Cessna 414 Chancellor

MJ Aviation

Aircraft Charter and Leasing

Sierra AE

On October 8, 2020, about 1115 eastern daylight time, a Cessna 414, N8132Q, was substantially damaged when it was involved in an accident at North Palm Beach County General Aviation Airport (F45), West Palm Beach, Florida. The private pilot and six passengers sustained serious injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to the pilot’s son, a multiengine airplane rated passenger who was seated in the front right seat, his father was flying family members to Claxton-Evans County Airport, Claxton, Georgia, where they planned a fuel stop before proceeding to their home-base of Columbus Municipal Airport, Columbus, Indiana. After the preflight inspection, engine start and taxi, he noted no irregularities when his father performed the engine run-up. His father then taxied onto the runway, checked the trim for takeoff, applied brakes, and advanced the throttles to full power. Once at full rpm, his father released the brakes and the airplane began its takeoff roll. Shortly into the takeoff roll, he felt a momentary “slight shudder” which appeared to come from the controls. As the airplane continued down the runway, he looked out of the window and thought that they should have rotated. He observed that the airspeed indicator showed about 10 to 15 knots past “blueline;” however, the airplane remained on the runway and continued to gain speed. The airplane was running out of runway, and the pilot’s son attempted to pull back on the control yoke; however, the controls would not move, so he pulled the throttles back to idle and applied maximum braking; he estimated that the airplane’s indicated airspeed was between 120 and 130 knots when the aborted takeoff was initiated. The airplane departed the paved portion of the runway, travelled through the grass and impacted a dirt mound before coming to rest in a marsh. A witness who observed the takeoff stated, “They were going fast enough to fly, but they weren’t coming up off the ground.” He further stated said the engines never lost power until the pilot shut them off in an attempt to stop. Initial examination of the airplane by a Federal Aviation Administration inspector revealed that it came to rest upright and submerged in about 5 ft of water about 450 ft beyond the departure end of runway 14. The fuselage and cabin area remained relatively intact. The right wing and engine were separated. The right elevator was bent upwards nearly vertical with the vertical stabilizer; the left elevator separated. The left wing and engine remained attached in their respective locations, with the outboard portion of the left wing sheared at the wing tip fuel tank.

Warbird Associates

On October 29, 2019, at 1058 eastern daylight time, a Cessna 414A airplane, N959MJ, was destroyed when it was involved in an accident in Colonia, New Jersey. The commercial pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations (CFR) Part 91 personal flight. The pilot’s spouse reported that he planned to depart Leesburg Executive Airport (JYO), Leesburg, Virginia, about 0900 local; however, he delayed his departure due to the weather at his destination, Linden Airport (LDJ), Linden, New Jersey. She reported that the pilot was scheduled to give a lecture in Queens, New York, in the afternoon. Review of radar and flight plan data provided by the Federal Aviation Administration (FAA) revealed that the airplane departed JYO at 0950 on an instrument flight rules (IFR) flight plan and proceeded on course to LDJ. At 1053:20, the airplane’s radar altitude was 2,000 ft mean sea level (msl) and its position was over the DAPVY GPS waypoint, which was the first waypoint associated with the GPS-A circling instrument approach procedure to LDJ. The airplane then turned to a northeast heading, which was consistent with the final approach course for the GPS-A approach. For the next 2 1/2 minutes, the airplane descended along the final approach course and crossed the final approach fix (GEZSY) about 1,200 ft msl (radar altitude). During the descent from DAPVY to GEZSY, the airplane’s groundspeed varied from about 110 knots, to 140 knots, and then to 100 knots. The airplane continued to descend after GEZSY and crossed the subsequent waypoint of 3 nautical miles (nm) from BAUTZ about 700 ft msl. From GEZSY t0 3nm to BAUTZ the groundspeed varied from about 100 knots, to 115 knots, and to 85 knots. The airplane subsequently descended to 600 ft msl, maintained course, and remained at 600 ft for about 1 minute. During this time, groundspeed varied and increased from about 80 knots to 90 knots before decreasing to 65 knots. At 1058:02, the airplane’s flight track turned left off course and the airplane rapidly descended. The final radar return, at 1058:07, was less than 1/10 mile from the accident site and showed the airplane at 200 ft msl headed northwest. About 1050, the controller provided the pilot with a recently received pilot report (PIREP) for cloud bases at 500 ft overcast at nearby Newark Liberty International Airport (EWR). The pilot acknowledged and subsequently informed the controller that LDJ was reporting bases at 700 ft. The controller then informed the pilot that the automated report at EWR was reporting an 800 ft broken ceiling. At 1051:50 the pilot was cleared for the GPS-A nonprecision circling instrument approach procedure to LDJ. At 1056:56, the controller stated to the pilot, “say flight conditions.” The pilot immediately responded, “say again oh we're still IFR.” At 1058:06 the controller again asked the pilot to say the flight conditions; however, there was no response. At 1058:12, the controller stated to the pilot, “check altitude immediately;” however, there was no response from the pilot. This was the only altitude warning the controller provided to the pilot. The controller attempted to reach the pilot again multiple times, but there was no response.

KL Management

The commercial pilot departed for a cross-country, personal flight with no flight plan filed. No evidence was found that the pilot received a preflight weather briefing; therefore, it could not be determined if he checked or received any weather information before or during the accident flight. Visual meteorological conditions existed at the departure airport; however, during the departure climb, the weather transitioned to instrument meteorological conditions (IMC) with precipitation, microburst, and rain showers over the accident area. During the takeoff clearance, the air traffic controller cautioned the pilot about deteriorating weather conditions about 4 miles east of the airport. Radar data showed that, about 5 1/2 minutes after takeoff, the airplane had climbed to about 7,800 ft above ground level before it started a rapid descending right turn and subsequently impacted the ground about 9.6 miles east of the departure airport. Recorded data from the airplane’s Appareo Stratus 2S (portable ADS-B receiver and attitude heading and reference system) revealed that, during the last 15 seconds of the flight, the airplane’s attitude changed erratically with the pitch angle fluctuating between 45° nose-down and 75°nose-up, and the bank angle fluctuating between 170° left and 150° right while descending from 5,500 to 500 ft above ground level, indicative of a loss of airplane control shortly after the airplane entered the clouds. Several witnesses located near the accident site reported seeing the airplane exit the clouds at a high descent rate, followed by airplane parts breaking off. One witness reported that he saw the airplane exit the overcast cloud layer with a nose down pitch of about 60°and remain in that attitude for about 4 to 5 seconds “before initiating a high-speed dive recovery,” at the bottom of which, the airplane began to roll right as the left horizontal stabilizer separated from the airplane, immediately followed by the remaining empennage. He added that the left wing then appeared to shear off near the left engine, followed by the wing igniting. An outdoor home security camera, located about 0.5 mile north-northwest of the accident location, captured the airplane exiting the clouds trailing black smoke and then igniting. Examination of the debris field, airplane component damage patterns, and the fracture surfaces of separated parts revealed that both wings and the one-piece horizontal stabilizer and elevators were separated from the empennage in flight due to overstress, which resulted from excessive air loads. Although the airplane was equipped with an autopilot, the erratic variations in heading and altitude during the last 15 seconds of the flight indicated that the pilot was likely hand-flying the airplane; therefore, he likely induced the excessive air loads while attempting to regain airplane control. Conditions conducive to the development of spatial orientation existed around the time of the in-flight breakup, including restricted visibility and the flight entering IMC. The flight track data was consistent with the known effects of spatial disorientation and a resultant loss of airplane control. Therefore, the pilot likely lost airplane control after inadvertently entering IMC due to spatial disorientation, which resulted in the exceedance of the airplane’s design stress limits and subsequent in-flight breakup. Contributing to accident was the pilot’s improper decision to conduct the flight under visual flight rules despite encountering IMC and continuing the flight when the conditions deteriorated. Toxicology testing on specimens from the pilot detected the presence of delta-9-tetrahydrocanninol (THC) in heart blood, which indicated that the pilot had used marijuana at some point before the flight. Although there is no direct relationship between postmortem blood levels and antemortem effects from THC, it does undergo postmortem redistribution. Therefore, the antemortem THC level was likely lower than detected postmortem level due to postmortem redistribution from use of marijuana days previously, and it is unlikely that the pilot’s use of marijuana contributed to his poor decision-making the day of the accident. The toxicology testing also detected 67 ng/mL of the sedating antihistamine diphenhydramine. Generally, diphenhydramine is expected to cause sedating effects between 25 to 1,120 ng/mL. However, diphenhydramine undergoes postmortem redistribution, and the postmortem heart blood level may increase by about three times. Therefore, the antemortem level of diphenhydramine was likely at or below the lowest level expected to cause significant effects, and thus it is unlikely that the pilot’s use of diphenhydramine contributed to the accident.

Category III Aviation

The pilot and four passengers were nearing the completion of a cross-county business flight. While maneuvering in the traffic pattern at the destination airport, the controller asked the pilot if he could accept a shorter runway. The pilot said he could not, so he was instructed to enter a holding pattern for sequencing; less than a minute later, the pilot said he could accept the shorter runway. He was instructed to conduct a left 270° turn to enter the traffic pattern. The pilot initiated a left bank turn and then several seconds later the bank increased, and the airplane subsequently entered a steep nose-down descent. The airplane impacted a shopping center parking lot about 1.6 miles from the destination airport. A review of the airplane's flight data revealed that, shortly after entering the left turn, and as the airplane’s bank increased, its airspeed decreased to about 59 knots, which was well below the manufacturer’s published stall speed in any configuration. Postaccident examination of the airframe and engines revealed no anomalies that would have precluded normal operation. It is likely that the pilot failed to maintain airspeed during the turn, which resulted in an exceedance of the aircraft's critical angle of attack and an aerodynamic stall.

Southern Aircraft Consultancy

The aircraft departed Dunkeswell Airfield on the morning of the accident for a flight to Retford (Gamston) Airfield with three passengers on board, two of whom held flying licences. The passengers all reported that the flight was uneventful and after spending an hour on the ground the aircraft departed with two passengers for Enstone Airfield. This flight was also flown without incident.The pilot reported that before departing Enstone he visually checked the level in the aircraft fuel tanks and there was 390 ltr (103 US gal) on board, approximately half of which was in the wingtip fuel tanks. After spending approximately one hour on the ground the pilot was heard to carry out his power checks before taxiing to the threshold of Runway 08 for a flight back to Dunkeswell with one passenger onboard). During the takeoff run the left engine was heard to stop and the aircraft veered to the left as it came to a halt. The pilot later recalled that he had seen birds in the climbout area and this was a factor in the abandoned takeoff. The aircraft was then seen to taxi to an area outside the Oxfordshire Sport Flying Club, where the pilot attempted to start the left engine, during which time the right engine also stopped. The right engine was restarted, and several attempts appeared to have been made to start the left engine, which spluttered into life before stopping again. Eventually the left engine started, blowing out clouds of white and black smoke. After the left engine was running smoothly the pilot was seen to taxi to the threshold for Runway 08. The takeoff run sounded normal and the landing gear was seen to retract at a height of approximately 200 ft agl. The climbout was captured on a video recording taken by an individual standing next to the disused runway, approximately 400 m to the south of Runway 08. The aircraft was initially captured while it was making a climbing turn to the right and after 10 seconds the wings levelled, the aircraft descended and disappeared behind a tree line. After a further 5 seconds the aircraft came into view flying west over buildings to the east of the disused runway at a low height, in a slightly nose-high attitude. The right propeller appeared to be rotating slowly, there was some left rudder applied and the aircraft was yawed to the right. The left engine could be heard running at a high rpm and the landing gear was in the extended position. The aircraft appeared to be in a gentle right turn and was last observed flying in a north-west direction. The video then cut away from the aircraft for a further 25 seconds and when it returned there was a plume of smoke coming from buildings to the north of the runway. The pilot reported that the engine had lost power during a right climbing turn during the departure. He recovered the aircraft to level flight and selected the ‘right fuel booster’ pump (auxiliary pump) and the engine recovered power. He decided to return to Enstone and when he was abeam the threshold for Runway 08 the right engine stopped. He feathered the propeller on the right engine and noted that the single-engine performance was insufficient to climb or manoeuvre and, therefore, he selected a ploughed field to the north of Enstone for a forced landing. During the approach the pilot noticed that the left engine would only produce “approximately 57%” of maximum power, with the result that he could not make the field and crashed into some farm buildings. There was an immediate fire following the accident and the pilot and passenger both escaped from the wreckage through the rear cabin door. The pilot sustained minor burns. The passenger, who was taken to the John Radcliffe Hospital in Oxford, sustained burns to his body, a fractured vertebra, impact injuries to his chest and lacerations to his head.

Make it Happen Aviation

The twin-engine airplane, flown by an airline transport pilot, was approaching the destination airport after a cross-country flight in night instrument meteorological conditions. The destination airport weather conditions about 1 minute before the accident included an overcast ceiling at 200 ft and 1/2-mile visibility with light rain and fog. According to air traffic control (ATC) data, the flight received radar vectors to the final approach course for an instrument landing system (ILS) approach to runway 20. As shown by a post accident simulation study based on radar data and data recovered from the airplane's electronic horizontal situation indicator (EHSI), the airplane's flight path did not properly intercept and track either the localizer or the glideslope during the instrument approach. The airplane crossed the final approach fix about 360 ft below the glideslope and then maintained a descent profile below the glideslope until it leveled briefly near the minimum descent altitude, likely for a localizer-only instrument approach. However, the lateral flight path from the final approach fix inbound was one or more dots to the right of the localizer centerline until the airplane was about 1 nautical mile from the runway 20 threshold when it turned 90° left to an east course. The turn was initiated before the airplane had reached the missed approach point; additionally, the left turn was not in accordance with the published missed approach instructions, which specified a climb on runway heading before making a right turn to a 270° magnetic heading. The airplane made a series of pitch excursions as it flew away from the localizer. The simulation study determined that dual engine power was required to match the recorded flight trajectory and ground speeds, which indicated that both engines were operating throughout the approach. The simulation results also indicated that, based on calculated angle of attack and lift coefficient data, the airplane likely encountered an aerodynamic stall during its course deviation to the east. The airplane impacted the ground about 2.2 miles east-northeast of the runway 20 threshold and about 1.75 miles east of the localizer centerline. According to FAA documentation, at the time of the accident, all components of the airport's ILS were functional, with no recorded errors, and the localizer was radiating a front-course to the correct runway. Additionally, a post accident flight check found no anomalies with the instrument approach.An onsite examination established that the airplane impacted the ground upright and in a nose-low attitude, and the lack of an appreciable debris path was consistent with an aerodynamic stall/spin. Wreckage examinations did not reveal any anomalies with the airplane's flight control systems, engines, or propellers. The glideslope antenna was found disconnected from its associated cable circuit. Laboratory examination and testing determined that the glideslope antenna cable was likely inadequately connected/secured during the flight, which resulted in an unusable glideslope signal to the cockpit avionics. There was no history of recent maintenance on the glideslope antenna, and the reason for the inadequate connection could not be determined. Data downloaded from the airplane's EHSI established that the device was in the ILS mode during the instrument approach phase and that it had achieved a valid localizer state on both navigation channels; however, the device never achieved a valid glideslope state on either channel during the flight. Further, a replay of the recorded EHSI data confirmed that, during the approach, the device displayed a large "X" through the glideslope scale and did not display a deviation pointer, both of which were indications of an invalid glideslope state. There was no evidence of cumulative sleep loss, acute sleep loss, or medical conditions that indicated poor sleep quality for the pilot. However, the accident occurred more than 2 hours after the pilot routinely went to sleep, which suggests that the pilot's circadian system would not have been promoting alertness during the flight. Further, at the time of the accident, the pilot likely had been awake for 18 hours. Thus, the time at which the accident occurred and the extended hours of continuous wakefulness likely led to the development of fatigue. The presence of low cloud ceilings and the lack of glideslope guidance would have been stresses to the pilot during a critical phase of flight. This would have increased the pilot's workload and situational stress as he flew the localizer approach, a procedure that he likely did not anticipate or plan to conduct. In addition, weight and balance calculations indicated that the airplane's center of gravity (CG) was aft of the allowable limit, and the series of pitch excursions that began shortly after the airplane turned left and flew away from the localizer suggests that the pilot had difficulty controlling airplane pitch. This difficulty was likely due to the adverse handling characteristics associated with the aft CG. These adverse handling characteristics would have further increased the pilot's workload and provided another distraction from maintaining control of the airplane. Therefore, it is likely that the higher workload caused by the pilot's attempt to fly an unanticipated localizer approach at night in low ceilings and his difficulty maintaining pitch control of the airplane with an aft CG contributed to his degraded task performance in the minutes preceding the accident.