Cessna 525 CitationJet CJ1

Nelvo Fries

Private Venezuelan

The crew departed Porlamar-Del Caribe-General en Jefe Santiago Mariño Airport on a ferry flight to Caracas-Oscar Machado Zuloaga Airport. After takeoff, while climbing, the crew encountered unknown technical problems and was cleared to return for an emergency landing. After touchdown, the aircraft was unable to stop within the remaining distance. It overran, lost its undercarriage and came to rest, bursting into flames. Both pilots were seriously injured and suffered burns. The aircraft was partially destroyed by fire.

VanCon

Owned by a construction company and registered under Vancon Holdings LLC (VanCon Inc.), the aircraft was parked at Spanish Fork-Springville Airport when it was stolen at night by a private pilot. After takeoff, hew flew southbound to Payson, reduced his altitude and voluntarily crashed the plane onto his house located in Payson. The airplane disintegrated on impact and was destroyed by impact forces and a post crash fire. The pilot was killed. His wife and daughter who were in the house at the time of the accident were uninjured despite the house was also destroyed by fire. Local Police declared that the pilot intentionally flew the airplane into his own home hours after being booked for domestic assault charges. An examination of the airplane found no anomalies with the flight controls that would have contributed to the accident. Toxicology testing revealed the presence of a medication used to treat depression, obsessive-compulsive disorder, some eating disorders, and panic attacks; the pilot did not report the use of this medication to the Federal Aviation Administration. The pilot had a known history of depression, anxiety, and anger management issues. The circumstances of the accident were consistent with the pilot's intentional flight into his home.

Augusta Aviation LLC

The instrument rated private pilot was drinking alcohol before he arrived at the airport. Before the flight, he did not obtain a weather briefing or file an instrument flight rules flight plan for the flight that was conducted in instrument meteorological conditions. The pilot performed a 3-minute preflight inspection of the airplane and departed with a tailwind (even though he had initially taxied the airplane to the runway that favored the wind) and without communicating on the airport Unicom frequency. After departure, the airplane climbed to a maximum altitude of 11,500 feet mean sea level (msl), and then the airplane descended to 4,300 ft msl (which was 1,400 ft below the minimum safe altitude for the destination airport) and remained at that altitude for 9 minutes. Afterward, the airplane began a descending left turn, and radar contact was lost at 2054. The pilot did not talk to air traffic control during the flight and while operating in night instrument meteorological conditions. During the flight, the airplane flew through a line of severe thunderstorms with heavy rain, tornados, hail, and multiple lightning strikes. Before the airplane's descending left turn began, it encountered moderate-to-heavy rain. The airplane's high descent rate of at least 6,000 ft per minute and impact with a mountain that was about 450 ft from the last radar return, the damage to the airplane, and the distribution of the wreckage were consistent with a loss of control and a high-velocity impact. Examination of the airplane revealed no evidence of any preimpact mechanical anomalies. Based on the reported weather conditions at the time the flight, the pilot likely completed the entire flight in night instrument meteorological conditions. His decision to operate at night in an area with widespread thunderstorms and reduced visibility were conducive to the development of spatial disorientation. The airplane's descending left turn and its high-energy impact were consistent with the known effects of spatial disorientation. The pilot was not aware of the conditions near and at the destination airport because he failed to obtain a weather briefing and was not communicating with air traffic control. Also, the pilot's decision to operate an airplane within 8 hours of consuming alcohol was inconsistent with the Federal Aviation Administration's regulation prohibiting such operations, and the level of ethanol in the pilot's toxicology exceeded the level allowed by the regulation. Overall, the pilot's intoxication, combined with the impairing effects of cetirizine, affected his judgment; contributed to his unsafe decision-making; and increased his susceptibility to spatial disorientation, which resulted in the loss of control of the airplane.

Donald L. Baker

The airline transport pilot and passenger departed on a cross-country flight in instrument meteorological conditions in the light business jet. About 1 minute after departure, air traffic control instructed the pilot to climb and maintain an altitude of 14,000 ft mean sea level (msl). About 3 minutes later, the pilot stated that the airplane's flight management system (FMS) had failed. Shortly thereafter, he requested a climb and stated that he was "trying to get to clear skies." Over the next several minutes, the controller provided the pilot with headings and altitudes to vector the airplane into visual meteorological conditions. During this time, and over the course of several transmissions, the pilot stated that he was "losing instruments," was hand-flying the airplane (likely indicating the autopilot was inoperative), and that he wanted to "get clear of the weather." Radar data indicated that, during the 10-minute flight, the airplane conducted a series of climbs and descents with large variations in airspeed. About 2 minutes before the loss of radar contact, the airplane entered a climbing right turn, reaching its highest altitude of about 21,000 ft, before it began a rapidly descending and tightening turn. Performance data revealed that, during this turn, the airplane entered a partially-inverted attitude, exceeded its design maneuvering speed, and reached a peak descent rate of about 36,000 ft per minute. Radar contact was lost at an altitude of about 16,000 ft msl, and the airplane subsequently experienced an inflight breakup. The wreckage was distributed over a debris path that measured about 3/4-mile long and about 1/3-mile wide. Postaccident examination and testing of various flight instruments did not indicate what may have precipitated the inflight anomalies that the pilot reported prior to the loss of control. Additionally, all airframe structural fractures were consistent with ductile overload, and no evidence of any preexisting condition was noted with the airframe or either engine. The airplane was equipped with three different sources of attitude information, all three of which were powered by separate sources. It is unlikely that all three sources would fail simultaneously. In the event the pilot experienced a dual failure of attitude instrumentation on both the pilot and copilot sides, airplane control could have been maintained by reference to the standby attitude indicator. Further, the pilot would have been afforded heading information from the airplane's standby compass. Although the pilot did not specifically state to the controller the nature of the difficulties he was experiencing nor, could the investigation identify what, if any, anomalies the pilot may have observed of the airplane's flight instruments, the pilot clearly perceived the situation as one requiring an urgent ascent to visual conditions. As a single pilot operating without the assistance of an additional crewmember in a high-workload, high-stress environment, the pilot would have been particularly susceptible to distraction and, ultimately, a loss of airplane control due to spatial disorientation.

Planalto Indústria Mecânica

The aircraft departed Goiânia on a flight to Aruanã, carrying two pilots and five passengers who should take part to the funeral of former football player Fernandão who died in an helicopter crash. Following an uneventful flight, the crew completed the landing on runway 24 which is 1,280 metres long. After touchdown, the aircraft was unable to stop within the remaining distance and overran. While contacting soft ground, the nose gear collapsed then the aircraft collided with a concrete fence and came to a halt 150 metres further against a second fence. All seven occupants were injured, the captain seriously. The aircraft was damaged beyond repair.

Brink Constructors

The airline transport pilot was conducting a business flight with six passengers on board. Radar data showed that, after crossing the final approach fix for an instrument approach at the destination airport, the airplane descended below the minimum descent altitude (MDA) of 2,480 ft mean sea level (msl); dark night, instrument meteorological conditions existed at that time. Subsequently, when the airplane was about 2 miles from the airport and about 2,070 ft msl, the airplane impacted a utility pole, which was 10 ft above ground level (agl). After impacting the pole, the pilot executed a missed approach, and about 40 minutes later, he landed the airplane without further incident at another airport. On-scene examination showed that the impact had scattered debris from the separated utility pole for about 200 ft into a snow-covered field. Examination of the airplane revealed that the impact resulted in substantial damage to the nose structure, lower and upper fuselage, and horizontal stabilizer. Further examinations of the airplane, including its static system, both altimeters, both vertical speed indicators, and the radar altimeter system revealed no evidence of preaccident mechanical malfunctions or failures that would have precluded normal operation. The pilot reported that he thought he had leveled the airplane at an altitude above the MDA and that at no time during the descent and approach did the airplane's radar altimeter sound an alert indicating that the airplane was below 400 ft agl radar altitude. He also reported that he never saw the terrain, any obstructions, nor the runway lights or airport environment. Despite the pilot's statement, given the radar data and the impact evidence, it is apparent that he descended the airplane below the MDA, which resulted in the subsequent impact with the utility pole. It could not be determined why the radar altimeter did not alert the pilot that the airplane was only 10 ft above the ground. The pilot's second-class medical certificate, which had been issued more than 20 months before the accident, had expired. The medical certificate limitation section in the expired certificate stated, "Not valid for night flying or by color signal control." There is no evidence that these restrictions contributed to the accident.

Jeanette A. Symons

The instrument-rated private pilot departed on an instrument flight rules (IFR) cross-country flight plan in near-zero visibility with mist, light freezing rain, and moderate mixed and clear icing. After departure, and as the airplane entered a climbing right turn to a track of about 260 degrees, the pilot reported to air traffic control that she was at 1,000 feet, climbing to 10,000 feet. The flight remained on a track of about 260 degrees and continued to accelerate and climb for 38 seconds. The pilot then declared an emergency, stating that she had an attitude indicator failure. At that moment, radar data depicted the airplane at 3,500 feet and 267 knots. Thirteen seconds later, the pilot radioed she wasn't sure which way she was turning. The transmission ended abruptly. Radar data indicated that at the time the transmission ended the airplane was in a steep, rapidly descending left turn. The fragmented airplane wreckage, due to impact and subsequent explosive forces, was located in a wooded area about 6 miles south-southwest of the departure airport. Examination of the accident site revealed a near vertical high-speed impact consistent with an in-flight loss of control. The on-site examination of the airframe remnants did not show evidence of preimpact malfunction. Examination of recovered engine remnants revealed evidence that both engines were producing power at the time of impact and no preimpact malfunctions with the engines were noted. The failure, single or dual, of the attitude indicator is listed as an abnormal event in the manufacturer's Pilot's Abbreviated Emergency/Abnormal Procedures. The airplane was equipped with three different sources of attitude information: one incorporated in the primary flight display unit on the pilot's side, another single instrument on the copilot's side, and the standby attitude indicator. In the event of a dual failure, on both the pilot and copilot sides, aircraft control could be maintained by referencing to the standby attitude indicator, which is in plain view of the pilot. The indicators are powered by separate sources and, during the course of the investigation, no evidence was identified that indicated any systems, including those needed to maintain aircraft control, failed. The pilot called for a weather briefing while en route to the airport 30 minutes prior to departure and acknowledged the deteriorating weather during the briefing. Additionally, the pilot was eager to depart, as indicated by comments that she made before her departure that she was glad to be leaving and that she had to go. Witnesses indicated that as she was departing the airport she failed to activate taxi and runway lights, taxied on grass areas off taxiways, and announced incorrect taxi instructions and runways. Additionally, no Federal Aviation Administration authorization for the pilot to operate an aircraft between 29,000 feet and 41,000 feet could be found; the IFR flight plan was filed with an en route altitude of 38,000 feet. The fact that the airplane was operating at night in instrument meteorological conditions and the departure was an accelerating climbing turn, along with the pilot's demonstrated complacency, created an environment conducive to spatial disorientation. Given the altitude and speed of the airplane, the pilot would have only had seconds to identify, overcome, and respond to the effects of spatial disorientation.

Sun Quest Executive Air Charter

Line personnel reported that as the airplane was being fueled, the second pilot loaded more than one bag in the left front baggage compartment. With fueling complete, line personnel saw the second pilot pull the front left baggage door down, but not lock or latch it. Witnesses near midfield of the 8,001-foot long runway, reported that the airplane was airborne, and the front left baggage door was closed. Witnesses near the end of the runway, reported that the airplane was about 200 feet above ground level (agl) and they noted that the front left baggage door was open and standing straight up. All of the witnesses reported that the airplane turned slightly left, leveled off, and was slow. The airplane began to descend, and the wings were slightly rocking before it stalled, broke right, and collided with the terrain. Investigators found no anomalies with the airframe or engines that would have precluded normal operation. The forward baggage doors' design incorporates a key lock in the lower center of each door, and two latches in the left and right bottom section of the doors. There are two hinges in the upper left and right sections of the door. The handles latched the door to the door frame in the fuselage. The key would be in the horizontal position in an unlocked condition, and in the vertical position in a locked condition. The front left baggage door was found within the main wreckage debris field and had sustained mechanical and thermal damage. The key lock was in the horizontal position. Several instances of a baggage door opening in flight have been recorded in Cessna Citation airplanes. In some cases, the door separated, and in others it remained attached. The crews of these other airplanes returned to the airport and landed successfully.

Viaçao Cometa

The twin engine airplane departed Rio de Janeiro-Santos Dumont at 1402LT on a positioning flight to Jacarepaguá Airport located 23 km southwest from Santos Dumont Airport. After takeoff, the copilot informed ATC he maintained the altitude of 1,500 feet via route Bravo until the coast. Shortly later, while cruising in clouds at an altitude of 1,380 feet, the aircraft struck the slope of Mt Morro da Taquara located in the Tijuca National Park. The wreckage was found near Alto da Boa Vista and both pilots were killed. At the time of the accident, weather conditions were considered as marginal with low ceiling above the mountainous area.

Tango Corporation

The corporate jet airplane experienced a loss of elevator trim control (runaway trim) that resulted in an uncommanded nose-low pitch attitude. The pilot reported that following the loss of elevator trim authority the airplane was extremely difficult to control and the elevator control forces were extremely high. The pilot continued to maneuver the airplane, but eventually ditched it into a nearby marine cove. The runaway trim condition was not immediately recognized by the pilot and he stated that, by that point in the event sequence, the control forces were so great that he had little time to troubleshoot the system and elected to continue on his established heading and ditch the airplane. Pulling the circuit breaker, which is called for by the checklist in the event of a trim runaway, would have arrested the trim movement. Post accident examination and functional testing of the airplane's electric pitch trim printed circuit board (PCB) showed a repeatable fault in the operation of the PCB's K6 relay, resulting in the relay contacts remaining closed. This condition would be representative of the autopilot pitch trim remaining engaged, providing an electrical current to drive continuous nose-down trim to the elevator trim motor. Examination of the airplane's maintenance records showed that the PCB was removed and replaced in conjunction with the phase inspection prior to the accident. Further examination of the airplane's maintenance records revealed that the replacement PCB was originally installed in an airplane that experienced an "electric trim runaway on the ground." Following the trim runaway, the PCB was removed and shipped to the manufacturer. After receiving the PCB the manufacturer tested the board and no discrepancies were noted. The unit was subsequently approved for return to service and later installed on the accident airplane. The investigation revealed a single-point failure of trim runaway (failed K6 relay) and a latent system design anomaly in the autopilot/trim disconnect switch on the airplane's pitch trim PCB. This design prohibited the disengagement of the electric trim motor during autopilot operation. As a result of the investigation, the FAA issued three airworthiness directives (AD 2003-21-07, AD 2003-23-20, and AD 2004-14-20), and the pitch trim printed circuit board was redesigned and evaluated for compliance with safety requirements via system safety assessment.

Mike G. Rutherford

The flight was approaching a private airport (elevation 983 feet msl), that did not have an instrument approach system, during instrument meteorological conditions. The pilot informed the air traffic controller that he had the airport in sight, and cancelled his instrument flight plan. The twin turbofan airplane impacted a tree approximately 4,000 feet northeast of the airport in an upright position. The airplane then impacted the ground in an inverted position approximately 200 yards from the initial impact with the tree. The weather observation facility located 16 miles northeast of the accident site was reporting an overcast ceiling at 400 feet agl, and visibility 4 statute miles in mist. The weather observation facility elevation was 541 feet msl. Local residents in the vicinity of the accident site stated that there was heavy fog and drizzle at the time of the accident. The pilot had filed an alternate airport (with a precision instrument approach); however, he elected not to divert to the alternate airport. Examination of the wreckage did not reveal any evidence of pre-impact anomalies that would have prevented operation of the airplane.

College of the Ozarks

Prior to takeoff from Lambert Field/St. Louis International Airport, St. Louis, Missouri, the pilot contacted the operations manager at M. Graham Clark Airport, Point Lookout, Missouri, and asked about the current weather conditions there. The operations manager told the pilot that the weather was "pretty poor." The airplane took off from St. Louis, at 1411 cst. At 1447:12 cst, the pilot checked in with Springfield Approach Control. The pilot was told to expect the ILS approach to runway 2 at the Springfield-Branson Regional Airport. At 1501:01 cst, the pilot requested to go to Point Lookout and shoot the GPS to runway 11. Springfield Approach instructed the pilot to descend to 3,000 feet msl and cleared him for the approach. At 1507:08 cst, Springfield radar showed the airplane crossing the initial waypoint at 3,000 feet msl, and turn to 116 degrees approach heading. At 1507:17 cst, the airplane descended to 2,500 feet msl. At 1508:51 cst, Springfield Approach cleared the pilot to change to advisory frequency. "Call me back with your cancellation or your miss." The pilot responded, "Okay we're, we're RAWBE inbound and we will call you on the miss or cancellation." The operations manager at M. Graham Clark Airport said that he heard the pilot on the airport's common frequency radio say, "Citation 525KL is RAWBE inbound on the GPS 11 approach." At 1509:01 cst, Springfield radar showed the airplane begin a descent out of 2,500 feet msl. The last radar contact was at 1509:48 cst. The airplane was five nautical miles from the airport on a 296 degree radial, at 2,100 feet msl. At 1530 cst, the operations manager heard Springfield approach trying to contact the airplane. The operations manager initiated a search for the airplane. At 1430 cst, the weather observation at the M. Graham Clark Airport was 300 feet overcast, rain and mist, 3/4 miles visibility, temperature 53 degrees F, winds variable at 3 knots, altimeter 29.92 inches HG. Approach minimum weather for the GPS RWY11 straight in approach to Point Lookout are a minimum ceiling of 600 feet and visibility of 1 mile for a category B aircraft. An examination of the airplane wreckage revealed no anomalies. The results of FAA toxicology testing of specimens from the pilot revealed concentrations of Doxepin in kidney and liver. The Physicians' Desk Reference states that "... drowsiness may occur with the use of this drug, patients should be warned of the possibility and cautioned against driving a car or operating dangerous machinery while taking the drug." The physician who prescribed the Doxepin to the pilot said that he was using it to treat the pilot's "irritable bowel" condition. According to his wife, the pilot had not slept well for several nights, up to the day of the accident, due to problems he was having with the FAA. A friend, who spoke with the pilot just before the accident flight, confirmed the pilot saying "I haven't slept for three days." The friend stated further that the pilot "wasn't himself that day."

Alpha Wolf Enterprises

A Cessna 525 and a Cessna 172 collided in flight about 3,400 feet mean sea level on converging courses, with the 525 heading north and the 172 heading southwest. The converging speed was about 300 knots. The 525 departed under instrument flight rules, received vectors, and was initiating a climb on course. Training in the 525 emphasizes maximum use of the autopilot to afford greater outside scanning by the single pilot. The 525 was in radio contact with terminal approach control and the pilot's acknowledgement of the climb clearance was interrupted by the collision. The 172 had departed a local airfield, located just outside the 30 mile Mode C veil airspace of a terminal airport, and proceeded southwest. The collision occurred as the 172 was approaching Class D airspace of a military tower, and the pilot was initiating radio contact with the military tower. The terminal approach controller in contact with the 525 stated he did not observe the primary target of the 172, and conflict alert software was not installed. The 172 did not display a transponder signal and the transponder switch was subsequently found in the 'off' position. A cockpit visibility study indicated that from a fixed eye position the 172 was essentially hidden behind aircraft structure of the 525 for the 125 seconds before impact. The 172 could be seen by shifting the pilot's eye position. The 525 was viewable in the left lower section of the 172's windscreen. Both airplanes were operating in visual flight conditions.