Piper PA-61 Aerostar (Ted Smith 601)

Scott R. Shaw

Doobie Air

Raul Ignacion Posada

While approaching Durango Airport on a flight from Celaya, the twin engine aircraft entered an uncontrolled descent and crashed in an open field located near the village of Ceballos, about 16 km northwest of the Durango Intl Airport. The burned wreckage was found near the Peña del Aguila Dam. Both occupants were killed.

Tiadaghton Aviation

On April 23, 2020, at 2139 mountain daylight time (MDT), radar contact was lost with a Piper Aerostar 601X, N601X. The airplane was destroyed when it was involved in an accident near Craig, Colorado. The uncertificated (student rated) pilot sustained fatal injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The airplane was not equipped with automatic dependent surveillance-broadcast (ADS-B), which was required for operations in airspace that included class E airspace at or above 10,000 ft. The flight had not been operating on a flight plan and had no communications with air traffic control as required when it operated in class A airspace above 18,000 ft. Aircraft maintenance logbooks showed that the airplane received it last regulatory annual inspection dated November 21, 2019, and its last altimeter inspection, up to 30,000 ft, was dated June 27, 2014. Radar track data indicated that N601X departed Jersey Shore Airport (P96), Jersey Shore, Pennsylvania, about 1119 MDT, flying westbound at a cruise altitude of about 3,500 feet msl and had an average ground speed of about 180 - 190 kts until stopping at Findlay Airport (FDY), Findlay, Ohio, about 1251 MDT. Track data indicates N601X departed FDY about 1337 MDT, flying westbound at an altitude of about 3,500 ft, climbed once to about 5,500 ft, then descended to about 3,500 ft until later climbing to a cruise altitude of between 8,500-9,500 ft before descending into and landing at Red Oak Municipal Airport (RDK), Red Oak, Iowa, about 1618 MDT. Track data indicates N601X likely departed RDK about 1708 MDT, continuing westbound again, climbing to a maximum cruise altitude of about 9,500 ft, then descended and landed at Northern Colorado Regional Airport (FNL), Ft Collins/Loveland, Colorado, about 1949 MDT. A line service technician employed by a fixed base operator (FBO) at FNL stated that he was sitting in the line shack when he saw N601X taxi from the runway. He said the airplane's right engine was not running, and the pilot was trying to start it. The engine did not restart, and the airplane continued to taxi to the ramp. He asked the pilot if everything was "okay," and the pilot said, "yeah cut it a little close on fuel." He said the airplane was leaning "quite a bit" toward the right, which he attributed to a fuel imbalance. The line service technician said there was "a lot" of fuel staining under the right wing and on top of the wing. He did not look at the left wing and did not know if the left wing had fuel stains. He said he looked in the airplane and did not see it equipped with ADS-B; he said that he did not know how the pilot was going to fly over the mountains. He said the airplane was equipped with a panel mounted Garmin 430 and a transponder with round knobs. He said he saw an oxygen tank in the airplane and did not know the amount of oxygen that was present in the tank. The line service technician said the airplane did not have a pressurization system. The line service technician said he topped of all three fuel tanks: left wing, right wing and fuselage tank. He said during fueling of left tank, he had to push up the right wing up because it was leaning downward. The pilot told him to make sure that the fuel tank cap on the fuselage was on tight because "the thing leaks." The line service technician said he double checked the fuselage fuel tank cap, and it was on "tight." The line service technician said the engines sounded fine except for the pilot running out of fuel during the after-landing taxi. He did not think the airplane was in "very good" condition. A customer service representative at the FBO stated the pilot told her he purchased the airplane in New York and was "going to try to get over the mountains." The pilot said he flew on a commercial flight from California and on the same day he purchased the airplane. He said he had to go over the mountains and through Utah and was destined to California. She said the pilot was "really tired" and did not have cash to buy Red Bull, so she made him coffee. The pilot told her that he left New York later than he wanted too because he was talking with the former airplane owner. He told her the airplane was his fifth airplane that he owned. Radar track data indicates N601X departed FNL about 2037 MDT turning westbound, climbing through about 12,000 ft, and made a left, almost 360° turn, continuing to climb throughout the turn, then flying west/southwest bound and reaching about 16,000 ft. The airplane continued west/southwest for a little over 40 miles climbing again and reaching about 22,000 ft, then turning right about 90° flying northbound, momentarily, before turning left and heading west/northwest and descending to about 20,000 ft, then back up again to about 22,000 ft, briefly, then back down to about 20,000 ft. The airplane then turned left to the southwest, then southbound, entering erratic flight climbing to over 23,000 ft, momentarily, before beginning to descend, entering a tight looping turn to the left and losing altitude rapidly, then showing a west/northwest heading in the final segment before track data was lost at about 2139 MDT. An alert notice was issued, and the airplane wreckage was located by the Colorado State Highway Patrol on April 24, 2020, about 0336 MDT, about 15 miles west of Craig, Colorado.

LKJ Properties

On approach to Springfield-Abraham Lincoln, the pilot reported trouble with his instruments when the airplane descended and crashed left wing first in a garden located in Sangamon County, about 7 miles southeast of the airport, bursting into flames. The aircraft was destroyed and all three occupants were killed, among them former Springfield Mayor Frank Edwards.

Robert T. Knight Sr.

The mechanic who maintained the airplane reported that, on the morning of the accident, the right engine would not start due to water contamination in the fuel system. The commercial pilot and mechanic purged the fuel tanks, flushed the fuel system, and cleaned the left engine fuel injector nozzles. After the maintenance work, they completed engine ground runs for each engine with no anomalies noted. Subsequently, the pilot ordered new fuel from the local fixed-based operator to complete a maintenance test flight. The pilot stated that he completed a preflight inspection, followed by engine run-ups for each engine with no anomalies noted and then departed with one passenger onboard. Immediately after takeoff, the right engine stopped producing full power, and the airplane would not maintain altitude. No remaining runway was left to land, so the pilot conducted a forced landing to a field about 1 mile from the runway; the airplane landed hard and came to rest upright. Postaccident examination revealed no water contamination in the engines. Examination of the airplane revealed numerous instances of improper and inadequate maintenance of the engines and fuel system. The fuel system contained corrosion debris, and minimal fuel was found in the lines to the fuel servo. Although maintenance was conducted on the airplane on the morning of the accident, the right engine fuel injectors nozzles were not removed during the maintenance procedures; therefore, it is likely that the fuel flow volume was not measured. It is likely that the corrosion debris in the fuel system resulted when the water was recently purged from the fuel system. The contaminants were likely knocked loose during the subsequent engine runs and attempted takeoff, which subsequently blocked the fuel lines and starved the right engine of available fuel.

Carman W. Rollo

Before departing on the flight, the private pilot, who did not hold a current medical certificate, fueled the multiengine airplane and was seen shortly thereafter attempting to repair a fuel leak of unknown origin. The pilot did not hold a mechanic certificate and review of the maintenance logbooks revealed that the most recent annual inspection was completed 2 years before the accident. After performing undetermined maintenance to the airplane, the pilot reported to a witness that he had fixed the fuel leak. The pilot then taxied to the runway for takeoff. Witnesses reported that a large fuel stain was present on the ramp where the airplane had been parked; however, the amount of fuel that leaked from the airplane could not be determined. The pilot aborted the first takeoff shortly after becoming airborne. Although he did not state why he aborted the takeoff, he told the tower controller that he did not need assistance; shortly thereafter, he requested and was cleared for a second takeoff. During the initial climb, the pilot declared an emergency and was cleared to land on any runway. Witnesses reported that the airplane was between 400 ft and 800 ft above the ground in a left bank and appeared to be turning back to land on an intersecting runway. They thought the airplane was going to make it back to the runway, but the airplane's bank angle increased past 90° and the nose suddenly dropped; the airplane subsequently impacted terrain. One of the pilots likened the maneuver to a stall/spin, Vmc roll, or snap roll. Examination of the flight controls and engines did not reveal any anomalies that would have prevented normal operation. The position of the fuel valves was consistent with the fuel being shut off to the left engine. The fuel valves, with the exception of the left main valve, functioned when power was applied. The left main valve was intact, but the motor was found to operate intermittently. The amount of fuel found in the left engine injection servo was less than that in the right engine; however, the cylinder head temperatures and exhaust gas temperatures were consistent between both engines for the duration of the flight, and whether or to what extent the left engine may have experienced a loss of power could not be determined. The available evidence was insufficient to determine why the pilot declared an emergency and elected to return to the airport; however, the airplane's increased left bank and nose-down attitude just before impact is consistent with a loss of control.

Kurt Heitmeier

The commercial pilot stated that, during the takeoff roll, the airplane swerved to the right, and he corrected to the left and aborted the takeoff; however, the airplane departed the left side of the runway and collided with an embankment. At the time of the accident, a quartering tailwind was present. The pilot had no previous experience in the accident airplane make and model or in any other multiengine airplane equipped with engines capable of producing 300 horsepower. During a postaccident conversation with a mechanic, the pilot stated that the airplane "got away from him" during the attempted takeoff. Because a postaccident examination of the airplane did not reveal any evidence of a preimpact mechanical malfunction or failure of the airplane's flight controls or nosewheel steering system that would have precluded normal operation and the pilot did not have any previous experience operating this make and model of airplane, it is likely that the pilot lost directional control during takeoff with a quartering tailwind.

Ian McMahon

The pilot reported that the purpose of the flight was to reposition the airplane to another airport for refuel. During preflight, he reported that the airplane's two fuel gauges read "low," but the supplemental electronic fuel totalizer displayed 55 total gallons. He further reported that it is not feasible to visual check the fuel quantity, because the fueling ports are located near the wingtips and the fuel quantity cannot be measured with any "external measuring device." According to the pilot, his planned flight was 20 minutes and the fuel quantity, as indicated by the fuel totalizer, was sufficient. The pilot reported that about 12 nautical miles from the destination airport, both engines began to "surge" and subsequently lost power. During the forced landing, the pilot deviated to land in grass between a highway, the airplane touched down hard, and the landing gear collapsed. The fuselage and both wings sustained substantial damage. The pilot reported no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation. The pilot reported in the National Transportation Safety Board Pilot/ Operator Aircraft Accident Report that there was a "disparity" between the actual fuel quantity and the fuel quantity set in the electronic fuel totalizer. He further reported that a few days before the accident, he set the total fuel totalizer quantity to full after refueling, but in hindsight, he did not believe the fuel tanks were actually full because the wings may not have been level during the fueling. The "Preflight" chapter within the operating manual for the fuel totalizer in part states: "Digiflo-L is a fuel flow measuring system and NOT a quantity-sensing device. A visual inspection and positive determination of the usable fuel in the fuel tanks is a necessity. Therefore, it is imperative that the determined available usable fuel be manually entered into the system."

Private American

Following an uneventful flight from Bitburg, the pilot was cleared for an approach to Karlsruhe-Baden Baden Airport Runway 21. On final approach, while completing a sharp turn to the left to join the runway, the twin engine airplane stalled and crashed in an open field, bursting into flames. The pilot was seriously injured and the aircraft was destroyed by a post crash fire. The wreckage was found about 500 metres from the runway threshold and 350 metres to the left of the runway extended centerline.

David Anderson

Witnesses reported observing the airplane flying slowly toward the airport at a low altitude. The left engine was at a low rpm; "sputtering," "knocking," or making a "banging" noise; and trailing black smoke. One witness said that, as the airplane passed over his location, he saw the tail "kick" horizontally to the right and the airplane bank slightly left. The airplane subsequently collided with trees and impacted a field 1/2 mile north of the airport. Disassembly of the right engine revealed no anomalies, and signatures on the right propeller blades were consistent with power and rotation on impact. The left propeller was found feathered. Disassembly of the left engine revealed that the spark plugs were black and heavily carbonized, consistent with a rich fuel-air mixture; the exhaust tubing also exhibited dark sooting. The rubber boot that connected the intercooler to the fuel injector servo was found dislodged and partially sucked in toward the servo. The clamp used to secure the hose was loose but remained around the servo, the safety wire on the clamp was in place, and the clamp was not impact damaged or bent. The condition of the boot and the clamp were consistent with improper installation. The time since the last overhaul of the left engine was about 1,050 hours. The last 100-hour inspection occurred 3 months before the accident, and the airplane had been flown only 0.8 hour since then. It could not be determined when the rubber boot was improperly installed. Although the left engine had failed, the pilot should have been able to fly the airplane and maintain altitude on the operable right engine, particularly since he had appropriately feathered the left engine.

Private American

The pilot's friend reported that the pilot planned to fly his recently purchased twin-engine airplane over his friend's home to show it to him and another friend. The pilot's friends and several other witnesses reported observing the pilot performing low-level, high-speed aerobatic maneuvers before the airplane collided with trees and then terrain. A 1.75-liter bottle of whiskey was found in the airplane wreckage. A review of the pilot's Federal Aviation Administration medical records revealed that he had a history of alcohol dependence but had reportedly been sober for almost 4 years. Toxicological testing revealed that the pilot had a blood alcohol content of 0.252 milligrams of alcohol per deciliter of blood, which was over six times the limit (0.040) Federal Aviation Regulations allowed for pilots operating an aircraft.

Din S. Vimadalal

The twin engine aircraft suffered an accident at Hermosillo-General Ignacio Pesqueira Garcia Airport. After touchdown, the airplane veered off runway, collided with a fence and came to rest on its belly. All occupants escaped uninjured while the aircraft was damaged beyond repair.

M %26 H Ventures

On the day of the accident, a mechanic taxied the airplane onto the runway and performed a full power check of both engines, exercised both propellers, and checked each magneto drop with no discrepancies reported. Following the engine run, the mechanic taxied the airplane to the fuel ramp where the fuselage fuel tank was filled; after fueling, the fuselage tank had 41.5 gallons of usable fuel. The mechanic then taxied the airplane to the ramp where the engines were secured and the fuel selector switches were placed to the off position. The mechanic reported that, at that time, the left fuel tank had 4 to 5 gallons of fuel, while the right fuel tank had about 2 to 3 gallons of fuel; the unusable fuel amount for each wing tank is 3 gallons. The pilot taxied the airplane to the approach end of runway 18 and was heard to apply takeoff power. A pilot-rated witness noted that, at the point of rotation, the airplane pitched up fairly quickly to about 20 degrees and rolled left to about 10 to 15 degrees of bank. The airplane continued rolling left to an inverted position and impacted the ground in a 40 degree nose-low attitude. A postcrash fire consumed most of the cockpit, cabin, both wings, and aft fuselage, including the vertical stabilizer, rudder, and fuselage fuel tank. Postaccident inspection of the flight controls, which were extensively damaged by impact and fire, revealed no evidence of preimpact failure or malfunction. Although the flap actuators were noted to be asymmetrically extended and no witness marks were noted to confirm the flap position, a restrictor is located at each cylinder’s downline port by design to prevent a rapid asymmetric condition. Therefore, it is likely that the flap actuators changed positions following impact and loss of hydraulic system pressure and did not contribute to the left roll that preceded the accident. Examination of the engines and propellers revealed no evidence of preimpact failure or malfunction that would have precluded normal operation. Postaccident examination of the fuselage fuel sump revealed the left fuel selector was in the crossfeed position, while the right fuel selector was likely positioned to the on position. (The as-found positions of the fuel selector knobs were unreliable due to postaccident damage.) The starting engines checklist indicates that the pilot is to move both fuel selectors from the on position to the crossfeed position, and back to the on position while listening for valve actuation/movement. The before takeoff checklist indicates that the pilot is to verify that the selectors are in the on position. Although the left engine servo fuel injector did not meet flow tests during the postaccident investigation, this was attributed to postaccident heat damage. Calculations to determine engine rpm based on ground scars revealed that the left engine was operating just above idle, and the right engine was operating about 1,315 rpm, which is consistent with a left engine loss of power and the pilot reducing power on the right engine during the in-flight loss of control. Examination of both propellers determined that neither was feathered at impact. Although the as-found position of the left fuel selector knob could be considered unreliable because of impact damage during the accident sequence, given that right wing fuel tank had no usable fuel, it is unlikely that the experienced pilot would have moved the left fuel selector to the crossfeed position in response to the engine power loss. It is more likely that the pilot failed to return the left fuel selector to the on position during the starting engines checklist and also failed to verify its position during the before takeoff checklist; thus, the left engine was being fed only from the right fuel tank, which had very little fuel. There was likely enough fuel in the right tank and lines for the pilot to taxi and takeoff before the left engine failed, causing the airplane to turn to the left, from which the pilot did not recover.

Norman B. Ivans

The pilot reported that, immediately after touchdown, the airplane began “wavering” and moments later veered to the left. He attempted to regain directional control with the application of “full right rudder” and the airplane subsequently departed the right side of the runway. A witness reported that the airplane’s touchdown was “firm” but not abnormal. As the airplane approached the left side of the runway, it yawed right and skidded down the runway while facing right. As the airplane began moving to the right side of the runway, the witness heard the right engine increase to near full power. The airplane spun to the left, coming to rest facing the opposite direction from its approach to landing. Another witness reported seeing the propellers contact the ground. The pilot attributed the loss of directional control to a main landing gear malfunction. Post accident examination of the airplane revealed that the left propeller assembly was feathered and that the right propeller blades were bent forward, indicative of the right engine impacting terrain under high power. Both throttle levers were found in the aft/closed position, and both propeller control levers were in the full-forward position. The propeller control levers exhibited little friction and could be moved with pressure from one finger. The evidence suggested that the pilot inadvertently feathered the left propeller assembly during the accident sequence. The pilot did not report any pre accident malfunctions or failures with the airplane’s engines or propeller assemblies that would have precluded normal operation.

Private Argentinian

The twin engine aircraft departed Rosario-Islas Malvinas Airport at 2215LT on a return trip to Córdoba, carrying two pilots. Bound to the northwest at an altitude of 8,000 feet, the crew was cleared to descend to 6,000 feet few minutes after takeoff. At 2242LT, the crew reported his position over Ubrel. Twenty minutes later, at 2300LT, while cruising in poor weather conditions, the aircraft entered an uncontrolled descent and crashed in an open field located 6 km from Las Varillas. The wreckage was found the following morning. The aircraft was totally destroyed and both occupants were killed.

Francisco Zermeño

Shortly after takeoff from runway 09 at Tijuana-General Abelardo L. Rodríguez Airport, while in initial climb, the twin engine aircraft entered an uncontrolled descent and crashed onto a garage, bursting into flames. Both occupants as well as one people in his car were killed.

5583 N.W.T.

The twin engine aircraft was en route from Yellowknife, NT to Fort St. John, BC. The pilot noticed fumes and smoke coming from behind the rear cabin wall. The cabin was depressurized and the door opened to clear the smoke. A forced landing was conducted onto the frozen surface of Falaise Lake, NT. The pilot immediately egressed, however, the aircraft was soon engulfed in flames and was completely consumed. The pilot was not injured and was flown out by helicopter.

Aeropremiere

After takeoff, the right engine experienced a loss of power followed by the left engine losing power. The pilot maneuvered the airplane toward the nearest open field and the airplane impacted terrain during landing, resulting in a circumferential split in fuselage near the aft pressure bulkhead. The airplane was equipped with 4 fuel tanks: 2 located in each wing outboard of the engine nacelle (65-gallon capacity), 1 main fuselage tank (about 44-gallon capacity), and 1 auxiliary tank located in forward section of baggage compartment (45-gallon capacity). The airplane was capable of carrying 209.5 gallons usable fuel and the pilot stated that prior to departure he filled the main fuselage tank to capacity, added 20 gallons in the auxiliary tank and 25 gallons in each wing tank, which he equated to a total of 131 gallons on board. The fuselage contained two fuel filler necks, one for each fuselage tank (main and auxiliary). The auxiliary tank was clearly placarded with a red placard visibly standing out against a silver paint stripe; the main tank was not clearly placarded, with a red placard blending easily with red paint stripe. A salvage retriever recalled that during recovery the left wing contained 17 gallons of fuel, the right wing contained 57 gallons of fuel, the main fuselage tank contained 2.5 gallons of fuel, and the auxiliary fuselage tank contained 28 gallons of fuel. A postaccident examination of the airplane and engines revealed no anomalies that would have precluded normal operation. The main fuselage tank and auxiliary fuselage tank were not breached and the fuel sumps contained check valves which prevent the back-flow of fuel from one fuel tank to another. Based on the evidence it is likely that the pilot exhausted the airplane's fuel supply in the main fuselage tank, which resulted in the loss of power to both engines.

ENS Corporation

The visibility at the time of the accident was 1/2 mile with fog and the vertical visibility was 100 feet. A witness stated that the pilot checked the weather, but that he appeared to be in a hurry and took off without performing a preflight inspection of the aircraft. After takeoff, air traffic control instructed the pilot to turn left to a heading of 270 degrees. The pilot reported to the controller that he was at 1,300 feet climbing to 3,000 feet and the controller cleared the pilot to climb to 4,000 feet; the pilot acknowledged the clearance. Witnesses on the ground noted that the airplane was loud; one witness located about 1.5 miles from the departure airport reported that the airplane flew overhead at treetop height. The airplane impacted trees and a residence about 2.3 miles north-northeast of the departure airport. The airplane's turning ground track and the challenging visibility conditions were conducive to the onset of pilot spatial disorientation. Post accident inspection failed to reveal any mechanical failure that would have resulted in the accident. The pilot purchased the airplane about three months prior to the accident; at that time he reported having 72.6 hours of instrument flight experience and 25 hours of multi-engine experience, with none in the accident airplane make and model. After purchasing the airplane, the pilot received 52 hours of flight instruction in the accident airplane in 7 days. Logbook records were not located to establish subsequent flight experience.

Alexander Gray

The private pilot was continuing a cross-country flight after having stopped for fuel. About 20 minutes into the flight, the pilot said both engines started running rough, and he turned the airplane toward the nearest airport and descended. The pilot reported that he did not think the airplane would make it to the airport, and that due to the rugged terrain, he felt it was better to ditch the airplane in a large lake he was flying over. The pilot reported there were no mechanical anomalies prior to the loss of engine power. He said he felt that fuel contamination was the cause of the engine problem, and that not fueling during heavy rain might have prevented the problem. Fuel samples were taken from the fuel supply where he added fuel, and the equipment used to fuel the airplane. No other instances of fuel contamination were reported, and according to the FAA inspector the fuel samples were tested, and found to be clean. The airplane was not recovered from the lake, and has not been examined by the NTSB.

FTBA

During the initial climb, a "throbbing or surging" sound was heard as the airplane departed in gusting wind conditions with a 600-foot ceiling and 1/2 mile visibility in snow. Moments later the airplane came "straight down" and impacted the ground. During examination of the wreckage, it was discovered that that the fuel selector switch for the right engine had been in the "X-FEED" position during the accident. Examination of documents discovered in the wreckage revealed, three documents pertaining to operation of an Aerostar. These documents consisted of two airplane flight manuals (AFMs) from two different manufacturers, and a checklist. Examination of the first of the AFMs revealed, that it had the name of both the pilot and the operator on the cover of the document. Further examination revealed that it had been published 4 years prior to the manufacture of the accident airplane, and contained information for a Ted Smith Aerostar Model 601P, which the operator had previously owned. This document contained no warnings regarding the use of the crossfeed system during takeoff. Examination of the second of the two AFMs found in the wreckage revealed that it was the Federal Aviation Administration (FAA) approved AFM for the accident airplane. Unlike the first AFM, the second AFM advised that the fuel selector "X-FEED" position should be used in "level coordinated flight only." It also advised that each engine fuel selector "must be in the ON position for takeoff, climb, descent, approach, and landing." It also warned that, if the airplane was not in a level coordinated flight attitude, "engine power interruptions may occur on one or both engines" when "X-FEED" is selected "due to unporting of the respective engine's fuel supply intake port." Review of the checklist contained in the FAA approved AFM for the Piper Aircraft Model 601P under "STARTING ENGINES," required a check of the crossfeed system prior to engine start by selecting each fuel selector to "ON," then selecting "X-FEED," and after verifying valve actuation and annunciator light illumination, returning the fuel selector to "ON." Additionally, under "BEFORE TAKEOFF" It also required that the fuel selectors be checked in the "ON" position, and that the "X-FEED" annunciator light was out, prior to takeoff. Examination of the pilot's checklist revealed that, it consisted of multiple pages inserted into plastic protective sleeves and included both typed, and hand written information. A review of the section titled "BEFORE TAKEOFF" revealed that the checklist item "Fuel Selectors - ON Position," which was listed in the AFM, had been omitted.

Robert B. North Jr.

On the day of the accident, the pilot was returning to his home airport, after dropping off friends at a different airport. No weather briefing or flight plan was filed with Flight Service for either flight. A witness and radar data depicted the accident airplane on a straight-in approach for runway 1, in a landing configuration, at a ground speed of approximately 120 knots. The last radar target was recorded about 1/4 mile from the runway threshold, at an altitude of approximately 150 feet agl. The wreckage was later found about 1/2 mile east of the runway threshold. Review of weather information revealed general VFR conditions along the route of flight, and at reporting stations near the accident site. Gusty winds, low-level wind shear, and moderate to severe turbulence also prevailed at the time of the accident. In addition, weather radar depicted scattered light snow showers in the vicinity of the accident site, and possibly a snow squall. Examination of the wreckage did not reveal any preimpact mechanical malfunctions. The pilot had a total flight experience of 14,000 hours, with 8,500 hours in multiengine airplanes, including 2,600 hours in the same make and model as the accident airplane. He also had 4,100 hours of instrument flight experience.

Sky Lifts

The 700-hour private pilot flying the twin-engine airplane with four passengers aboard used approximately three-quarters of runway 18 before becoming airborne. After establishing a positive rate of climb, the pilot retracted the landing gear and pitched the airplane for a 92 knot climb. Shortly thereafter the rate of climb decreased and the airplane's control authority began to decay. The pilot responded by applying full throttle to both engines and reduced the angle of attack in an attempt to regain airspeed. The pilot was able to arrest the airplane's decaying airspeed and descent; however, the airplane collided with a barn and then a grassy field before coming to rest in an upright position. The pilot and passengers were able to egress the airplane unassisted and the airplane was engulfed in flames a few minutes later. About 23 minutes after the mishap the weather reporting station 24 miles north of the accident site reported, the wind from 230 degrees at 6 knots, the temperature 84 degrees Fahrenheit, and dew point of 60 degrees Fahrenheit. Runway 18 was reported as a 4,002-foot long by 60-foot wide asphalt runway with trees near the departure end. The field elevation at the airport was reported at 544 feet and the density altitude was calculated at 1,860 feet. The estimated weight of the airplane at the time of departure was near its maximum gross weight of 6,000 pounds. The pilot reported that he had not performed a weight and balance check, calculated density altitude, and was not sure of how much fuel was onboard the airplane prior to departure. The pilot further reported that there were no apparent anomalies with the airplane.

James W. Kincaid

After takeoff for a maintenance check flight, both engines on the twin-engine airplane experienced a loss of engine power. The 7,200-hour pilot had recently purchased the airplane, which had not been flown for nearly four years. The pilot, who is also a certificated airframe and powerplant mechanic, completed the inspection of the airplane prior to takeoff. During the engine run-up, the pilot noticed that the RPM and manifold pressure on the left engine did not correspond with those of the right engine. During the takeoff roll, the pilot believed the RPM on both engines began to rise to near acceptable levels, but not entirely. However, he did not abort the takeoff. The airplane became airborne for a short time, and then began to descend into trees before impacting the ground. The reason for the reported loss of engine power could not be determined.

Kline and Associates

Immediately after taking off and raising the landing gear, the pilot noticed the left engine began to lose power. The airplane subsequently veered to the left before impacting up slopping terrain in a left wing low attitude, resulting in a fire breaking out which consumed the left side of the airplane. A postaccident examination revealed that the left engine had sustained thermal but no impact damage, and that the engine's right hand turbocharger had no thermal or impact damage. A further examination indicated that no restrictions were found in the center section of the turbocharger and there was no damage to the housing or the impeller; however, the impeller was frozen in the center section and would not turn. Indications of grooving and scraping from a lack of lubrication to the bearings and drive shaft was observed. No mechanical anomalies with the aircraft were noted by the pilot prior to takeoff which would have prevented normal operations.

Private American

The pilot attempted a night landing on a taxiway in front of the control tower, which was closed at the time. The airplane overran the end of the taxiway, rolled down an embankment and struck trees. The pilot, whose identity was not confirmed, was believed to have incurred minor injuries. He subsequently paid a passerby to take him to a local hotel, and after a night's rest, he left the area. Ownership of the airplane could not be determined due to a recent sale. Approximately 250 kilos of cocaine were found onboard the airplane. Further investigation was being conducted by federal authorities and local law enforcement.

Aviation Flight Standards

The commercial pilot, who managed the airplane and jointly owned it with one of the passengers, departed from a 3,930-foot-long, asphalt runway on a warm day. Weight and balance calculations, which investigators derived from estimated weights for total fuel, passengers, and cargo loads, determined that the airplane was likely within center of gravity limitations and about 208 pounds below its maximum gross weight. One witness stated that the airplane became airborne near the end of the runway before it began a shallow climb and clipped small branches on the tops of trees that were about 30 feet tall. That witness and others observed that the airplane continued past the trees, made a steep bank to the left, rolled inverted, and nose-dived to the ground. The witnesses' descriptions of the airplane's flightpath and the examination of the debris path and wreckage at the accident site are consistent with an impact following an aerodynamic stall. According to calculations performed using the airplane's published performance data chart, for the airplane's configuration and estimated weight and the density altitude conditions at the time of the accident, the airplane would have required about 3,800 feet on a paved, level runway to clear a 50-foot obstacle with the pilot using the short-field takeoff technique. Although the chart does not make any allowances for an upsloping runway or provide data for a 30-foot obstacle, the runway slope is slight (a 27-foot rise over the entire length) and likely did not significantly increase the airplane's takeoff roll, and interpolation of the data revealed no significant distance differences for the shorter obstacle. However, according to the chart, the 3,800-foot distance is contingent upon the pilot holding the airplane's brakes, applying full engine power with the brakes set, and then releasing the brakes to initiate the takeoff roll. In addition, the airplane's ability to achieve its published performance parameters (which are derived from test flights in new airplanes) can be degraded by a number of factors, such as pilot deviations from the published procedures, reduced engine performance, or increased aerodynamic drag associated with minor damage and wear of the airframe. It could not be determined where on the runway the pilot initiated the takeoff roll or at what point full engine power was applied. However, because the runway was only 130 feet longer than the airplane required (according to its published performance data), there was little margin for any deviations from the published takeoff procedure. Although examination of the engines, propellers, and related systems revealed no evidence of precrash anomalies, postaccident damage precluded engine performance testing to determine whether the engines were capable of producing their full-rated power. Therefore, the significance of maintenance issues with the airplane (in particular, a mechanic's assessment that the turbochargers needed to be replaced and that the airplane's required annual inspection was not completed) could not be determined with respect to any possible effect on the airplane's ability to perform as published. A review of Federal Aviation Administration (FAA) and insurance records revealed evidence that the pilot may have been deficient with regard to his ability to safely operate a PA 60-601P. For example, according to FAA records, as a result of an April 2004 incident in which the pilot landed the accident airplane on a wet grassy runway with a tailwind, resulting in the airplane going off the runway and striking a fence, the FAA issued the pilot a letter of reexamination to reexamine his airman competency. However, the pilot initially refused delivery of the letter; he subsequently accepted delivery of a second letter (which gave the pilot 10 days to respond before the FAA would suspend his certificate pending compliance) and contacted the FAA regarding the matter on Monday, August 2, 2004 (the day before the accident), telling an FAA inspector to "talk to his lawyer." In addition, as a result of the same April 2004 incident, the pilot's insurance company placed a limitation on his policy that required him to either attend a certified PA-60-601P flight-training program before he could act as pilot-in-command of the accident airplane or have a current and properly certificated pilot in the airplane with him during all flights until he completed such training. There was no evidence that the pilot adhered to either of the insurance policy requirements. In addition, the FAA had a previous open enforcement action (a proposed 240-day suspension of the pilot's commercial certificate) pending against the pilot for allegedly operating an airplane in an unsafe manner in September 2003; that case was pending a hearing with an NTSB aviation law judge at the time of the accident. Although the FAA's final rule for Part 91, Subpart K, "Fractional Ownership Operations," became effective on November 17, 2003, the regulations apply to fractional ownership programs that include two or more airworthy aircraft. There was no evidence that the pilot had a management agreement involving any other airplane; therefore, the rules of Part 91, Subpart K, which provide a level of safety for fractional ownership programs that are equivalent to certain regulations that apply to on-demand operators, did not apply to the accident flight. In the year before the accident, the FAA had conducted a ramp check of the pilot and the accident airplane and also conducted an investigation that determined there was not sufficient evidence that the pilot was conducting any illegal for-hire operations.

Aero Dreams

A witness at a nearby maintenance facility stated the pilot telephoned him and told him that, during engine start, one engine sputtered and abruptly stopped. The witness stated the pilot told him he wanted to fly the airplane over to have the problem looked at. A witness, who was an airline transport-rated corporate pilot, observed the airplane on takeoff roll and stated the airplane rotated "really late," using approximately 4,000 feet of runway. He stated the airplane climbed to about 400 or 500 feet, then descended in a left spin into the trees. The airplane collided with the ground and caught fire. Examination of the right engine revealed external fire damage and no evidence of mechanical malfunction. Examination of the left engine revealed external fire damage. Disassembly examination of the left engine revealed the rear side of the No. 5 piston from top to bottom was eroded away with characteristics consistent with detonation. The spark plugs displayed "normal" deposits and wear, except the No. 5 bottom plug was contaminated with a fragment of piston ring material, the No. 5 top plug had a dark sooty appearance, and the nose core of the No. 2 bottom plug was fragmented. Flow bench examination of the left fuel servo revealed no abnormalities. The fuel flow manifold diaphragm was heat-damaged. Flow bench examination of the fuel injector lines and nozzles on a serviceable fuel flow manifold revealed the lines and nozzles were free of obstruction. A review of Emergency Operating Procedures for the Aerostar 601P revealed the following: "Normal procedures do not require operation below the single engine minimum control speed, however, should this condition inadvertently arise and engine failure occur, power on the operating engine should immediately be reduced and the nose lowered to attain a speed above ... the single engine minimum control speed."

Private Australian

The Ted Smith Aerostar 601 aircraft, registered VH-WRF, departed Coolangatta at 1301 ESuT with a flight instructor and a commercial pilot on board. The aircraft was being operated on a dual training flight in the Byron Bay area, approximately 55 km south-south-east of Coolangatta. The aircraft was operating outside controlled airspace and was not being monitored by air traffic control. The weather in the area was fine with a south-easterly wind at 10 - 12 kts, with scattered cloud in the area with a base of between 2,000 and 2,500 ft. The purpose of the flight was to introduce the commercial pilot, who was undertaking initial multi-engine training, to asymmetric flight. At approximately 1445, the operator advised Australian Search and Rescue that the aircraft had not returned to Coolangatta, and that it was overdue. Recorded radar information by Airservices Australia revealed that the aircraft had disappeared from radar coverage at 1335. Its position at that time was approximately 18 km east-south-east of Cape Byron. Search vessels later recovered items that were identified as being from the aircraft in the vicinity of the last recorded position of the aircraft. Those items included aircraft checklist pages, a blanket, a seat cushion from the cabin, as well as a number of small pieces of cabin insulation material. No item showed any evidence of heat or fire damage. No further trace of the aircraft was found.

NDB Equipment Finance

The airplane collided with mountainous terrain 5 miles from the departure airport during a dark night takeoff. Review of recorded radar data found a secondary beacon code 7267 (the code assigned to the airplane's earlier inbound arrival ) on the runway at 2021:08, with a mode C report consistent with the airport elevation. Two more secondary beacon returns were noted on/over the runway at 2021:12 and 2021:19, reporting mode C altitudes of 1,600 and 1,700 feet, respectively. Between 2021:08 and 2021:38, the secondary beacon target (still on code 7267) proceeded on a northeasterly heading of 035 degrees (runway heading) as the mode C reported altitude climbed to 2,000 feet and the computed ground speed increased to 120 knots. Between 2021:38 and 2021:52, the heading changed from an average 035 to 055 degrees as the mode C reports continued to climb at a mathematically derived 1,300 feet per minute and the ground speed increased to average of 170 knots. At 2022:23, the code 7267 target disappeared and was replaced by a 1200 code target. The mode C reports continued to climb at a mathematically derived rate of 1,200 feet per minute as the ground speed increased to the 180- knot average range. The computed average heading of 055 degrees was maintained until the last target return at 2022:53, which showed a mode C reported altitude of 3,500 feet. The accident site elevation was 3,710 feet and was 0.1 miles from the last target return. The direct point to point magnetic course between Scottsdale and Santa Fe was found to be 055 degrees. Numerous ground witnesses living at the base of the mountain where the accident occurred reported hearing the airplane and observing the aircraft's lights. The witnesses reported observations consistent with the airplane beginning a right turn when a large fireball erupted coincident with the airplane's collision with the mountain. No preimpact mechanical malfunctions or failures were found during an examination of the wreckage. The radar data establishes that the pilot changed the transponder code from his arrival IFR assignment to the VFR code 30 seconds before impact and this may have been a distraction.

George W. Willard

The airplane crashed into rising terrain after departure from an uncontrolled public airport. The runway used by the pilot is 4,600 feet long and has a 1.8 percent upward gradient. The density altitude was 4,937 feet msl, and a slight quartering tailwind existed at the time. The pilot held in position, powered up the engines, and started his departure. The airplane was observed using most of the runway length before rotation and then it assumed a higher than normal pitch attitude in the initial climb. Witnesses watched the airplane turn left following the route of a canyon and into rising terrain. The reciprocal runway departs towards decreasing elevations. In the area of the crash, two witnesses reported the airplane was at a low altitude, nose high, and wallowing just before it descended into a drainage area 0.69 miles from the runway. Post accident examination of the engines revealed worn camshaft lobes and tappets, which would negatively affect the ability of the engines to produce full rated power. One engine exhibited severe rust on the entire crankshaft. The accident site was located in a canyon, and the wreckage and ground scars was confined to an area about the diameter of the wing span. Major portions of the airframe and most of the engine accessories were consumed by a post accident fire. Examination of the wreckage established that all major components of the airframe and powerplants were at the site.

Columbine Farm

The airplane was destroyed during an attempted forced landing following an in-flight fire in cruise flight. The pilot was reported to be flying the airplane to an airport in order to have maintenance work performed on the right engine due to a boost problem. It was reported that the pilot had another mechanic at another airport look at the airplane. A work order for a transient airplane was found that indicated work performed on the right engine turbocharger system about 1 month before the accident. The work order shows that the wastegate oil filter was found clogged and collapsed and that it was cleaned, straightened and reinstalled. The pilot operated the airplane with a right engine boost problem. The boost problem with the right engine is evidenced by the previous work order, the excessive amount of runway used during takeoff, the reported smoke from the right engine after takeoff, and the airplane not climbing as expected after takeoff. Due to the reduced power from the right engine, the pilot was required to apply left brake in order to maintain directional control during takeoff, as evidenced by the blued left brake disk with metal transfer into the relief holes and slots. As a result of the pilot using left brake during takeoff, a fire erupted in the left wheel well, which spread to the aft fuselage. This is evidenced by the sooting, fire, and heat damage to the wheel well, the carpet above the wheel well, and aft fuselage. The fuselage immediately behind the baggage compartment had extensive fire damage. The damage in this area included blistered paint on the upper surface, and a two foot square section of the left fuselage skin that was burned away. The area that was burned away was in the vicinity of the hydraulic fluid reservoir. The aluminum hydraulic fluid reservoir was not found, only the steel filler neck, mounting screws, and cap were found. No evidence of fire was found within the right main landing gear wheel well or in the engine compartments. A witness reported seeing the airplane flying south and trailing smoke then banking to the left making a complete circle before descending and ultimately impacting the ground.

Trans Porter International Airlines

The pilot was aware of thunderstorms along his route of flight. He paralleled a line of storms for about 20 minutes looking for a hole in the storms to penetrate, without any success. He turned, and climbed to an altitude of 13,500 feet. He noticed what seemed to be an opening to the south, and turned southbound, through the hole, for about 2 or 3 miles, and then the hole closed. He turned the airplane to the right to reverse course, when he inadvertently penetrated a cell. At this point he said he "lost control of the airplane, and was turned upside down…...heading straight down towards the ground...…traveling at a high rate of speed..….the airspeed indicator was pegged." At an altitude of about 2,000 feet, he was able to level the wings, reduce power and raise the nose. He said he was then able to slow the airplane for a "controlled crash landing," straight a head in a sugar cane field. According to the Sheriff's Report, he struck the field in which the aircraft was lying in immediately after slowing the airplane. The distance from the initial impact area to where the airplane came to rest was about 75 yards.

Timothy A. Patrick

The airplane collided with mountainous terrain during approach to the destination airport. While approaching the airport, the pilot requested vectors for a localizer approach to runway 19. Due to traffic, air traffic control (ATC) issued the pilot a holding clearance. The airplane was approaching the holding fix about 8,000 feet, when the pilot advised ATC that the airplane was picking up a little ice. ATC initially offered an amended clearance of 9,000 feet, but the pilot declined. Subsequently, he accepted the clearance and climbed back to 9,000 feet. ATC then told the pilot that after one more airplane had landed, he would be issued an approach clearance. The airplane was about 9,200 feet when the pilot replied "thank you." Review of radar data revealed that the accident airplane made one complete 360-degree turn, and one 270-degree turn on the non-holding side of the published holding pattern. During the two turns, the airplane descended to approximately 8,400 feet, climbed to 8,900 feet, then descended again to 8,300 feet. The two turns were tighter than the expected standard 2-minute turns in a holding pattern, with radii ranging from 0.3 to 0.4 nautical miles and 0.1 to 0.2 nautical miles respectively. Following the two holding turns, no more radio transmissions or radar returns were received by ATC. Examination of the wreckage did not reveal any preimpact mechanical malfunctions. Another pilot flying in the area reported moderate rime ice at 8,000 feet, but added that he climbed out of the ice and was between cloud layers at 9,000 to 10,000 feet.

Crosco

Witnesses watching N900CE's approach for landing to runway 17 at Marco Island Executive Airport stated the pilot appeared to have difficulty aligning the Machen modified Aerostar with the runway centerline. They stated the aircraft appeared unstable about the yaw and roll axes, and appeared too fast. Winds were from the southwest at about 15 knots, gusting to about 20 knots. One pilot/witness close to the touchdown area saw the right wheel touch down instantly, and climb back up to about 50 feet, agl without the full addition of engine power. Most witnesses thought he was either performing a go-around or an extended touch down further down the runway. The airplane continued, "..more and more wobbly" until it entered a climbing attitude and sharp left bank and turn. About half way down the runway the left wing dropped until it contacted the terrain left of the runway, and the aircraft slid into mangrove trees and burned. During postcrash examination, flight control continuity from surface to cockpit floorboards was confirmed. No condition was found with either engine or propeller that would have precluded proper operation, precrash. A witness listening to the pilot's initial radio call up for approach and landing stated that no abnormality was reported by the pilot. Postmortem toxicology testing on specimens obtained from the pilot by the FAA Toxicology and Accident Research Laboratory and the Dade County Medical Examiner revealed quinine found in the blood and urine. The side effects of quinine can include disturbances of vision, hearing, and balance.

IEG Venture Management

The airport consisted of a single runway oriented on a heading of 140/320 degrees. A taxiway oriented on a 120 degree heading intersected the runway at its midpoint. The pilot reported that the visibility was 500-1,000 feet with fog at the time of departure. Before he took off, the pilot asked his passenger to walk the length of the runway to observe any obstructions, due to the reduced visibility. The pilot then taxied to the run-up pad, set the heading of his HSI to 120 degrees, and initiated the takeoff. When the airspeed reached 80 knots, the pilot realized he had initiated the takeoff on the taxiway instead of the runway. He aborted the takeoff and attempted to maneuver the airplane to the runway. The airplane crossed the runway, impacted a tree, and came to rest upright in a cornfield. The weather reported at the time of the accident at an airport 9 miles away was: wind from 320 degrees at 2 knots; visibility 1/16 mile with fog; sky partially obscured; ceiling 200 feet overcast.

Robert C. Donoho

While on a cross-country flight, according to radar data and weather information, the pilot descended below terrain clearance altitude and entered IMC conditions. The aircraft impacted a mountain peak approximately 100 feet below the summit. No flight plan had been filed and the pilot was not instrument rated.

Cimber Air

During the takeoff roll on runway 25 at Randers Airport, the right engine lost power then failed. The pilot continued the takeoff procedure and completed the rotation. Just after liftoff, while in initial climb, smoke spread from the right engine into the cockpit. The pilot attempted an emergency landing when the aircraft crash landed, collided with trees and came to rest about 500 metres past the runway end. The pilot escaped uninjured and the aircraft was damaged beyond repair.

N3193X Bonanza Corporation

While operating in IMC, the pilot was vectored to the final approach course for an ILS approach. Weather at the airport was ceiling 200 feet and visibility 3/4 mile in mist. The pilot was cleared for the approach, which he acknowledged. No other transmissions were received from the accident airplane. Radar data showed the airplane intercept the final approach course, then track inbound. The airplane crossed the outer marker 420 feet below the glide slope. The last radar return showed the airplane at 440 feet agl, 3.9 miles from the runway. The airplane impacted the ground at a shallow angle about 1 mile north of the airport on the opposite side of the missed approach procedure. The elevation of the accident site was approximately 40 feet lower than the airport. The pilot had about 350 hours of total flight experience. No pre-impact failures were identified with the airframe, engines, flight controls, or flight instruments.

Mark H. Johnson

During takeoff, the twin-engine airplane was observed to roll left, pitch nose down, and impact terrain shortly after the pilot reported to ATC that he had a problem. Witnesses reported that the left engine was producing black smoke during the takeoff roll. One witness stated that the airplane had slowed to approximately 60-70 mph prior to rolling to the left. A mechanic, who worked on the airplane prior to the accident, stated that the pilot reported being unable to maintain manifold pressure (MP) with the left engine. The mechanic found that the left engine's rubber interconnect boot, which routes induction air between the turbocharger controller elbow and the fuel servo, was 'gaping open.' The mechanic reseated the boot and tightened the clamp. The pilot flew the airplane and reported no problems. During a second flight, the pilot reported that the left engine was again unable to maintain MP. Prior to the accident flight, the pilot informed the mechanic that the 'hose had slid off again' and that it had been reinstalled and he 'felt sure it was o.k.' A witness stated that he saw the pilot working on the left engine the morning of the accident. At the accident site, the left engine's interconnect boot was found disconnected. The clamp securing the boot was not located. No other preimpact anomalies were found with the engines, propellers, turbochargers, or fuel servos.

Michael H. Wright

The pilot departed on runway 06 with zero degrees of flaps. A witness said that she noticed that the airplane appeared to wobble and shudder, and immediately went into a steep right bank turn right after takeoff. The airplane then went into the clouds which were 200 to 400 feet agl. Radar data indicated that the airplane made several 90 degree turns prior to impacting the mountainous terrain 2.55 nm from the departure end of the runway. The pilot normally used 20 degrees of flaps for takeoff. A test pilot said that the airplane handles significantly different during takeoff if zero degrees of flaps are used verses 20 degrees of flaps. The upper cabin's entry door was found, with the locking handle and locking pins, in the closed position. No preimpact engine or airframe anomalies, which might have affected the airplane's performance, were identified.

Manfred W. Engler

The airplane took off from Port Huron, Michigan, on April 1, 1999, at 1130 est. The airplane was scheduled to arrive in Freemont, Ohio. An employee of the pilot's company said that the pilot was going to meet a customer there. At 1230 est, the customer called the company inquiring about the pilot. The employee said that the pilot 'would have taken the shortest route, over [Lake] St. Clair, Ontario [Province], and [Lake] Erie,' to get to Freemont, Ohio. An ALNOT was issued at 1803 est. Search and rescue operations were conducted by the U. S. Coast Guard, Civil Air Patrol, and the Canadian Search and Rescue Center. The search was suspended on April 10, 1999, at 2125 est. The passenger's body was discovered on May 1, 1999, in the Lake St. Clair shipping channel, approximately 6.9 miles east of St. Clair Shores, Michigan. On July 2, 1999, the pilot's body was found in Lake St. Clair. Parts of the airplane identified from the make and model of aircraft were recovered with the bodies.

Mountain Aerostar

Shortly after the airplane took off, a witness about 1 mile from the airport observed the airplane about 150 feet above the ground in a left turn, before it disappeared into the clouds. A witness across from where the airplane crashed stated he was in his shed when he heard the sound of an airplane overhead. When the sound faded and returned, like the airplane had circled above the shed, he stepped outside and looked for the airplane. He saw the airplane exit the clouds in a near vertical position and impact the ground. He described the engine noise as loud and smooth. The airplane impacted in a field about 3/4 miles from the departure airport and was consumed by a post crash fire. Streaks of oil were observed on the leading edge of the right horizontal stabilizer extending to its upper and lower surfaces. Disassembly of both engines did not reveal any pre-impact mechanical malfunctions. A weather observation taken after the accident reported included a visibility of 2 miles with light drizzle and mist, and the ceiling was 400 foot overcast. Witnesses described the weather at the accident site as '...pretty foggy,' and worse than the conditions reported at the airport.

Gary L. Blackman

During arrival at night, the flight was being controlled by a developmental controller (DC), who was being supervised by an instructor (IC). The pilot (plt) was instructed to descend & cross the STILL Intersection (Int) at 3,000 ft. STILL Int was aligned with the localizer (loc) approach (apch) course, 10.1 mi from the apch end of runway 17 (rwy 17); the final apch fix (FAF) was 3.9 mi from the rwy. About 5 mi before reaching STILL Int, while on course & level at 3,000 ft, the plt was cleared for a Loc Rwy 17 Apch. Radar data showed the aircraft (acft) continued to STILL Int, then it turned onto the loc course toward the FAF. Shortly after departing STILL Int, while inbound on the loc course, the acft began a descent. Before the acft reached the FAF, the DC issued a frequency change to go to UNICOM. During this transmission, the IC noticed a low altitude alert on the radar display, then issued a verbal low altitude alert, saying, 'check altitude, you should be at 1,500 ft (should have said '1,800 ft' as that was the minimum crossing altitude at the FAF), altitude's indicating 1,200, low altitude alert.' There was no response from the plt. This occurred about 2 mi before the FAF. Minimum descent altitude (MDA) for the apch was 720 ft. The acft struck tree tops at 750 ft, about 1/2 mi before the FAF. The IC's remark 'you should be at 1,500 ft' was based on an expired apch plate with a lower FAF minimum crossing altitude; the current minimum crossing altitude at the FAF was 1,800 ft. Apch control management had not made the current plate available to the controllers. Investigation could not determine whether a current apch plate would have prompted an earlier warning by the controllers.

William Z. Williams

About three hours and twenty minutes after departing Bellingham, Washington, for Midland, Texas, the pilot contacted Klamath Falls (Oregon) Tower and told the controller of his intention to land. About 10 minutes later, while about 30 miles north of Klamath Falls, the pilot reported he was low on fuel and was not able to find the city. The tower responded with instructions that would take the pilot south to the airport. But because the pilot seemed not to be following the instructions, but was instead continuing to the west, he was switched to Seattle Center. Center provided the pilot with a southeasterly heading direct to Klamath Falls, but less than a minute later radar and radio contact with the aircraft was lost. Other pilots overheard the pilot transmit that he had lost power in one engine, and later state that he had lost power in both. Soon thereafter the aircraft was seen to descend to about 200 to 300 feet above the surface of Lake of the Woods. The aircraft then began to slow and its nose began to rise. As it was slowing, one of the engines surged back to a high power setting, and the aircraft almost immediately rolled quickly to the side and dove nearly straight down into the lake. During the post-accident inspection of the airframe, the throttle for the right engine was found retarded to idle, but the throttle for the left engine was found in the full-forward (maximum power) position. A review of the Aerostar owner's manual revealed that the Engine Failure/Restart checklist called for the throttle for a failed engine (both engines in this case) to be retarded to the 'Cracked 1/2 inch open' position. Toxicological results indicate the presence in the pilot's blood of chlordiazepoxide and three of its active metabolites, norchlordiazepoxide, nordiazepam, and oxazepam. Chlordiazepoxide (Librium) is a tranquilizer often used to treat anxiety and tension. At sufficient levels it can have significant adverse effects on judgement, alertness, and performance. It is known to cause drowsiness, mental dullness, and euphoria. The results also indicate the presence of diphenhydramine in the pilot's blood. Diphenhydramine is a sedating antihistamine, and in sufficient quantities is known to produce drowsiness, impaired coordination, blurred vision, and reduced mental alertness.

CG Aviation

The airplane departed the airport and crashed shortly thereafter. Before departure, the airplane was fueled with 120 gallons of 100LL aviation fuel. According to the refueler, the airplane had full fuel tanks. The refueler also indicated the pilot had stated he wanted to be airborne prior to the arrival of bad weather. After the accident, the engines and propellers were disassembled and examined. No engine or propeller discrepancies were noted, except (post impact) heat damage.

David S. Ladow

The non instrument-rated pilot filed an IFR flight plan, but did not request nor was given a weather briefing. Shortly after taking off into low instrument meteorological conditions, he reported he was returning to the airport, but did not give a reason why. He never declared an emergency. The last transmission was when the pilot said he had 'the problem resolved,' and was continuing on to his destination. Various witnesses said the engines were 'revvying' and 'unsynchronized,' and that the propellers were being 'cycled.' One witness said brownish-black smoke trailed from the right engine. The airplane struck one ridge, then catapulted approximately 1,000 feet before striking another ridge. There was post impact fire. Both propellers bore high rotational damage. Disassembly of the engines, propellers, turbochargers, and various components failed to disclose what may have prompted the pilot to want to return to the airport. Internal components of the right engine, however, were black and, according to a Textron Lycoming representative, were indicative of 'an excessively rich mixture.' A psychiatrist had recently treated the pilot for depression, attention deficit and bipolar disorders. The pilot also had a history of alcohol and drug abuse. Postmortem toxicology protocol disclose the presence of Fluoxetine (an antidepressant), Norfluoxetine (its metabolite), and Hydrocodone (the most commonly prescribed opiate).

Roger Dunbar

The pilot had departed Swainsboro, Georgia at 1930 EST on an IFR flight. About 12 minutes later, he informed Jacksonville Center that he was very dizzy and could not see. There were no other recorded transmissions from the pilot. The airplane was tracked on radar until radar contact was lost at 2130. The airplane was at a heading of 110 degrees and an altitude of 9,000 feet the entire time. Attempts to locate the airplane by aerial intercept were uneventful. All shipping vessels along the airplane's expected course, were notified of the airplane's estimated fuel exhaustion point. No contact was reported and the search was suspended. Prior to departing Swainsboro, the pilot had mentioned to his wife that he had a headache. A review of the pilot's medical records revealed that he had twice indicated on his application for a medical certificate that he had a medical history of unconsciousness. In addition, he was being treated for hypertension with Norvasc and chlorthalidone prescription drugs.