's workload as the airplane began to rapidly accumulate structural icing. Because of the malfunctioning instruments, it is likely that the pilot became disoriented while attempting to maneuver and maintain control of the airplane as the ice accumulated, which led to a loss of control.

Airnor - Aeronaves del Noroeste

Based on the information available, at 20:40 the ONT (National Transplant Organization) informed the Santiago Airport (LEST) that they were going to make a “hospital flight”. The aircraft was refueled at the Santiago Airport with 1062 liters of fuel. According to communications, the crew of aircraft EC-IBA contacted the Santiago tower at 21:46 to request permission to start up and information on the weather and the runway in use at Asturias. At 21:54 they were cleared to take off. According to the airport operations office, the aircraft landed in Asturias (LEAS) at 22:27. The hospital flight service commenced at 22:15. The RFFS accompanied the ambulance to the aircraft at 22:30 and at 22:44 the aircraft took off en route to Porto. The aircraft was transferred from Madrid control to Santiago approach at 22:52 at flight level 200 and cleared straight to Porto (LPPR). Based on the information provided by Porto Airport, the aircraft landed at 23:40. While waiting for the medical team to return, the crew remained in the airport’s facilities. According to some of the personnel there, the crew made some comments regarding the bad weather. There was fog, especially on the arrival route. At 01:34 and again at 02:01 the crew was supplied with the flight plan information, information from the ARO-LPPR office and updated weather data. The aircraft was refueled at the Porto Airport with 1,000 l of fuel and took off at 02:34. At 02:44 the aircraft contacted approach control at Santiago to report its position. Four minutes later the crew contacted the Santiago tower directly to ask about the weather conditions at the field (see Appendix C). The aircraft landed once more in Asturias at 03:28. At 03:26 the RFFS was again activated to escort the ambulance to the aircraft. The service was deactivated at 04:00. The crew requested updated weather information from the tower, which provided the information from the 03:00 METAR. According to the flight plan filed, the estimated off-block time (EOBT) for departing from the Asturias Airport was 03:45, with an estimated flight time to Santiago of 40 minutes. The alternate destination airport was Vitoria (LEVT). The aircraft took off from Asturias at 03:38. At 03:56 the crew established contact with Santiago approach control, which provided the crew with the latest METAR from 03:30, which informed that the runway in use was 17, winds were calm, visibility was 4,000 m with mist, few clouds at 600 ft, temperature and dew point of 13° and QNH of 1,019. The aircraft was then cleared to conduct an ILS approach to runway 17 at the Santiago Airport. At 04:15 the crew contacted the tower controller, who reported calm winds and cleared them to land on runway 17. At 04:18 the COSPAS-SARSAT system detected the activation of an ELT. The system estimated the position for the beacon as being in the vicinity of the LEST airport. At 04:38 the tower controller informed airport operations of a call he had received from SAR that a beacon was active in the vicinity of the airport, and requested that a marshaller go to the airport where the airplane normally parked to see if it was there. At 04:44 the marshaller confirmed that the aircraft was not in its hangar and the emergency procedure was activated, with the various parties involved in the search for the airplane being notified. At 05:10 the control tower called the airport to initiate the preliminary phase (Phase I) before activating the LVP. At 05:15 the RFFS reported that the aircraft had been found in the vicinity of the VOR. At 05:30 the LVP was initiated (Phase II). At 07:51 the LVP was terminated. The last flight to arrive at the Santiago Airport before the accident had landed at 23:33, and the next flight to arrive following the accident landed at 05:25.

Ross Aviation - UK

Pilot B arrived at Biggin Hill Airport, Kent, at about 1100 hrs for the planned flight to Pau, France. At about 1130 hrs he helped tow the aircraft from its overnight parking position on the Southern Apron to a nearby handling agent whose services were being used for the flight. A member of staff employed by the handling agent saw Pilot B carry out what was believed to be an external pre-flight check of the aircraft. Pilot B also asked another member of staff to provide a print out of the weather information for the flight. Pilot A arrived at about 1145 hrs and joined Pilot B at the aircraft. Witnesses described nothing unusual in either pilots’ demeanour. Three passengers arrived at the handling agent at about 1300 hrs and waited in a lounge whilst their bags were taken to the aircraft and loaded into the baggage hold in the nose. A member of the handling agency, who later took the passengers to the aircraft, reported that Pilot B met them outside the aircraft. After they had all boarded, the agent heard Pilot B say that he would give them a safety brief. Pilot B then closed the aircraft door. Pilot A called for start at 1317 hrs. He called for taxi at 1320 hrs and the aircraft was cleared to taxi to the holding point A1. No one could be identified as a witness to the aircraft’s start or subsequent taxi to the holding point. At 1331 hrs ATC cleared the aircraft to line up on Runway 21 and at 1332 hrs cleared it to take off. Both clearances were acknowledged by Pilot A. The takeoff was observed by the tower controller who stated that everything appeared normal. No transmissions were made between the aircraft and ATC until one minute after takeoff when, at 1334 hrs, the following exchange was made. Numerous witnesses reported seeing the aircraft at around this time flying over a built-up area, about 2 nm north-north-east of Biggin Hill Airport, where it was observed flying low, passing over playing fields and nearby houses. Witnesses reported that the aircraft was maintaining a normal flying attitude with some reporting that the landing gear was up and others that it was down. Some described seeing it adopt a nose-high attitude and banking away from the houses just before it crashed. Some witnesses stated that there was no engine noise coming from the aircraft whilst others stated that they became aware of the aircraft as it flew low overhead due to the loud noise it was making, as if the engines were at high thrust. Two witnesses described hearing the aircraft make a pulsing, intermittent noise. The location of witnesses and the description of the aircraft noise they heard are also shown in Figure 1. Having flown over several houses at an extremely low height the aircraft’s left wing clipped a house which bordered a small area of woodland. The aircraft then impacted the ground between this and another house and caught fire. There were no injuries to anyone on the ground but all those on board the aircraft were fatally injured.

Southwest Orthopedic %26 Sports Medicine Clinic

On March 4, 2008, about 1515 central standard time, a Cessna 500, N113SH, registered to Southwest Orthopedic & Sports Medicine Clinic PC of Oklahoma City, Oklahoma, entered a steep descent and crashed about 2 minutes after takeoff from Wiley Post Airport (PWA) in Oklahoma City. None of the entities associated with the flight claimed to be its operator. The pilot, the second pilot, and the three passengers were killed, and the airplane was destroyed by impact forces and post crash fire. The flight was operated under 14 Code of Federal Regulations (CFR) Part 91 with an instrument flight rules flight plan filed. Visual meteorological conditions prevailed. The flight originated from the ramp of Interstate Helicopters (a 14 CFR Part 135 on demand helicopter operator at PWA) and was en route to Mankato Regional Airport, Mankato, Minnesota, carrying company executives who worked for United Engines and United Holdings, LLC.

IHR Administrative Services

The twin-engine turbojet airplane was attempting to land on a runway with standing water when the accident occurred. Before the landing attempt, the pilot was told that the runway was wet from a recent rain shower. Witnesses reported seeing the airplane on the runway traveling at a high speed and then increase engine power to abort the landing with about 1/4 of the runway remaining. The surviving passenger reported that the runway was "soaked and shiny with water." He stated that the airplane landed hard and fishtailed during the landing roll. During the aborted landing the airplane impacted a jet-blast deflector located off the departure end of the runway. The airplane then proceeded through the airport perimeter fence and impacted a residential structure before coming to a stop. The airplane and residential structure were destroyed during a postaccident fire. An examination of the airframe and engines did not reveal any anomalies associated with a preimpact failure or malfunction. The airplane was not equipped with thrust reversers or an anti-skid braking system. Radar track data analysis indicated that when the airplane was about 1/4 mile from the end of the runway it was approximately 16 knots above its target landing reference speed (Vref) and had a descent rate of 1,150 feet per minute. The runway was 4,875 feet long. The calculated landing distance for a runway with standing water is 4,789 feet.

Flite Services

The right main landing gear collapsed on landing. According to the flight crew, after departure they preceded to Mountain Air Airport, where they performed a "touch-and-go" landing. Upon raising the landing gear following the touch-and-go landing, they got an "unsafe gear" light. The crew stated they cycled the gear back down and got a "three green" normal indication. They cycled the gear back up and again got the "gear unsafe" light. They diverted to Greensboro, North Carolina, and upon landing in Greensboro the airplane's right main landing gear collapsed. After the accident, gear parts from the accident airplane were discovered on the runway at Mountain Air Airport. Metallurgical examination of the landing gear components revealed fractures consistent with overstress separation and there was no evidence of fatigue. Examination of the runway at Mountain Air Airport by an FAA Inspector showed evidence the accident airplane had touched down short of the runway.