accident report Archives - FLYING Magazine https://cms.flyingmag.com/tag/accident-report/ The world's most widely read aviation magazine Tue, 13 Aug 2024 18:12:30 +0000 en-US hourly 1 https://wordpress.org/?v=6.4.4 NTSB Releases Prelim Report on Vintage WACO YKC Crash https://www.flyingmag.com/aircraft/ntsb-releases-prelim-report-on-vintage-waco-ykc-crash/ Tue, 13 Aug 2024 18:12:27 +0000 https://www.flyingmag.com/?p=213382&preview=1 Agency investigation reveals the VFR aircraft was in foggy conditions at the time of the accident.

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Weather may have been a key factor in the fatal crash of a 1934 WACO YKC in Selden, Kansas, in June, according to the National Transportation Safety Board (NTSB)

The antique aircraft’s owners—Dave and Jeanne Allen—were killed in the June 30 accident.

According to the preliminary report released by the agency (below), thick fog was reported by residents in the area at the time of the accident.

The Allens, from Elbert, Colorado, were both accomplished pilots. Dave was a retired airline pilot, and Jeanne flew gliders. The accident airplane, the teal cabin-class model, had been restored by the Allens and was one of the most photographed vintage airplanes at airshows and fly-ins.

What Happened

According to the NTSB preliminary report, on June 30 the Allens were planning to fly from Knox County Airport (4I3) in Mount Vernon, Ohio, to Oberlin Municipal Airport (KOIN) in  Kansas. According to SkyVector, the straight-line distance is approximately 829 nm. 

The Allens made two fuel stops en route—one at the Shelby County Airport (2H0) in Shelbyville, Illinois, around 8:40 a.m. CDT, and another at the Chillicothe Municipal Airport (KCHT) in Missouri, about 11:35 a.m.

[Courtesy: Meg Godlewski]

The aircraft was not equipped for IFR flight as it was not required to be when it rolled off the assembly line in 1934. The panel of the WACO was period correct with the required original instruments, including an airspeed indicator, altimeter, slip-skid indicator, magnetic compass, and vertical speed indicator.

Investigators also found a hand-held Garmin GPSMAP 496 and an Appareo Stratus 3 in the aircraft. The circuit boards of both were recovered and retained for further examination.

While in Shelbyville, Jeanne Allen made the first of several text messages to the manager of Oberlin Municipal Airport stating that their estimated time of arrival would be around 5 p.m., according to the NTSB report. A second message sent later said that the weather was looking too low for VFR at Oberlin, so they would divert to Phillipsburg Municipal Airport (PHG) in Kansas, approximately 57 nm to the west.

Dave and Jeanne Allen, in front of their 1934 WACO YKC. [Courtesy: Meg Godlewski]

From the ground, Dave Allen made several telephone calls to both the Oberlin Municipal Airport manager and a family friend in Colby, Kansas, to inquire about the weather en route and possible destinations.

According to the NTSB, the airport manager told him that the weather conditions included low ceilings and visibility, and he did not know when or if the weather would improve.

The family friend told investigators that, based on the telephone conversation, he assumed the couple would stay overnight in Colby.

The WACO took off from Chillicothe Municipal Airport at 5:10 p.m.. Approximately six minutes later, the passenger sent a text to the manager in Oberlin stating they were “going to try and go south to get out of this stuff.”

ATC radar data, beginning at 5:46 p.m., showed the airplane making several climbing turns starting at an altitude of 3,025 feet msl. The aircraft reached a maximum altitude of 4,625 feet msl over the accident site, then began descending right bank. Data was lost by 5:49 p.m. The last readout shows the aircraft on a heading of 75 degrees, with a groundspeed of 109 knots and an altitude of 3,800 feet msl, which put it approximately 1,050 feet agl.

The accident site was in a flat agricultural field about 0.10 nm southeast of the last received ATC radar position. The impact marks and debris were consistent with the airplane hitting the ground in about a 90-degree right bank and about 40-degree nose-down attitude. There was a postaccident fire.

NTSB said that an oil rig crew, located about a half mile from the accident site, reported that fog was so dense it could not see the top of its derrick.

The NTSB final report with the probable cause of the accident is expected to be released in about 18 months.

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NTSB Cites Blade Separation in Electric Aircraft Accident https://www.flyingmag.com/ntsb-cites-blade-separation-in-electric-aircraft-accident/ Tue, 13 Feb 2024 23:08:39 +0000 https://www.flyingmag.com/?p=195335 The National Transportation Safety Board is citing blade failure as the cause of the crash of a remotely piloted Joby Aviation electric aircraft in 2022.

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Co-authored with Jack Daleo.

The National Transportation Safety Board is citing blade failure as the cause of the crash of a remotely piloted Joby Aviation electric aircraft in 2022. According to the NTSB’s final report, the accident, which took place on February 16, happened during the second test flight of the day for the JAS4-2, the first of two second-generation preproduction prototypes.

Since JAS4-2, an uncrewed experimental aircraft designated N542AJ, was involved in flight testing, it was being observed from a manned chase airplane.

The flight began about 09:42 PST with a normal vertical takeoff, transition to wing-borne flight, and climb up to 11,000 feet msl. The remote pilot in command (PIC) put the aircraft into a descent, with the unit reaching a maximum dive speed of 181 knots. As the aircraft passed through 8,900 feet the propeller from propulsion station 3 located on the right inboard wing experienced oscillations in rpm and motor vibrations.

Per the NTSB report, “after reaching a maximum dive speed of 181 knots indicated airspeed (kias) at an altitude of approximately 8,900 feet, a propeller blade on propulsion station 3 experienced a bending failure near the root of the blade which culminated in the release of the propeller blade.” 

The released blade impacted the propeller on propulsion station 4—located on the right wing outboard—which subsequently resulted in a release of the impacted blade. 

The result was a cascading effect, with the other propeller blade failures and separations from the propulsion motors, resulting in loss of aircraft control. The aircraft rolled to the left then entered an inverted dive, and crashed in an uninhabited area near Jolon, California. There were no injuries, and the aircraft was destroyed.

“Experimental flight test programs are intentionally designed to determine the limits of aircraft performance and, in doing so, provide critical insight and learnings that support the safe operation of aircraft as well as inform final design elements,” Joby said in a statement to FLYING. “Since the accident, we’ve incorporated a range of improvements to our design and testing methodologies, many of which were already planned, and our second preproduction prototype aircraft has flown nearly 25,000 miles, including more than 100 flights flown by a pilot on board as well as exhibition flights in New York City.”

The company added it will continue to work with the FAA to resolve any safety issues before type certification. It will also share any relevant findings with other electric vertical takeoff and landing (eVTOL) aircraft manufacturers.

According to information recorded by Joby during the test flight, “the variable pitch actuator for station 3 was commanding a typical cruise pitch when the blade release occurred, whereas video evidence indicated a steeper pitch on some blades immediately before the initial blade release.”

The company went on to state that accelerometer data for station 3 “showed a rapid growth in vibration after reaching the accident flights test condition before the initial blade release.” There was also an oscillation present for station 3 at the time, and examination of Joby’s prior flight test data revealed “consistent asymmetric behavior between station 2 and station 3, despite identical mirrored designs.” 

About the Pilot

The remote PIC was 62 years old and held a commercial pilot certificate for airplane single-engine and multiengine land along with ratings for helicopter and glider in addition to unmanned aerial systems (UAS). At the time of the event, the PIC had a total of  2,965 hours total time, with 43 hours flying the JAS4-2.

About the Aircraft

The aircraft was all-electric, fly-by-wire, and capable of vertical takeoff and landing. The design has space for five occupants, pilot, and four passengers, though it could be piloted remotely. The design’s maximum gross takeoff weight was 4,200 pounds. 

The aircraft was configured with six tilting propellers directly driven by six dual-powered electric motors with power supplied by four battery packs. The six electric propulsion unit (EPU) stations are identified numerically based on location as station 1 (outboard left wing), station 2 (inboard left wing), station 3 (inboard right wing), station 4 (outboard right wing), station 5 (left tail), and station 6 (right tail). Each of the six variable pitch propeller assemblies were equipped with five blades and actuated by a single variable pitch actuator driving a mechanical pitch change mechanism.

Joby conducted a frame-by-frame review of GoPro video captured during the test flight to help the NTSB reach a conclusion as to the cause of the crash.

The accident did not slow down Joby, as last week the FAA accepted its propulsion system certification plan. According to company officials, this is a “critical step” toward type certification of its electric vertical takeoff and landing (eVTOL) air taxi.

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NTSB Reports No Bolts in Blown Out 737 Max Door https://www.flyingmag.com/ntsb-reports-no-bolts-in-blown-out-737-max-door/ Wed, 07 Feb 2024 00:11:36 +0000 https://www.flyingmag.com/?p=194759 The Boeing airliner flew missing critical parts.

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The National Transportation Safety Board (NTSB) has released its preliminary report on the investigation into the loss of a door plug during flight aboard Alaska Airlines Flight 1282. According to the report released today, critical bolts were removed from the door assembly at the Boeing Factory in Renton, Washington and evidently were not replaced before the aircraft entered service.

The Boeing jet had a mid exit door (MED) blow out just minutes after taking off from Portland International Airport (KPDX) as the aircraft climbed through 16,000 feet. The pilots declared an emergency and returned for landing. 

The NTSB spent several days in the Portland area gathering evidence, including the blown mid exit door (MED) which was recovered from a backyard. The door has a series of stop pads that line it up with the fuselage. Four bolts are used to secure the door in place.

Investigators closely examined the recovered MED, looking for witness marks that would indicate the four required restraining bolts designed to keep the door in place were installed on the aircraft at the time of the event. 

The 19-page report states, “Overall, the observed damage patterns and absence of contact damage or deformation around holes associated with the vertical movement arrestor bolts and upper guide track bolts in the upper guide fittings, hinge fittings, and recovered aft lower hinge guide fitting indicate that the four bolts that prevent upward movement of the MED plug were missing before the MED plug moved upward off the stop pads.”

According to the report, the MED for the accident aircraft was built by Spirit AeroSystems in Malaysia and then shipped to Spirit AeroSystems in Wichita to be added to the fuselage. The fuselage was delivered to the Boeing factory in Renton in August of 2023. In September, it was noted that there were five damaged rivets on the edge frame forward for the left MED plug. A photograph of this was included in the NTSB report.

In order to replace the damaged rivets, the left MED plug had to be opened, which entailed the removal of the two vertical arrestor bolts and two upper guide track bolts. Records show that the repairs were made by Spirit AeroSystems personnel. A photograph of the MED plug closed with no retention hardware was sent via text to Boeing team members who were discussing interior restoration after the completion of the rivet work during the second shift the next day.

The report further states, “The investigation continues to determine what manufacturing documents were used to authorize the opening and closing of the left MED plug during the rivet rework.”

The Details

The aircraft was delivered to Alaska Airlines on October 31, 2023, and put into service on November 11. Prior to the accident flight, the flight crews had noticed and reported three separate anomalies with the aircraft’s pressurization system. As there is a triple redundancy, two run by computer and one manually, FAA rules allowed the aircraft to remain in use, although the airline removed it from overwater operations until maintenance could be performed. At the time of the accident, the aircraft had accumulated 510 total hours and 154 cycles (takeoffs and landings).

The Aftermath

There were 177 people on board Flight 1282. The NTSB report notes that seven passengers and one flight attendant received minor injuries. The force of the decompression ripped open the cockpit door and deformed the interior of the cabin. Several seats were twisted, and loose objects such as cell phones, paper, and toys were sucked out into the night sky. Video of the aftermath showing oxygen masks hanging down and a gaping hole in the side of the airline has gone viral, as some of the passengers, fearing the airline was going to crash, sent goodbye messages to loved ones even before the airliner landed without incident back at PDX.

Within hours, Alaska Airlines grounded its fleet of 737 Max 9. The next day, the FAA issued a blanket grounding for all the aircraft pending inspections.

Alaska Airlines and United Airlines spent the better part of two weeks with a significant portion of their fleets grounded. The aircraft have since returned to service.

Meanwhile, the FAA and NTSB are continuing with the investigation, including putting Boeing and its contractors under more scrutiny for their manufacturing and quality control processes.

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King Air 350 Accident Proved to Be Fatal Misstep https://www.flyingmag.com/king-air-350-accident-proved-to-be-fatal-misstep/ Tue, 09 Jan 2024 22:52:26 +0000 https://www.flyingmag.com/?p=192491 A fatal 2019 King Air 350 accident near Dallas exhibited all the signs of a random pilot error.

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On June 30, 2019, a Beechcraft King Air 350 twin turboprop, leaving Addison Airport (KADS) near Dallas on a flight to Florida, crashed into a hangar beside the runway. Either the impact or the ensuing explosion and fire killed all 10 people aboard.

The catastrophe was recorded by a number of surveillance cameras, some located not far from the point of impact. Video showed the airplane airborne, initially drifting left, then yawing left to an extreme sideslip angle before rapidly rolling into an inverted dive. The sequence took just a few seconds. Once the left wing had dropped, the low altitude made recovery impossible.

The crew had not reported any trouble to the tower. National Transportation Safety Board (NTSB) investigators reconstructed the event by analyzing surveillance videos and the sound spectrum of the engines captured as background noise by the cockpit voice recorder, as well as extracting data from the airplane’s ADS-B and terrain awareness warning systems. They concluded the critical left engine had spooled down for some reason, and the pilot had reacted by pressing on the left rudder pedal rather than the right. Only the combination of asymmetric thrust with added rudder, the NTSB found, could bring the airplane to the extreme yaw angle observed in the videos, as asymmetric thrust alone would not have been sufficient.

The only communications between the two pilots recorded during the accident sequence were an exclamation of “What in the world?” by the pilot flying and the copilot’s statement, three and a half seconds later, that “You just lost your left engine.” (The King Air is a single-pilot airplane. The copilot frequently flew with the pilot to gain experience, but was not permitted to touch the controls when passengers were aboard.)

The NTSB suspected the spooldown of the left engine might have been caused by a faulty friction setting on the left power lever, which could have allowed it to creep backward during the takeoff roll. This is a known susceptibility of King Airs; the power levers are spring-loaded toward idle, each has its own friction knob, and they rely on positive friction to keep them from drifting. The power quadrant was too badly damaged in the post-crash fire to allow investigators to tell anything about the position of the left power lever or the friction settings. Uncommanded power rollbacks on the PT6-series engines can have other causes, however, which would not necessarily be detectable in a severely burned wreckage, and so the attribution to the friction setting remained speculative.

The quadrant frictions are a checklist item, but the CVR recording disclosed no pre-takeoff briefing and none of the expected checklist or V-speed callouts. According to other pilots who had flown with him, the pilot, 71, a 16,450-hour ATP, was “not strong on using checklists” and “just jumped in the airplane and went.” He was, on the other hand, “super strong” on knowledge of the airplane, in which he had logged 1,100 hours. According to the pilot who administered his most recent proficiency check, he had performed well on the simulated engine failure on takeoff. The check ride took place in the airplane, however, not in a simulator, and so as a safety precaution the engine cut, which had been briefed in advance, did not occur until the airplane was safely airborne and climbing. A successful performance under such controlled circumstances did not guarantee success in exigent ones.

The NTSB’s reconstruction of the takeoff showed the pilot had rotated at 102 kias, slightly below the V1 (go/abort) speed of 106 kias and 8 knots below the calculated rotation speed of 110 knots. The airplane was fully airborne at 106 kias and was at around 110 kias when the power began to roll back. The airplane drifted left, reaching a maximum altitude of 100 feet. Three seconds later, it was at 70 feet and the airspeed was 85 knots. One second later, it plunged through the hangar roof.

The standard procedure for loss of an engine in the King Air 350 is to establish a positive rate of climb with a pitch angle of 10 degrees, retract the landing gear, and feather the propeller on the inoperative engine while maintaining V2 (minimum safe climb speed with an engine out) to 400 feet agl. Above 400 feet, the airplane is allowed to accelerate, the flaps are retracted, and the climb continues at 125 kias.

None of this happened, however, because the pilot, in spite of his lifetime of flying experience and countless successful proficiency checks, stepped on the wrong rudder pedal.

There was a time when the NTSB often cited fatigue as a contributing factor in accidents, but at some point it must have become obvious that plenty of well-rested pilots crashed too, so unless a pilot literally fell asleep at the wheel, fatigue could never be proved to have been a link in a causal chain. In this case, the pilot had a history of severe sleep apnea. To the extent that the FAA was aware of it, the agency had taken no action, although in principle the condition could have been disqualifying. The NTSB turned its back on this opportunity to invoke fatigue. “No evidence,” the agency wrote, “indicates that the pilot’s medical conditions or their treatment were factors in the accident.”

I would have expected the NTSB’s finding of “probable cause” to be something like “…the pilot’s inappropriate reaction to a loss of power in the left engine, which resulted in loss of control.” Instead, it blamed “the pilot’s failure to maintain airplane control,” which seems rather vague and generic. Among the contributing factors, “failure to conduct the airplane manufacturer’s emergency procedure” is a little misleading, since he did begin to execute the procedure but bungled it. The agency added his “failure…to follow the manufacturer’s checklists during all phases of operation,” even though the only link between checklists and the crash was the hypothetical faulty friction setting for which there was no material evidence. Two King Air pilots with whom I discussed the accident were skeptical of the friction theory because they said matching torques on two PT6s during takeoff involves enough fiddling with the power levers that it would be impossible for the pilot to be unaware of a sloppy-feeling lever.

I suspect the NTSB wanted to blame the accident on the pilot not being a by-the-book kind of person. None of his associates the NTSB interviewed suggested he was reckless or incompetent—quite the opposite. The problem with pinning the accident on a personality trait of the pilot is that the mistake of stepping on the wrong rudder pedal is not connected in any obvious way to that. It seems more like one of those random human mistakes we all sometimes make—but hope we will never make at a critical moment.

Note: This article is based on the National Transportation Safety Board’s report of the accident and is intended to bring the issues raised to our readers’ attention. It is not intended to judge or reach any definitive conclusions about the ability or capacity of any person, living or dead, or any aircraft or accessory.


This column first appeared in the August 2023/Issue 940 print edition of FLYING.

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Used Aircraft Guide Live: Wrecks Revisited https://www.flyingmag.com/used-aircraft-guide-live-wrecks-revisited/ https://www.flyingmag.com/used-aircraft-guide-live-wrecks-revisited/#comments Thu, 14 Dec 2023 23:43:09 +0000 https://www.flyingmag.com/?p=190611 For any used aircraft model, a look at the most recent 100 wrecks that make the NTSB database is the same as it's been for years.

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An important part of the Aviation Consumer magazine Used Aircraft Report monthly feature is the accident scan section. For any used model, a look at the most recent 100 wrecks that make the NTSB database is the same as it’s been for years: Pilots are wrecking aircraft for the same reasons they always have. We know that many of these wrecks might have been avoided with better maintenance, better training, better judgement and simply by buying the right airplane in the first place.

In this episode of Aviation Consumer Live, Aviation Consumer’s Larry Anglisano and Rick Durden talk about some recent reports (and some older ones, too) they studied in the Used Aircraft Guide and offer some tips on what you should and shouldn’t do if you break an aircraft.

Want more? Look for the Stupid Pilot Tricks annual feature in the January 2024 issue of sister publication IFR Magazine.

Editor’s Note: This video was produced by Aviation Consumer magazine.

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Lessons from the Truckee NTSB Case Study https://www.flyingmag.com/lessons-from-the-truckee-ntsb-case-study/ Thu, 30 Nov 2023 19:53:43 +0000 https://www.flyingmag.com/?p=189289 The only good thing to come out of aviation accidents, be they large or small, is that we can often learn from the mistakes of others.

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The only good thing to come out of aviation accidents, be they large or small, is that we can often learn from the mistakes of others. I adopted this mindset years ago when I was tasked with writing up accident reports from the National Transportation Safety Board (NTSB). In hindsight, the mistakes can be glaring, leaping off the page. How to mitigate the risks and the failures that led to the event takes a little more thought.

The NTSB recently released a video of a panel discussion about the 2021 accident involving a Challenger 605 attempting a circle to land approach at Truckee-Tahoe Airport (KTRK), in Truckee, California, that resulted in the deaths of the flight crew, six passengers, and two dogs. The probable cause of the accident was released in August of this year and listed as a combination of an unstabilized approach and the flight crew’s poor crew resource management and decision making. The panel discussion took the event apart step by step to identify the issues and suggest ways to mitigate these risks.

The panel was led by NTSB board member Michael Graham. The participants included Stephen Stein, NTSB senior accident investigator of the Truckee event, Richard Meikle, executive vice president for operations and safety at Flight Safety International, Scott Snow, head of training and performance at CAE Incorporated, and three Part 135 operators, Stephen Myers, executive vice president of Elite Jets, Jeff Baum, founder and CEO of Wisconsin Aviation, and Patrick McGuire, representing commercial and business aviation safety management.

The discussion began with a review of the accident, which took place on July 26, 2021. The accident occurred in the daytime, but visibility was somewhat compromised as there was smoke in the air because of forest fires.

Per the 26-page NTSB report, the captain and first officer were flying a Part 135 flight fromCoeur d’Alene, Idaho, to Truckee. According to Stein, the captain was employed by Aeolus Air Charter, Inc. a Part 135 operator. The first officer was a contract pilot hired through a website. The captain had recently undergone recurrency training with the employer. It was noted that the first officer had not undergone this company training, and it was the first time they had flown together. There were references to the FO helping the captain with programming the flight management system.

According to Airnav.com, the airport elevation is 5,904 feet and the airport has two runways: Runway 11/29, measuring 7,001 by100 feet, and Runway 2/20, measuring 4,654 by 75 feet.

The cockpit voice recorder captured the flight, the crew discussing and briefing the straight-in approach to Runway 11. The NTSB report notes that most of the flight was uneventful until descent, when air traffic control told the flight crew to expect the RNAV GPS approach for Runway 20.

The captain was pilot flying and the FO was pilot monitoring the flight. Both determined that Runway 20 was too short for Challenger at its expected landing weight. The report states “Instead of making a request to ATC for the straight-in approach to Runway 11 (the longer runway), the captain told the FO they could take the Runway 20 approach and circle to land on Runway 11, and the FO relayed this information to ATC. ATC approved, and the flight crew accepted the circle-to-land approach.”

Although the descent checklist required that the flight crew brief the new circle-to-land approach, as the flight crew’s acceptance of the new approach invalidated the previous straight-in approach brief, the crew failed to brief the new approach.

The situation deteriorated from there as both the pilot and copilot were behind the airplane until it stalled short of the runway and off the centerline, resulting in a fireball that was caught on a hotel security camera.

“Briefing the approach gives you a chance to get a shared mental model between the flight crew members,” said Stein, noting that the FO at one point asked how they were going to get down from 15,000 feet to 12,000 feet in 2 nautical miles, adding that the aircraft was at 250 knots, which was too fast as they needed to be below 230 knots for the circle to land.

It was noted that ATC instructed the flight crew to hold, but “the captain was slow in complying with this instruction, so the FO started the turn to enter the holding pattern and then informed ATC once they were established in the hold.”

Approximately 20 seconds later, ATC cleared them for the approach. Before the FO confirmed the clearance with ATC, he asked the captain if he was ready for the approach, and the captain stated that he was. However, the aircraft was still too fast. The FO suggested a 360 degree turn to the captain, but the captain never acknowledged the excessive airspeed and did not turn.

The FO continued to coach the captain. Upon visual identification of the airport, the FO instructed the captain to make a turn 90 degrees to the right to put the airplane on an approximate heading of 290 degrees, which would put the aircraft parallel to Runway 11. According to the NTSB, this was consistent with the manufacturer’s operating manual procedures for the downwind leg of the circling approach.

However, the FO instructed the captain to roll out of the turn prematurely, and the captain stopped the turn on a heading of about 233 degrees which resulted in the aircraft on a 57 degree angle left of the downwind course parallel with Runway 11 and what the NTSB described as “an unnecessarily tight turning radius.”

When the aircraft began the turn to final, the airplane was still about 1.3 nm from the maximum circling radius that was established for the airplane’s approach category.The break down in cockpit communication and command structure continued, as the FO deployed 45 degrees of flaps after confirming with the captain although the manufacturer’s operating manual procedures for the downwind leg called for a flap setting of 30 degrees.

The aircraft was at 162 knots, approximately 44 knots above the landing speed of 118 knots that the crew had calculated and planned on earlier in the flight. The FO addressed this by telling the captain, “I’m gonna get your speed under control for you.”

Investigators noted that at this point it appeared as though the throttles were reduced as the engine fan speeds (N1) began to decrease from about 88 percent to about 28 percent. As the aircraft slowed, the FO repeatedly attempted to point out the airport to the captain, who appeared to be having difficulty seeing the runway – possibly due to the wildfire smoke in the area.

The FO continued to coach and reassure the captain through the circle-to-land until they entered the base leg when the FO repeatedly asked for control of the aircraft. There was no verbalized positive exchange of controls.

The jet crossed the extended centerline in a left bank and the FO remarked they were still too high. At this point one of the pilots fully deployed the flight spoilers, which increased the airplane’s sink rate. The airspeed now dropped to 135 knots, which was 17 knots above the Vref speed based on what the NTSB called “the erroneous basic operating weight programmed into the airplane’s flight management system.

The bank angle increased and the stall protection system (SPS) stick shaker and stick pusher engaged. The captain asked the FO, “What are you doing?” and the FO repeatedly asked the captain to let him have the airplane. The stick shaker and stick pusher briefly disengaged, then engaged again as the aircraft entered a rapid roll to the left consistent with a left wing stall resulting in an impact with terrain and post crash fire.

Failure to Brief

As noted in the panel discussion, the issues began with the crew’s failure to brief the circling approach. Although the FO repeatedly pointed out the aircraft was too high and too fast, the captain did not act upon this information. Because the aircraft was too fast, they did not have the time to configure the airplane and make corrections, thus reducing the safety margin.

As noted in the report, “The circling approach maneuver began at 160 kts, which was 20 kts higher than the upper limit of the circle-to-land approach speed established for this airplane’s approach category (category C) and did not drop below the category C maximum speed until the flight crew was preparing to start their base leg turn.”

It was suggested based on the conversations in the cockpit per the voice recorder that the crew did not recognize the severity of the situation and the FO was trying to salvage the approach, resulting in numerous preventable safety challenges.

What We Can Take Away From This

There are a number of lessons to be learned from this event. (Puts on flight instructor cap). For starters, be wary when flying with someone unfamiliar to you. At the airline level, pilots undergo the same training so, in theory, they understand what is expected of them during the flight and know how to work together as a crew. The role of crew members and communication of expectations have been taught and rehearsed in the simulator.

The panelists noted that when an individual undergoing training has difficulties in any of these areas, they are counseled and retrained—or removed, if the situation warrants it.

The standards of performance need to be respected and enforced, starting at the flight school level, and before each flight the CFI needs to verbalize expectations with the learner. Sadly, this often doesn’t happen because the CFI is there for their hours, not necessarily to teach—that one-off flight adds to their logbook, and the learner becomes “someone else’s problem” when the instructor moves on. This must not continue. Some CFIs are reluctant to address the learner’s shortcomings for fear of hurting their feelings or losing a client. If you choose your words carefully, you can help the client. Lying to them about their performance or using vague language like “You did okay” doesn’t help anyone one, and sets them up for a larger failure down the road.

If the instructor introduces the airman certification standards at the beginning of the lesson with the caveat “these are the minimum standards,” it puts in place the metrics for success.

The instructors must make sure the learners understand that these standards and that these metrics are established by the FAA, not the instructor or the flight school—and they are non negotiable.

CRM Training Should Begin Early

The concept of crew resource management (CRM) is a concept introduced in ground school but often not discussed or practiced in the cockpit. This can be addressed once the learner is taught how to use the checklist and perform a passenger briefing.Their job is to fly and if they need the instructor’s assistance or the instructor has to take the controls, that needs to be verbalized with the phrase “my airplane, I have the controls” or “you have the controls” and a positive exchange taking place.

The learner needs to listen to the CFI—and here’s where it gets tricky. If the learner ignores the CFI or locks up on the controls, refusing to let go, the CFIs need to do whatever it takes to get them to release.

This is a delicate area, especially when the learner is larger and physically stronger than the CFI. There may be some learners the CFI refuses to fly with because of this. While most CFIs don’t get into the cockpit with the idea they are going to physically assault the person next to them, I recall the words of my first CFI, a retired police officer who told me, “It is better to talk to twelve than be carried by six,” meaning it is better to have to explain yourself in a court of law than be buried because a learner killed you both in an accident. You do what you have to do, and hope you live to tell the story.

Use the Checklists, Brief the Approaches

The appropriate use of the checklist and a verbal briefing of the approaches should be taught and practiced from day one. When the private pilot candidate is in level flight in the practice area with the CFI at the side, the cruise flight and pre-maneuver checklist should be verbalized.

Before leaving the practice area to return to the airport, the pre-landing and approach checklist with a review of entry into the pattern including appropriate aircraft configuration, altitudes and airspeeds should be reviewed. Far too many private pilots do not follow these procedures, resulting in the “chop, drop, hope you stop (before running out of runway)” approach. Part of this review is a reminder of the sterile cockpit rule before entering the pattern, because this is a task-intensive part of the flight.

In the Truckee accident the copilot was reluctant to assert control when it was obvious that the captain was behind the airplane—for example, when the aircraft was too fast. It is understandable that you don’t want to create conflict in the cockpit, or possibly lose your job, but let’s look at the bigger picture: would you rather talk to twelve or be carried by six?

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A Skymaster Taking Off on One Engine? https://www.flyingmag.com/a-skymaster-taking-off-on-one-engine/ Mon, 27 Nov 2023 14:13:26 +0000 https://www.flyingmag.com/?p=188895 The NTSB links a potentially preventable Cessna 337 Skymaster accident in remote Alaska to an inadvertent stall.

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Alaskan flying entails decisions and improvisations that pilots in the contiguous U.S. seldom contemplate. Remote locations, rugged terrain, and harsh weather on one hand, and, on the other, the urgent human needs that airplanes fulfill, create a press-on-regardless mentality. It takes a hardy pilot to survive.

In June 2000, near the Yukon River in the state’s southwestern corner, a Cessna 337 crashed shortly after takeoff, killing one such pilot.

The airstrip near the remote town of Marshall then consisted of 1,940 feet of hard gravel surface, 30 feet wide, 90 feet above sea level. The wind was calm, the sky clear, the landscape illuminated by the late-evening twilight of the Alaskan midsummer.

There was one witness, not of the crash itself, but of the events that preceded it. The starter motor on the rear engine had failed. The pilot’s companion offered to fly him somewhere to get a replacement, but the pilot, who had logged 600 hours in the 337 and said that he had done single-engine takeoffs in it before, was determined to take off using just the front engine. The pilot and his companion paced out a distance on the runway, and the pilot said that if he was not airborne by that point, he would abort the takeoff.

His companion then watched from beside the runway as the Cessna accelerated. Its nosewheel was lifting off as it passed the abort point. The airplane climbed to about 50 feet, the wings rocked slightly, and it then disappeared behind a low hill. Satisfied that the pilot was safely on his way, the other man left the airport. An hour later, he learned that the pilot had not arrived.

The airplane and the pilot’s body were later recovered from a small lake not far from the runway. The landing gear was retracted, the flaps set at the 1/3 position.

The 337 was equipped with a Robertson STOL kit. The handbook for the conversion recommends a special maximum-performance takeoff procedure. It is to set 2/3 flaps, lift the nose at 44 kias, climb at 56 kias to clear obstacles, then accelerate to 87 kias before reducing the flaps to 1/3 and retracting the gear. Blue-line—that is, single engine best rate of climb—speed is 87 kias at gross weight, and is the same for the Robertson conversion and the stock 337.

The airplane was relatively light. The National Transportation Safety Board calculated that it weighed 3,462 pounds, but that included an implausible allowance of 108 pounds for oil, evidently the result of confusing quarts with gallons. The likely actual takeoff weight would have been below 3,400 pounds.

The Cessna manual gives single-engine rates of climb, at a weight of 4,000 pounds, of 425 fpm with the front engine out and 340 fpm with the rear engine out. (When the rear propeller is not operating, there is excess drag due to separated flow on the relatively blunt rear cowling. The Robertson kit includes some aerodynamic mods to reduce that drag.) Cessna’s rate of climb figures apply at the blue line speed and assume a feathered prop on the dead engine. The propeller of the accident airplane was not feathered, however, because in order for a propeller to feather, it must be windmilling, and it’s pretty certain that the airplane never got to windmilling speed.

The single-engine rate of climb diminishes rapidly at lower than blue-line airspeeds. If the airplane climbs 340 fpm at 87 kias, it will climb only 200 fpm at 60. That is why one is well advised to accelerate promptly to the blue-line speed when taking off in any multiengine airplane.

Neither Robertson nor Cessna published any data or recommendations concerning single-engine takeoffs; in fact, the FAA eventually forbade them. POH guidance for engine-out emergencies assumes that the engine failure occurs after the airplane becomes airborne. The Cessna manual, however, does provide this admonitory note:

“The landing gear should not be retracted until all immediate obstacles are cleared, regardless of which engine is out… Airplane drag with the landing gear doors opened and the gear partially extended is greater than the drag with the gear fully extended.”

The manual cites a 240-fpm reduction in blue-line climb rate with the gear in transit and a dead rear engine. It does not specify what the penalty for a stopped, unfeathered propeller would be. But it is very probable that with the gear in transit, a stationary unfeathered prop, and a low airspeed, the vertical speed would be reduced to zero or less.

We don’t know at what indicated speed the pilot rotated, only that he lifted the nosewheel at the agreed abort point. Presumably he then became airborne. By establishing an abort point on the runway, however, the pilot had, in effect, set up the conditions for a short-field takeoff. Such a takeoff implied a low rotation speed and possibly quite a lot of flaps.

With only half the expected power available, however, the short-field strategy was not ideal. A higher rotation speed and a cleaner configuration would have been preferable. An airplane airborne out of ground effect at low speed accelerates with difficulty. Obviously, the problem is far worse when half the installed power is missing. The way to avoid that situation is to delay rotation until you have plenty of speed and to use little or no flaps, because flaps add drag. At sea level, a 3,400-pound airplane with a 210-hp engine and a constant-speed prop can comfortably get airborne without flaps in 1,900 feet; there was no need to use the special capabilities conferred by the Robertson conversion. In fact, it would have been better to delay rotating until almost the end of the runway.

The NTSB concluded that the accident had been the result of an inadvertent stall, citing as well the “improper retraction of the landing gear” and the pilot’s “overconfidence in the airplane’s ability.” It seems likely that a stall occurred, since, if the airplane had merely failed to climb, the pilot might have ditched it under control in the lake and very possibly survived. (The pilot seemingly did survive the impact, although with serious injuries; the official cause of death was drowning.)

In my opinion, the pilot’s confidence in the airplane was not misplaced. Very probably, it could have made the takeoff successfully if only the pilot had used the full length of the runway and then delayed retracting the landing gear until he reached the blue-line speed. The terrain ahead was low and flat; any rate of climb at all would have been sufficient. By setting an abort point, as if the main concern were the possibility that the front engine would fail, the pilot had inadvertently stacked the deck against himself.

This article is based on the National Transportation Safety Board’s report of the accident and is intended to bring the issues raised to our readers’ attention. It is not intended to judge or to reach any definitive conclusions about the ability or capacity of any person, living or dead, or any aircraft or accessory.

This column first appeared in the June 2023/Issue 938 edition of FLYING magazine.

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NTSB Preliminary Report on Kentucky Fatal Crash Released https://www.flyingmag.com/ntsb-preliminary-report-on-kentucky-fatal-crash-released/ Wed, 18 Oct 2023 19:42:15 +0000 https://www.flyingmag.com/?p=185417 The NTSB has released its preliminary findings on the fatal crash of a Piper PA-28-161 near Whitesville, Kentucky, in September involving a flight instructor and private pilot candidate on a night flight.

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The National Transportation Safety Board (NTSB) has released its preliminary findings on the fatal crash of a Piper PA-28-161 near Whitesville, Kentucky, in September involving a flight instructor and private pilot candidate on a night flight.

According to the report, the pair flew into a thunderstorm. The event has received national attention because the CFI, Timothy McKellar Jr., 22, made several social media posts during the flight that included demeaning comments about the learner, Connor Quisenberry, 18. McKellar also posted an image of approaching thunderstorms along the route of flight. McKellar acknowledged the storms and the flight continued.

The Timeline

On September 27, McKellar and Quisenberry were attempting a night cross-country flight fromOwensboro/Daviess County Regional Airport (KOWB) to Bowling Green-Warren County Regional Airport (KBWG) in Kentucky on a VFR flight plan. The aircraft, a Piper Warrior, belonged to Eagle Flight Academy in Owensboro. According to social media accounts, McKellar completed his solo at the school in 2020, then finished his training at ATP. McKellar’s Facebook profile lists him as a flight instructor employed at ATP. McKellar had a significant social media presence, and often the posts were about flying.

The NTSB notes that, according to the operator of the aircraft and Quisenberry’s regular instructor, this was the first time he had flown with McKellar. In his Snapchat, McKellar remarks “me and this student should not get along if he was my full-time student. I’ve seen faster at the Special Olympics,” then the camera angle is reversed to show Quisenberry, flashlight in hand, performing what appears to be the preflight inspection of the Warrior. The time stamp of the Snapchat shows 8:39 p.m. as McKellar is heard saying, “C’mon.” He posts that the pair have a three-hour flight ahead. McKellar is eager to get the three-hour flight completed because he has to be up at 4:30 a.m. the next day.

According to the NTSB, automatic dependent surveillance-broadcast (ADS-B) data shows the airplane took off from KBWG around 21:55 local time, climbed to an altitude of 4,500 feet msl, and proceeded on a northwesterly course toward KOWB, on a VFR flight plan. According to SkyVector, the distance between the two airports is 58.6 nm. McKellar posted video of the night takeoff and a portion of the in-flight cruise.

McKellar refers to Quisenberry as “Forrest Gump” and posts that he is “just giving it to him straight up,” to which Quisenberry allegedly replies to the criticism by saying, “I don’t mind you being hard on me. I know I need it.” 

The Weather

METARs from the area at the time of the flight show severe weather with lightning in all quadrants. Additionally, the TAFs from earlier in the day indicate the possibility of convective weather.

At 22:15, approximately one hour after takeoff, McKellar posted an annotated weather image from a mobile-device-based aviation navigation tool. The image shows the airplane’s  position northwest of Bowling Green, Kentucky, along with the planned route of flight to KOWB. Weather radar imagery was also displayed in the image, which had been annotated with a circle around the flight track and nearby weather radar returns and a comment from McKellar about the storms approaching like “angry hornets.”

A screen grab of the post is included in the NTSB report, with attention called to the location of the approaching storms, airplane’s position (blue airplane icon), the planned route of flight (magenta line), and the depicted weather radar imagery with the storms circled in red.

The report notes the pilot contacted ATC at 22:44, and the controller advised the flight of heavy to extreme precipitation at the airplane’s 9 o’clock position, roughly northwest of the planned route. ADS-B data showed that the airplane continued its course, and about two minutes later, McKellar requested an “instrument flight rules clearance.”

The controller issued the clearance and assigned a turn to the east to get out of the weather.

McKellar advised ATC that the airplane was “getting blown around like crazy.” The airplane’s flight track showed a turn to the northwest, followed by a right circling turn. The controller reiterated the heading of 090 degrees. McKellar replied that they were in “pretty extreme turbulence.”

The flight track showed a continuing descending turn to the right. There were no further communications. The last ADS-B position was recorded at 22:49 at an altitude of 2,200 feet. The wreckage, described by the NTSB as a “debris field,” was found spread over 25 acres in a hilly, densely wooded area.

The Wreckage

The NTSB noted that all major components of the airplane, with the exception of the left portion of the stabilator, were located in the debris field.

The aircraft had been torn in half with the forward fuselage, including the cockpit, engine, and right wing located together in the most westerly portion of the debris field. The left wing was located 800 feet away.

The empennage with vertical stabilizer intact was located over a ridge about 200 feet north of the forward fuselage. The rudder was torn diagonally from top to bottom, with the lower portion remaining attached to the vertical stabilizer and the upper portion separated and located near the empennage in the debris field.

The stabilator was torn chordwise just outboard of the hinges, with the right side located 1,500 feet away from the fuselage. The wreckage was recovered and sent to a salvage facility for further examination. The engine displayed impact damage, but the NTSB did not uncover any preaccident anomalies or malfunctions that would have precluded normal operation.

The final report will be issued in a few months after the investigation is completed.

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NTSB Cites Unauthorized Takeoff in Boston Near-Miss Report https://www.flyingmag.com/ntsb-cites-unauthorized-takeoff-in-boston-near-miss-report/ Fri, 04 Aug 2023 20:15:17 +0000 https://www.flyingmag.com/?p=177136 Investigation has attributed a ‘flight crew taking off without clearance’ for the February
incident at Logan International between a private jet and airliner.

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The National Transportation Safety Board has concluded a near miss involving a JetBlue airliner and a private business jet at Logan International Airport (KBOS) in Boston last winter was caused by the pilot of the private jet taking off without a clearance.

The incident at KBOS happened the night of February 27, 2023, involving a Learjet 60 and a Embraer E-190 operated by JetBlue.

Hop-A-Jet, a private charter company, operated the Learjet 60, which was heading to Fort Lauderdale Executive Airport (KFXE) in Florida. JetBlue Flight 206 was arriving from Nashville, Tennessee.

The Crews Involved

The pilot of the Learjet, age 63, held an airline transport pilot certificate and had approximately 22,544 hours total time, of which 2,317 were in a Learjet 60. He had flown 51 hours in the preceding 30 days.

The copilot of the Learjet, age 23, held an ATP with 2,027 hours total time and 388 in the make and model.

The captain of the Embraer E190, age 36, held an ATP and had a total of 7,505 hours with 1,673 in the E190. The copilot, age 25, also held an ATP and had 2,280 hours total time, of which 75 were in the make and model.

At the time of the incident, the first officer of the JetBlue aircraft was the pilot flying. According to the NTSB, the Embraer was flying the ILS 4 Right and had been cleared to land. The crew of the Embraer was listening to the tower frequency and heard an aircraft being given instructions to line up and wait (LUAW) on Runway 9. Runways 4R and 9 intersect.

“As they entered the flare after crossing the threshold of Runway 4R, about 30 feet above the ground, [the JetBlue pilot] saw an airplane cross 4R on Runway 9 from his left and going to the right, but could not estimate how far away the airplane was,” the NTSB report said.

The jumpseat of the Embraer was occupied by an airline employee who was commuting. The jumpseat occupant was not wearing a headset, and the cockpit speakers were not turned on so he could not hear the communication with ATC.

“It was a clear night, so on an approximately 5-mile final for Runway 4R, I decided to video the night approach/landing,” he told NTSB investigators. “On short final, a business jet can be seen crossing our path on their takeoff roll on Runway 9 as our crew performed a go-around. I did not see the business jet until it passed in front of us. I stopped the video shortly thereafter.”

A screengrab from the video shows the Learjet directly in the path of the larger airplane. The pilot of the Embraer initiated a go-around.

Per the NTSB report, the captain of the Learjet stated it received clearance to cross Runway 4 Left on Taxiway Echo, then take Taxiway Mike to Runway 9.

“He said they had heard a clearance that seemed to be ‘line up and wait’,” the report stated. “He further stated that he probably responded to the clearance, but in his mind they were cleared for takeoff.”

Investigators say a ground-detection system alerted the tower of the aircraft’s proximity to each other, so the tower issued a “go-around” to the Embraer.

Meanwhile, the Learjet continued with the takeoff. During cruise, it received a message from ATC providing a phone number to call upon landing.

“The number was called when they arrived at their destination, and they learned they had taken off without authorization and caused an airplane that had been cleared to land on Runway 4 to execute a go-around, passing about 400 feet above them,” the report noted.

The NTSB concluded that the probable cause of the incident was the “Hop-A-Jet flight crew taking off without a takeoff clearance.”

As part of the investigation, the pilots, copilots, and jumpseat occupant were interviewed.

“I can not understand what happened to me during the clearance,” the Learjet pilot told NTSB. “The only thing that comes to my mind is that the cold temperature in Boston affected me. I was not feeling completely well and had a stuffed nose.”

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