Saturday, September 14, 2013

What Do You Do? Tom Fischer, Chief Flight Instructor: Fischer Aviation at Essex County / Caldwell Airport (KCDW), New Jersey

MYFOXNY.COM -  Flying around New York City has been a way of life for flight instructor Tom Fischer. 

His father gave him his first lesson at the age of 12. 

In the latest installment of, What Do You Do? Good Day NY sat down with the pilot to talk about life high above the Tristate region.

FischerAviation.com/The-School

Source: http://www.myfoxny.com
 
August 25, 2009:    Flight instructor Tom Fischer had been on an instructional flight with a student when he noticed issues with the plane's engine oil pressure.

NTSB Identification: ERA09LA481 
14 CFR Part 91: General Aviation
Accident occurred Tuesday, August 25, 2009 in Rockaway, NJ
Probable Cause Approval Date: 12/20/2010
Aircraft: CESSNA 172RG, registration: N6117R
Injuries: 1 Minor,1 Uninjured.

NTSB investigators may not have traveled in support of this investigation and used data provided by various sources to prepare this aircraft accident report.

The certificated flight instructor (CFI) and dual/student pilot were practicing maneuvers when the CFI noticed that the left main gear of the airplane was wet. As he looked for the source of the substance he noticed that the airplane’s oil pressure was critically low and immediately headed back to the airplane’s base. On the way, the engine came “to a halt with the propeller stopping” and the CFI elected to land in an empty section of a mall parking lot. The airplane’s nose landing gear contacted a curb and the right wing impacted a tree before coming to a stop. An examination of the wreckage revealed the fluid on the wheel to be oil leaking from the engine, which covered the bottom and empennage section of the airplane. A teardown examination of the engine found the No. 3 and No. 4 pistons with damage consistent with overheating and oil starvation. The lower portion of the No. 3 piston was destroyed. There was no internal or external evidence with the engine to account for the oil leak. The engine oil system was examined and found to be unremarkable. The CFI stated that a quart of oil was added, for a total 6.7 quarts of oil in the engine, prior to the accident flight.

The National Transportation Safety Board determines the probable cause(s) of this accident to be:
A total loss of engine power due to oil starvation for undetermined reasons.

US aviation regulator puts Directorate General of Civil Aviation on notice

The US Federal Aviation Administration (FAA) has put the Directorate General of Civil Aviation (DGCA) on a 45-day notice after its audit showed that there is lack of coordination in airworthiness and flight operations in the country, which poses risk to the passenger's life.

According to sources, a team of FAA inspectors carried out a five- day inspection this week and found serious flaws in safety preparedness and the manner in which on- job training is imparted to DGCA employees.

If the DGCA fails to put its house in order within 45 days, FAA will downgrade India's air safety rating, sources said. Such a downgrade would eventually lead to Air India and Jet Airways having to go through more rigorous checks at international airports, which could upset flight schedules and inconvenience passengers. It would also pose problems in getting additional flights for domestic carriers to international destinations.

However, a top DGCA official told Mail Today on condition of anonymity on Friday that the FAA representatives " have not observed any major lapse on safety issues". " What they have told us that we need to upgrade our special operations. They have found us lacking in airworthiness and flight operations. We have been put on a 45- day notice. I think there has been some sort of oversight by FAA representatives in this regard. We will soon send them our point of view," the official added.

FAA has pointed out that DGCA lacks adequate skilled manpower for a specific technical work required to monitor air operations, worthiness and safety at DGCA. Instead, it has been upgrading its current staff for this highly technical jobs by giving them training.


Original Article:   http://businesstoday.intoday.in

T.F. Green (KPVD) holds Disaster Preparedness Exercise

News, Weather and Classifieds for Southern New England  


WARWICK, R.I. -   Saturday, NBC 10 got a glimpse inside the emergency process at T.F. Green during a Disaster Preparedness Exercise that was put on by the Rhode Island Airport Corporation, the Rhode Island Emergency Management, and emergency response partners.

The Federal Aviation Administration requires this type of exercise once every three years, and our cameras were allowed in to get a close up view of the proceedings.

NBC 10 spoke with Rebecca Bromberg, Communications Affairs Manager , who emphasized the main purpose of the drill; "that's the whole point of an exercise like this, to find out the glitches with communications, with emergency response, so that we're better prepared if we do have a real accident here at the airport."

Alan Andrade, Vice President of Operations and Maintenance, explained the scenario for this particular exercise, "the initial call was that an aircraft landed and the nose gear collapsed, and then we had a mishap, we had injuries."

In Saturday's scenario, the actual airplane was replaced by a couple of buses, but the emergency responders are very real, and so is the communication among them.

The emergency protocol uses a color-coded bracelet system complete with bar codes so that patients can be tracked through every step of the rescue process.

An emergency triage center is set up on airport grounds to process those with minor injuries, and EMTs are on hand to transport those more seriously injured.

More than 20 agencies and upwards of 250 people took part in a Disaster Preparedness Exercise that was held Saturday morning at T.F. Green Airport.

The exercise was put on by the Rhode Island Airport Corporation (RIAC), the Rhode Island Emergency Management (RIEMA), and the emergency response partners for the purpose of assisting aviation, law agencies, and first responders in incident preparedness.

In a press release RIAC President and CEO Kelly Fredericks described the purpose of the exercise saying "this required exercise tests our responsiveness in the event of an incident or accident. There is a great deal of required communication and cooperation between first responders, city and state agencies and RIAC."

The exercise was conducted as if it were an actual incident, including participation from area hospitals; it lasted several hours and was held primarily on the northeast side of the airfield.


Original Article:   http://www.turnto10.com

Spacek SD-1 TG Minisport, N123SD: Fatal accident occurred September 06, 2013 in Spanish Fork, Utah

Aviation Accident Final Report - National Transportation Safety Board: http://app.ntsb.gov/pdf 

Docket And Docket Items  -  National Transportation Safety Board:   http://dms.ntsb.gov/pubdms


Aviation Accident Data Summary  -  National Transportation Safety Board:   http://app.ntsb.gov/pdf

http://registry.faa.gov/N123SD

NTSB Identification: WPR13FA399
14 CFR Part 91: General Aviation
Accident occurred Friday, September 06, 2013 in Spanish Fork, UT
Probable Cause Approval Date: 08/05/2015
Aircraft: TYLER IVES SD-1 TG, registration: N123SD
Injuries: 1 Fatal.

NTSB investigators either traveled in support of this investigation or conducted a significant amount of investigative work without any travel, and used data obtained from various sources to prepare this aircraft accident report.

The owner/builder reported that the accident flight was the fourth test flight for the experimental airplane. One of the three ground crewmembers reported that, for this flight, the pilot wanted to test the airplane’s G limits, perform stalls, and conduct touch-and-go takeoffs and landings. While the pilot was flying the airplane in the traffic pattern, two of the ground crewmembers observed the airplane perform an unscheduled roll. About 1 minute later, they observed the airplane perform a second roll. One of the ground crewmembers reported that, about midway through the second roll, the pilot lost airplane control, and the ballistic parachute subsequently deployed with the airplane traveling at a high rate of speed; almost immediately after deployment, the parachute separated from the airframe. The airplane then spun toward the ground and was destroyed by impact forces. The Pilot’s Operating Handbook (POH) contained a warning that aerobatics and intentional spins were prohibited. The POH also indicated that the minimum deployment altitude for the parachute was 210 ft and recommended that the parachute be deployed at the lowest airspeed possible and not above 150 mph; the airplane was operating at the airport’s traffic pattern altitude of about 1,000 ft above ground level when the parachute deployed. The airplane’s never-exceed speed was 131 mph; the airplane’s actual speed at the time of the parachute’s deployment could not be determined. Although the airplane was likely traveling within the speed and altitude specified for parachute deployment, the pilot was performing a prohibited roll when it deployed.

All of the parachute system’s hardware was accounted for during the postaccident examination of the system. The examination of the three parachute lines that were attached to the fuselage per the kit specifications revealed that two of the lines had been cut and that the third line exhibited overstress fractures. It is likely that the lines were severed when the parachute was deployed during the roll and that the remaining line then failed due to overload. Due to the severity of the damage and fragmentation of the airframe, it could not be determined if the pilot intentionally deployed the parachute following the loss of control during the roll maneuver or if a malfunction occurred that caused the parachute to deploy unintentionally. Once the parachute separated, the airplane was likely uncontrollable. Although postaccident toxicological tests detected chlorpheniramine, a sedating antihistamine, in the pilot’s cavity, it is unlikely that the pilot was impaired at the time of the accident.

The National Transportation Safety Board determines the probable cause(s) of this accident as follows:
The pilot’s failure to maintain airplane control while performing prohibited aerobatic maneuvers and the deployment and separation of the ballistic parachute system from the airframe for reasons that could not be determined due to the severity of impact damage to the system.

HISTORY OF FLIGHT

On September 6, 2013, at 0809 mountain daylight time, an Ives SD-1 TG experimental amateur-built airplane, N123SD, departed controlled flight and impacted flat open terrain in a nose-low attitude about 1 mile west of the Spanish Fork Airport-Springville-Woodhouse Field (U77), Spanish Fork, Utah. The pilot operated the airplane under the provisions of 14 Code of Federal Regulations Part 91, as a test flight for the owner/builder of the airplane. The pilot, the sole occupant, was fatally injured; the airplane was destroyed. Visual meteorological conditions prevailed for the local area flight that departed U77 about 0805, and no flight plan had been filed.

According to the owner of the airplane, the accident flight was the fourth test flight. Ground crew members reported that the pilot arrived at the airport about 0645, and a preflight inspection was performed, with no discrepancies noted with the airplane. Three GoPro cameras were mounted to the airplane and to the pilot. The ground crew also reported that the pilot was flying the airplane in the traffic pattern at the time of the accident.

One of the ground crew reported that he did not personally witness the accident, but he stated that the other ground crew started shouting about the pilot performing barrel rolls, which he had never performed before. He further reported that the barrel rolls were not scheduled for the day's test flight.

Another one of the ground crew reported that the pilot performed one roll, and midway through the second roll, the ballistic parachute was deployed, almost immediately separating itself from the airframe. He stated that the airplane began to spin at a rapid rate until it impacted the ground.

The last ground crew member reported that the pilot had wanted to test G-limits of the airplane, perform a few stalls, and some touch-and-go takeoffs and landings. He stated that the pilot performed a few stalls to full recovery, and then proceeded to do one successful roll. As the pilot attempted to do a second roll, he lost control of the airplane. The parachute was pulled at a high rate of speed, detaching from the airplane.

Two of the ground crew reported that the pilot was equipped with a radio, but he had not made radio contact with them.

PERSONNEL INFORMATION

The pilot, age 40, held a commercial pilot certificate with ratings for airplane single-engine and multiengine land, and instrument airplane. He also held a certified flight instructor (CFI) certificate with ratings for airplane single-engine and multiengine land, and instrument airplane. The pilot was issued a second-class airman medical certificate on May 3, 2013; it had the limitation that the pilot must wear corrective lenses. At the time of his medical examination, the pilot reported a total time of 930 hours with 130 hours accrued in the last 6 months. The pilot's logbook was not located during the investigation. According to the airplane owner, the accident pilot had been their test pilot; the pilot had flown the airplane on each of its three previous test flights, accumulating about 3-4 hours of flight time.

AIRCRAFT INFORMATION

The single-seat, low-wing, fixed-gear, experimental amateur built Skycraft Airplane SD-1 Minisport (SD-1-TG), serial number USA00103, was issued a special airworthiness certificate on February 13, 2013. A Hirth F-23 LW engine, serial number 903429, powered the airplane. The airplane's operating limitations were dated February 16, 2013.

A review of the airplane logbook indicated that between August 2013, and September 5, 2013, the airplane and engine had accrued 5.16 hours of flight time. On August 24, following a flight test, which included stall characteristics, the airplane ground looped upon landing. The wing was repaired, and on August 31, the airplane underwent another test flight, which included spin and stall characteristics. The logbook entry indicated that the airplane was spin resistant.

The airplane came equipped with a ballistic parachute, Galaxy Rescue Systems (Galaxy Holding s.r.o.); the retaining cables had three anchoring points on the airplane. Two were located at the firewall/engine structure, and the third was located at the aft bulkhead. The parachute cables were attached per the kit specifications, and the activation handle was located on the right side just forward of the flap control. According to the maintenance manual, depending on the model, the main canopy is open and fully inflated between 50-60 feet, in the direction of firing, which is about 1.5-3.2 seconds after being activated. The owner/builder reported that operation testing for the ballistic parachute system was accomplished via computer modeling and information attained from the manufacturer.

According to the Pilot's Operating Handbook, under the Operating Limitations for the ballistic recovery system, parachute deployment was recommended to be done at the lowest airspeed possible, and not to exceed 150 miles per hour (mph), and it was recommended that the parachute not be deployed if the airplane becomes inadvertently inverted. The minimum deployment altitude was 210 feet. The airplane's never-exceed-speed was 131 mph. In addition, the Operating Limitations contained a warning that aerobatics and intentional spins were prohibited.

The instruction manual for assembly and use of the GRS (Galaxy Rescue System) stated in part that once the system has been activated, once the airplane starts to descend under the canopy to the ground, there may be some aircraft control available, assuming the control surfaces are intact (Part 8. Activation of the system in a hazardous situation page 21 section 8.2 After firing the system). Section 8.5 titled Possible emergency scenarios, identified a "fall into a spin from a low altitude" situation. It stated in part that if the airplane entered into a spin, the pilot should not try to control the spin, but should fire the GRS unit immediately. Another scenario was "pilot disorientation", where the section indicated that in the event of an incapacitation scenario, use of the GRS unit may be the only solution out of the incapacitation event.

MEDICAL AND PATHOLOGICAL INFORMATION

A postmortem examination was conducted by the Utah Department of Health, office of the Medical Examiner. The cause of death was reported as total body blunt force injuries. The toxicology was positive for carboxyhemoglobin detected in the abdominal cavity blood (USL) 7.4 percent. Chlorpheniramine detected in cavity blood (FAA) 0.012 mg/L, as well as a positive detection in the liver.

The Federal Aviation Administration's (FAA) Forensic Toxicology Research Team, Civil Aerospace Medical Institute, performed forensic toxicology on specimens from the pilot. The toxicology was negative for carbon monoxide, and volatiles. A cyanide screening was not performed. The toxicology was positive for chlorpheniramine which was detected in the liver, and 0.012 (ug/ml, ug/g) chlorpheniramine detected in blood (cavity). Chlorpheniramine is a sedating antihistamine used to treat allergy and common cold symptoms. It is available over the counter under various trade names, including Chlor-Trimeton and Chlortabs.

WRECKAGE AND IMPACT INFORMATION

The airplane impacted an open field, with a debris field of about 200 feet. The entire airplane came to rest at the accident site; however, it was destroyed by impact forces.

AIRPORT INFORMATION

According to the Airport/Facility Directory for the Spanish Fork Airport-Springville-Woodhouse Field (U77), Spanish Fork, the traffic pattern altitude is 1,000 feet above ground level (5,500 mean sea level)

TESTS AND RESEARCH

Flight control continuity was established from the cockpit to the rudder, and through identification of the associated hardware; aileron control tubes and associated hardware were identified. The wooden propeller had been destroyed during the accident sequence. Also during the accident sequence, the engine case had been split in two. All major components were accounted for. 

Examination of the parachute system revealed that all hardware was accounted for. However, due to extensive damage to the parachute system, a functional check could not be performed.

Three fiber rope cables from the parachute to include attached fuselage fragments, two pieces of control tube, and a portion of fiberglass fragment, were sent to the National Transportation Safety Board (NTSB) Material/s Laboratory for examination. The control tubes exhibited bending overstress fracture features.

According to the NTSB Materials Laboratory specialist, the airplane had been equipped with a Galaxy GRS 6/375 ballistic parachute system. The parachute was located immediately behind the cockpit and the cables were attached to three mounting points on the fuselage. For the purpose of this report, the three parachute cables had been labeled Line A, B, and C.

Examination of parachute line A utilizing 50X to 200X zoom digital microscope revealed that the filaments at the frayed end had fractured in overstress. The Materials Laboratory specialist further noted that a fragment of the fuselage remained connected to line A; it exhibited overstress fractures as well.

Examination of parachute lines B and C revealed that the lines were unremarkable, and that both lines had been cut. The detailed report is attached to the public docket for this accident.

The pilot's Apple iPhone 4 had been recovered and shipped to the NTSB's Vehicle Recorder Division. The recorder specialist reported that two photos were recovered from the day of the accident. One picture, partially blurred the occupant, showed the nose of the airplane pointed toward the ground. The second picture recorded the weather. A detailed report is attached to the public docket for this accident.

Two GoPro's were also located in the wreckage, and shipped to the NTSB Vehicle Recorder Division. Due to impact damage, the recorder specialist was not able to recover any information.


Jay Lessley, a sergeant with the Utah County Sheriff's Department, was killed in an early morning plane crash near Spanish Fork Friday, Sept. 6, 2013. Lessley was off duty at the time of the accident.
























NTSB Identification: WPR13FA399
14 CFR Part 91: General Aviation
Accident occurred Saturday, September 06, 2003 in Spanish Fork, UT
Aircraft: Tyler Ives SD-1 TG, registration: N123SD
Injuries: 1 Fatal.

This is preliminary information, subject to change, and may contain errors. Any errors in this report will be corrected when the final report has been completed. NTSB investigators either traveled in support of this investigation or conducted a significant amount of investigative work without any travel, and used data obtained from various sources to prepare this aircraft accident report.

On September 6, 2013, about 0810 mountain daylight time, an Ives SD-1 TG experimental amateur-built airplane, N123SD, departed controlled flight and impacted flat open terrain in a nose-low attitude about 1 mile west of the Spanish Fork Airport-Springville-Woodhouse Field (U77),  Spanish Fork, Utah. The pilot operated the airplane under the provisions of 14 Code of Federal Regulations Part 91, as a test flight for the owner/builder of the airplane. The pilot, the sole occupant, was fatally injured; the airplane was destroyed. Visual meteorological conditions prevailed for the local area flight that departed U77 about 0805, and no flight plan had been filed. 

Federal Aviation Administration complaint: Long Island jet charter company given preferential treatment

The Federal Aviation Administration is reviewing a complaint that state officials have given preferential treatment to a jet charter and management company that wants to do more business at Republic Airport.

Competitors have also alleged the application process has been expedited for the company, Talon Air, which is owned by Adam Katz, a real estate developer and major donor to the Democratic Party and some of its candidates.

The company applied more than a year ago to become a fixed-based operator, or FBO, at the Farmingdale airport. FBOs provide a range of aviation services and are the only companies allowed to sell fuel there, a potentially lucrative concession at one of the region's busiest general aviation airports.

Officials from the state Department of Transportation, which oversees Republic, said they were still reviewing the application, but had received approval from the state comptroller's office to bypass a formal bidding process because Talon already meets minimum FBO standards and has 25 years left on its airport lease, precluding another company from operating on that property for at least that long.

Talon executives and DOT officials have denied preferential treatment; and a DOT letter to the FAA in June says the allegations are "unsupported and unsubstantiated."

Atlantic Aviation, the company that filed the complaint, is one of Republic's two existing FBOs. It leases space to Talon and has traded lawsuits with the company in contract disputes related to the lease. It could lose market share to Talon if Talon wins status as a third FBO.

Atlantic lawyer Leonard Kirsch alleges that "local, state and federal elected officials" who have received donations from Katz "are actively trying to promote the approval of Talon's FBO application."

The complaint does not name any of those recipients, but records show Katz, his wife and companies he controls donated at least $300,000 since 2006 to the state Democratic Party and to prominent Democrats, including Gov. Andrew M. Cuomo and Nassau District Attorney Kathleen Rice. They donated at least $2,000 to Nassau County Republicans.

Katz said his political contributions were unrelated to his aviation business, and representatives for Cuomo and Rice dismissed suggestions that Katz had bought influence.

The complaint also cites a safety report commissioned by Atlantic that warns that added traffic from Talon's FBO business could bring congestion and "safety issues," and that Talon's proposed fuel farm could create safety problems of its own.

Talon has commissioned its own safety report rebutting Atlantic's allegations, and Talon lawyer Greg Zucker said Atlantic was trying to "stifle competition" with its complaint.

John Wraga, executive director of the Independent Fixed Base Operators Association, said an FBO designation would let Talon compete for retail fuel sales, a major source of revenue for most of the country's 3,200 FBOs. It would also let the company, which now buys fuel from Atlantic Aviation, fuel its own charter aircraft. "They would save a fortune," Wraga said. "Fuel is one of the biggest expenses for charter aircraft."

Other airport business leaders complained the process was well underway when they learned in the spring that Talon had submitted an unsolicited FBO application to the DOT in March 2012.

Frank Nocerino, a Republican who chairs the Republic Airport Commission, whose members are appointed by the governor to advise on airport management, said the DOT's failure to notify his group had been "ill-advised."

Anthony Russo, an owner of Republic-based Northeastern Air Management, said his company had asked airport management about FBO status, but had been told the airport would need to first issue a public request for proposals, something it was not prepared to do.

Announcement of the exemption from bidding for Talon this spring left Russo "appalled and upset," he said. His company has since filed an FBO application of its own, he said.

Beau Duffy, a DOT spokesman, said the department's evaluation of Talon's application was independent and that the company had "absolutely not" gotten any special treatment. Under federal rules meant to encourage competition, the department can only deny the application if it compromises safety or efficiency at the airport, he said.

He also said its evaluation was ongoing, though William Howe, the DOT's contract management bureau director, wrote to the state comptroller's office in February that the department "has approved Talon's request to become a FBO at Republic Airport."

Duffy said that did not mean the department had given final approval, only that it supported bypassing the formal bidding process for Talon.


Original Article:  http://www.newsday.com

A crash course in PR: Rule Number 1 - don't hide: Thai Airways Airbus A330-300, HS-TEF, Flight TG-679, Accident occurred September 08, 2013 in Bangkok, Thailand

When the unthinkable happens, it pays to be prepared and not make up crisis handling policy on the hoof that can backfire with disastrous results

THAI Airways International flew into a storm of controversy last week after it decided to paint over its name and corporate logo following the crash of an Airbus 330-300 (flight TG 679) at Suvarnabhumi late last Sunday night which left 14 people injured.

Originally, THAI official Smud Poom-on said that hiding the airline's name and logo was a recommendation from the Star Alliance group known as the ''crisis communication rule'', and was intended to protect the image of both the airline and other members of Star Alliance.

But the airline later issued a statement saying: "THAI generally practices the de-identifying of an aircraft after an incident (or accident), the company also clarifies that it is not a Star Alliance policy or procedure to de-identify aircraft."

Star Alliance is group of 28 airlines around the world, including Lufthansa, United, Air China, Singapore Airlines, ANA and THAI.

Full article and photo:  http://www.bangkokpost.com 

The great airline cover-up 

Flight TG 679 came out of the north and east from southern China last Sunday night, as it did habitually each late evening, homing in on its Suvarnabhumi airport base. At 11.25pm, the Airbus A330-300, its 288 passengers and its 14 crew members kissed the runway.

A few seconds later, the plane shuddered, took a right turn off Runway 19R and drove at speed into the wet grass. Sparks or flames - there is a dispute - came from the starboard engine as it ploughed a furrow in the verge, bending and partly breaking up.

The plane came to a halt. The pilot issued emergency instructions. With the aircraft leaning to the right, evacuation chutes popped out of the left side of the aircraft, and crew and passengers began vacating the scene at speed. Some passengers were hurt in the slide, and in a reasonable time 14 were placed in ambulances and taken to hospital. Two were held overnight, but no one suffered life-threatening injuries.

At that point, less organised and thoughtful people took over. Senior airline executives were quickly notified, among them Sorajak Kasemsuvan, THAI president, who headed immediately for the airport.

The biggest cover-up in Thai Airways history was already under way.

An unidentified manager or airline executive whose name is currently unknown ordered the cover-up. Maintenance crews were quickly assembled.

They grabbed buckets of black paint, long-handled brushes, the keys to a long-armed cherry picker and headed down to TG 679, mired deeply into the soft, rain-soaked earth separating the two Suvarnabhumi runways.

The cherry picker manoeuvred under the imposing tail of the Airbus.

A worker, paint and brushes at the ready, was hoisted 17.2 metres in the air, almost to the top of the tail, where a Thai national flag graced the aircraft.

He began smearing over the flag with the black paint, like a kindergarten finger painter, not at all worried about staying inside the lines.

When he finished covering up the flag, the cherry picker was lowered several metres so he could start painting over the THAI logo. Then he was moved to the lower-left body, just behind the wing, and then to the front, just aft of the cockpit, to paint over other airline identification.

Asked why the airline tried to cover up the national identify, name and logo of Thai Airways International, an airline spokesman said it was "the crisis communication rule of Star Alliance to de-identify" - a great new word - any aircraft in an accident.

Unfortunately, Star Alliance spokesman Markus Ruediger was on international TV within hours denying any such policy.

THAI then had to "clarify", in international view, its claim. It could come up with no reason to scrawl over the stranded plane's markings. But by then, the world was laughing or marvelling at how THAI had manufactured a public relations disaster out of a relatively minor incident.

In a second kerfuffle, passengers from the incident complained they were treated insensitively, herded like cattle. The airline had no crisis room, no crisis staff, no crisis policy. Water, information and general guidance was all as scarce as hen's teeth.

THAI chairman Ampon Kittiampon was angry. He appeared to feel the ungrateful passengers aboard TG 679 clearly over-stepped.

"The incident was unavoidable, but the pilots and the attendants made the right decisions to protect the lives and property of their passengers. The crew exceeded their duties and should be appreciated by passengers."

Transport Minister Chadchart Sittipunt was unimpressed by the chairman's demand that uppity passengers should be giving wais and multiple thanks for the privilege of cheating death on his airliner. He ordered THAI to take immediate steps to write proper guidelines on how to handle accidents in the event there is another.

Meanwhile, the cause of the accident is obviously going to be sifted through THAI's high-powered and self-interested corporate machine. The official version, unlikely to be affected by the facts of the upcoming investigations, is that the Airbus has known landing-gear problems and that is what caused the aircraft to skid off the Suvarnabhumi runway.

That story, too, is likely to cause some to wonder about a cover-up.

Story and Comments/Reaction:  http://www.bangkokpost.com

Taobao aircraft auction fails to take off

 

An aircraft auction launched by the nation's leading online shopping platform, Taobao.com, was a crashing failure - at least on the first two days of bidding. 

 As of 4 pm on Thursday, 30 hours after the auction started, only eight people had bid for an Australian-made light sport aircraft. The plane was offered to pay 1.05 million yuan - about $245,170 - by the last bidder, and nobody had even made any bids for four jets that are also being offered.

The auction involves five new small aircraft, as well as a used helicopter. Prices for the other items range from 1.05 million yuan to 16.8 million yuan.

As of 3 pm on Friday, 61 users had shown an interest in the 3.53 million yuan second-hand helicopter, according to Taobao.

Anybody can take part in the auction after providing a deposit of 2,000 yuan for the Australian-made aircraft or 50,000 yuan for the four jets. No deposit is required for the helicopter, which has a fixed price, according to Li Feng'an from communications department of Taobao.

The aircraft auction will end at 10 am on Monday.

Taobao is a subsidiary of China's largest e-commerce company, Alibaba Group Holding Ltd.

The central government has promised to gradually open parts of the country's low-altitude airspace (altitudes below 1,000 meters) for private flights to promote the general aviation sector.
 

Original Article:   http://www.chinadaily.com.cn

Pilatus Aircraft Ltd - Apex Avionics System

 
 Video Published on September 11, 2013 

Based in Stans, Switzerland, Pilatus Aircraft Ltd was established in 1939. Seventy percent of all PC-12s which come off the production line in Stans, Switzerland are finished to customer specifications (interior and exterior livery) in Colorado. The American subsidiary is also responsible for PC-12 marketing, sales and servicing activities in North and South America.

Opinion: Is airport taking a step backward? -- The Eastern Iowa Airport (KCID), Cedar Rapids, Iowa

Updated: 14 September 2013 | 12:01 pm in Letters to the Editor

The Eastern Iowa Airport is undergoing a major change.

In 1964, the Cedar Rapids Fire Department opened a fire station located at the airport. Before that, the specialized equipment was stored in the Iowa Manufacturing Building at the airport. In 1976, Cedar Rapids fire turned the safety back to the airport and it was manned with duel-trained individuals, police and fire. This station always has been manned 24 hour a day. In 1969, the airport had 31 commercial flights per day and in 2000 it hit a record of 1 million passengers through the airport.

After 49 years of 24-hour coverage, they are going to change to 20 hours of coverage per day.

Is the airport going to be locked for these four hours? How many more flights do we have now than we had in 1969? How many more passengers do we have? What happens to the out-of-town person who misses a flight or gets a flight canceled, where does he go for four hours? What happens to an airport closed for the night?

This should be a major concern. With the tensions in the Middle East and after 9/11 and security issues, and other incidents across the nation, why are we reducing our security that is already in place?

Are we not trying to increase our volume of flights, passengers, etc., and have the security for them? This sounds like a step backward.

Cyndy Staton

Cedar Rapids

Original Article: http://thegazette.com

Hawker Beechcraft 390 Premier IA, The Vein Guys, N777VG: Accident occurred February 20, 2013 in Thomson, Georgia

NTSB Identification: ERA13MA139  
14 CFR Part 91: General Aviation
Accident occurred Wednesday, February 20, 2013 in Thomson, GA
Probable Cause Approval Date: 10/21/2014
Aircraft: BEECH 390, registration: N777VG
Injuries: 5 Fatal,2 Serious.

NTSB investigators traveled in support of this investigation and used data obtained from various sources to prepare this aircraft accident report.

The purpose of the flight was to return employees of a vein care practice to their home base at Thomson-McDuffie County Airport (HQU), Thomson, Georgia. The pilot was the pilot flying, and the copilot was the pilot not flying. (The National Transportation Safety Board [NTSB] notes that although the copilot is referred to as such in this report, his role in the cockpit is not required by federal regulations.) The departure from John C. Tune Airport, Nashville, Tennessee, and en route portions of the flight were uneventful. During the flight, the copilot reminded the pilot about a speed restriction and also reminded the pilot to adjust his altimeter. The pilot responded to the altimeter reminder by stating, "say, I'm kinda out of the loop or something. I don't know what happened to me there but I appreciate you lookin' after me there." About 4 minutes later, on approach to HQU, the pilot lowered the landing gear, and the ANTI SKID FAIL message illuminated in the cockpit; the copilot commented on the illumination. The pilot continued the approach; he did not respond to the copilot and did not refer to the Abnormal Procedures section of the Federal Aviation Administration (FAA)-approved Abbreviated Pilot Checklist to address the antiskid system failure message. The airplane touched down on runway 10 about 2005, and about 7 seconds later, the pilot initiated a go-around. (In postaccident interviews, neither the pilot nor the copilot recalled the reason for the go-around.) The airplane lifted off near the departure end of the 5,503 ft-long runway. According to enhanced ground proximity warning system (EGPWS) data, when the airplane was about 63 ft above ground level, the left wing struck a utility pole, which was 72 ft high and about 1,835 ft from the runway threshold, severing the outboard portion of the wing. The airplane continued another 925 ft before crashing in a wooded area.

Examination of the wreckage revealed no evidence of any preimpact failures or malfunctions of the engines or flight controls. The reason for the antiskid system malfunction could not be determined due to the general destruction of the wreckage.

For an antiskid inoperative condition, the Abbreviated Pilot Checklist only provides landing distance values for flaps up and flaps 10 degrees. The pilot should have selected one of those two flap settings for landing and determined the landing distance required. The first data recorded by the EGPWS showed that the airplane was configured at flaps 30. The flaps were transitioning through flaps 15 at the time of impact.

When the antiskid system fails, the landing distance required for full stop increases greatly: according to the Abbreviated Pilot Checklist, the landing distance would increase about 130 percent with flaps up and 89 percent with flaps 10. Thus, the required landing distance for the weather conditions that prevailed at HQU at the time of the accident with flaps up was 7,066 ft, and the required landing distance with flaps 10 was 5,806 ft. HQU runway 10's available runway length for landing was 5,208 ft, which did not meet the flaps up or flaps 10 performance penalty requirements with an antiskid system failure, thus requiring a diversion to a longer runway. It is likely that after touchdown, the pilot recognized that the airplane was not slowing as he expected and might not stop before the end of the runway. Rather than risk a high-speed overrun, he elected to conduct a go-around.

The NTSB determined that at the time the airplane struck the utility pole, the landing gear was extended, the flaps were in transit (retracting) toward the 10-degree position, and the lift dump system was deployed. Lift dump is a critical system to assist in stopping the Beechcraft 390 Premier (Premier 1A) during landing. Section 3A of the airplane flight manual (AFM) (Abnormal Procedures) included the following warning: "Extending lift dump in flight could result in loss of airplane control leading to airplane damage and injury to personnel. Continued safe flight with lift dump extended has not been demonstrated." The wreckage examination as well as drag estimates based on recovered EGPWS data indicate that the lift dump remained extended during the airplane's go-around attempt. The airplane drag associated with lift dump, flaps, and landing gear likely resulted in only marginal climb performance. While Beechcraft does not publish a procedure for a go-around after touchdown, aerodynamic data for the 390 Premier (Premier IA) suggest that if the airplane were configured with lift dump retracted and flaps 10 degrees or less, it would have been capable of a significantly higher climb rate after the failed landing attempt.

The pilot displayed a lack of systems knowledge of the accident airplane. First, the pilot demonstrated a lack of understanding of the antiskid system. Although the pilot had received antiskid system failure training during his recurrent simulator training on January 4, 2013, he stated in postaccident interviews that he did not think they needed the antiskid system for the landing at HQU and that the performance penalty would only apply if you were "trying to make your numbers." Because of this faulty belief, when the antiskid failure illumination occurred, the pilot did not take action. Second, the pilot selected a flap position (flaps 30) that was prohibited by the antiskid failure procedures in the AFM. Third, he performed a go-around with the lift dump extended. Both the AFM and a placard in the cockpit warned against extending the lift dump in flight. When the pilot decided to go around, he should have immediately retracted the lift dump per the AFM restriction for lift dump extension in flight.

The utility pole (Pole 48) that was struck was erected, along with several others, in 1989 by Georgia Power. The FAA was not notified before the construction of the utility poles in 1989; accordingly, no obstruction evaluation was done, and no depictions or mention of possible obstructions in the area were included on associated aeronautical charts. After the accident, Georgia Power submitted FAA Forms 7460-1 for four utility poles east of the airport, including Pole 48. The FAA conducted aeronautical studies on the poles and, on May 31, 2013, determined in its initial findings that Pole 48 did not comply with FAA obstruction standards and was "presumed to be a hazard to air navigation." The study also stated that if the pole were lowered to a height of 46 ft or less, it would comply with obstruction standards. After the FAA issued the preliminary obstruction determinations, Georgia Power requested that the FAA conduct further study on the four obstructions to determine if a favorable determination could be achieved. On August 12, 2013, the FAA published public notices announcing the four aeronautical studies and invited interested parties to submit relevant comments before September 18, 2013. According to an FAA official, the final determinations for the four obstructions were not completed at the time of this report. Since the initial aeronautical studies were conducted, the FAA Flight Data Center issued several notices to airmen to alert pilots about obstructions and also to amend the approach and departure procedures at HQU accordingly. In addition, the FAA increased the glideslope angle for the runway 28 precision approach path indicator from 3.00 to 3.50 degrees. Although the FAA has deemed the pole a presumed hazard, the pilot's attempted flight with the extended lift dump made airplane control and continued safe flight unlikely.

In evaluating the pilot's performance, the NTSB considered that the pilot experienced a sleep restriction, a circadian disruption the night before the accident, and long duty hours and extended wakefulness. The pilot normally slept about 8 hours per night; however, he only slept 5 hours the night before the accident (February 19). Further, the pilot awoke about 0200 on the morning of the accident, which was significantly earlier than his normal waking time of about 0600. On the day of the accident, he reported that upon arrival in Nashville, he slept for about 4 hours in a chair in the pilot lounge. However, his cell phone activity indicated outgoing calls during that time, suggesting interruptions to his sleep, which would have fragmented any sleep the pilot did obtain and degrade its restorative quality. Additionally, the accident took place about 2006, indicating an extended period of wakefulness based on the early awakening. Based on the available evidence, the pilot was likely suffering from fatigue at the time of the accident. Research indicates that fatigue associated with sleep loss, circadian disruption, and long duty hours can lead to increased difficulty in sustaining and directing attention, memory errors, and resultant lapses in performance. An NTSB safety study found that flight crewmembers who were awake for more than 12 hours made more procedural errors, tactical decision errors, and errors of omission than those awake less than 12 hours (NTSB. 1994. A Review of Flightcrew-Involved Major Accidents of U.S. Air Carriers, 1978 through 1990. SS-94/01. Washington, DC). Twice during the accident flight, the copilot gave the pilot reminders (one about the speed restriction and one about the altimeter). The pilot responded by indicating that he was "out of the loop." Further, the pilot did not refer to the Abbreviated Pilot Checklist for the antiskid system failure (for which the copilot commented on the illuminated light) or retract the lift dump when he elected to go around. Had the pilot not been fatigued, he likely would have paid closer attention to the flight and not had lapses in performance.

Both pilots survived, with serious injuries, and all five passengers, who were seated in the back, died. Postaccident examination showed that the seat buckles in the back were not fastened and the shoulder harnesses were not attached or pulled out. According to the copilot, the "fasten seatbelt" sign was on (the seatbelt chime was recorded by the cockpit voice recorder), but he did not remember giving a briefing on seatbelts. The pilot indicated that he did not remember seeing if the passengers had their seatbelts on. All six of the passenger seats had been forcibly detached from the airplane fuselage, and three were consumed by fire. All of the passengers sustained multiple traumatic injuries. Although proper use of restraint systems in survivable accidents can dramatically lessen or prevent serious injuries to occupants, due to the high impact forces and fragmentation of the cabin in this accident, it is unknown whether the use of restraints would have affected the survivability of the passengers.

Member Sumwalt filed a concurring statement that can be found in the public docket for this accident. Member Weener joined the statement.

The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The pilot's failure to follow airplane flight manual procedures for an antiskid failure in flight and his failure to immediately retract the lift dump after he elected to attempt a go-around on the runway. Contributing to the accident were the pilot's lack of systems knowledge and his fatigue due to acute sleep loss and his ineffective use of time between flights to obtain sleep.

Member Sumwalt filed a concurring statement that can be found in the public docket for this accident. Member Weener joined the statement.

***This report was modified on August 25, 2014, and October 21, 2014. Please see the docket for this accident to view the original report.***

HISTORY OF FLIGHT

On February 20, 2013, about 2006 eastern standard time (EST), a Beechcraft Corporation 390 Premier (Premier IA), N777VG, collided with a utility pole, trees, and terrain following a go around at Thomson-McDuffie County Airport (HQU), Thomson, Georgia. The airline transport-rated pilot and copilot were seriously injured, and the five passengers were fatally injured. The airplane was registered to the Pavilion Group, LLC, and was operated under the provisions of 14 Code of Federal Regulations (CFR) Part 91 as a business flight. Night visual meteorological conditions prevailed, and an instrument flight rules (IFR) flight plan was filed. The flight originated at John C. Tune Airport (JWN), Nashville, Tennessee, about 1827 central standard time (1927 EST).

On the morning of the accident, the pilot and copilot left their respective homes in South Carolina about 0230 for the 1-hour drive to HQU (where the airplane was based) to fly five passengers, who were employees of Vein Guys®, to JWN. (The National Transportation Safety Board [NTSB] notes that while the copilot is referred to as such in this report, his role in the cockpit is not required by federal regulations.) The airplane departed HQU about 0406 and arrived at JWN about 0459. (Although JWN is located in the central time zone, all subsequent times in this report are in EST unless otherwise noted.) Both pilots stated in postaccident interviews that the flight to JWN was uneventful and the weather was good. They reported that at the JWN terminal, they slept in the crew break room, completed paperwork, and worked on the computer. They left for a late lunch about 1500 and returned to the airport about 1630.

According to security camera footage from the JWN terminal, both pilots were observed walking toward the airplane about 1913, and about 1918, the five passengers were seen walking toward the airplane while one crewmember performed an external walk-around inspection. About 1923, the airplane taxied from the parking area and departed JWN at 1927. The pilot was the pilot flying and was in the left cockpit seat.

About 1927, the flight crew contacted departure control while climbing through 3,500 ft mean sea level (msl) and requested an IFR clearance to HQU. About 1930, the flight crew contacted the Memphis air route traffic control center (ARTCC) while climbing through 14,000 ft msl, and about 1933, the flight was cleared to climb and maintain a cruising altitude of flight level (FL) 270. According to flight crew interviews, the en route weather was good, and a tailwind in excess of 70 knots was observed.

About 1948, the flight crew contacted the Atlanta ARTCC and was cleared to descend to FL240. About 1953, the flight crew was given a further descent clearance to 11,000 ft msl along with the Athens, Georgia, altimeter setting. About the same time, the copilot tuned in the HQU automated weather observation system (AWOS) to receive the most current weather at the destination airport. The AWOS at 1935 reported calm wind, temperature 10 degrees C, 10 statute miles visibility or greater, scattered clouds at 12,000 ft, and an altimeter setting of 30.13 inches of mercury. The pilot then set up the flight management guidance system for a visual approach to runway 10 at HQU with a 3.4-degree descent to the runway from a 5-mile final approach. The copilot tuned the instrument landing system for runway 10 as a backup.

About 1956, the flight crew advised the Atlanta ARTCC that they were descending through 18,500 ft, and 2 minutes later, they cancelled their IFR flight plan. About 1958, the copilot stated to the pilot, "ten thousand comin' up captain and you blowin' through." About 1959, the copilot told the pilot to adjust his altimeter. The pilot responded, "say, I'm kinda out of the loop or something. I don't know what happened to me there but I appreciate you lookin' after me there." The flight crew was then directed to contact Augusta approach control, and about 2000, the flight crew contacted Augusta approach control and advised that they were descending out of 8,400 ft and had HQU in sight. About 2002, the flight crew advised Augusta approach control that they would switch to the local HQU advisory frequency.

Concurrently, the pilot began to perform an "S" turn along the final approach path to the runway. About 1 minute later, the enhanced ground proximity warning system (EGPWS) aural alert announced that the airplane was 1,000 ft above the ground, and the pilot lowered the landing gear. According to the cockpit voice recorder (CVR), after the landing gear was lowered, about 2004, the copilot noted that the "ANTI SKID FAIL" annunciator light illuminated. The pilot continued the approach, and, about 2005, the airplane touched down on runway 10. Witnesses reported that after the airplane touched down, they heard or saw it go around. According to the CVR, the takeoff warning horn sounded about 0.3 seconds before the pilot stated that he was performing a go-around. The airplane lifted off near the departure end of the runway. The copilot directed the pilot to increase pitch. According to EGPWS data, as the airplane climbed to an altitude of about 63 ft above the ground, about 9 seconds after liftoff, the left wing struck a utility pole located about 0.25 miles east of the departure end of the runway. The airplane continued about 925 ft before colliding with trees and terrain. It was destroyed by impact forces and a postcrash fire.

During a postaccident interview, when asked about the approach, landing, and go-around at HQU, the pilot recalled checking the airplane's landing light switches to prepare for the landing. The next thing he remembered was waking up in the hospital on February 24, 2013. He did not recall any additional details about the approach, landing, or go-around or any airplane system anomalies, including any antiskid problems, during the flight.

In postaccident interviews, the copilot did not recall anything unusual about the glidepath and recalled being about 1 or 2 knots above reference speed. The copilot thought that the airplane touched down on runway 10 within 200 ft of the 1,000-ft runway marker. As he began to reference the after landing checklist, he heard the pilot announce a go-around, but the copilot did not know the reason for the go-around. He stated that he began to monitor the airspeed indicator, saw that they were at 105 knots approaching the end of the runway, and thought "it was going to be close." The engines sounded like they always did on a normal takeoff. He thought something hit the airplane on his side and recalled seeing trees in the windshield. The next thing he remembered was seeing someone with a flashlight at the accident scene. He did not recall any alarm or aural caution before the go-around and indicated that everything looked normal.

PERSONNEL INFORMATION

The Pilot

The pilot, age 56, held an airline transport pilot (ATP) certificate with a single pilot type rating on the Premier IA. (The 390 Premier is the same as the Premier I/IA series.) He also held a flight instructor certificate with airplane single engine land, airplane multiengine land, and instrument airplane privileges. He was the director of operations for Sky's the Limit, doing business as Executive Shuttle, a 14 CFR Part 135 operator based in Greenwood, South Carolina. He was hired by the Pavilion Group to provide private pilot services for their Premier IA under the provisions of 14 CFR Part 91. The pilot reported 13,319 hours total flying time, including 12,609 hours as pilot-in-command (PIC). He reported 198 hours, all as PIC, in the Premier IA. The pilot held a second-class Federal Aviation Administration (FAA) medical certificate, issued October 29, 2012, with a limitation to possess glasses for near/intermediate vision.

According to interviews and training records, the pilot attended the FlightSafety Premier I Series (RA-390) initial training course at the FlightSafety Wichita Learning Center, Wichita, Kansas, from June 7, 2012, through June 22, 2012. The ground instruction consisted of 58 hours of ground training and 11.5 hours of briefing/debriefing. The pilot also attended flight simulator training, which consisted of 15 hours of simulator training. He was type rated on the Premier IA on June 22, 2012, following a 2.2-hour simulator session and a 2.5-hour oral/written examination.

The pilot also attended the FlightSafety Premier I Series (RA-390) recurrent PIC course at the FlightSafety Greater Philadelphia/Wilmington Learning Center, Wilmington, Delaware, from January 3, 2013, through January 5, 2013. The ground instruction consisted of 12 hours of training and 4.5 hours of briefing/debriefing. The simulator portion of the training consisted of 7 hours of simulator time.

A copilot who previously flew with the pilot stated that the pilot was experienced, professional, and possessed good flying skills. Both copilots who flew with the pilot, including the accident copilot, stated that they did not have a specific role on the flights they flew with him in the Premier IA.

On February 15, the pilot flew the owner of Vein Guys® and his family to Orlando, Florida, and remained in Orlando until Monday, February 18. He did not use a copilot for the Orlando trip. On February 18, he flew the family to HQU and then drove to his residence, going to bed about 2100. On February 19, he awoke about 0500 for a 0930 flight to Olive Branch, Mississippi, with the accident copilot and Vein Guys® staff. The return flight landed at HQU about 1700 that evening. He arrived at his residence about 1820 and went to bed about 2100.

On the day of the accident, the pilot awoke about 0200 and arrived at HQU about 0330 for the 0400 flight to JWN. He described February 20 as a "tough, tough day" because of the early departure time. After arriving at JWN, he slept for about 4 hours in a chair in the pilot lounge. He did not sleep again that day. A review of the pilot's cell phone records revealed three outgoing calls were made during his 4-hour sleep break. The pilot indicated that he normally slept about 8 hours per night and that he typically awoke about 0600.

The Copilot

The copilot, age 40, held an ATP certificate. He possessed no type ratings. He was employed by and flew charters for Executive Shuttle, which was owned by the accident pilot. He accompanied the accident pilot on the Premier IA flights at the pilot's request and estimated that he had about 45 flight hours in the Premier IA. He reported 2,932 hours total time, including 2,613 hours as PIC. The copilot held a second-class FAA medical certificate, issued February 12, 2013, with no limitations.

The copilot received no simulator training in the Premier IA before the accident and did not complete formal training courses in the Premier IA. He received a 14 CFR 61.55 logbook endorsement on October 10, 2012, from the accident pilot, stating that he demonstrated the skill and knowledge required for safe operation of the Premier IA as second-in-command.

On Monday, February 18, the copilot was at home and awoke between 0600 and 0630 and went to bed about 2200. On Tuesday, February 19, he awoke between about 0530 and 0600 and flew with the captain to Olive Branch. After returning to HQU, the copilot made the 1-hour drive to his home but was not certain what time he went to bed or fell asleep. The last cell phone activity that day occurred about 2148. On Wednesday, February 20, the copilot awoke between about 0200 and 0215 and drove with the accident captain to HQU for the flight to JWN. The copilot told investigators he was able to sleep for about 4 to 5 hours in the pilot lounge (awakening about 1000 central time).

AIRCRAFT INFORMATION

The Premier IA was a carbon fiber composite fuselage, metal low-wing airplane powered by two Williams FJ44-2A turbofan engines mounted on the aft fuselage each rated at 2,300 lbs of thrust.

The Premier IA was not equipped with reverse thrust, and wheel braking was the primary means of stopping the airplane after landing. (The lift dump assists in putting weight on the wheels, which makes braking more effective.) The airplane was equipped with an electrically controlled antiskid system. According to the manufacturer, the system offered protection from skids and could provide consistently shorter landing rolls for all runway conditions. The ANTI SKID FAIL annunciator would illuminate if a malfunction existed in the system when the ANTI SKID switch was in the NORM (normal) position.

Activation of the lift dump switch extended the three spoiler panels on each wing and overrode normal spoiler operation. A placard was located on the cockpit pedestal immediately aft of the lift dump switch that read, "WARNING DO NOT EXTEND IN FLIGHT." In addition, the Hawker Beechcraft Premier I/IA Model 390 Airplane Flight Manual (AFM), Section 3A—Abnormal Procedures, page A-25, states, "Do not extend lift dump in flight." Section 3A of the AFM (Abnormal Procedures) included the following warning: "Extending lift dump in flight could result in loss of airplane control leading to airplane damage and injury to personnel. Continued safe flight with lift dump extended has not been demonstrated."

The airframe and engine maintenance logbooks were not located after the accident. Pavilion Group used CAMP Systems as their maintenance management provider, and the Hawker Beechcraft Service Center, Atlanta, Georgia, also provided maintenance services.

The most recent record of maintenance performed on the airplane occurred on January 29, 2013, at Aeronautical Services, Greenwood, South Carolina. The maintenance included replacement of the left and right main tires, touching up exterior paint, and a battery capacity check. The total time on the airplane was not recorded at that time.

The most recent maintenance record indicating aircraft total time was on January 4, 2013, when the airframe total time was 635.4 hours. The most recent comprehensive airframe and engine inspection was recorded on June 15, 2012. The 600-hour Schedule A inspection was accomplished at 503.3 hours total time and 565 total airframe cycles.

METEOROLOGICAL INFORMATION

The National Weather Service (NWS) reported no significant weather and no precipitation over the region. The area forecast applicable for HQU expected light wind and scattered to broken high cirrus clouds, with visibility unrestricted. The NWS also issued an airmen's meteorological information that was current at the time of the accident for moderate turbulence below 8,000 ft over the area.

HQU was equipped with an AWOS that issued observations every 20 minutes. The HQU 1955 observation reported calm wind, visibility 10 miles or greater, sky clear, temperature 9 degrees C, dew point -4 degrees C, and altimeter setting 30.12 inches of mercury. The HQU 2015 observation reported wind from 240 degrees at 6 knots, visibility 10 miles or greater, broken ceiling at 12,000 ft above ground level (agl), temperature 11 degrees C, dew point -3 degrees C, and altimeter setting 30.15 inches of mercury.

AIRPORT INFORMATION

General

HQU was a general aviation airport with one asphalt runway (runway 10-28) measuring 5,503 ft long and 100 ft wide, with precision instrument markings on both ends. The runway had high-intensity runway edge lights that changed from white to amber for the last 2,000 ft in both directions. Both ends had red threshold lights and green approach lights. Adjacent to the touchdown zone for both ends of the runway was a two-unit precision approach path indicator (PAPI) system set at 3 degrees. (As later discussed, following an aeronautical study after the accident, the FAA changed the glidepath angle for the runway 28 PAPI to 3.5 degrees.) Postaccident tests and inspections of the airport lighting systems indicated that the lighting system was operating normally at the time of the tests.

The runway and taxiway lights were pilot-adjustable to low, medium, and high settings and would remain on for 15 minutes after activation. The PAPIs would not activate when the runway lights were set to the low setting. A City of Thomson administrator managed the airport with the help of an on-site airport manager who also managed a local fixed base operation (Spirit Aviation). The airport manager did not prepare or keep any logs about airport self-inspections, regular maintenance, wildlife strikes, lighting activation, or periodic inspection/calibration of the PAPI units. According to the airport manager, a local electrical contractor accomplished all preventative and repair work on the airport's lights and navigational aids on an as needed basis. After the accident, the airport began keeping weekly logs of lighting outages, maintenance, and general field conditions.

The Georgia Department of Transportation (GDOT) inspected HQU biennially to ensure compliance with the requirements set out in GDOT's Rules and Regulations for Licensing of Certain Open-to-the-Public Airports. The GDOT inspections also included an airport inspection for the FAA's Airport Safety Data Program. The two most recent inspection reports from 2010 and 2012 determined that HQU met the minimum state licensing requirements but failed to meet federal requirements for precision and visual approaches. Specifically, runway 10 failed to meet FAA Part 77 reporting requirements for a 50:1 obstruction-free, precision instrument approach to 200 ft from the runway end. Similarly, runway 28 failed to meet the FAA Part 77 reporting requirements for a 34:1 obstruction-free, nonprecision instrument approach to 200 ft from the runway end. The obstructions listed for both approaches were trees, left and right of centerline. The 2012 inspection report for the runway 28 approach included an obstruction characterized as a power line, 66 ft high, and 2,200 ft from the displaced threshold, extending from the centerline to 400 ft right of centerline, which provided a 27:1 approach to 200 ft from the runway end and a 33:1 approach to the displaced threshold.

The Thomson city administrator stated that before 2012, no GDOT inspection report had identified the power line east of the airport as a potential obstruction. To determine whether the power line was an obstruction and to provide data in support of an official airport layout plan, the city administrator authorized a formal survey of the airport. The survey had not been completed at the time of the accident or at the time of this report.

Airport Obstructions

During the accident sequence, the airplane struck a concrete electrical utility pole (Pole 48) that was about 1,835 ft east of the runway 28 threshold and 50 ft left of the extended runway centerline. Pole 48 was 72 ft high, and the airplane struck the pole about 58 ft agl. The pole was not equipped with lights, but orange visibility balls were on the adjacent wires.

The pole was owned and maintained by Georgia Power, a regional utility that supplied electric power to local businesses and residents. Pole 48 was erected in 1989, along with similar poles and electrical utility lines, to provide electrical power to the Milliken and Company textile plant adjacent to HQU. Thomson McDuffie County entered into an "aviation easement" agreement with Deering Milliken, the owner of the Milliken Kingsley textile factory adjacent to HQU, in September 1973. The provisions of the easement were designed to protect the approach surface east of the airport. The text of the easement stated that Deering Milliken "…will not hereafter erect or permit the erection or growth of any structure, trees, or other object within or upon said parcel, which lies within the approach area of the 9-27 [now 10-28] runway to a height above the approach surface. Said approach surface being an inclined plane with a slope of 34:1, i.e. one ft of elevation for each 34 ft of horizontal distance, located directly over the center of said parcel." Milliken and Company entered into easement agreements with Georgia Power in May 1977 and again in August 1989 to grant the right to construct, erect, install, operate, and maintain "poles, wires, transformers, service pedestals, and other necessary apparatus" to supply electrical power to the Milliken Kingsley textile plant.

Title 14 CFR Part 77 establishes standards for approach surfaces to runways of various types and requires notice to the FAA of any proposed construction or alteration of existing structures that may affect the national airspace system. FAA Advisory Circular 70-7460-1K, "Obstruction Marking and Lighting," provides guidance on compliance with 14 CFR Part 77 and procedures for notifying the FAA of proposed construction or alteration. Specifically, a Notice of Proposed Construction or Alteration Form (FAA Form 7460-1) is required for notification. Upon receipt of Form 7460-1, the FAA will conduct an aeronautical study to determine the effects of the construction or alteration on navigable airspace. Then, the FAA will determine if the construction or alteration constitutes a hazard to air navigation.

Georgia Power did not notify the FAA before constructing the utility poles in 1989; therefore, the FAA had no knowledge of the poles as potential obstructions. Accordingly, there were no depictions or mention of possible obstructions on associated aeronautical charts.

After the accident, Georgia Power submitted FAA Forms 7460-1 for four utility poles east of the airport, including Pole 48. The FAA conducted aeronautical studies on the poles and, on May 31, 2013, issued initial findings from the studies. Regarding Pole 48, the FAA determined in its initial findings that "…the structure as described exceeds obstruction standards and/or would have an adverse physical or electromagnetic interference effect upon navigable airspace or air navigation facilities. Pending resolution of the issues described below, the structure is presumed to be a hazard to air navigation." The study also stated that if the pole were lowered to a height of 46 ft or less it would not exceed obstruction standards, and a favorable determination could subsequently be issued. The FAA reported similar findings on the other three structures. The FAA stated in its findings that to pursue a favorable determination at the originally submitted height, further study would be necessary, and a formal request would be required within 60 days.

After the FAA issued the preliminary obstruction determinations, Georgia Power requested that the FAA conduct further study on the four obstructions to determine if a favorable determination could be achieved. On August 12, 2013, the FAA published public notices announcing the four aeronautical studies and invited interested parties to submit relevant comments before September 18, 2013. According to an FAA official, the final determinations for the four obstructions were not completed at the time of this report. Since the aeronautical studies were conducted, the FAA Flight Data Center issued several notices to airmen to alert pilots about obstructions and also to amend the approach and departure procedures at HQU accordingly. In addition, the FAA increased the glideslope angle for the runway 28 PAPI from 3.00 to 3.50 degrees.

FLIGHT RECORDERS

Although not required, the airplane was equipped with an L-3/Fairchild FA2100-1010 CVR. The CVR recording contained the last 30 minutes of digital audio, which was stored in solid-state memory modules. The CVR sustained significant heat and structural damage as a result of the accident. Despite the damage to the unit, three channels of recorded audio were available, ranging from good to excellent quality. The recording began at 1935:13 as the flight was at FL240, and the recording stopped about 2006 during the crash sequence. The airplane was not equipped with a flight data recorder, nor was it required to be so equipped.

WRECKAGE AND IMPACT INFORMATION

The airplane struck Pole 48, and sections of the pole and attached power lines were found along the wreckage debris path, which was oriented from west to east on an approximate magnetic heading of 085 degrees. The left wing was completely severed about 13 ft inboard from the wing tip and exhibited no fire damage. The severed wing was located about 320 ft east of Pole 48.

Various fragments of the airplane structure were found along the debris path leading to the main wreckage site, which was located about 925 ft east of Pole 48. Multiple trees, up to 2 ft in diameter, were severed or toppled in the main wreckage impact zone. The main wreckage consisted of the center wing section, a portion of the right wing, the main landing gear, the baggage compartment, the emergency locator transmitter rack, and the empennage. The main wreckage was damaged by a postcrash fire and contained melted aluminum and burnt composite material. The forward fuselage was about 60 ft east of the main wreckage and was damaged by a postcrash fire.

The right engine was separated from the fuselage and was on the south side of the debris path between the main wreckage and the forward fuselage shell. The left engine was severed into two main sections with the compressor and the turbine and exhaust section located in a shallow pond on the north side of the debris path. A large portion of the ground in the vicinity of the accident site was charred and burned by a postcrash fire.

All three landing gear assemblies were located on scene. The left and right main landing gear actuators separated from the landing gear but remained attached to the wing structure. Measurements of the actuator positions, as found, corresponded to the "gear extended" or "down" position.

An examination of the nose landing gear actuator piston revealed that its extension was at an intermediate position. The nose landing gear had an external downlock mechanism to secure the gear in the down-and-locked position. The mating side of the external downlock mechanism was not observed and therefore precluded determination of the position of the nose landing gear. Fire and impact damage to the antiskid system components (antiskid control unit, power brake/antiskid control valve, and wheel speed transducers) prevented their functional testing.

The wreckage was transported to a storage facility where additional examinations of the wreckage were performed. The landing gear switch, which was cockpit-mounted, was found with the instrument subpanel attached to electrical wire. The switch exhibited heat and thermal damage consistent with a postcrash fire. The metal part of the switch handle was found in the down (extended) detent, and the J-hook was engaged on the handle. The lift dump switch assembly, which was mounted on the cockpit center console, was not located.

The electrically controlled and operated wing flap system was examined. The four flap positions available to the pilot were UP (0 degrees), 10, 20, and DN (30 degrees/full down). While the flap handle was found in the 10-degree detent, measurements of the flap actuator positions revealed that the flaps were at approximately the 15-degree position (a nonselectable, in-transit position) at the time of impact.

MEDICAL AND PATHOLOGICAL INFORMATION

Both the pilot and copilot sustained serious injuries. Drug and alcohol testing on the pilot and copilot was conducted by the FAA Civil Aerospace Medical Institute after the accident. Toxicology results were negative for both pilots on a wide range of drugs, including major drugs of abuse.

The Georgia Bureau of Investigation Division of Forensic Science listed the cause of death for all passengers as blunt force injuries.

SURVIVAL ASPECTS

The pilot's seat was found with the seatback and seat pan cushions attached to the frame, which was severely damaged with broken tubes in the seatback and seat bottom. The upper shoulder area of the seat was crushed forward and to the right. The seat, which was located near the remains of the cockpit, appeared to be forcefully detached from the cockpit floor track rails with small floor track pieces attached to the seat post. First responders removed the pilot from his 4-point restraint by cutting the belt webbing.

The copilot's seat was found attached to the floor structure in the remains of the cockpit. The seatback, seat pan cushions, and the 4-point restraint were consumed by the postcrash fire. The seat frame was severely damaged with broken tubes in the seatback and seat bottom. First responders found the copilot out of his seat and walking along an access road near the main wreckage area.

All six passenger seats were found scattered among the wreckage and were detached from the airplane floor structure. The seat backs and bottoms of all seats exhibited severe damage, including breakage of the structural tubing framework. The restraint systems on the passenger seats were attached to their respective seat frames, and all six buckles were unlatched. The belt webbing was intact on three of the seats, and the remaining three passenger seat restraints were consumed by fire. One of the six shoulder harnesses was found attached to the lap portion of the female buckle. The other five shoulder harnesses were found retracted in the seatback frame. None of the six passenger seat belt buckles or associated fittings were damaged.

TESTS AND RESEARCH

Enhanced Ground Proximity Warning System

The airplane was equipped with a Honeywell Mark V EGPWS. The nonvolatile memory (NVM) was downloaded, and, by design, the EGPWS recorded airplane performance data based on a parameter exceedance, which was, in this event, an excessive bank angle, most likely the result of the separation of the left wing after impact with Pole 48. The unit captured the data during the 20 seconds before the exceedance. The unit was designed to record for 10 seconds after the exceedance; however, only 2 seconds were recorded because electrical power to the unit ceased during the crash sequence.

The data indicated that during the go-around attempt, the airplane lifted off near the departure end of runway 10 (consistent with the copilot's statement). Per the EGPWS data, the landing gear remained in the down position until impact. The calibrated airspeed was about 125 knots when the airplane lifted off. The airplane continued straight ahead and slowly accelerated and gradually climbed, until a rapid pitch up was recorded, from 10.5 to 27.4 degrees within 1 second. One second later, the roll increased from 2.1 degrees left to 71.7 degrees left.

The first data recorded by the EGPWS showed that the airplane was configured at flaps 30. The flaps were transitioning through flaps 15 at the time of impact.

Engines

During postaccident examination, the No. 1 (left) engine exhibited extensive impact deformation and was split at the interstage case flange, aft of the axial low pressure compressor (LPC). The fan blades exhibited tip bending opposite the direction of rotation, and the low pressure turbine (LPT) shaft was twisted consistent with a sudden stoppage due to impact.

The No. 2 (right) engine was intact; however, some components, including the LPC, high pressure compressor, high pressure turbine, and LPT all exhibited blade tip rubs with corresponding case rubs. The accessory gearbox tower shaft was sheared, and damage consistent with impact was noted to the fuel pump, oil lube, and scavenge pump.

Wing Spoiler System Actuators

Examination and disassembly of the lift dump actuators revealed that one unit was 0.457 inch from full extension (panel extended), and the other unit was 0.221 inch from full extension. A determination of left or right could not be made due to fire and impact damage.

Examination and disassembly of the left blow-down actuator revealed that the unit was seized at the fully extended position. Damage to the clevis at the end of the actuator was consistent with the roll/speedbrake/spoiler panel in the fully extended position at impact. The right blow-down actuator had minimal damage and was fully functional when tested. Its position at impact could not be determined.

Examination and disassembly of the left roll control actuator revealed that the unit was 0.022 inch from the fully extended position. The right roll control actuator had minimal damage and was found to be fully functional when tested. Its position at impact was 0.201 inch from the fully extended position.

Spoiler Control Unit

The spoiler control unit (SCU) interfaced with the hydraulics and controlled hydraulic actuation of the six spoiler panels across the wings. The SCU was responsible for providing surface position commands and monitoring hydraulic components for malfunction detection and protection.

Exterior examination of the SCU revealed major fire and impact damage to the unit's housing. The bit and diagnostic card was also fire damaged. The data on the NVM chip were downloaded but were inconclusive; therefore, a determination of the actuation of the spoilers before and during the accident could not be made based on SCU data.

Flight Management Computer (FMC-3000)

The airplane was equipped with a Rockwell Collins FMC-3000 flight management computer. The unit was tested and operated normally on a test bench. NVM analysis indicated that no internal faults occurred on the FMC-3000 near the time of accident.

Air Data Computers (ADC-3000)

The airplane was equipped with two Rockwell Collins ADC-3000 air data computers (ADC). Examination revealed that the mounts on both ADCs were damaged from impact, indicative of forces during impact in excess of 20g. Both units operated normally on a test bench. The first unit showed a final power cycle with weight coming off wheels at 4 minutes after power on and weight on wheels again at 44 minutes after power on. Following the weight on wheels, within the 44th minute after power on, 3 faults were indicated in the NVM. In order, they were for a faulty Ps (static pressure) counter, a faulty Qc (impact pressure) counter, and an unexpected interruption. According to Rockwell Collins, these faults were most likely due to extreme acceleration causing electrical connections between the circuit cards within the ADC to fail. The second unit showed a final power cycle with weight coming off wheels at 4 minutes after power on and a return to weight on wheels at 44 minutes after power on. No faults were observed in the NVM.

Airplane Performance Study

The NTSB produced an airplane performance study of the landing and go-around phases of the accident flight largely based on information from the CVR and the EGPWS, as well as the physical evidence documented at the accident site. To attain the unfactored landing distance performance numbers contained in the AFM, the following conditions had to be met: thrust as required to maintain a 3-degree approach angle, retarding thrust to idle at 50 ft agl; approach speed at VREF; flaps down; antiskid normal; maximum braking; and lift dump extended after touchdown.

Beechcraft calculated stopping performance for several scenarios related to the accident flight. Beechcraft indicated that with the estimated stopping distance for the accident airplane with no antiskid system operative and the lowest braking action recorded during the flight test, the airplane would require about 1,560 ft to stop from the first speed recorded by the EGPWS (83 kts). This estimate decreases to 1,350 ft when moderate braking is applied. Based on EGPWS data, after touching down, the pilot did not stop the airplane within the first 2,900 ft beyond the runway 10 threshold and initiated a go-around with more than 2,400 ft of hard surface remaining; the first speed was recorded at this point. (The actual touchdown point was not recorded and could not be determined.) The wreckage examination, as well as drag estimates based on recovered EGPWS data, indicated that the lift dump remained extended during the go-around attempt. The airplane drag associated with the lift dump, flaps, and landing gear extended resulted in only marginal climb performance.

ORGANIZATIONAL AND MANAGEMENT INFORMATION

According to its website, Vein Guys® was a group of four physicians that operated several vein care centers in the southeastern United States, with offices in Augusta, Georgia; Atlanta, Georgia; Nashville, Tennessee; and Raleigh, North Carolina. According to interviews, the Pavilion Group was a subsidiary established by the owners of Vein Guys® to handle all business activities associated with the ownership and operation of its private airplane, which it used to shuttle physicians and staff between their offices in Georgia, Tennessee, and North Carolina and also for private flights to vacation destinations.

Before owning the accident airplane, the Pavilion Group owned a King Air 300 (N401BL) and used the pilot services of Executive Shuttle (owned by the accident pilot). The Pavilion Group sold the King Air and, in June 2012, purchased the accident airplane and continued to use the pilot services of Executive Shuttle. The Pavilion Group's airplanes were operated under the provisions of 14 CFR Part 91. According to the accident pilot, the Pavilion Group paid for the pilot's initial and recurrent Premier IA ground and simulator training at FlightSafety. Although Executive Shuttle operated as Sky's the Limit, a 14 CFR Part 135 certificate holder, the pilot stated in interviews that there was no signed contract between Executive Shuttle and the Pavilion Group (or Vein Guys®) for pilot services on the Pavilion Group's airplane, and all Premier IA flights Executive Shuttle operated for the Pavilion Group were conducted under 14 CFR Part 91.

ADDITIONAL INFORMATION

Takeoff Warning System

The airplane was equipped with a takeoff configuration warning system that provided an automatic aural warning to the flight crew during the initial portion of takeoff if the airplane was in a configuration that would not allow for a safe takeoff. The aural warning would continue until the airplane's configuration was changed to allow for safe takeoff, until action was taken by the pilot to abandon the takeoff roll, or until weight was off of the wheels. If either lift dump surface was not retracted, the speed brake/lift dump lever sensors were in the extended range, either flap position was greater than 22 degrees, or the pitch trim was outside of a predetermined range for takeoff, the aural warning would activate in the cockpit.

Antiskid System Failure and Pilot's Corrective Action

Pilots receiving training at FlightSafety on the Premier IA were taught to use the FAA approved Abbreviated Pilot Checklist to handle system malfunctions. A failure of the antiskid system was included in the Abnormal Procedures section of the checklist. According to the checklist, the pilot should move the antiskid switch to OFF and plan for a flaps 10 or flaps up landing. The antiskid failure procedure also provided a note stating that landing distance would increase about 130 percent with flaps up and 89 percent with flaps 10.

According to the Antiskid Failure Checklist (which is within the Abbreviated Pilot Checklist), the pilot was required to account for the loss of the antiskid system by applying a performance penalty to the normal landing distance, depending on the flap setting selected (flaps 10 or flaps up). Using weather conditions that prevailed at HQU at the time of the accident, the required landing distance with flaps up was 7,066 ft, and the required landing distance with flaps 10 was 5,806 ft. HQU runway 10's available runway length for landing was 5,208 ft, which did not meet the flaps up or flaps 10 performance penalty requirements, and a diversion to a longer runway would have been required. The Premier IA AFM Antiskid Fail procedure included a note that stated, "Use of flaps 20 or DN (30) for landing, with anti-skid failed, is prohibited."

The simulator instructor who provided the pilot's initial training stated in a postaccident interview that he would expect the pilot to use the written checklist for a systems failure, determine the proper flap setting for landing, and then apply the performance penalty for the landing, adding that the Antiskid Failure Checklist emphasized that the landing must be made with only flaps 10 or UP. According to the pilot's FlightSafety training records, he received antiskid system failure training during his recurrent simulator training on January 4, 2013.

On June 17, 2013, both pilots listened to the CVR recording for the accident flight, and according to subsequent interviews, neither pilot recalled seeing the ANTI SKID FAIL annunciator light illuminated on the approach. According to interviews with both pilots and a review of the CVR recording, the ANTI SKID FAIL abnormal checklist as outlined in the Abbreviated Pilot Checklist for the Premier IA was not conducted by the accident crew before landing at HQU. Further, the pilot stated that he did not think they needed the antiskid system on the landing at HQU and said the performance penalty would only apply if you were "trying to make your numbers" in the book made by the test pilots by applying maximum braking.

Balked Landing/Go-Around

According to recorded data and witness statements, the flight crew attempted a go-around after landing at HQU. The pilot did not recall the event during interviews, while the copilot stated that they conducted a go-around after the airplane touched down. Procedures for the Premier IA (AFM and Pilot Checklist) referred to the discontinuation of a landing approach as a "balked landing."

According to the FAA's Airplane Flying Handbook (FAA-H-8083, page G-2), a balked landing was synonymous with a go-around. Per the FAA Pilot/Controller Glossary, a go around was a situation when a pilot abandons his/her approach to land. The Airplane Flying Handbook (chapter 8), "Approaches and Landings," states the following: "The go around is not strictly an emergency procedure. It is a normal maneuver that may at times be used in an emergency situation.…Although the need to discontinue a landing may arise at any point in the landing process, the most critical go-around will be one started when very close to the ground. Therefore, the earlier a condition that warrants a go-around is recognized, the safer the go around/rejected landing will be."

According to the FAA's Aeronautical Information Manual (page PCG T-4), a touchdown was the point at which an aircraft first made contact with the landing surfaces. The Airplane Flying Handbook (FAA-H-8083-3A, page 8-7) explained that the landing process was not over until the airplane decelerated to a normal taxi speed or came to a complete stop. The FAA indicated in its May 14, 2013, response to NTSB Information Request 13-267 that a pilot may execute a balked landing/go-around if he/she determined that, after first contact with the landing surface, positive control had not been maintained or if continuing the landing process may expose the aircraft to unsafe conditions such as an unexpected appearance of hazards on the runway.

FlightSafety Premier IA instructors and evaluators in Wichita, Kansas, and Wilmington, Delaware, stated during postaccident interviews that a balked landing was an airborne maneuver typically taught to be performed at an altitude of 50 ft on the approach, and Premier pilots were not taught to execute a balked landing in the Premier IA following touchdown on the runway. The FlightSafety instructors and evaluators also stated that they discouraged students from executing a balked landing after touchdown. Beechcraft Premier IA manuals and FlightSafety training guidance for the Premier IA do not contain language prohibiting a balked landing procedure after touchdown.

The pilot told investigators that he did not recall if anyone at FlightSafety told him not to conduct a go-around or balked landing after touching down during his training. The pilot also stated that the only balked landings he conducted in training were while airborne. When asked by investigators if he recalled anyone at FlightSafety telling him not to conduct a go-around or balked landing after touching down, the pilot said "no." The pilot further stated that a balked landing was something that occurred in the air, and on the ground it was called a "touch and go." The pilot did not remember ever doing a touch and-go in the simulator and had never done one in a Premier.

On March 29, 2011, the NTSB issued Safety Recommendation A-11-18, asking the FAA to "require manufacturers of newly certificated and in-service turbine-powered aircraft to incorporate in their Aircraft Flight Manuals a committed-to-stop point in the landing sequence (for example, in the case of the Hawker Beechcraft 125-800A airplane, once lift dump is deployed) beyond which a go-around should not be attempted." On June 10, 2013, the FAA indicated that it was impractical to fully implement the recommendation but that it would address the NTSB's concerns by issuing an Information for Operators (InFO). Pending the issuance of the InFO and the NTSB's review of an acceptable plan of action to ensure that all operators incorporate the guidance, the NTSB classified Safety Recommendation A-11-18 "Open—Acceptable Alternate Response."



NTSB Identification: ERA13MA139
14 CFR Part 91: General Aviation
Accident occurred Wednesday, February 20, 2013 in Thomson, GA
Aircraft: BEECH 390, registration: N777VG
Injuries: 5 Fatal,2 Serious.

NTSB investigators traveled in support of this investigation and used data obtained from various sources to prepare this aircraft accident report.

HISTORY OF FLIGHT

On February 20, 2013, about 2006 eastern standard time (EST), a Beechcraft Corporation 390 Premier (Premier IA), N777VG, collided with a utility pole, trees, and terrain following a go around at Thomson-McDuffie County Airport (HQU), Thomson, Georgia. The airline transport-rated pilot and copilot were seriously injured, and the five passengers were fatally injured. The airplane was registered to the Pavilion Group, LLC, and was operated under the provisions of 14 Code of Federal Regulations (CFR) Part 91 as a business flight. Night visual meteorological conditions prevailed, and an instrument flight rules (IFR) flight plan was filed. The flight originated at John C. Tune Airport (JWN), Nashville, Tennessee, about 1827 central standard time (1927 EST).

On the morning of the accident, the pilot and copilot left their respective homes in South Carolina about 0230 for the 1-hour drive to HQU (where the airplane was based) to fly five passengers, who were employees of Vein Guys®, to JWN. (The National Transportation Safety Board [NTSB] notes that while the copilot is referred to as such in this report, his role in the cockpit is not required by federal regulations.) The airplane departed HQU about 0406 and arrived at JWN about 0459. (Although JWN is located in the central time zone, all subsequent times in this report are in EST unless otherwise noted.) Both pilots stated in postaccident interviews that the flight to JWN was uneventful and the weather was good. They reported that at the JWN terminal, they slept in the crew break room, completed paperwork, and worked on the computer. They left for a late lunch about 1500 and returned to the airport about 1630.

According to security camera footage from the JWN terminal, both pilots were observed walking toward the airplane about 1913, and about 1918, the five passengers were seen walking toward the airplane while one crewmember performed an external walk-around inspection. About 1923, the airplane taxied from the parking area and departed JWN at 1927. The pilot was the pilot flying and was in the left cockpit seat.

About 1927, the flight crew contacted departure control while climbing through 3,500 ft mean sea level (msl) and requested an IFR clearance to HQU. About 1930, the flight crew contacted the Memphis air route traffic control center (ARTCC) while climbing through 14,000 ft msl, and about 1933, the flight was cleared to climb and maintain a cruising altitude of flight level (FL) 270. According to flight crew interviews, the en route weather was good, and a tailwind in excess of 70 knots was observed.

About 1948, the flight crew contacted the Atlanta ARTCC and was cleared to descend to FL240. About 1953, the flight crew was given a further descent clearance to 11,000 ft msl along with the Athens, Georgia, altimeter setting. About the same time, the copilot tuned in the HQU automated weather observation system (AWOS) to receive the most current weather at the destination airport. The AWOS at 1935 reported calm wind, temperature 10 degrees C, 10 statute miles visibility or greater, scattered clouds at 12,000 ft, and an altimeter setting of 30.13 inches of mercury. The pilot then set up the flight management guidance system for a visual approach to runway 10 at HQU with a 3.4-degree descent to the runway from a 5-mile final approach. The copilot tuned the instrument landing system for runway 10 as a backup.

About 1956, the flight crew advised the Atlanta ARTCC that they were descending through 18,500 ft, and 2 minutes later, they cancelled their IFR flight plan. About 1958, the copilot stated to the pilot, "ten thousand comin' up captain and you blowin' through." About 1959, the copilot told the pilot to adjust his altimeter. The pilot responded, "say, I'm kinda out of the loop or something. I don't know what happened to me there but I appreciate you lookin' after me there." The flight crew was then directed to contact Augusta approach control, and about 2000, the flight crew contacted Augusta approach control and advised that they were descending out of 8,400 ft and had HQU in sight. About 2002, the flight crew advised Augusta approach control that they would switch to the local HQU advisory frequency.

Concurrently, the pilot began to perform an "S" turn along the final approach path to the runway. About 1 minute later, the enhanced ground proximity warning system (EGPWS) aural alert announced that the airplane was 1,000 ft above the ground, and the pilot lowered the landing gear. According to the cockpit voice recorder (CVR), after the landing gear was lowered, about 2004, the copilot noted that the "ANTI SKID FAIL" annunciator light illuminated. The pilot continued the approach, and, about 2005, the airplane touched down on runway 10. Witnesses reported that after the airplane touched down, they heard or saw it go around. According to the CVR, the takeoff warning horn sounded about 0.3 seconds before the pilot stated that he was performing a go-around. The airplane lifted off near the departure end of the runway. The copilot directed the pilot to increase pitch. According to EGPWS data, as the airplane climbed to an altitude of about 63 ft above the ground, about 9 seconds after liftoff, the left wing struck a utility pole located about 0.25 miles east of the departure end of the runway. The airplane continued about 925 ft before colliding with trees and terrain. It was destroyed by impact forces and a postcrash fire.

During a postaccident interview, when asked about the approach, landing, and go-around at HQU, the pilot recalled checking the airplane's landing light switches to prepare for the landing. The next thing he remembered was waking up in the hospital on February 24, 2013. He did not recall any additional details about the approach, landing, or go-around or any airplane system anomalies, including any antiskid problems, during the flight.

In postaccident interviews, the copilot did not recall anything unusual about the glidepath and recalled being about 1 or 2 knots above reference speed. The copilot thought that the airplane touched down on runway 10 within 200 ft of the 1,000-ft runway marker. As he began to reference the after landing checklist, he heard the pilot announce a go-around, but the copilot did not know the reason for the go-around. He stated that he began to monitor the airspeed indicator, saw that they were at 105 knots approaching the end of the runway, and thought "it was going to be close." The engines sounded like they always did on a normal takeoff. He thought something hit the airplane on his side and recalled seeing trees in the windshield. The next thing he remembered was seeing someone with a flashlight at the accident scene. He did not recall any alarm or aural caution before the go-around and indicated that everything looked normal.

PERSONNEL INFORMATION

The Pilot

The pilot, age 56, held an airline transport pilot (ATP) certificate with a single pilot type rating on the Premier IA. (The 390 Premier is the same as the Premier I/IA series.) He also held a flight instructor certificate with airplane single engine land, airplane multiengine land, and instrument airplane privileges. He was the director of operations for Sky's the Limit, doing business as Executive Shuttle, a 14 CFR Part 135 operator based in Greenwood, South Carolina. He was hired by the Pavilion Group to provide private pilot services for their Premier IA under the provisions of 14 CFR Part 91. The pilot reported 13,319 hours total flying time, including 12,609 hours as pilot-in-command (PIC). He reported 198 hours, all as PIC, in the Premier IA. The pilot held a second-class Federal Aviation Administration (FAA) medical certificate, issued October 29, 2012, with a limitation to possess glasses for near/intermediate vision.

According to interviews and training records, the pilot attended the FlightSafety Premier I Series (RA-390) initial training course at the FlightSafety Wichita Learning Center, Wichita, Kansas, from June 7, 2012, through June 22, 2012. The ground instruction consisted of 58 hours of ground training and 11.5 hours of briefing/debriefing. The pilot also attended flight simulator training, which consisted of 15 hours of simulator training. He was type rated on the Premier IA on June 22, 2012, following a 2.2-hour simulator session and a 2.5-hour oral/written examination.

The pilot also attended the FlightSafety Premier I Series (RA-390) recurrent PIC course at the FlightSafety Greater Philadelphia/Wilmington Learning Center, Wilmington, Delaware, from January 3, 2013, through January 5, 2013. The ground instruction consisted of 12 hours of training and 4.5 hours of briefing/debriefing. The simulator portion of the training consisted of 7 hours of simulator time.

A copilot who previously flew with the pilot stated that the pilot was experienced, professional, and possessed good flying skills. Both copilots who flew with the pilot, including the accident copilot, stated that they did not have a specific role on the flights they flew with him in the Premier IA.

On February 15, the pilot flew the owner of Vein Guys® and his family to Orlando, Florida, and remained in Orlando until Monday, February 18. He did not use a copilot for the Orlando trip. On February 18, he flew the family to HQU and then drove to his residence, going to bed about 2100. On February 19, he awoke about 0500 for a 0930 flight to Olive Branch, Mississippi, with the accident copilot and Vein Guys® staff. The return flight landed at HQU about 1700 that evening. He arrived at his residence about 1820 and went to bed about 2100.

On the day of the accident, the pilot awoke about 0200 and arrived at HQU about 0330 for the 0400 flight to JWN. He described February 20 as a "tough, tough day" because of the early departure time. After arriving at JWN, he slept for about 4 hours in the pilot lounge. He did not sleep again that day. A review of the pilot's cell phone records revealed three outgoing calls were made during his 4-hour sleep break. The pilot indicated that he normally slept about 8 hours per night and that he typically awoke about 0600.

The Copilot

The copilot, age 40, held an ATP certificate. He possessed no type ratings. He was employed by and flew charters for Executive Shuttle, which was owned by the accident pilot. He accompanied the accident pilot on the Premier IA flights at the pilot's request and estimated that he had about 45 flight hours in the Premier IA. He reported 2,932 hours total time, including 2,613 hours as PIC. The copilot held a second-class FAA medical certificate, issued February 12, 2013, with no limitations.

The copilot received no simulator training in the Premier IA before the accident and did not complete formal training courses in the Premier IA. He received a 14 CFR 61.55 logbook endorsement on October 10, 2012, from the accident pilot, stating that he demonstrated the skill and knowledge required for safe operation of the Premier IA as second-in-command.

On Monday, February 18, the copilot was at home and awoke between 0600 and 0630 and went to bed about 2200. On Tuesday, February 19, he awoke between about 0530 and 0600 and flew with the captain to Olive Branch. After returning to HQU, the copilot made the 1-hour drive to his home but was not certain what time he went to bed or fell asleep. The last cell phone activity that day occurred about 2148. On Wednesday, February 20, the copilot awoke between about 0200 and 0215 and drove with the accident captain to HQU for the flight to JWN. The copilot told investigators he was able to sleep for about 4 to 5 hours in the pilot lounge (awakening about 1000 central time).

AIRCRAFT INFORMATION

The Premier IA was a carbon fiber composite fuselage, metal low-wing airplane powered by two Williams FJ44-2A turbofan engines mounted on the aft fuselage each rated at 2,300 lbs of thrust.

The Premier IA was not equipped with reverse thrust, and wheel braking was the primary means of stopping the airplane after landing. (The lift dump assists in putting weight on the wheels, which makes braking more effective.) The airplane was equipped with an electrically controlled antiskid system. According to the manufacturer, the system offered protection from skids and could provide consistently shorter landing rolls for all runway conditions. The ANTI SKID FAIL annunciator would illuminate if a malfunction existed in the system when the ANTI SKID switch was in the NORM (normal) position.

Activation of the lift dump switch extended the three spoiler panels on each wing and overrode normal spoiler operation. A placard was located on the cockpit pedestal immediately aft of the lift dump switch that read, "WARNING DO NOT EXTEND IN FLIGHT." In addition, the Hawker Beechcraft Premier I/IA Model 390 Airplane Flight Manual (AFM), Section 3A—Abnormal Procedures, page A-25, states, "Do not extend lift dump in flight." Section 3A of the AFM (Abnormal Procedures) included the following warning: "Extending lift dump in flight could result in loss of airplane control leading to airplane damage and injury to personnel. Continued safe flight with lift dump extended has not been demonstrated."

The airframe and engine maintenance logbooks were not located after the accident. Pavilion Group used CAMP Systems as their maintenance management provider, and the Hawker Beechcraft Service Center, Atlanta, Georgia, also provided maintenance services.

The most recent record of maintenance performed on the airplane occurred on January 29, 2013, at Aeronautical Services, Greenwood, South Carolina. The maintenance included replacement of the left and right main tires, touching up exterior paint, and a battery capacity check. The total time on the airplane was not recorded at that time.

The most recent maintenance record indicating aircraft total time was on January 4, 2013, when the airframe total time was 635.4 hours. The most recent comprehensive airframe and engine inspection was recorded on June 15, 2012. The 600-hour Schedule A inspection was accomplished at 503.3 hours total time and 565 total airframe cycles.

METEOROLOGICAL INFORMATION

The National Weather Service (NWS) reported no significant weather and no precipitation over the region. The area forecast applicable for HQU expected light wind and scattered to broken high cirrus clouds, with visibility unrestricted. The NWS also issued an airmen's meteorological information that was current at the time of the accident for moderate turbulence below 8,000 ft over the area.

HQU was equipped with an AWOS that issued observations every 20 minutes. The HQU 1955 observation reported calm wind, visibility 10 miles or greater, sky clear, temperature 9 degrees C, dew point -4 degrees C, and altimeter setting 30.12 inches of mercury. The HQU 2015 observation reported wind from 240 degrees at 6 knots, visibility 10 miles or greater, broken ceiling at 12,000 ft above ground level (agl), temperature 11 degrees C, dew point -3 degrees C, and altimeter setting 30.15 inches of mercury.

AIRPORT INFORMATION

General

HQU was a general aviation airport with one asphalt runway (runway 10-28) measuring 5,503 ft long and 100 ft wide, with precision instrument markings on both ends. The runway had high-intensity runway edge lights that changed from white to amber for the last 2,000 ft in both directions. Both ends had red threshold lights and green approach lights. Adjacent to the touchdown zone for both ends of the runway was a two-unit precision approach path indicator (PAPI) system set at 3 degrees. (As later discussed, following an aeronautical study after the accident, the FAA changed the glidepath angle for the runway 28 PAPI to 3.5 degrees.) Postaccident tests and inspections of the airport lighting systems indicated that the lighting system was operating normally at the time of the tests.

The runway and taxiway lights were pilot-adjustable to low, medium, and high settings and would remain on for 15 minutes after activation. The PAPIs would not activate when the runway lights were set to the low setting. A City of Thomson administrator managed the airport with the help of an on-site airport manager who also managed a local fixed base operation (Spirit Aviation). The airport manager did not prepare or keep any logs about airport self-inspections, regular maintenance, wildlife strikes, lighting activation, or periodic inspection/calibration of the PAPI units. According to the airport manager, a local electrical contractor accomplished all preventative and repair work on the airport's lights and navigational aids on an as needed basis. After the accident, the airport began keeping weekly logs of lighting outages, maintenance, and general field conditions.

The Georgia Department of Transportation (GDOT) inspected HQU biennially to ensure compliance with the requirements set out in GDOT's Rules and Regulations for Licensing of Certain Open-to-the-Public Airports. The GDOT inspections also included an airport inspection for the FAA's Airport Safety Data Program. The two most recent inspection reports from 2010 and 2012 determined that HQU met the minimum state licensing requirements but failed to meet federal requirements for precision and visual approaches. Specifically, runway 10 failed to meet FAA Part 77 reporting requirements for a 50:1 obstruction-free, precision instrument approach to 200 ft from the runway end. Similarly, runway 28 failed to meet the FAA Part 77 reporting requirements for a 34:1 obstruction-free, nonprecision instrument approach to 200 ft from the runway end. The obstructions listed for both approaches were trees, left and right of centerline. The 2012 inspection report for the runway 28 approach included an obstruction characterized as a power line, 66 ft high, and 2,200 ft from the displaced threshold, extending from the centerline to 400 ft right of centerline, which provided a 27:1 approach to 200 ft from the runway end and a 33:1 approach to the displaced threshold.

The Thomson city administrator stated that before 2012, no GDOT inspection report had identified the power line east of the airport as a potential obstruction. To determine whether the power line was an obstruction and to provide data in support of an official airport layout plan, the city administrator authorized a formal survey of the airport. The survey had not been completed at the time of the accident or at the time of this report.

Airport Obstructions

During the accident sequence, the airplane struck a concrete electrical utility pole (Pole 48) that was about 1,835 ft east of the runway 28 threshold and 50 ft left of the extended runway centerline. Pole 48 was 72 ft high, and the airplane struck the pole about 58 ft agl. The pole was not equipped with lights, but orange visibility balls were on the adjacent wires.

The pole was owned and maintained by Georgia Power, a regional utility that supplied electric power to local businesses and residents. Pole 48 was erected in 1989, along with similar poles and electrical utility lines, to provide electrical power to the Milliken and Company textile plant adjacent to HQU. Thomson McDuffie County entered into an "aviation easement" agreement with Deering Milliken, the owner of the Milliken Kingsley textile factory adjacent to HQU, in September 1973. The provisions of the easement were designed to protect the approach surface east of the airport. The text of the easement stated that Deering Milliken "…will not hereafter erect or permit the erection or growth of any structure, trees, or other object within or upon said parcel, which lies within the approach area of the 9-27 [now 10-28] runway to a height above the approach surface. Said approach surface being an inclined plane with a slope of 34:1, i.e. one ft of elevation for each 34 ft of horizontal distance, located directly over the center of said parcel." Milliken and Company entered into easement agreements with Georgia Power in May 1977 and again in August 1989 to grant the right to construct, erect, install, operate, and maintain "poles, wires, transformers, service pedestals, and other necessary apparatus" to supply electrical power to the Milliken Kingsley textile plant.

Title 14 CFR Part 77 establishes standards for approach surfaces to runways of various types and requires notice to the FAA of any proposed construction or alteration of existing structures that may affect the national airspace system. FAA Advisory Circular 70-7460-1K, "Obstruction Marking and Lighting," provides guidance on compliance with 14 CFR Part 77 and procedures for notifying the FAA of proposed construction or alteration. Specifically, a Notice of Proposed Construction or Alteration Form (FAA Form 7460-1) is required for notification. Upon receipt of Form 7460-1, the FAA will conduct an aeronautical study to determine the effects of the construction or alteration on navigable airspace. Then, the FAA will determine if the construction or alteration constitutes a hazard to air navigation.

Georgia Power did not notify the FAA before constructing the utility poles in 1989; therefore, the FAA had no knowledge of the poles as potential obstructions. Accordingly, there were no depictions or mention of possible obstructions on associated aeronautical charts.

After the accident, Georgia Power submitted FAA Forms 7460-1 for four utility poles east of the airport, including Pole 48. The FAA conducted aeronautical studies on the poles and, on May 31, 2013, issued initial findings from the studies. Regarding Pole 48, the FAA determined in its initial findings that "…the structure as described exceeds obstruction standards and/or would have an adverse physical or electromagnetic interference effect upon navigable airspace or air navigation facilities. Pending resolution of the issues described below, the structure is presumed to be a hazard to air navigation." The study also stated that if the pole were lowered to a height of 46 ft or less it would not exceed obstruction standards, and a favorable determination could subsequently be issued. The FAA reported similar findings on the other three structures. The FAA stated in its findings that to pursue a favorable determination at the originally submitted height, further study would be necessary, and a formal request would be required within 60 days.

After the FAA issued the preliminary obstruction determinations, Georgia Power requested that the FAA conduct further study on the four obstructions to determine if a favorable determination could be achieved. On August 12, 2013, the FAA published public notices announcing the four aeronautical studies and invited interested parties to submit relevant comments before September 18, 2013. According to an FAA official, the final determinations for the four obstructions were not completed at the time of this report. Since the aeronautical studies were conducted, the FAA Flight Data Center issued several notices to airmen to alert pilots about obstructions and also to amend the approach and departure procedures at HQU accordingly. In addition, the FAA increased the glideslope angle for the runway 28 PAPI from 3.00 to 3.50 degrees.

FLIGHT RECORDERS

Although not required, the airplane was equipped with an L-3/Fairchild FA2100-1010 CVR. The CVR recording contained the last 30 minutes of digital audio, which was stored in solid-state memory modules. The CVR sustained significant heat and structural damage as a result of the accident. Despite the damage to the unit, three channels of recorded audio were available, ranging from good to excellent quality. The recording began at 1935:13 as the flight was at FL240, and the recording stopped about 2006 during the crash sequence. The airplane was not equipped with a flight data recorder, nor was it required to be so equipped.

WRECKAGE AND IMPACT INFORMATION

The airplane struck Pole 48, and sections of the pole and attached power lines were found along the wreckage debris path, which was oriented from west to east on an approximate magnetic heading of 085 degrees. The left wing was completely severed about 13 ft inboard from the wing tip and exhibited no fire damage. The severed wing was located about 320 ft east of Pole 48.

Various fragments of the airplane structure were found along the debris path leading to the main wreckage site, which was located about 925 ft east of Pole 48. Multiple trees, up to 2 ft in diameter, were severed or toppled in the main wreckage impact zone. The main wreckage consisted of the center wing section, a portion of the right wing, the main landing gear, the baggage compartment, the emergency locator transmitter rack, and the empennage. The main wreckage was damaged by a postcrash fire and contained melted aluminum and burnt composite material. The forward fuselage was about 60 ft east of the main wreckage and was damaged by a postcrash fire.

The right engine was separated from the fuselage and was on the south side of the debris path between the main wreckage and the forward fuselage shell. The left engine was severed into two main sections with the compressor and the turbine and exhaust section located in a shallow pond on the north side of the debris path. A large portion of the ground in the vicinity of the accident site was charred and burned by a postcrash fire.

All three landing gear assemblies were located on scene. The left and right main landing gear actuators separated from the landing gear but remained attached to the wing structure. Measurements of the actuator positions, as found, corresponded to the "gear extended" or "down" position.

An examination of the nose landing gear actuator piston revealed that its extension was at an intermediate position. The nose landing gear had an external downlock mechanism to secure the gear in the down-and-locked position. The mating side of the external downlock mechanism was not observed and therefore precluded determination of the position of the nose landing gear. Fire and impact damage to the antiskid system components (antiskid control unit, power brake/antiskid control valve, and wheel speed transducers) prevented their functional testing.

The wreckage was transported to a storage facility where additional examinations of the wreckage were performed. The landing gear switch, which was cockpit-mounted, was found with the instrument subpanel attached to electrical wire. The switch exhibited heat and thermal damage consistent with a postcrash fire. The metal part of the switch handle was found in the down (extended) detent, and the J-hook was engaged on the handle. The lift dump switch assembly, which was mounted on the cockpit center console, was not located.

The electrically controlled and operated wing flap system was examined. The four flap positions available to the pilot were UP (0 degrees), 10, 20, and DN (30 degrees/full down). While the flap handle was found in the 10-degree detent, measurements of the flap actuator positions revealed that the flaps were at approximately the 15-degree position (a nonselectable, in-transit position) at the time of impact.

MEDICAL AND PATHOLOGICAL INFORMATION

Both the pilot and copilot sustained serious injuries. Drug and alcohol testing on the pilot and copilot was conducted by the FAA Civil Aerospace Medical Institute after the accident. Toxicology results were negative for both pilots on a wide range of drugs, including major drugs of abuse.

The Georgia Bureau of Investigation Division of Forensic Science listed the cause of death for all passengers as blunt force injuries.

SURVIVAL ASPECTS

The pilot's seat was found with the seatback and seat pan cushions attached to the frame, which was severely damaged with broken tubes in the seatback and seat bottom. The upper shoulder area of the seat was crushed forward and to the right. The seat, which was located near the remains of the cockpit, appeared to be forcefully detached from the cockpit floor track rails with small floor track pieces attached to the seat post. First responders removed the pilot from his 4-point restraint by cutting the belt webbing.

The copilot's seat was found attached to the floor structure in the remains of the cockpit. The seatback, seat pan cushions, and the 4-point restraint were consumed by the postcrash fire. The seat frame was severely damaged with broken tubes in the seatback and seat bottom. First responders found the copilot out of his seat and walking along an access road near the main wreckage area.

All six passenger seats were found scattered among the wreckage and were detached from the airplane floor structure. The seat backs and bottoms of all seats exhibited severe damage, including breakage of the structural tubing framework. The restraint systems on the passenger seats were attached to their respective seat frames, and all six buckles were unlatched. The belt webbing was intact on three of the seats, and the remaining three passenger seat restraints were consumed by fire. One of the six shoulder harnesses was found attached to the lap portion of the female buckle. The other five shoulder harnesses were found retracted in the seatback frame. None of the six passenger seat belt buckles or associated fittings were damaged.

TESTS AND RESEARCH

Enhanced Ground Proximity Warning System

The airplane was equipped with a Honeywell Mark V EGPWS. The nonvolatile memory (NVM) was downloaded, and, by design, the EGPWS recorded airplane performance data based on a parameter exceedance, which was, in this event, an excessive bank angle, most likely the result of the separation of the left wing after impact with Pole 48. The unit captured the data during the 20 seconds before the exceedance. The unit was designed to record for 10 seconds after the exceedance; however, only 2 seconds were recorded because electrical power to the unit ceased during the crash sequence.

The data indicated that during the go-around attempt, the airplane lifted off near the departure end of runway 10 (consistent with the copilot's statement). Per the EGPWS data, the landing gear remained in the down position until impact. The calibrated airspeed was about 125 knots when the airplane lifted off. The airplane continued straight ahead and slowly accelerated and gradually climbed, until a rapid pitch up was recorded, from 10.5 to 27.4 degrees within 1 second. One second later, the roll increased from 2.1 degrees left to 71.7 degrees left.

Engines

During postaccident examination, the No. 1 (left) engine exhibited extensive impact deformation and was split at the interstage case flange, aft of the axial low pressure compressor (LPC). The fan blades exhibited tip bending opposite the direction of rotation, and the low pressure turbine (LPT) shaft was twisted consistent with a sudden stoppage due to impact.

The No. 2 (right) engine was intact; however, some components, including the LPC, high pressure compressor, high pressure turbine, and LPT all exhibited blade tip rubs with corresponding case rubs. The accessory gearbox tower shaft was sheared, and damage consistent with impact was noted to the fuel pump, oil lube, and scavenge pump.

Wing Spoiler System Actuators

Examination and disassembly of the lift dump actuators revealed that one unit was 0.457 inch from full extension (panel extended), and the other unit was 0.221 inch from full extension. A determination of left or right could not be made due to fire and impact damage.

Examination and disassembly of the left blow-down actuator revealed that the unit was seized at the fully extended position. Damage to the clevis at the end of the actuator was consistent with the roll/speedbrake/spoiler panel in the fully extended position at impact. The right blow-down actuator had minimal damage and was fully functional when tested. Its position at impact could not be determined.

Examination and disassembly of the left roll control actuator revealed that the unit was 0.022 inch from the fully extended position. The right roll control actuator had minimal damage and was found to be fully functional when tested. Its position at impact was 0.201 inch from the fully extended position.

Spoiler Control Unit

The spoiler control unit (SCU) interfaced with the hydraulics and controlled hydraulic actuation of the six spoiler panels across the wings. The SCU was responsible for providing surface position commands and monitoring hydraulic components for malfunction detection and protection.

Exterior examination of the SCU revealed major fire and impact damage to the unit's housing. The bit and diagnostic card was also fire damaged. The data on the NVM chip were downloaded but were inconclusive; therefore, a determination of the actuation of the spoilers before and during the accident could not be made based on SCU data.

Flight Management Computer (FMC-3000)

The airplane was equipped with a Rockwell Collins FMC-3000 flight management computer. The unit was tested and operated normally on a test bench. NVM analysis indicated that no internal faults occurred on the FMC-3000 near the time of accident.

Air Data Computers (ADC-3000)

The airplane was equipped with two Rockwell Collins ADC-3000 air data computers (ADC). Examination revealed that the mounts on both ADCs were damaged from impact, indicative of forces during impact in excess of 20g. Both units operated normally on a test bench. The first unit showed a final power cycle with weight coming off wheels at 4 minutes after power on and weight on wheels again at 44 minutes after power on. Following the weight on wheels, within the 44th minute after power on, 3 faults were indicated in the NVM. In order, they were for a faulty Ps (static pressure) counter, a faulty Qc (impact pressure) counter, and an unexpected interruption. According to Rockwell Collins, these faults were most likely due to extreme acceleration causing electrical connections between the circuit cards within the ADC to fail. The second unit showed a final power cycle with weight coming off wheels at 4 minutes after power on and a return to weight on wheels at 44 minutes after power on. No faults were observed in the NVM.

Airplane Performance Study

The NTSB produced an airplane performance study of the landing and go-around phases of the accident flight largely based on information from the CVR and the EGPWS, as well as the physical evidence documented at the accident site. To attain the unfactored landing distance performance numbers contained in the AFM, the following conditions had to be met: thrust as required to maintain a 3-degree approach angle, retarding thrust to idle at 50 ft agl; approach speed at VREF; flaps down; antiskid normal; maximum braking; and lift dump extended after touchdown.

Beechcraft calculated stopping performance for several scenarios related to the accident flight. Beechcraft indicated that with the estimated stopping distance for the accident airplane with no antiskid system operative and the lowest braking action recorded during the flight test, the airplane would require about 1,560 ft to stop from the first speed recorded by the EGPWS (83 kts). This estimate decreases to 1,350 ft when moderate braking is applied. Based on EGPWS data, after touching down, the pilot did not stop the airplane within the first 2,900 ft beyond the runway 10 threshold and initiated a go-around with more than 2,400 ft of hard surface remaining; the first speed was recorded at this point. (The actual touchdown point was not recorded and could not be determined.) The wreckage examination, as well as drag estimates based on recovered EGPWS data, indicated that the lift dump remained extended during the go-around attempt. The airplane drag associated with the lift dump, flaps, and landing gear extended resulted in only marginal climb performance.

ORGANIZATIONAL AND MANAGEMENT INFORMATION

According to its website, Vein Guys® was a group of four physicians that operated several vein care centers in the southeastern United States, with offices in Augusta, Georgia; Atlanta, Georgia; Nashville, Tennessee; and Raleigh, North Carolina. According to interviews, the Pavilion Group was a subsidiary established by the owners of Vein Guys® to handle all business activities associated with the ownership and operation of its private airplane, which it used to shuttle physicians and staff between their offices in Georgia, Tennessee, and North Carolina and also for private flights to vacation destinations.

Before owning the accident airplane, the Pavilion Group owned a King Air 300 (N401BL) and used the pilot services of Executive Shuttle (owned by the accident pilot). The Pavilion Group sold the King Air and, in June 2012, purchased the accident airplane and continued to use the pilot services of Executive Shuttle. The Pavilion Group's airplanes were operated under the provisions of 14 CFR Part 91. According to the accident pilot, the Pavilion Group paid for the pilot's initial and recurrent Premier IA ground and simulator training at FlightSafety. Although Executive Shuttle operated as Sky's the Limit, a 14 CFR Part 135 certificate holder, the pilot stated in interviews that there was no signed contract between Executive Shuttle and the Pavilion Group (or Vein Guys®) for pilot services on the Pavilion Group's airplane, and all Premier IA flights Executive Shuttle operated for the Pavilion Group were conducted under 14 CFR Part 91.

ADDITIONAL INFORMATION

Takeoff Warning System

The airplane was equipped with a takeoff configuration warning system that provided an automatic aural warning to the flight crew during the initial portion of takeoff if the airplane was in a configuration that would not allow for a safe takeoff. The aural warning would continue until the airplane's configuration was changed to allow for safe takeoff, until action was taken by the pilot to abandon the takeoff roll, or until weight was off of the wheels. If either lift dump surface was not retracted, the speed brake/lift dump lever sensors were in the extended range, either flap position was greater than 22 degrees, or the pitch trim was outside of a predetermined range for takeoff, the aural warning would activate in the cockpit.

Antiskid System Failure and Pilot's Corrective Action

Pilots receiving training at FlightSafety on the Premier IA were taught to use the FAA approved Abbreviated Pilot Checklist to handle system malfunctions. A failure of the antiskid system was included in the Abnormal Procedures section of the checklist. According to the checklist, the pilot should move the antiskid switch to OFF and plan for a flaps 10 or flaps up landing. The antiskid failure procedure also provided a note stating that landing distance would increase about 130 percent with flaps up and 89 percent with flaps 10.

According to the Antiskid Failure Checklist (which is within the Abbreviated Pilot Checklist), the pilot was required to account for the loss of the antiskid system by applying a performance penalty to the normal landing distance, depending on the flap setting selected (flaps 10 or flaps up). Using weather conditions that prevailed at HQU at the time of the accident, the required landing distance with flaps up was 7,066 ft, and the required landing distance with flaps 10 was 5,806 ft. HQU runway 10's available runway length for landing was 5,208 ft, which did not meet the flaps up or flaps 10 performance penalty requirements, and a diversion to a longer runway would have been required. The Premier IA AFM Antiskid Fail procedure included a note that stated, "Use of flaps 20 or DN (30) for landing, with anti-skid failed, is prohibited."

The simulator instructor who provided the pilot's initial training stated in a postaccident interview that he would expect the pilot to use the written checklist for a systems failure, determine the proper flap setting for landing, and then apply the performance penalty for the landing, adding that the Antiskid Failure Checklist emphasized that the landing must be made with only flaps 10 or UP. According to the pilot's FlightSafety training records, he received antiskid system failure training during his recurrent simulator training on January 4, 2013.

On June 17, 2013, both pilots listened to the CVR recording for the accident flight, and according to subsequent interviews, neither pilot recalled seeing the ANTI SKID FAIL annunciator light illuminated on the approach. According to interviews with both pilots and a review of the CVR recording, the ANTI SKID FAIL abnormal checklist as outlined in the Abbreviated Pilot Checklist for the Premier IA was not conducted by the accident crew before landing at HQU. Further, the pilot stated that he did not think they needed the antiskid system on the landing at HQU and said the performance penalty would only apply if you were "trying to make your numbers" in the book made by the test pilots by applying maximum braking.

Balked Landing/Go-Around

According to recorded data and witness statements, the flight crew attempted a go-around after landing at HQU. The pilot did not recall the event during interviews, while the copilot stated that they conducted a go-around after the airplane touched down. Procedures for the Premier IA (AFM and Pilot Checklist) referred to the discontinuation of a landing approach as a "balked landing."

According to the FAA's Airplane Flying Handbook (FAA-H-8083, page G-2), a balked landing was synonymous with a go-around. Per the FAA Pilot/Controller Glossary, a go around was a situation when a pilot abandons his/her approach to land. The Airplane Flying Handbook (chapter 8), "Approaches and Landings," states the following: "The go around is not strictly an emergency procedure. It is a normal maneuver that may at times be used in an emergency situation.…Although the need to discontinue a landing may arise at any point in the landing process, the most critical go-around will be one started when very close to the ground. Therefore, the earlier a condition that warrants a go-around is recognized, the safer the go around/rejected landing will be."

According to the FAA's Aeronautical Information Manual (page PCG T-4), a touchdown was the point at which an aircraft first made contact with the landing surfaces. The Airplane Flying Handbook (FAA-H-8083-3A, page 8-7) explained that the landing process was not over until the airplane decelerated to a normal taxi speed or came to a complete stop. The FAA indicated in its May 14, 2013, response to NTSB Information Request 13-267 that a pilot may execute a balked landing/go-around if he/she determined that, after first contact with the landing surface, positive control had not been maintained or if continuing the landing process may expose the aircraft to unsafe conditions such as an unexpected appearance of hazards on the runway.

FlightSafety Premier IA instructors and evaluators in Wichita, Kansas, and Wilmington, Delaware, stated during postaccident interviews that a balked landing was an airborne maneuver typically taught to be performed at an altitude of 50 ft on the approach, and Premier pilots were not taught to execute a balked landing in the Premier IA following touchdown on the runway. The FlightSafety instructors and evaluators also stated that they discouraged students from executing a balked landing after touchdown. Beechcraft Premier IA manuals and FlightSafety training guidance for the Premier IA do not contain language prohibiting a balked landing procedure after touchdown.

The pilot told investigators that he did not recall if anyone at FlightSafety told him not to conduct a go-around or balked landing after touching down during his training. The pilot also stated that the only balked landings he conducted in training were while airborne. When asked by investigators if he recalled anyone at FlightSafety telling him not to conduct a go-around or balked landing after touching down, the pilot said "no." The pilot further stated that a balked landing was something that occurred in the air, and on the ground it was called a "touch and go." The pilot did not remember ever doing a touch and-go in the simulator and had never done one in a Premier.

On March 29, 2011, the NTSB issued Safety Recommendation A-11-18, asking the FAA to "require manufacturers of newly certificated and in-service turbine-powered aircraft to incorporate in their Aircraft Flight Manuals a committed-to-stop point in the landing sequence (for example, in the case of the Hawker Beechcraft 125-800A airplane, once lift dump is deployed) beyond which a go-around should not be attempted." On June 10, 2013, the FAA indicated that it was impractical to fully implement the recommendation but that it would address the NTSB's concerns by issuing an Information for Operators (InFO). Pending the issuance of the InFO and the NTSB's review of an acceptable plan of action to ensure that all operators incorporate the guidance, the NTSB classified Safety Recommendation A-11-18 "Open—Acceptable Alternate Response."


http://registry.faa.gov/N777VG

NTSB Identification: ERA13MA139
14 CFR Part 91: General Aviation
Accident occurred Wednesday, February 20, 2013 in Thomson, GA
Aircraft: BEECH 390, registration: N777VG
Injuries: 5 Fatal,2 Serious.

This is preliminary information, subject to change, and may contain errors. Any errors in this report will be corrected when the final report has been completed. NTSB investigators traveled in support of this investigation and used data obtained from various sources to prepare this aircraft accident report.

On February 20, 2013, at 2006 eastern standard time, a Beechcraft 390 Premier 1A, N777VG, was destroyed following a collision with a utility pole, trees, and terrain following a go-around at Thomson-McDuffie Regional Airport (HQU), Thomson, Georgia. The airline transport-rated pilot and co-pilot were seriously injured, and five passengers were fatally injured. The airplane was registered to the Pavilion Group LLC and was operated by the pilot under the provisions of 14 Code of Federal Regulations Part 91 as a business flight. Night visual meteorological conditions prevailed, and an instrument flight rules flight plan was filed. The flight originated at John C. Tune Airport (JWN), Nashville, Tennessee, about 1828 central standard time (1928 eastern standard time).

The purpose of the flight was to transport staff members of a vascular surgery practice from Nashville to Thomson, where the airplane was based. According to initial air traffic control information, the pilot checked in with Augusta approach control and reported HQU in sight. About 2003, the pilot cancelled visual flight rules flight-following services and continued toward HQU. The last recorded radar return was observed about 2005, when the airplane was at an indicated altitude of 700 feet above mean sea level and 1/2 mile from the airport. There were no distress calls received from the crew prior to the accident.

Witnesses reported that the airplane appeared to be in position to land when the pilot discontinued the approach and commenced a go-around. The witnesses observed the airplane continue down the runway at a low altitude.

The airplane struck a poured-concrete utility pole and braided wires about 59 feet above ground level. The pole was located about 1/4 mile east the departure end of runway 10. The utility pole was not lighted. During the initial impact with the utility pole, the outboard section of the left wing was severed. The airplane continued another 1/4 mile east before colliding with trees and terrain. A postcrash fire ensued and consumed a majority of the airframe. The engines separated from the fuselage during the impact sequence. On-scene examination of the wreckage revealed that all primary airframe structural components were accounted for at the accident site. The landing gear were found in the down (extended) position, and the flap handle was found in the 10-degree (go-around) position.

An initial inspection of the airport revealed that the pilot-controlled runway lights were operational. An examination of conditions recorded on an airport security camera showed that the runway lights were on the low intensity setting at the time of the accident. The airport did not have a control tower. An inspection of the runway surface did not reveal any unusual tire marks or debris.

Weather conditions at HQU near the time of the accident included calm wind and clear skies.



The cases are  Davidson v. Georgia Power Co., No. 2013CV236154; McCorkle v. Georgia Power Co., No. 2013CV236158; Porter v. Georgia Power Co., No. 2013CV236151; and Volpitto v. Georgia Power Co., No. 2013236150 


The families of four of the five passengers killed when an executive jet crashed while trying to land at Thomson-McDuffie County Airport in February have sued multiple defendants in Fulton County Superior Court, including the airport authority, its municipal owners and the Georgia Power Co., which owned a power pole and lines the plane hit.

One pilot walked away and the other suffered serious injuries after the Beechcraft Premier 1 crashed at about 8 p.m. on Feb. 20. According to the complaints and contemporaneous news accounts, the plane was arriving from Nashville's John C. Tune Airport and preparing to touch down when the pilots aborted the landing to circle around for another attempt. Then it struck a tree and an unlighted 60-foot concrete utility pole about a quarter-mile from the end of the runway, shearing off a wing and catching fire before it crashed into the ground, where most of the wreckage burned.

Killed were Dr. Steven Roth, a vascular surgeon, nurse anesthetist Lisa Volpitto, ultrasound technicians Heidi McCorkle and Tiffany Porter, and Kim Davidson, a secretary. All worked for The Vein Guys, a vascular practice with offices in Atlanta, Augusta and Nashville.

Rescuers found the pilot, Jeremy Hayden, walking near the wreckage of the plane. The co-pilot, Richard Trammell, was still strapped into his cockpit seat and was hospitalized with critical injuries.

On Sept. 9, the survivors of Volpitto, McCorkle, Porter and Davidson filed suit, naming as defendants Georgia Power and its parent, Southern Co.; the city of Thomson and McDuffie County, joint owners of the airport and the airport authority; Milliken & Co., the chemical and textile company whose Kingsley Plant at the end of the runway provided the easement for the utility pole; Spirit Aviation, the airport's operator; and The Sky's the Limit d/b/a Executive Shuttle, a company owned by Trammell that employed both pilots.

Three of the suits also name Pavilion Group, the company that owned the aircraft, and the estate of victim Roth, who owned Pavilion; his widow and executrix, Mary Anne Roth, is also named. The fourth was filed on behalf of Volpitto's daughter and husband, Augusta anesthesiologist G. David Volpitto, who—according to a story in The Augusta Chronicle—also worked with The Vein Guys.

All four suits, filed simultaneously, accuse all the defendants of negligence leading to the accident. Moraitakis & Kushel partner Nicholas Moraitakis, representing the McCorkle and Porter survivors, said that there had been "some cooperation and coordination" among the plaintiffs.

"The only thing I can say is that it's very early in the process, and I'm not in any position to offer any other comment," said Moraitakis.

The attorneys for Davidson and Volpitto, John Clark of Macon's Clark & Smith and Turner Padget Graham & Laney partner Wayne Byrd of Myrtle Beach, S.C., respectively, did not respond to requests from comment.

According to a public probate notice, Roth's estate is represented by William Fletcher of Augusta's Fletcher, Harley & Fletcher. He could not be reached.

A spokesman for Georgia Power said he could not comment on the litigation.

The cases are Davidson v. Georgia Power Co., No. 2013CV236154; McCorkle v. Georgia Power Co., No. 2013CV236158; Porter v. Georgia Power Co., No. 2013CV236151; and Volpitto v. Georgia Power Co., No. 2013236150

Original Article:   http://www.dailyreportonline.com


Related:  http://www.wrdw.com