Tag: After the Accident

Citation Pilot Crashes After Argument With Girlfriend

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citation pilot crashes after argument with girlfriend - Citation Pilot Crashes After Argument With Girlfriend
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A 51-year-old pilot flying alone in his personal Citation jet lost control of the single-pilot jet shortly after takeoff, crashed and was killed upon impact. The National Transportation Safety Board (NTSB) determined the probable cause of this April 2018 accident was “loss of control while operating in night instrument meteorological conditions as a result of spatial disorientation.” It’s an all-too-common NTSB statement of probable cause, typically seen when a visual flight rules (VFR) pilot pushes into bad weather. But this was an experienced instrument pilot in a well-equipped aircraft. So, what happened?

The pilot claimed 1,900 hours total time on his last medical, but a logbook recovered from the wreckage shows 737 hours, with 13 hours in the previous 30 days. He had FAA ratings for single and multiengine land, instrument airplane and a Cessna CE-525S type rating. The S part of the type-rating allowed him to fly the small-business jet single-pilot.

The 1996 Cessna 525 CitationJet had 3,311 hours at its last maintenance inspection. It’s a safe, modern capable twin-jet. This one had a large multifunction display and a Garmin MX20, which displayed satellite weather information and color-coded terrain. It was a smart-looking jet, painted with flowing green ribbons over a white base. Sometimes the pilot flew it alone, but mostly he flew with his father or brother, both of whom also had CE-525S type ratings. They usually flew on an instrument flight rules (IFR) flight plan, taking turns to swap left- and right-seat duties. The three of them worked together at the family’s lumber company. They based the plane close to home at the Shenandoah Valley Regional Airport (KSHD), Virginia, where they also had a Beech Baron.

On Saturday, the accident pilot flew the Citation solo from KSHD to the Chesterfield County Airport (KFCI), 82 miles to the southeast. He was in position to perform a flight review Sunday morning and to spend time with his girlfriend. She said the review on Sunday was “satisfactory on everything,” though there are no details about it in the NTSB docket. He returned to her house around noon, then went to the grocery store and watched some baseball on television. The plan was he would fly home on Monday.

The pilot’s girlfriend told the NTSB he had “a couple of drinks when they were fixing dinner.” While she was looking at baseball information on his phone, a text came in of a “personal and explicit nature.” It upset her. Although they “kept everything on the down-low,” she had believed they were in a committed relationship. She asked him to leave, and he left in an Uber around 7:30 p.m.

According to the Safety Board, she thought he was going to a hotel. That would have worked out fine. But instead, he went to KFCI. While it’s admittedly speculative, the Citation was his ride home and his regular, familiar and reliable means of transportation. It might have represented an attractive means of escape from the drama and, even, a kind of therapy for him. 

The Uber dropped him off at the single-runway nontowered airport at 8:02 p.m., 10 minutes past sunset. Security camera footage at KFCI shows him walking straight out to the plane. An FBO line service employee went out and asked if he needed any fuel. The pilot said no, he was good. The line service agent didn’t notice anything out of the ordinary during the quick interaction, telling the NTSB that he saw, “nothing about the pilot that made him think he shouldn’t be flying this jet.” Engines started at 8:17 p.m., the Citation turned around on the ramp and stayed there for a bit. 

Now the late-shift employee began to notice some odd behavior. The pilot never transmitted on the CTAF. Instead, he taxied around on the ramp some more, then to the departure end of runway 15. Inexplicably, he then taxied back. Was this an inflection point? Maybe only after starting the engines did he remember the couple glasses of wine. Maybe only after starting the engines did he realize there was weather to the west. This flight wasn’t planned for that evening, nor was the relationship stress expected. 

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KFCI was VFR, with broken cloud layers at 3,200 and 4,000 feet, good visibility underneath, wind from 140 degrees at 12 knots.  However, on his route to the west, a solid line of powerful storms was raging. The pilot had Foreflight on an iPad in the cockpit. Plus, the plane had a satellite weather display, but we don’t know what he looked at before takeoff. We do know he didn’t call anyone for a briefing.

FAA Flight Services was well aware of the weather. Along the route were tornado warnings and urgent pilot reports from CRJ-200 and Boeing 737 aircraft calling moderate turbulence above overcast ceilings of 1,500 feet in heavy rain and lightning. SIGMET 36E was active, warning of severe thunderstorms with tops to flight level 420 with tornadoes, 1-inch hail and wind gusts to 60 knots possible. The pilot didn’t file a VFR or IFR flight plan or talk once to air traffic control.

Perhaps ignorant of all of this, the pilot taxied the CJ once again, this time to the departure end of Runway 33. The plane took off at 8:33 p.m., still in radio silence, with about a 12-knot tailwind. Radar tracking showed a pretty consistent northwest heading. Mode C reported an initial climb to 11,500 feet, almost certainly in the clouds without the pilot having requested or received an IFR clearance. Shortly thereafter, the aircraft descended rapidly about 4,300 feet. This is below the minimum IFR safe altitude of 5,700 feet around the KSHD airport. According to the NTSB report, the weather then got bad. He flew alone directly into and through the line of intense thunderstorms. After nine minutes of straight and level flight, at 8:54 p.m., there was a left turn and sudden descent, more than 6,000 feet per minute down. 

The pilot’s girlfriend told the NTSB he had ‘a couple of drinks when they were fixing dinner.’ While she was looking at baseball information on his phone, a text came in of a ‘personal and explicit nature.’ It upset her. 

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The only witness had just finished putting his kids to sleep and was himself getting into bed. He told the NTSB he heard the “screaming of the engines” and saw lights flash overhead. Then he heard, indeed, felt the airplane impact the ground, followed by a bright fireball. He remembers the clouds were really low, and “there was a ton of rain.” The jet had crashed into nearby woods, all components found together, highly fragmented, in a compact accident site. The Board reports, “the damage to the airplane and the distribution of the wreckage were consistent with a loss of control and a high-velocity impact.”

The closest official weather station, 13 miles away at the Charlottesville-Albemarle Airport (KCHO), had visibility of 2.5 miles, broken ceiling at 700 feet, overcast at 1,500 feet, temperature and dewpoint 11 degrees Celsius, lightning detected to the northeast and south. Other nearby airports were all recording solid IFR conditions with rain and lightning. Local TV news reported several houses in the area damaged by the storm and thousands more houses with no power.

, investigators found no pre-impact abnormalities with what was left of the aircraft. An official answer to why and how an IFR pilot in his well-equipped jet would take off without a clearance and lose control was likely provided by toxicology testing. The FAA’s Forensic Sciences Laboratory found ethanol at a concentration of 0.08 gm/dl in the pilot’s muscle tissues—twice the FAA alcohol limit of 0.04 gm/dl. (The federal limit to legally drive in the United States is a blood alcohol content of 0.08%.) Also, the medical drug cetirizine was present. Cetirizine is an over-the-counter antihistamine medication used to relieve allergy symptoms. It comes with the warning “avoid alcoholic drinks…be careful when driving a motor vehicle or operating machinery.”

The NTSB final report lays it out clearly: “the pilot’s intoxication, combined with the impairing effects of cetirizine, affected his judgment; contributed to his unsafe decision-making; and increased his susceptibility to spatial disorientation, which resulted in the loss of control of the airplane.”

Looking back, it’s sometimes simple to see when an accident could have been prevented. But when unexpected emotional events unfold, it’s not so easy in the moment to look forward. And it can be harder still to change trajectories. Unfortunately, under the influence of alcohol, this pilot chose flight. 

Risking A Career (Or More) On A Drink

NTSB Finds Wealth Of Failures Leading To Boeing B-17 Crash In Connecticut

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ntsb finds failures leading to boeing b 17crash connecticut - NTSB Finds Wealth Of Failures Leading To Boeing B-17 Crash In Connecticut
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 “Departure,” the pilot of the 1944 vintage B-17 bomber radioed to the air traffic controller now in charge of the flight, “N3012 is with you, stand by one, please.”

A few words can tell us a lot. It was clear that right after takeoff, the pilots were working a problem. N93012, known as “Nine-O-Nine,” was a historic Boeing B-17 World War II-era bomber starting a historic experience flight for paying passengers. Six minutes after that transmission, the aircraft would crash while the pilot attempted to bring it back to the airport. Most of the airframe was destroyed by impact forces and fire. Six people got out alive. Seven others, including the two pilots, died.

This was two years ago. Online there was a lot of immediate—and sometimes uninformed —speculation. In April, the National Transportation Safety Board (NTSB) issued its final report. Drawing from survivor accounts, video recordings, ADS-B data, engineering simulations and traditional wreckage analysis, it describes what happened in detail. I’ve reviewed the docket, climbed through B-17s, and discussed the accident with B-17 instructors, mechanics and loadmasters. There was a lot to be learned.

In all, 12,731 B-17s were built during the years 1935 to 1945. This massive fleet dropped more bombs during World War II than any other U.S. plane. With four big radial engines, a wingspan over 100 feet, a top speed of 287 mph, a 2,000-mile range with a 6,000-pound bombload, and bristling with guns, it was a battleship of the sky. In time and technology, it’s halfway between the Wright Flyer and the Lunar Lander. It was soon eclipsed, however, and many thousands of existing B-17s were relegated over the next several years to non-battle duty and aircraft boneyards. 

Eighty years later, a few of them are still flying. On the morning of Wednesday, Oct. 2, 2019, at the Bradley International Airport (KBDL) in Windsor Locks, Connecticut, that number decreased from 10 to nine. 

Weather certainly wasn’t a problem. At 9:51 a.m., the official KBDL observation was 73° Fahrenheit, with calm winds, few clouds at 11,000 feet, and ceiling broken at 18,000 feet. No obscuration, no precipitation.

Pilot experience wasn’t a problem, either. The 75-year-old aircraft commander had 20 years of flying the B-17. In fact, his over 7,000 B-17 hours were touted as more time in the Fortress than any other pilot ever. His 23-year-old chief pilot described him as “masterful in the airplane…he lived in that thing; cleaned it, worked on it, flew it. I can’t think of any negative aspect of his flying performance.” An experienced warbird examiner described his last yearly check ride as “very routine. [He] was a master in that airplane…he didn’t fly, he wore that airplane. I’ve never seen anybody that could fly and be as smooth and knowledgeable about an airplane.” In the right seat was a former USAF pilot and retired airline captain with about 22,000 total flight hours and multiple type ratings.

Ten passengers paid $450 each for a 25-minute ride in the 1944 B-17G on a national “Wings of Freedom” tour. Serial number 44-83575 was built too late to see combat and after the war was converted to an SB-17G variant, flying search and rescue missions in Puerto Rico. It ended its military service in the Nevada desert, subjected to nuclear weapons testing. After 13 years, enough time, they said, to allow the radiation to subside, the airframe was decommissioned. In civilian hands, it was restored as a bomber, a water and borate bomber. For two decades, it fought forest fires.

In 1986, the airframe was bought by the nonprofit The Collings Foundation and restored to a war-time configuration, complete with (non-functional) gun turrets. It was painted in the colors of the 323rd Bomb Squadron, becoming what’s referred to as a tribute ship for a war-time B-17G, serial number 42-31909. Those last three numbers, Nine-O-Nine, explain its nickname. That aircraft did fly in the war, completing an Eighth Air Force record of 140 combat missions without an abort or loss to the crews that flew it. After the war, after 21 engine changes, four wing-panel changes and 600 patched bullet holes, crews at a scrapping yard in Kingman, Arizona, did what the Luftwaffe never could, destroying the stately big bomber. 

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The Collings loadmaster/flight engineer/mechanic arrived on the ramp at 8:15 a.m. to start preparing the aircraft. He added oil and checked the maintenance logs. Passengers arrived around 8:30 a.m., signing liability releases in the FBO. The loadmaster helped a fueler with adding 160 gallons of 100LL, bringing the total gas onboard to 800 gallons, enough for both the planned morning and afternoon flights. There was a lot of eager anticipation. Friends and relatives recorded videos. Everybody walked out, loaded up, and waited for the four 1,200-horsepower Curtiss-Wright Cyclone R-1820 nine-cylinder engines to breathe life into the old plane.

Because the engine-numbering methodology is important to understand the accident, let’s review. The engines are numbered from left to right, from the pilot’s perspective, with the No. 1 engine being the one farthest from the left. The No. 2 engine is the other engine on the left, closer to the fuselage. The engines on the right wing, again, progressing from left to right, are Nos. 3 and 4, respectively.

The first engine to be started, No. 3, inboard right wing, proved problematic. It’s typically started first so that you can use its generator to start the other engines. The starter turned the prop just fine, but the engine wouldn’t run. The flight engineer got out, opened up the cowling and used pressurized nitrogen gas to dry some early-morning condensation from the magnetos. 

No. 3 started successfully. At that point, a start of outboard right engine No. 4 was attempted, but it, too, would not run on the first attempt. So, No. 3 was shut down, and the same drying process was repeated for engine 4. At times, the pilot got out of the aircraft and directed actions. At times there was shouting. Eventually, engine 3 was started again and was followed by good starts of engines 4, 2 and 1.

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After the oil warmed up, the flight engineer said there were engine and propeller system checks. All engines were run up and the magnetos checked. He remembered that “everything was perfect, I mean, we had no drop, we had no backfire. We had nothing. I mean, there was no reason not to fly.” 

At 9:34 a.m., N93012 called Bradley clearance delivery for a 20-minute local VFR flight to the east, no further than 20 miles, 2,000 feet or below. While the pilots had their lap belts on, the flight engineer/loadmaster was unstrapped, sometimes standing between the two pilots and sometimes walking around in the back of the plane. He had no assigned actual seat.

The pilots contacted the Bradley International ground controller at 9:38, requesting takeoff from runway 6 at its intersection with runway 33. The full length of runway 6 is 9,509 feet, and from that intersection, there’s still almost 6,000 feet usable, well more than enough for a B-17, and the shortcut halved their taxi distance. Still, they had to wait for possible wake-turbulence from departing jet traffic to pass, but soon enough, at 9:46, Bradley Tower transmitted, “N93012, wind light and variable at three, turn right heading 095, Runway 6 at Runway 33, cleared for takeoff.” 

The ground roll and initial climb appeared normal, and the flight crew started the right turn and was handed over to departure. 

As soon as the landing gear had been retracted, airspeed at 124 mph, the flight engineer/loadmaster took off his headset, tapped the shoulders of two passengers to let them know they could go down into the nose, and went back through the plane to let everybody else know they could unstrap, walk around and look out. 

One surviving passenger said he could hear an engine running rough.

A few seconds after telling the departure radar controller to standby, the pilots informed ATC, “Boeing 93012, we would like to return to the field.”

“N93012, sorry, say again.”

“Yeah, we are returning to the field immediately.”

“N93012, do you need any assistance?”

“Negative.”

“And what’s the reason for coming back?”

“We have a rough mag on No. 4 engine, we would like to return for it out.”

The plane’s airspeed was down to 110 mph on a right diagonal flight path at 675 feet AGL, the highest altitude of the flight.

There was, indeed, an engine problem. The right outboard, No. 4 engine, was losing power. The flight engineer saw the RPM falling. The pilot said he “wanted to cage it.” The flight engineer wasn’t ready to shut it down yet. 

Regardless, the pilot unilaterally reached over and shut down the No. 4 engine. He then feathered the propellor. He didn’t coordinate or verify these actions with the co-pilot. The flight engineer/loadmaster went back into the aircraft to tell the passengers to sit down and strap in. 

 “Not yet lined up with the runway, N93012 crashed into the approach lights 1,000 feet short of the runway, then turned hard right.

ATC cleared the flight onto the downwind leg for the northeast-facing Runway 6, a leg that is usually flown at nearly twice the altitude that the B-17 was then flying at, and requested confirmation that the crew wanted an immediate landing. 

“When you get a chance, yeah.” The plane banked to enter right downwind on the 45-degree line, slowly losing altitude the whole time. The controller, who was also working inbound jet traffic, asked if they needed to be on the ground right now. The reply was, “I kinda would like to be on the ground as soon as possible.” The controller canceled the jet’s approach clearance and said, “N012, you can progress however necessary for Runway 6.” On the landline, he informed Bradley tower the B-17 was having a mag issue, coming back to the field, no emergency—it just needs to get on the ground. 

Now the plane was joining downwind, flying parallel and backward to the runway, the standard procedure, before the base-leg turnaround to the runway. At the downwind point, however, the plane was only at about 475 feet AGL and still descending. 

And there was another problem. The No. 3 engine, the other right side powerplant, was not producing enough power. The plane was slower than it should have been, too, its airspeed below 100 mph. Around this time, the pilots lowered the landing gear.

Bradley tower cleared the flight to land on Runway 6 and advised that the wind was calm. The crew acknowledged the landing clearance. Twenty seconds later, the tower asked, “N93012, uh, ahh, how’s your progress for Runway 6?” At that point, investigators determined, the plane was at 375 feet AGL. Almost stepping on each other, there are two transmissions. What sounds like the PIC says, “We’ll get there.” A second voice, most likely the co-pilot’s, chimes in with, “midfield downwind now.” Those were the crew’s final transmissions. 

Continuing to descend, the Nine-O-Nine turned a base leg at 200 feet above the ground and far slower than is normal or safe. Its turn toward the runway was, again, low and too tight, but it looked as though they might just make it.

They didn’t. Not yet lined up with the runway, N93012 crashed into the approach lights 1,000 feet short of the runway, then turned hard right. Impact forces on the right wing, and power from engines 1 and 2 on the left wing, caused it to careen across the grass infield and a taxiway. It smashed hard into a huge metal tank and some storage sheds. Several passengers were thrown around inside the cabin, and the plane burst into flames. The tower controller closed the airfield and cleared all emergency ground vehicles to the crash site using any route, “the quickest way possible.”

The two pilots died in their seats. Five of the passengers died. The loadmaster and five passengers got out alive, most with serious burns, cuts and bruises.

“Backing up the accident sequence, being low and with multiple engine issues, why didn’t the plane get on the ground quicker by using another option?

, the Safety Board survival factors group looked at why some of the occupants lived while others died. No one reason seems to have made a clear difference. The loadmaster, who wasn’t strapped in any seat, lived. The pilots, using lap belts, died. Neither pilot was using the provided shoulder harnesses. Some seatbelts failed. One passenger told the NTSB he was unfamiliar with the military-style seatbelt and was never able to close the buckle successfully. It was “missing the piece that allowed the two sides to clasp together.” Another remembers the loadmaster saying, “the belts would probably be loose but not to worry about it.”

Immediately after Nine-O-Nine came to a final stop, a fire burned fast and hot, fed by hundreds of gallons of gasoline on board. One passenger spent 78 days in the hospital recovering from burns. Only two occupants didn’t suffer burn injuries. One was a command chief master sergeant in the Air National Guard wearing his service-issue flight gloves. No one else had protective clothing. Two passengers wore shorts. A different warbird organization, the Commemorative Air Force (CAF), requires its flight crews to be outfitted in fire-protective Nomex flight suits and passengers to wear long pants and closed-toe shoes. 

Why did Nine-O-Nine miss the runway and smash into buildings rather than sliding to a stop straight ahead on the runway? It’s important to understand that when the engine power to one or more engines on a multi-engine plane is interrupted, the plane’s natural tendency is to turn toward the side of the plane with reduced power. 

Both of those malfunctioning engines, Nos. 3 and 4, were on the right side of the plane, so its natural tendency in the air would have been to turn to the right, toward those underpowered engines. The pilot can counteract this failed-engine effect through use of the rudder pedals, but there are limits to the ability to keep an airplane heading straight, especially when its airspeed is low, as Nine-O-Nine’s was. 

The NTSB concluded, “a safer course of action would have been to retard all engines to idle and use maximum braking to stop the airplane, and/or to use differential braking and rudder to yaw the airplane back to the left and parallel to the runway while rolling to a stop.” They were too low and too slow to make a landing on the runway. 

But why did the plane get so low on base? Even with No. 4 feathered and No. 3 failing, they still had two good engines. While performance-limited, the B-17G is controllable and flyable with two same-side engines out. There are data supporting this in the original flight manuals. Moreover, approaches and landings like this are practiced in B-17 training programs. But what you don’t do is lower the gear way back on midfield downwind. It’s too much added drag. NTSB performance and engineering analysis of the ADS-B data indicates, “if the landing gear had been kept retracted until the final approach, the airplane would likely have overflown the runway approach lights and touched down past the runway threshold.”

The Collings Foundation disputes this finding, claiming it takes one minute for the landing gear to extend. However, the original Field Service Manual for the B-17G states, “the motor should retract the landing gear in about 23 seconds and extend in about 20 seconds. (Replace motor unit if over 45 seconds.)” An instructor told me “his” B-17G main gear extends in 29 seconds. The Army Air Force Pilot Training Manual for the Flying Fortress is clear about the timing during two-engine landings: “Put down landing gear on base leg if the base leg is close to the field; otherwise, wait until you are close enough.” 

Backing up the accident sequence again, being low and with multiple engine issues, why didn’t the plane get on the ground quicker by using another option? Look at the flight path laid over the aerial photograph. Runway 33 might have been a better choice than returning to the takeoff runway. To get back to the airport via 6,847-foot-long Runway 33 would have taken one turn to line up and land. It was closed, but the pilots knew its condition as it was the runway they taxied down before taking off. NTSB analysis found “an approach and landing on runway 33 (instead of runway 6) could likely have been accomplished more easily, at higher speeds and along a nominal glide path.”

The counterargument is that Runway 33 was temporally closed, except, that is, for taxiing. Still, in an emergency, all bets are off, and the pilots could have asked to land on Runway 33 despite its being officially closed. If the pilot had declared an emergency, he could have just announced to the controller that that was his intention.

Why didn’t the pilots declare an emergency? It seems clear that an engine failure right after takeoff in a historic WWII airplane carrying paying passengers is a prime example of an emergency situation. All the co-pilot had to do was say, “Mayday, Mayday, Mayday,” three times so there’s no doubt. It would have automatically triggered the controller to initiate the rolling of emergency services on the ground, maybe saving lives by having them already in position to fight the fire and pull people free.

Two of the NTSB’s primary areas of focus were airspeed and altitude. The B-17 still had two good engines, so why were they slowly descending? The answer is Nine-O-Nine was behind the power curve. It got too slow and stayed too slow. NTSB technical analysis found “the airplane was operating at or below 100 mph, below the airspeed for maximum g [flight path angle].” The current manual used by the EAA to fly its B-17G Aluminum Overcast states for double engine failures, “there is a critical airspeed of approximately 115-120 mph below which the airplane will not climb.”

“The NTSB found the Collings Foundation ‘was not effective in identifying and mitigating safety risks.’

Original B-17G manual AN 01-20EG-1 is very clear: “Do not try to climb or hold altitude at any speed before 120 MPH IAS. If at lower speed, dive (even when near ground) to reach 120 I.A.S. as soon as possible.” There were plausible pathways to a safe return to a normal landing on a runway. If the crew had flown straight out, pitched down to accelerate to a faster airspeed then, once at that critical airspeed, slowly climbed while maintaining airspeed discipline, they could have, the argument goes, made it back to a runway for a safe landing, even with two failed engines. So what were the engine problems?

No. 4 engine had multiple deficiencies with its magnetos. Both of the units, which supply the electrical impulses to the spark plugs, were seriously out of specification. In addition, the P-lead to both magnetos was separated, allowing a grounding tab to short out the left magneto. And leads that should have been clipped in position were held on by a single strand of loose safety wire. 

No. 3 engine had pistons and spark plugs with “evidence of detonation that would have resulted in a significant loss of engine power,” the NTSB found. 

Of the 18 spark plugs, all but two had a gap in excess of the manufacturer’s recommended 0.022 inches. Specks of lead found on the tips of the plugs were indictive of the fuel/air charge in the cylinders exploding rather than burning smoothly. 

Engine 3 may have been running smoothly at low power settings during taxi, but there is clear evidence its performance would have been highly degraded at higher power settings.

Pilots perform engine runups before takeoff to try to catch these kinds of issues. But on this day, two factors may have intervened. The Collings checklist in Nine-O-Nine called for checking the magnetos at 1,600 rpm, while the original B-17G checklists state 1,900 to 2,000 rpm. Other operators currently check them during a runup at 2,350 rpm. These higher-power settings are more likely to reveal engine system problems. Additionally, there is testimony by some survivors that an engine runup wasn’t conducted. This is disputed by the Collings Foundation and the surviving flight engineer.

NTSB aerodynamic flight analysis is consistent with the evidence found during the physical engine teardowns. Nine-O-Nine was power limited. During the initial climb, the power delivered to the airplane was only equivalent to that of 3.5 engines at the nominal Flight Handbook climb power setting of 925 shaft horsepower per engine. With the feathering of engine 4, the power delivered dropped to the equivalent of two engines at climb power.

Losing two engines at the same time suggests a possible common cause. Sometimes that’s bad fuel or no fuel, or, in combat, it could be explained by enemy fire. The shared element here was the mechanic. The NTSB states the tolerances in the engine 3 spark plugs and engine 4 magnetos both should have been checked at the aircraft’s last 25-hour inspection, conducted nine days before the accident. All the recent work and inspections were performed on tour by the director of maintenance, who was also the pilot of the flight.

It would be easy to blame the accident on this one person. He shut down and feathered engine 4 without checklist or CRM. He failed to accelerate to critical airspeed. Investigators asked pointed questions about his checklist use. He almost never let co-pilots fly. He garnered public praise but also private grumblings. The NTSB Operational Group Chairman said, “We’ve got a lot of testimony that he was kind of crusty and ornery.” His reported flight times on FAA medical applications over the years didn’t add up, often showing implausibly large increases. 

And indeed, the Safety Board’s finding of probable cause is clear. Nine-O-Nine crashed due to “the pilot’s failure to properly manage the airplane’s configuration and airspeed after he shut down the No. 4 engine following its partial loss of power during the initial climb. Contributing to the accident was the pilot/maintenance director’s inadequate maintenance.”

However, this kind of flying is not a one-person show. Above and around that pilot is a larger organizational safety structure and culture. Threat management models, manuals, checks and balances all fell short. The NTSB found the Collings Foundation “was not effective in identifying and mitigating safety risks.” 

Other B-17 operators use a four-person crew, separating the flight engineer and loadmaster jobs. They don’t have passengers standing up below 1,000 feet. Their crews practice evacuations in smoke-filled cabins. They have flight department policy manuals modeled after modern airline operations. Training flights are structured events. Safety briefings for passengers and crew are mandatory. One Nine-O-Nine survivor said, “having flown many times before, I found it strange that the one time I really needed instructions on how to use a seatbelt, they were not provided.”

The Safety Board found contributing to the accident was “the Collings Foundation’s ineffective safety management system (SMS), which failed to identify and mitigate safety risks; and the Federal Aviation Administration’s inadequate oversight of the Collings Foundation’s SMS.” The FAA has since revoked the Collings Foundation’s authorization to fly passengers on warbirds.

The SMS existed on paper. But the lived reality was different. Asked in an NTSB interview if there was a safety management program, the flight engineer/loadmaster replied, “What do you mean ‘safety management?’” 

The investigator asked, “Do they have a safety program at all?” 

To which the flight engineer/loadmaster replied, “That, I don’t know.” 

After The Accident: Piper Navajo Crashes After Fuel Starvation

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On March 12, 2019, a professional pilot flying a twin-engine Piper Navajo for a large commercial survey company starved the left engine of fuel, causing it to quit. Declining air traffic control’s offer of vectors to a nearby suitable airport, he continued on the sole remaining working engine toward his original destination (which was also his departure), the Cincinnati Lunken Airport (KLUK) in Ohio. It was 30 miles away. He almost made it.

Before we get into the disturbing details of the crash, let’s note the cause wasn’t fuel exhaustion but, rather, fuel starvation. The former is when there’s no fuel to be burned. The latter occurs when there’s fuel onboard, but for some reason, the pilot can’t or doesn’t get it to the engine, resulting in a loss of power in that engine.

Five miles from the airport, the plane came crashing down into the backyard of a suburban home. What fuel there was in the tanks ignited. The pilot, the only occupant, died in the blazing wreckage. Unpacking the National

Transportation Safety Board’s (NTSB) extensive accident docket reveals several lessons, in things that happened slowly and in things that happened quickly.

The 62-year-old pilot, a father and grandfather, was passionate about flying. However, he had a spotty resume. An old story in The Arizona Republic newspaper reports he was fired from a flight school in 2001 for fighting with another flight instructor. Then, in 2003, he was blamed by the NTSB for crashing a Cessna 172 while simulating engine failure with a student. Rather than stopping at 500 feet AGL, he continued the power-off descent to 20 feet. Unable to recover, they impacted the ground. Both pilots received only minor injuries, but the plane was substantially damaged. The president of the flight school said it was “a classic blunder that many pilots make. They get overconfident and put themselves in a position where they have no options. The facts are, he was too low and too slow.”

That accident didn’t stop him from flying. By 2019, he had over 6,400 total hours, including sitting right seat in a Learjet 35 and 1,350 hours in Piper Navajos. From his home near Phoenix, Arizona, he started flying for an aerial mapping company. They had had a nationwide fleet of 15 Piper Navajos, a workhorse cabin-class piston- twin. The stretched PA-31-350 Chieftain version could fit 10 seats and saw considerable service in decades past for small feeder airlines, corporations and freight outfits. This one, N400JM, built-in 1981, was equipped with two counter-rotating 350-horsepower Lycoming TIO-540-J2B engines. It had just three seats, as most of the floor space was occupied by a specialized aerial imaging platform. In 2017, to better handle long missions, and per a Supplemental Type Certificate (STC), nacelle fuel tanks were added aft of each engine.

Takeoff from KLUK was at 10:51 a.m. on a bright clear day. The pilot flew several closely spaced parallel survey tracks near Cincinnati, Ohio, at 9,500 feet before going north for data gathering near Dayton, Ohio. No flight plan needed, flying VFR taking photos along carefully prescribed GPS tracks for over four hours. Unexciting. Maybe even monotonous. At 3:02 p.m., N400JM called Columbus Approach requesting a progressive routing back to Lunken airport due to a fuel problem. “Say again?” replied ATC.

The “fuel problem” was clearly evident onboard because the left engine had coughed to a stop. The pilot repeated that N400JM wanted direct Lunken because of a fuel problem. Columbus Approach gave him a direct heading, then advised that another airport, Dayton-Wright Brothers Airport (KMGY), was 8 miles away. The pilot said he had KMGY in sight but rejected the offer, adding Lunken was “only 30 miles away.” Columbus Approach acknowledged the pilot’s intentions and offered to declare an emergency. The pilot demurred, pressing on.

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NTSB analysis shows the pilot did not feather the left prop. Feathering greatly reduces drag and is the standard procedure after an engine shutdown on a twin-engine airplane. This failure increased drag on the left side, causing control and performance issues. The right engine still had fuel and continued running. Now talking to Cincinnati Approach, the pilot reported he did not require any assistance, there was “a fuel issue,” but it “should be okay.” ATC continued to point out other possible landing airports, but the pilot declined them all.

Cincinnati Approach handed the Navajo over to Lunken Tower when he was about 12 miles out. The pilot checked in, advising he “had a fuel problem and was hoping to make the field.” On an 8-mile final for Runway 21L, the controller cleared N400JM to land. The pilot reported he was unsure if he would make it to the airport. It was now 3:13 p.m., just 11 minutes after the first sign of trouble. Radar contact was lost on a 5-mile final. Unable to see or hear N400JB, ATC activated the crash phone, notifying emergency services.

Descending and slowing on a long straight-in final, the pilot seemed to change plans, giving up on the airport, turning to the right, lining up with the fairway of a golf course. The radar groundspeed went from 140 knots to 98 to 82. Multiple witnesses described unusual engine sounds. They saw the low-flying plane appear crooked, left wing down,“like a stunt in an airshow.”At3:16p.m., the plane rolled left and nose-dived into a neighborhood from a few hundred feet up. It impacted a tree and came to a stop in the backyard of a house. Within three more minutes, it was consumed by flames, a fire fed by the remaining onboard fuel.

After the accident, the NTSB found the low-altitude loss of control to be the defining event. It determined probable cause as “fuel starvation to the left engine and the resulting loss of engine power to that engine, and a loss of airplane control due to the pilot’s failure to maintain the minimum controllable airspeed.” It cited FAA guidance for multiengine aircraft that props should be feathered before rotation stops, warning “the net result of a windmilling propeller is the aircraft total drag exceeds the power available, thus the aircraft is no longer able to sustain level flight.”

Photo By NTSB 640x392 - After The Accident: Piper Navajo Crashes After Fuel Starvation
The flight path of the Navajo shortly before it crashed showed how few options for a precautionary or emergency landing remained as altitude and airspeed bled away.

The whole time the pilot was heading to Lunken, he was losing altitude and airspeed. Get too slow in any airplane, and you hurt glide performance, and slower still it may stall. But planes with engines on the wings have an additional threat — Vmc roll. With one engine at low or no thrust and the other one producing power, there are several forces acting to yaw and/or roll the plane. We counter these asymmetric forces with rudder and ailerons. However, get too slow, and there isn’t enough control authority. Eventually, the plane will suddenly roll over into the “dead” engine. Vmc with a feathered prop in the PA-31-350 is listed in the POH as 76 knots indicated airspeed. The last groundspeed recorded was 82 knots.

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But why did the engine run out of fuel in the first place? The Board found a long history of problems and confusion, starting with the design of the after-market Nayak auxiliary fuel tanks. These are an FAA-approved STCmodification.A27-gallon tank is added in the nacelle behind each engine, using space that was originally a wing cargo locker. That’s a lot of gas. But there’s no fuel gauge for these tanks.

Piper Navajos were built with two fuel cells in each wing, a 56-gallon main inboard tank and a 40-gallon outboard tank. The engine can be selectively fed from either one or crossfed from the other wing’s fuel tanks. Each tank has a fuel quantity sensing unit, and there are two fuel gauges, left and right, that are switchable between inboard and outboard.

The modification piggybacks the added nacelle tank into the main inboard tank via a new fuel line, activated by selectable electric fuel pumps. Adjacent to the switches, there’s a placard: “DO NOT TRANSFER UNTIL MAIN TANK IS BELOW HALF FULL.” The POH notes it takes approximately 55 minutes to transfer all the fuel out of a nacelle tank. There is no fuel quantity sensing in the nacelle tank. There are no pressure or fuel flow sensors in this transfer line. A fact of this design is that it requires careful procedural steps and detailed fuel gauge/time logging to understand your total usable fuel. There are several worrying failure modes. What if there were a leak in the nacelle tank? What if a pump failed? How would you really know without sensors or indicators?

The NTSB found that the company gave no training and had no standardized procedures for fuel management. Different pilots had different techniques. The Safety Board alleged “company pilots had been instructed not to talk to investigators,“ but a few did. And what they said was eye-opening.

One pilot reported, “Sometimes you get on the ground and say, ‘Wow, I just flew six hours.’ Sometimes you get down and wonder how much fuel you do have left?!’” Another told the NTSB he quit the company the day before, as the boss had “just pushed him to his limit.” A third said he “always had a bad feeling…and he always felt they pushed their pilots to fly…and planes were not being maintained appropriately.” Pilots told the NTSB of at least three nacelle transfer pump failures in the company’s fleet within the last few months. Additionally, pilots were allegedly routinely pushed to do their own maintenance on aircraft.

A month before the accident, N400JM allegedly landed early after oil loss forced an in-flight engine shutdown. Asked about this and other incidents, the company CEO told NTSB investigators he was not aware of any maintenance issues or concerns with N400JM, and nobody had reported any problems at all with N400JM.

The last pilot to fly N400JM before the accident pilot flew it had a different tale, telling investigators it had a fuel leak. He had been flying the big Piper for a couple of weeks before a tornado hit his home, forcing the crew change. He shared a photo of blue 100LL fuel stains on a hangar floor after being left overnight. There was a plan to fill just the inboard or outboard tanks overnight to troubleshoot where the leak was coming from. He informed the company of the issue and heard of a plan to ferry the plane to the company base for maintenance.

According to family members, the accident pilot was aware of fuel issues with N400JM. After the crash, the pilot’s sister told a local TV station, “he had concerns…about the plane acting up.” A week before the crash, he told his brother-in-law, “there is a gas leak in this plane, and it’s bothering my sinuses.” The exact nature of any leak or pump failure is now impossible to determine. But forensic analysis shows there was, indeed, a problem.

At the crash site, no evidence of fuel was found in the left-wing inbound or outbound tanks. The NTSB states that in the left engine, “[essentially] no fuel was found during the examination and removal of fuel system components.” However, they do believe the left nacelle tank had fuel in it. “Given the extent of the fire damage to this area of the wreckage, and the witness report that the post-impact fire originated in this area, it is likely [the nacelle] tank contained fuel.” The nacelle fuel pump was too badly damaged to determine its pre-crash condition. The fuel system on the right side seemed nominal: “Fuel was found during the examination of the right engine fuel lines, injector lines and fuel pump.”

The final report notes the crossfeed valve was found closed but doesn’t address why the pilot didn’t open it to supply the left engine with fuel from the right side. The answer to this, and other questions, may have died with the pilot. There are so many links in the long accident chain. Ernest Hemingway succinctly described this kind of timeline in his 1926 novel The Sun Also Rises. Asked how do you go bankrupt, one character replied, “Gradually and then suddenly.”

Before the engine quit, there were years of pilot concerns about safe fuel management with the nacelle tanks. The company had months of fuel leaks, pump failures and alleged lack of maintenance action. After the engine quit, there were 14 minutes where the prop wasn’t feathered, and the fuel crossfeed wasn’t opened. There were 14 minutes of flying past suitable landing airports. And then, in a few seconds, a Vmc roll from 500 feet to the ground ended the chain. PP

After The Accident: GoPro Helps NTSB Determine Extra 300 Crash Cause

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On a clear, sunny afternoon over scenic hills outside San Diego, the paying passenger on an extreme aviation experience was having fun. After laughing and yelling through rolls, tumbles, tailslides, his expression suddenly changed. There was a problem. The pilot was going to open the canopy on the Extra 300 plane. Jumping out and using the parachute would be next.

He saw the canopy locking pins move. The big plexiglass bubble blew away, taking with it the GoPro camera. Six seconds later, still strapped in, they impacted rugged terrain in a high-energy, unsurvivable crash. Twenty seconds after that, the GoPro landed, where it lay undiscovered for two years. Once recovered, the video helped the National Transportation Safety Board understand more of what happened on Oct. 21, 2017, over the El Capitan Reservoir, California.

In the rear seat was a 54-year-old commercial pilot with about 4,300 total hours, of which 2,200 were as a flight instructor. His mother was an aviation physiologist, his father a Navy aviator, his wife an airline pilot. After a ground career at aerospace companies, he became a full-time pilot in San Diego, giving scenic rides and teaching tailwheel flying, aerobatics and emergency maneuver training. He was hired at the flight experience company in May 2017, passed training and by October had 113 hours in the Extra 300. The company president stated that he was a good mentor, conservative in nature, and provided supervision for some of the younger pilots.

In the front seat was a 34-year-old passenger who lived in McKinney, Texas. Father of two boys, he was not a pilot. However, this wasn’t his first time in a cockpit, as he’d flown with the same company at its Las Vegas location once before. The NTSB docket shows the $699 25-minute package purchased this time was advertised “for the aerobatic extremist…not for the faint of heart…you are at the controls…no flight experience necessary…includes our dynamic low level bombing run, where you strike a ground target utilizing the same tactics as an F-16 fighter jet!”

They were flying a 2009 Extra Flugzeugbau EA 300/L, a tandem two-seat tailwheel monoplane with 310 horsepower Lycoming engine driving a three-bladed constant-speed MT propeller. Designed in 1987 by Walter Extra, these are strong, sexy aerobatic thoroughbreds. This one looked especially sleek, with silver wings and a royal blue fuselage. Multiple cockpit cameras recorded flights for customers, but only the GoPro that flew off with the canopy survived the crash. The plane was part of a fleet of Extra 300’s in three vacation locations, Las Vegas, San Diego and Lake Tahoe.

Founded in 2011 by an ex-Air Force fighter pilot, the company sells thrill rides and fighter pilot experiences, along with some traditional tailwheel and aerobatic instruction. The sales pitch was aerial machismo, with an emphasis on high-speed high-g combat. Pilots wore flight suits and used call-signs. The accident pilot’s advertised moniker was “Bandito.” The company claimed to be the “premier civilian aerial combat training center in the world,” yet it wasn’t a military contractor. There were no tests or ratings. Neither a part 119 airline nor a defined commercial operator, this type of adventure flying exists in a regulatory gray area.

The owner had multiple discussions with several FAA offices regarding certification. FAR Part 135 wouldn’t work, as passengers are prohibited from touching flight controls, thus losing the appeal of “you fly the plane.” Other common regulatory options for paying passengers, like parachute jumpers (14 CFR § 105.9) or sightseeing air tours within a 25-mile radius (14 CFR § 91.147) don’t apply. Neither does the Living History Flight Experiences exemption (LHFE) that allows passenger flights in historic warbirds. It was agreed the operation would operate as a regular Part 91 flight school, requiring all company pilots to obtain flight instructor certificates. 

However, the traditional flight school model isn’t a perfect fit for these popular aviation attractions. It’s a problem in the regulations that’s actually older than the FAA, dating back to the CAB. More recently, in 2017, the Office of the Chief Counsel wrote an FAA legal interpretation to another operator who wanted to do “bucket list” rides and discovery flights scheduled by third parties like Groupon. Assistant Chief Counsel for Regulations Lorelei D. Peter defines instruction narrowly, requiring it to be for an FAA rating or a task like banner towing or crop dusting. She steered the inquirer toward using the rules for sightseeing air tours.

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Inspectors at the San Diego Flight Standards District Office had asked the company to be more explicit about the flight school nature of its business. The bottom of every page of the company website was changed to read, “flights are instructional in nature conducted by certified flight instructors under 14 CFR Part 61 of the United States Code. Instruction will be provided during ground and flight portions for all flights.” Despite this, a brochure picked up at the Lake Tahoe Airport by an FAA Inspector in June 2017 included several packages labeled as “rides.” This Lake Tahoe visit was the last time the FAA saw the accident airplane intact. Camera attachment points had been added to the airplane’s wings and stabilizer without a major repair or alteration maintenance record (FAA Form 337). Concerned these could interfere with aerodynamic flying characteristics, the FAA required them removed from all company aircraft and a series of missing placards be installed in the cockpits. 

The Saturday of the accident, the pilot woke up on a couch in Vegas. He’d flown in commercially the day before and slept at the company’s hangar/office/hospitality facility at Henderson Executive Airport (KHND), Nevada. Everyone that morning said he was in good spirits. At about 10 a.m., he flew a customer on a group combat mission. Then, with another employee, he flew the accident aircraft from KHND to his San Diego base, Gillespie Field in El Cajon (KSEE). It was a gorgeous SoCal day, 79 degrees Fahrenheit with clear skies and good visibility. A weather balloon launched that afternoon from nearby Miramar Air Station recorded winds aloft out of the northwest at 7 to 12 knots below 9,000 feet.

The GoPro HERO recording started a little before 4 p.m. The bubble canopy was open, passenger already strapped in. The camera faced aft, capturing the passenger’s upper body and face, with a clear view outside. The forward canopy lock and the tips of the horizontal stabilizer were also visible. It captured ambient audio but no intercom or radio talk. The canopy came down and was locked by the pilot. The NTSB notes the “seatbelt harness was loose around his shoulders and chest. The passenger’s headphones were equipped with a Velcro chin strap, which was not secured, and remained unsecured for the entire flight.” Engine start, run-up, taxi and takeoff were normal.

From runway 17 at KSEE, they flew out to the open countryside northwest of San Diego, cruising at 4,700 feet. It was a route the pilot had flown many times. Then came a series of aerobatic maneuvers between 4,300 and 6,900 feet. They did rolls, hammerheads and tailslides. The passenger appeared to be manipulating the stick during some of the flying. After the pilot completed a tumble, he asked, “how’s that?” and the passenger replied, “that was awesome.” 

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The passenger seemed to brace for something new. The pilot pitched up to 45 degrees, rolled right, let the nose drop, then the direction of roll reversed, and they transitioned into what appeared to the NTSB to be an inverted spin. Not fully secured, the passenger rose in his seat, reaching up to secure the headphones now pulling away from his head in negative g.

The direction of spin reversed. The rate of rotation began to increase. Wind noise loudened. A gap appeared between the canopy frame and the fuselage, consistent with airspeed approaching Vne. The passenger began to rock from side to side, forced up against his shoulder straps. He was smiling and making yelping sounds. But then his appearance changed. The NTSB believes the rocking was the pilot applying rapid control inputs, possibly to the rudder, trying to regain aircraft control. Something was very wrong.

“They were flying a 2009 Extra Flugzeugbau EA 300/L, a tandem two-seat tailwheel monoplane with 310 horsepower Lycoming engine driving a three-bladed constant-speed MT propeller.”

The Board said it’s likely that the pilot “quickly deduced that recovery was not possible and that a bailout was necessary.” The pilot activated the canopy release handle, it opened and the canopy blew off. The attached GoPro continued recording. The pilot came into view, left hand holding the canopy release handle, right hand by the stick. Inboard sections of the ailerons were visible, along with the leading edge of the horizontal stabilizer, vertical stabilizer and rudder. There was no evidence of bird strike, fire or flight control separation. Engine RPM sounded normal. The camera tumbled through the air. 

After six seconds, a couple of frames showed an orange glow on the ground next to the reservoir, with a black smudge above. The plane had impacted at high-speed in a near-vertical dive. The remaining fuel was burning. 

The crash wasn’t only seen by (what had been) the cockpit camera. Several ground witnesses took notice when the aerobatics stopped, and black smoke rose above a ridgeline. After the accident, the burning fuel started a wildfire that covered 20 acres before air tankers and helicopters brought the blaze under control. What was left was badly damaged, but careful NTSB analysis showed no evidence of pre-existing deficiencies with the aircraft.

We don’t really know what the problem was with aircraft control. The NTSB didn’t rule out inadvertent passenger interference with the flight controls. The position of his feet during the final maneuver couldn’t be determined, but he was bracing himself against the effects of negative g-forces with a loose seatbelt and a departing headset. Or it could have been something coming loose in the cockpit. 

That Extra 300 was subject to service bulletins pertaining to the flight controls, but, according to the NTSB report, they had not been performed. One required the addition of a safety clamp to the transponder after a report one slid out of its rack and jammed against the stick during aerobatics. The state of the wreckage didn’t allow examination of this possible cause. The Safety Board did note that FARs do not require compliance with service bulletins under Part 91.

This wasn’t the first time the NTSB had investigated the company’s fleet of Extras. In 2014, one of them had a wear-related rudder cable separation following aerobatics. Landing at McCarran International (KLAS) it veered off the runway, sustaining substantial damage. The Board found the company had not complied with a service bulletin addressing such possible failures. Also, in 2014, a company Extra landed on a street short of the runway at KHND after an unexplained loss of engine power. The aircraft suffered substantial damage to the right wing.

In 2016, a company Extra impacted terrain 10 miles south of KHND, killing the pilot and paying passenger. The Board found the passenger was airsick after air-to-air combat maneuvers, so the pilot planned a low-level simulated bombing run to return and land. The pilot’s postmortem toxicology testing was positive for tetrahydrocannabinol (THC), the primary psychoactive component of marijuana. He was faulted by the NTSB for “failure to conduct an adequate amount of clearing turns while maneuvering at low level.” Unlike airlines or other passenger-carrying operators, flight schools are not required to have drug/alcohol testing programs.

extra 300 crash after the accident two 640x469 - After The Accident: GoPro Helps NTSB Determine Extra 300 Crash Cause
Investigators were able to determine and/or confirm airspeeds and load factors by examining the video. What they discovered led to their statement of probable cause. Photos: NTSB

Digging deeper, the Board found more. In 2016, a company Extra had a failure and near-total separation of the windshield during aerobatic maneuvers. The Board has video that shows, while pulling out of the bottom of a loop, the pilot exceeded Vne speed by 40 knots. This caused the plexiglass to fracture and separate from the frame. He flew back to the airport with most of the canopy missing. The incident was not reported to the NTSB or FAA as required by regulations. When the company started, it had an FAA waiver to carry passengers for hire while flying in formation, but the waiver was suspended in 2012 after a possible low-flying incident. After a second incident involving low flying near the Hoover Dam, the waiver was revoked. Some company pilots had been sent letters of investigation and had certificate actions against them by the FAA for low-level aerobatics and unsafe flying.

The Extra 300L is an amazing airplane with a lot of structural integrity and no bad habits. It’s built for aerobatics, from its carbon fiber composite spar and carbon composite skin to the layout of the cockpit. Patty Wagstaff, aviation legend and active aerobatic instructor, told Plane & Pilot, “In 34 years of flying the Extra series of aircraft, I have found them to be incredibly safe, strong and predictable at all times when flown within their operation envelope and limitations.”

While fully capable of Unlimited category aerobatic competition, the 300 isn’t science fiction. It has some physical limitations that need to be respected. The POH and cockpit-placarded gravitational load limits are plus or minus 10 g. That’s more than the “mere” 9 g an F-16 can pull. The Extra’s ±10 g limitation is reduced to ±8 g with two occupants and further to ±6 g at higher weights. The NTSB collected video evidence that company pilots often exceeded these limitations.

The accident docket has photographic evidence of 9 g, even 10.5 g, with passengers. It was pretty common for passengers to black out due to G-LOC. There are also video stills of pilots maneuvering at 210 knots, over 50 knots above Va. The Board’s final report states the accident pilot “routinely flew airplanes beyond their operating limitations.” Furthermore, “review of footage taken with other pilots revealed a company-wide pattern of disregard for the airplane’s published operating limitations and the company’s own policies regarding airspeed and g limitations.” Damningly, the Board uncovered no evidence of the maintenance inspections required after over-g events, leading it to determine “the airplane was likely unairworthy at the time of the accident.” 

Every plane has limits. So does every pilot. The NTSB found the probable cause to be the pilot’s inability to regain aircraft control during aerobatics. Contributing, it says, was the company’s failure to provide effective internal oversight to identify and prohibit exceedance of the airplane’s performance parameters. Additionally, it cited the lack of a regulatory framework for the FAA to oversee such aviation experiences. 

Hurrying To Oshkosh, Never Arriving

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Screen Shot 2021 03 15 at 12.34.14 PM 640x374 - Hurrying To Oshkosh, Never Arriving
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In July 2017, after flying for about 12 minutes over Missouri, a Zenith Light Sport Aircraft crashed while turning back to the airport from where it had just departed. The 41-year-old pilot and his wife were both killed in the crash.

The pilot was a passionate outdoorsman, loving every sport he participated in. The list included motocross racing, hunting, skiing, scuba diving, skydiving and flying powered parachutes. In fact, most of his flight experience was in motorized parachutes, a glorious way to experience the air and slowly unroll- ing landscapes below. He had logged 162 hours in his Pegasus-powered parachute, cool flying that was seen in a local TV news story a year before the crash. KFSM 5NEWS captured attractive aerial views 800 feet above Arkansas, with the pilot saying, “There’s nothing like it. When you’re up in the air, your troubles are behind you, you get rid of the day, you’re just free.”

More recently, he had flown a few hours in a Cessna 150, earning a Light Sport Pilot certificate with single-engine land rating. He purchased a Zenith CH701SP Experimental Light Sport Aircraft. White with yellow trim, the short takeoff and landing (STOL) optimized tricycle-gear two-seater was a recreational plane, pure and simple.

The all-metal tricycle gear airplane had been constructed by a home-builder in 2003. Powered by a 100 hp Rotax 912ULS engine driving a three-bladed Warp-Drive 70-inch fixed-pitch composite propeller, the airframe had a total of 1,142 flight hours recorded in its logbook shortly before the accident. The National Transportation and Safety Board notes it wasn’t equipped or certified for instrument flight rules flight. The pilot had logged almost 100 hours in the Zenith before the fatal flight. Consistent with Sport Pilot limitations, he had logged no night or instrument flight time.

The goal was to fly to the EAA AirVenture airshow in Oshkosh, Wisconsin, from his hometown of Greenwood, Arkansas, a trip of about 580 nm. It’s a big undertaking for a new pilot in a small plane with limited range.

It just so happened that about halfway along the straight-line routing is the Mexico (Missouri) Memorial Airport (MYJ), home to the Zenith Aircraft Company. That’s where the pilot and his wife landed on July 26, bought 17.8 gallons of fuel and spent the night. The airport manager told the NTSB he believed they camped that evening next to the airplane. Their plan was to arrive at Oshkosh at 7:00 a.m. local time, right as the control tower opened. When the manager arrived at the airport the next morning, the airplane was gone.

According to the NTSB report, the couple broke camp predawn and took off around 4:40 a.m., while it was still very dark. No flight plan was filed. There is no record of the pilot having obtained a weather briefing, but in this iPad age, that’s not too surprising. However, the NTSB wrote, the weather should have given them pause, a long pause. At 04:15, the MYJ AWOS reported a visibility of 1.5 miles in heavy rain, broken clouds at 1,100 feet, overcast at 1,900 feet, barely VFR weather. Nevertheless, they departed toward Oshkosh.

Data from the U.S. Air Force/Civil Air Patrol reveals their flight path, first appearing on radar at 04:44 about 5 miles east of MYJ. At takeoff, the visibility was 7 miles in light rain, wind from 240 degrees at 7 knots, broken clouds at 600 and 1,200 feet, overcast at 1,900 feet, distant lightning in several quadrants. Cruising altitude varied between 2,000 and 2,800 feet above ground level, as the pilot maintained a steady northeast heading. After nine minutes, the radar track began to wander and then entered a right descending turn, completing a 180-degree track change, seemingly heading back to MYJ. But the descent continued, with a last radar return at 04:53.

The Zenith crashed into open, level farmland in a right-wing-low, nose-low attitude. There was one main impact crater, with a debris path extending for a couple of hundred feet. The MYJ weather at 04:55 was visibility 7 miles, scattered clouds at 600 feet, broken 3,300 feet, overcast 4,800 feet, thunderstorm and rain in the vicinity.

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After the accident, the wreckage lay undisturbed for almost a day. There was no flight plan filed. There were no witnesses. The installed C91A ELT did not activate. Eventually, friends and/or family members reported the couple missing. The Air Force Rescue Coordination Center provided search coordinates to the Missouri State Highway Patrol, which located the wet crash site at 1:00 in the morning. Both occupants were pronounced dead at the scene from blunt force trauma. Both the FAA and NTSB investigated the area.

The Safety Board’s final report defines the event as a VFR encounter with IMC. No pre-impact anomalies with the aircraft were found. The NTSB straightforwardly lays it out: “Although he had no night or instrument flight experience, the sport pilot departed in a non- instrument-certificated light sport airplane at night with an overcast ceiling and thunderstorms in the area.” He attempted a turn back but was “not paying attention to his altitude,” became spatially disoriented and lost control.

Why would a pilot make the decision to depart in that airplane in that weather? Clearly, he wanted to make it to Oshkosh at 7 a.m. Maybe he underestimated the weather. Maybe he didn’t understand how quickly anyone can lose control in IMC without the right instruments and training.

The NTSB also uncovered a physiological aspect to the accident, with postmortem toxicology testing and pilot medical records revealing prescription drugs taken for a history of chronic insomnia and anxiety. The Safety Board wrote, “It is likely that the pilot’s decision-making was degraded due to his combined use of temazepam and hydrocodone.” The patient warnings for hydrocodone, an opioid analgesic, say it “may impair the mental or physical abilities needed to perform potentially hazardous activities such as driving a car or operating machinery.”

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In a few moments, the beauty and freedom of flying the pilot once shared with TV viewers came crashing down quickly. It ended in a dark sodden bean field after a flight that never should have taken off—a flight in dark and stormy conditions by an inexperienced pilot flying a plane not equipped for instrument flight. All of those risk factors should have added up to a decision simply not to go flying. Tragically, that’s not how it turned out.

As a sad coda, NTSB crash site photos taken the day after the accident show bright sunshine and clear skies. PP

After The Accident: Fuel Exhaustion In Beech Baron 58

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beech baron b58 - After The Accident: Fuel Exhaustion In Beech Baron 58
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You’d think that a 65-year-old airline transport pilot with an estimated 5,671 hours of flying time would have learned that airplane engines won’t run without fuel. Based on what NTSB investigators reported about that particular ATP-rated pilot, he most certainly did know that basic fact of life and also appreciated the importance of making sure there was enough fuel onboard and tracking its usage. Nevertheless, the Beech 58 Baron he was flying ran out of fuel and crashed in Kerrville, Texas, on April 22, 2019, killing all six on board.

The airplane was manufactured in 1999. It had six seats and retractable landing gear. It was powered by two Continental IO-550-C engines, each rated at 300 horsepower. The airplane’s maximum gross weight was 5,500 pounds, and it had undergone an annual inspection on Aug. 27, 2018, about 105 flight hours before the accident. At the time of the accident, the airplane had about 3,834 hours on the airframe.

The airplane’s fuel system had a total capacity of 200 gallons, 100 gallons on each side. Each wing had three fuel cells with a total capacity of 83 gallons usable and 3 gallons unusable. The tip tanks held 14 gallons each, all of which were usable. The wing fuel cells and tip tanks on each side were interconnected, and when the fuel selector for each side was turned on, all usable fuel was available for the engine on that side. There were two fuel selectors mounted within a single faceplate. Turning the handles so the pointed ends faced each other activated crossfeed.

The airplane was on a Part 91 business flight from West Houston Airport (KIWS), Houston, Texas, to Kerrville Municipal Airport (KERV). A surveillance camera at KIWS showed that when doing a preflight inspection of the airplane, the pilot appeared to check the exterior fuel level sight gauge for the left wing but not the one on the right side. The pilot did not appear to draw samples from any of the airplane’s fuel drains.   

Departure was about 7:30 a.m. The pilot had filed an IFR clearance and contacted Houston Approach while climbing through 1,300 feet MSL. The controller advised that the flight was in radar contact and instructed the pilot to fly a heading of 220 degrees and climb to 3,000 feet. The pilot correctly read back the clearance, and then the controller told him to fly a heading of 260 degrees.

At 7:33, the controller cleared the flight to an intersection and, two minutes later, cleared it to climb to 4,000 feet. Three minutes after that, the controller instructed the pilot to climb and maintain 6,000 feet and to contact another Houston Approach controller. Twelve minutes later, the flight was handed off to Austin Approach Control.

At about 8:23, the flight was handed off to a Houston Center controller who gave the pilot the Kerrville altimeter setting and advised that he would be No. 1 for the airport. A minute later, the controller asked the pilot to let him know when he had the weather and NOTAMS for the airport, which the pilot said he did. The controller then asked which approach the pilot wanted, and the pilot asked for the RNAV Approach to Runway 12.

At about 8:33, the controller cleared the flight to descend to 4,000 feet and advised that the cloud bases were at 2,400 feet. The pilot acknowledged, and, about five minutes later, the controller cleared the flight for the RNAV Runway 12 approach at KERV.

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At about 8:43, the controller told the pilot to report his cancellation of the IFR clearance in the air or after landing and cleared him to switch to the airport’s advisory frequency. The pilot acknowledged the instructions.

According to ADS-B tracking information, at about 8:44:59, the airplane was about 13 miles from the runway when it began a steady descent from 3,900 feet. Data recovered from the airplane’s engine data monitoring (EDM) system revealed that the airplane’s left engine lost power at almost exactly the time the descent began, followed about 10 seconds later by the right engine losing power. About 40 seconds after the left engine lost power, it regained almost full power, according to the EDM data. When the EDM data stopped at about 8:51, the indication was that left engine still was producing power.

The ADS-B data showed that the airplane slowed as it descended. It was below the minimum controllable airspeed (Vmc) of 83 knots while between 500 feet above the ground and 300 feet above the ground. 

A witness saw the aircraft come out of the clouds with its nose up. He said he could see that the flaps were down. He said it appeared to be headed for the Kerrville Airport when it banked to the right, the nose went down, and it crashed. Another witness said that when he first saw the airplane, the nose was low, and it was rotating clockwise. He saw the airplane make one-half to three-quarters of a rotation before it disappeared from view.

The 8:55 a.m. weather observation at KERV included wind from 170 degrees at 11 knots gusting to 17 knots, visibility 10 miles, 1,200 feet AGL overcast sky, temperature 18°C, dew point 16°C. and altimeter setting 30.04.

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The airplane crashed in a rocky ravine about 6 miles from the airport. The elevation of the accident site was 1,868 feet MSL. There was no fire. No evidence was found of fuel spilling in the area around the airplane. No fuel could be seen in the right-side tanks. About a gallon was drained from the fuel cells in the left wing.

The right fuel selector was found in the “on” position, but no fuel was found in the valve or fuel strainer. The left fuel selector was positioned about three-quarters of the way toward the “on” position. A small amount of fuel was found in the selector and the fuel strainer.

The fuel quantity transmitters were recovered from the wreckage and sent for testing. The transmitters have floats, which move up or down as the level of fuel changes, and the floats move a mechanism that changes the electrical resistance of the circuitry, varying the strength of the voltage that causes the needles to move in cockpit fuel gauges. In Barons, when there is no usable fuel, the electrical resistance in the fuel transmitter circuit is zero ohms, and the cockpit fuel gauge reads empty. With at least 75 gallons available on a side, the resistance is 199 ohms, and the fuel quantity gauge reads full. An ohm is a unit used to measure the resistance that interferes with the flow of electricity.

Testing found that the fuel transmitters from the accident airplane were not accurate. The left-side fuel transmitters would have caused the gauge to show 5.16 more gallons of fuel than actually was present while the right-side gauge would be showing 5.5 more gallons than actually was in the tanks.

Misleading information on the fuel gauges wasn’t all. The investigation found that on April 14, eight days before the accident, the pilot telephoned a fuel order to an FBO at KIWS. A manager told investigators that the bill showed 113 gallons were added. Investigators found that the fuel log kept by the pilot showed that the airplane had 60 gallons on board before the April 14 fuel order, and the total fuel should have been recorded as 173 gallons. However, the pilot recorded 194 gallons as the quantity on board for his first flight on April 15. Therefore, the pilot introduced a 21-gallon error into his own tracking of fuel, according to what the NTSB’s investigators found. While the pilot’s fuel log indicated that the airplane had 50 gallons remaining at the end of the flight before the accident flight, when he wrote down the starting fuel for the accident flight, he jotted down 54 gallons, an additional 4-gallon error.

The NTSB speculated that the pilot relied on his own fuel log and fuel-flow data from the EDM to keep tabs on the fuel remaining.

The NTSB pointed to EDM data showing that the total fuel burn for the accident flight was 42 gallons. It said that the pilot’s flight planning documents showed that the estimated fuel consumption for the flight was 38 gallons. When investigators calculated fuel requirements for an IFR flight with an approach at an alternate and required reserves, they came up with a requirement of 67 gallons.

The Safety Board’s report noted that, using passenger weights provided by a medical examiner, the airplane was slightly over gross at a takeoff weight of 5,598 pounds with 50 gallons of fuel. The report said that the airplane’s center of gravity was aft of the limit by one-half inch at the time of the accident.

The Safety Board didn’t address the restoration of power on the right engine, and there’s no way to know whether that could have happened because of something the pilot did or a flight condition that somehow made unusable fuel become usable. What the Safety Board did suggest, however, is that the airplane could have made it to the airport with the right engine back in operation, provided that the pilot had executed engine-out procedures, which he didn’t. Those called for flaps to be in the retracted position and the propeller of the inoperative engine to be feathered. The pilot had not yet extended the landing gear.

The pilot held an ATP certificate for multi-engine and single-engine land and sea. He also held a second-class FAA medical certificate. Of the 5,671 hours he had logged, 5,565 were as pilot-in-command. He had 2,409 hours in Beech 58 airplanes.

A flight instructor who gave the pilot his most recent flight review told the NTSB that the pilot had good basic flying skills and normally expected to land with one hour of fuel remaining.

“A witness saw the aircraft come out of the clouds with its nose up. He said he could see that the flaps were down. He said it appeared to be headed for the Kerrville Airport when it banked to the right, the nose went down, and it crashed.

The pilot’s girlfriend said that the pilot was “in good shape physically, emotionally and psychologically” and that he exercised regularly.

The FAA conducted toxicological tests that showed the pilot was using five medications, none of which was considered impairing by the agency.

The NTSB determined that the probable cause of the accident was the pilot’s inadequate preflight planning and fuel management,which resulted in a loss of engine power due to fuel exhaustion. Also causal was the pilot’s failure to follow the one-engine inoperative checklist and maintain the airplane’s minimum controllable airspeed by properly configuring the airplane, which resulted in a loss of airplane controllability.

While the Safety Board did not include inaccurate readings on the fuel gauges as a feature of the probable cause, its report did discuss gauges as a known and long-term issue. It pointed out that the Beech 58 annual inspection guide for maintenance personnel specifies that the fuel gauge system should be checked “for proper operation and unusual fluctuations” and that the fuel quantity transmitters should be overhauled or replaced as necessary.

The NTSB noted that on Sept. 23, 2003, the FAA revised and updated a Special Airworthiness Information Bulletin (SAIB) that had been issued a few months earlier for operators of Cessna 100, 200, 300 and 400 series airplanes calling for fuel gauge systems to be checked for proper calibration and the checks to be repeated at five-year intervals. It said that based on the Kerrville accident and others in which inaccuracies were found with resistance-type fuel gauge systems, the FAA is working on an SAIB that would apply to all aircraft with those systems, as well. 

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