Sunday, September 07, 2014

Socata TBM700N (TBM900), N900KN: Fatal accident occurred September 05, 2014 in Caribbean Sea

Larry and Jane Glazer


The National Transportation Safety Board did not travel to the scene of this accident. 

Additional Participating Entities: 
Federal Aviation Administration; Washington, District of Columbia
Federal Aviation Administration; Miami, Florida
Bureau d'Enquêtes et d'Analyses; Toulouse, France

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

Investigation Docket - National Transportation Safety Board: https://dms.ntsb.gov/pubdms

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

NEW 51LG LLC: http://registry.faa.gov/N900KN

NTSB Identification: ERA14LA424
14 CFR Part 91: General Aviation
Accident occurred Friday, September 05, 2014 in Caribbean Sea, Unknown
Probable Cause Approval Date: 11/14/2017
Aircraft: SOCATA TBM 700, registration: N900KN
Injuries: 2 Fatal.

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 commercial pilot and his wife departed New York in their turboprop airplane on a cross-country flight to Florida. About 1 hour 40 minutes into the flight and while cruising at flight level (FL) 280, the pilot notified air traffic control (ATC) of an abnormal indication in the airplane and requested a descent to FL180. The responding controller instructed the pilot to descend to FL250 and turn left 30°, and the pilot acknowledged and complied with the instruction; he then again requested a lower altitude. Although the pilot declined emergency handling and did not specify the nature of the problem, the controller independently determined that the flight had encountered a pressurization issue and immediately coordinated with another ATC facility to clear nearby traffic. The controller then issued instructions to the pilot to descend to FL200 and change course; however, the pilot did not comply with the assignments despite acknowledging the instructions multiple times. The pilot’s failure to comply with the controller’s instructions, his long microphone pauses after concluding a statement over the radio, and his confusion were consistent with cognitive impairment due to hypoxia. Further, the pilot’s transmissions to ATC indicated impairment within 2 minutes 30 seconds of reporting the abnormal indication, which is consistent with the Federal Aviation Administration’s published time of useful consciousness/effective performance time ranges for the onset of hypoxia. 

Military airplanes were dispatched about 30 minutes after the pilot’s final transmission to ATC to intercept and examine the airplane. The pilots of the military airplanes reported that the airplane appeared to be flying normally at FL250, that both occupants appeared to be asleep or unconscious, and that neither occupant was wearing an oxygen mask. Photographs taken from one of the military airplanes revealed that the airplane’s emergency exit door was recessed into the fuselage frame, consistent with a depressurized cabin. The military airplanes escorted the airplane as it continued on a constant course and altitude until it approached Cuban airspace, at which point they discontinued their escort. Radar data indicated that the airplane continued on the same flight track until about 5 hours 48 minutes after takeoff, when it descended to impact in the Caribbean Sea north of Jamaica. The flight’s duration was consistent with a departure with full fuel and normal cruise endurance. 

Some of the wreckage, including fuselage and engine components, was recovered from the ocean floor about 4 months after the accident. Data recovered from nonvolatile memory in the airplane’s global air system controller (GASC) indicated that several fault codes associated with the cabin pressurization system were registered during the flight. These faults indicated that the overheat thermal switch (OTSW), which was associated with overheat protection, had activated, which resulted in a shutdown of the engine bleed air supply to the cabin pressurization system. Without a bleed air supply to maintain selected cabin pressure, the cabin altitude would have increased to the altitude of the outside environment over a period of about 4 minutes. 

The faults recorded by the GASC’s nonvolatile memory and associated system alerts/warnings would have been displayed to the pilot, both as discrete system anomaly messages on the crew alerting system (CAS) and as master warning and/or master caution annunciations. A witness report indicated that the pilot was known to routinely monitor cabin altitude while flying in the airplane and in his previous pressurized airplanes. Based on his instrument scanning practices and the airplane’s aural warning system, he likely would have observed any CAS message at or near its onset. Thus, the CAS messages and the associated alerts were likely the precipitating event for the pilot’s call to ATC requesting a lower altitude. 

The pilot was likely not familiar with the physiological effects of hypoxia because he had not recently been in an altitude chamber for training, but he should have been familiar with the airplane’s pressurization system emergency and oxygen mask donning procedures because he had recently attended a transition course for the accident airplane make and model that covered these procedures. However, the pressurization system training segment of the 5-day transition course comprised only about 90 minutes of about 36 total hours of training, and it is unknown if the pilot would have retained enough information to recognize the significance of the CAS messages as they appeared during the accident flight, much less recall the corresponding emergency procedures from memory. Coupled with the pilot’s reported diligence in using checklists, this suggests that he would have attempted a physical review of the emergency procedures outlined in the Pilot’s Operating Handbook (POH). A review of the 656-page POH for the airplane found that only one of the four emergency checklist procedures that corresponded to pressurization system-related CAS messages included a step to don an oxygen mask, and it was only a suggestion, not a mandatory step. The combined lack of emergency guidance to immediately don an oxygen mask and the rapid increase in the cabin altitude significantly increased the risk of hypoxia, a condition resistant to self-diagnosis, especially for a person who has not recently experienced its effects in a controlled environment such as an altitude chamber. 

Additionally, once the pilot reported the problem indication to ATC, he requested a descent to FL180 instead of 10,000 ft as prescribed by the POH. In a second transmission, he accepted FL250 and declined priority handling. These two separate errors were either early signs of cognitive dysfunction due to hypoxia or indications that the pilot did not interpret the CAS messages as a matter related to the pressurization system. 

Although the cabin bleed-down rate was 4 minutes, the pilot showed evidence of deteriorating cognitive abilities about 2 minutes 30 seconds after he initially reported the problem to ATC. Ultimately, the pilot had less than 4 minutes to detect the pressurization system failure CAS messages, report the problem to ATC, locate the proper procedures in a voluminous POH, and complete each procedure, all while suffering from an insidious and mentally impairing condition that decreased his cognitive performance over time.

Following the accident, the airplane manufacturer revised the emergency procedures for newly manufactured airplanes to require flight crews to don their oxygen masks as the first checklist item in each of the relevant emergency checklists. Further, the manufacturer has stated that it plans to issue the same revisions for previous models in 2017. 

The airplane manufacturer previously documented numerous OTSW replacements that occurred between 2008 and after the date of the accident. Many of these units were removed after the GASC systems in their respective airplanes generated fault codes that showed an overheat of the bleed air system. Each of the OTSWs that were tested at the manufacturer’s facility showed results that were consistent with normal operating units. Additionally, the OTSW from the accident airplane passed several of the manufacturer’s functional tests despite the presence of internal corrosion from sea water.

Further investigation determined that the pressurization system design forced the GASC to unnecessarily discontinue the flow of bleed air into the cabin if the bleed air temperature exceeded an initial threshold and did not subsequently fall below a secondary threshold within 30 seconds. According to the airplane manufacturer, the purpose of this design was to protect the structural integrity of the airplane, the system, and the passengers in case of overheat detection. As a result of this accident and the ensuing investigation, the manufacturer made changes to the programming of the GASC and to the airplane’s wiring that are designed to reduce the potential for the GASC to shut off the flow of bleed air into the cabin and to maximize the bleed availability. 

Contrary to its normal position for flight, the cockpit oxygen switch was found in the “off” position, which prevents oxygen from flowing to the oxygen masks. A witness’s description of the pilot’s before starting engine procedure during a previous flight showed that he may not have precisely complied with the published procedure for turning on the oxygen switch and testing the oxygen masks. However, as the pilot reportedly was diligent in completing preflight inspections and checklists, the investigation could not determine why the cockpit oxygen switch was turned off. Further, because the oxygen masks were not observed on either occupant, the position of the oxygen switch would not have made a difference in this accident. 

See the public docket for this accident for comments from the Bureau d’Enquêtes et d’Analyses. 

The National Transportation Safety Board determines the probable cause(s) of this accident as follows:

The design of the cabin pressurization system, which made it prone to unnecessary shutdown, combined with a checklist design that prioritized troubleshooting over ensuring that the pilot was sufficiently protected from hypoxia. This resulted in a loss of cabin pressure that rendered the pilot and passenger unconscious during cruise flight and eventually led to an in-flight loss of power due to fuel exhaustion over the open ocean. 

 Larry Glazer


NTSB Identification: ERA14LA424
14 CFR Part 91: General Aviation
Accident occurred Friday, September 05, 2014 in Caribbean Sea, Unknown
Aircraft: SOCATA TBM 700, registration: N900KN
Injuries: 2 Fatal.

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

HISTORY OF FLIGHT

On September 5, 2014, about 1410 eastern daylight time (EDT), a Daher-Socata TBM700 (marketed as a TBM900 model), N900KN, was destroyed when it impacted open water in the Caribbean Sea near the northeast coast of Jamaica. The commercial pilot and the passenger were fatally injured. An instrument flight rules flight plan was filed for the cross-county flight that originated from Greater Rochester International Airport (ROC), Rochester, New York, at 0826 and was destined for Naples Municipal Airport (APF), Naples, Florida. The personal flight was conducted under the provisions of Title 14 Code of Federal Regulations (CFR) Part 91.

The pilot used a fixed based operator (FBO) at ROC, his home airport, to hangar the airplane. On the day of the accident, FBO personnel towed the airplane to the ramp in advance of the pilot's arrival. The pilot arrived at the airport before the passenger, who was his wife, and briefly spoke with two of the FBO employees, who described his demeanor as relaxed. Once his wife arrived, they loaded their bags and then boarded the airplane. An FBO employee pulled the chocks and marshalled the airplane off the FBO ramp. 

Surveillance video retrieved from the ROC airport showed that the airplane departed at 0826. According to recorded Federal Aviation Administration (FAA) air traffic control (ATC) information, a controller instructed the pilot to climb to 9,000 ft mean sea level (msl) and fly direct to a waypoint on the pilot's flight plan. Several minutes later, the controller instructed the pilot to climb to Flight Level (FL) 280, and the pilot complied. The flight proceeded without incident for about 45 minutes. 

About 0912, ATC lost communications with the airplane for a few minutes. The airplane was operating in Cleveland Center's airspace at FL280 when the pilot was instructed to contact the controller of the next sector; however, he did not acknowledge the handoff or attempt to contact the handoff controller on the provided frequency. The controllers made multiple attempts to contact the pilot, but the pilot did not respond until about 4 minutes 30 seconds after the controller's initial handoff instruction. The pilot reported to the controller that "ah something happened I don't know what happened to you but we're back." The controller subsequently issued a new frequency, which the pilot acknowledged. 

About 0917, the passenger contacted the new sector as previously instructed. The sector controller instructed the flight to contact Washington Center and provided a new frequency. The passenger acknowledged the instruction and checked in with the controller at Washington Center. All further radio communications from the airplane were made by the pilot. 

At 1003:11, the pilot checked in with an Atlanta Center controller as instructed and confirmed that the flight was level at FL280. About 1 minute later, the pilot radioed "nine hundred kilo november we need to descend ah down to about one eight zero we ah have an indication that's not correct in the plane." The controller cleared the flight to FL250, and the pilot acknowledged, "two five zero and we need to get lower nine hundred kilo november." The controller asked whether the pilot was declaring an emergency, and at 1004:50, the pilot replied, "ah not yet but we'll let you know;" radar data indicated that the airplane had started to descend from FL280 and was at FL277 when this transmission occurred. The controller instructed the flight to turn left 30°, and at 1005:02, the pilot acknowledged, "thirty left nine hundred kilo November." The pilot's speech during this period did not display any anomalies.

About 1005, the controller contacted another ATC facility to coordinate the airplane's clearance to a lower altitude. Although the pilot had not declared an emergency and had not specified the nature of his problem, the second facility agreed to redirect another airplane after the controller reported that the pilot had "a pressurization issue." By 1006, the controller had coordinated efforts to descend the airplane to FL200 and then to FL180. 

At 1006:35, while the airplane was at FL250, the controller cleared the flight to descend and maintain FL200. After receiving no acknowledgement, the controller repeated his instruction at 1006:43, and the pilot quickly acknowledged, "two zero zero nine hundred kilo november." A continuation of the carrier signal on the audio recording indicated that the airplane transmit switch remained keyed (activated) for about 4 seconds after the pilot concluded his statement. Radar data showed that the airplane remained at FL250 instead of descending as cleared by ATC and acknowledged by the pilot.

At 1007:17, the controller cleared the flight direct to the Taylor VOR. No verbal response from the flight occurred, but the audio recording contained about 2 seconds of carrier signal, indicating that the airplane's radio transmit switch was keyed. The controller repeated his clearance, and at 1007:36, the pilot immediately responded, "direct taylor nine hundred kilo november." Radar data shows the airplane did not alter its course toward the Taylor VOR. 

At 1008:10, the controller asked the flight to confirm that it had received the descent clearance to FL200. At 1008:15, the pilot replied, "two zero zero kilo November." Review of the audio recording indicated that the pilot's voice was faint during this transmission.

At 1008:40, the controller stated, "November zero kilo November descend and maintain flight level two zero zero and you are cleared direct taylor." The pilot responded immediately with, "direct kilo November nine hundred kilo November." Review of the audio recording indicated that the faintness in the pilot's voice associated with the previous call was gone. Subsequently, the controller made numerous attempts to contact the pilot, but no further radio transmissions (either verbal or carrier signal) from the flight were received. 

About 1039, two Air National Guard (ANG) F-16s from McEntire Joint National Guard Base (MMT), Eastover, South Carolina, were vectored to intercept N900KN about 40 miles southeast of MMT. Minutes later, the F-16s intercepted the airplane on a 165° magnetic heading at FL250 and 175 knots indicated airspeed. One of the ANG pilots made several radio calls to the accident airplane but did not receive a response. The F-16s completed a visual inspection of the airplane, which did not reveal any visible damage to the airplane or an accumulation of ice; however, there was a small line of condensation noted along the bottom of the right cockpit window. The engine was running, and the anti-collision lights were operating normally. According to a statement from one of the ANG pilots, he observed two occupants in the cockpit. The left seat was occupied by a male seated with his back straight, while the right seat occupant's torso and head were slouched against the fuselage aft of the right cockpit window. The ANG pilot also observed headsets on both occupants and noted that the left seat occupant's boom mic was pointed straight up. About 1 hour 20 minutes after the airplane was first intercepted, the left seat occupant's head slumped forward, which enabled the ANG pilots to see his chest rising and falling. Neither occupant was wearing an oxygen mask. 

Two F-15s from Homestead Air Reserve Base (HST), Homestead, Florida, relieved the F-16s about 70 miles east of Daytona Beach, Florida about 1 hour after the initial intercept. According to one of the F-15 pilots, the airplane maintained the same heading, airspeed, and altitude as noted by the F-16 intercept from MMT. According to one of the F-15 pilot's statement, he did not observe any signs of smoke or fluids coming from the engine, which continued to function normally. The exterior lights and instrument panel were illuminated; however, the distance between the airplanes prevented the intercept pilots from reading the indications on the glass panel display. According to one of the F-15 pilots, the intercept group disengaged from the airplane before the flight reached Cuba. 

The intercept from HST captured several digital camera photographs of the airplane that were forwarded to the NTSB. Review of the photographs confirmed that neither occupant was wearing an oxygen mask. Magnification of the photographs showed that the bottom corners of the emergency exit door on the right side of the cabin appeared to be recessed into the fuselage frame. A postaccident demonstration by the manufacturer revealed that the airplane's emergency exit door protruded out from the fuselage frame when the airplane was pressurized. 

According to a review of FAA radar data, about 1409, the airplane entered a high rate of descent from FL250. The last radar target was recorded over open water about 10,000 ft msl, about 20 nautical miles north of Port Antonio, Jamaica. 

Search aircraft and watercraft from the Jamaican Defense Authority and the United States Coast Guard observed an oil slick and small pieces of debris scattered over 1/4 mile near the last radar target. The airplane was subsequently located by an autonomous underwater vehicle and recovered by a salvage effort about 4 months after the accident.

PERSONNEL INFORMATION

Pilot

The pilot, age 68, held a commercial pilot certificate with ratings for airplane single-engine land and instrument airplane. His most recent FAA third-class medical certificate was issued on August 6, 2013, with the limitation "must wear glasses for distant [vision], [and] have glasses for near vision." A pilot data information sheet provided by SIMCOM Aviation Training showed that, at the time of his most recent training, which took place 1 week before the accident, the pilot reported a total of 7,100 flight hours with 240 hours within the preceding 12 months. The pilot's personal logbook(s) were not located after the accident. According to a friend of the pilot, the pilot had a high altitude endorsement, but he may not have received any training experience in an altitude chamber.

Before he purchased the accident airplane, the pilot had owned two other Daher-Socata TBM700 airplanes, a TBM700 "A" model (N51HT) and a TBM850 "Legacy" model (N51LG). According to a service center, the pilot purchased the A model in 1994 and accumulated about 2,700 flight hours in the airplane. He subsequently purchased the TBM850 model without a G1000 avionics suite, which he flew for about 1,250 hours before buying the accident airplane in April 2014. 

The pilot's insurance policy authorized only the pilot and one other person to act as pilot in command of the accident airplane. Maintenance records indicated that the airplane was flown about 52 hours between the time the pilot purchased it and June 20, 2014. Data retrieved from a public flight tracking service showed that the airplane had accumulated about 50 additional flight hours between June 20, 2014, and the date of the accident. A cross-check of the flight tracking service's data with the FBO's departure/arrival log validated each flight with the exception of two arrivals. Thus, the maintenance records and flight tracking service data indicated that the airplane had been flown about 102 hours since the pilot acquired it.

The pilot completed a 5-day training course on the TBM900 at SIMCOM Aviation Training Center, Orlando, Florida on August 29, 2014, to satisfy an insurance policy requirement. According to a representative of SIMCOM, the course duration would have been about 8 hours per day for the first 3 days and about 6 hours per day for the remaining 2 days. The representative stated that the course's ground training addressed the technical aspects of the TBM900's airframe, engine, and avionics and included a review of the environmental system. The course's simulator training included environmental system inspections, failures, the controls for smoke or fume elimination, and emergency descent procedures. Proper oxygen mask donning procedures were also demonstrated and discussed. The pilot's instructor at SIMCOM stated that he instructs students to don their oxygen masks before troubleshooting any pressurization problems. The instructor further stated that he likely spent 45 minutes on pressurization system training in the classroom and another 45 minutes in the simulator. The airplane manufacturer reported that, at the time of the accident, SIMCOM had the only simulator that could present crew alerting system (CAS) messages related to the TBM900 pressurization system.

The pilot attended the course with a friend who was the other named pilot on the airplane's insurance policy, frequently accompanied him during personal flights, and commonly shared crewmember duties. According to the friend, who attended the first 3 days of the 5-day course, the pilot used a Garmin G1000 simulator program on his personal computer to familiarize himself with the system in advance of the SIMCOM course as this was his first airplane with a full glass cockpit display. 

The pilot and his friend completed numerous flights together, including twelve flights in the accident airplane. He stated that the pilot was "religious" about adjusting the cabin altitude in flight; in the TBM850, the pilot would normally enter a climb and adjust cabin altitude simultaneously. During flights in the TBM900, he observed the pilot monitor cabin altitude by placing his finger on the multi-function display to verify cabin altitude during each instrument scan. 

According to the pilot's friend, the pilot completed an "external walk around" inspection of the airplane before each flight. During inspections, the pilot's friend observed him physically open the door to the oxygen bottle and verify that the oxygen cylinder's valve was on. The pilot further used a gauge in the cockpit to confirm the flow of oxygen after he turned the cockpit oxygen switch on and tested the oxygen masks. 

Family and friends indicated that the pilot was in excellent health. He was an occasional cigar smoker, took one medication for cholesterol, rarely consumed alcohol, and exercised regularly. The family did not report any unusual behaviors with the pilot or his wife in the 72 hours before the accident. A friend of the pilot stated that the pilot appeared to be in "excellent health and spirits" when he met with him the day before the accident.

Pilot-Rated Passenger

The pilot-rated passenger, age 68, held a private pilot certificate with a rating for airplane single-engine land. She reported a total flight experience of 410 hours on her latest third-class medical certificate application, dated July 1, 1992. The pilot-rated passenger's personal logbook(s) were not located after the accident.

AIRCRAFT INFORMATION

According to FAA records, the Daher-Socata TBM900 model, serial number 1003, was manufactured in 2014 and powered by a single Pratt and Whitney PT6A-66D turbo-prop engine. A standard airworthiness certificate was issued on March 6, 2014, and the airplane was subsequently registered to the pilot on April 8, 2014. 

In March 2014, the factory-new airplane was delivered from the manufacturer's facility in France to an airplane sales and service company in Connecticut with a total of 37.6 flight hours. The service center completed several flights in the airplane before the pilot took possession of it in April 2014, at a total time of 44.3 flight hours. The first in-service inspection prescribed by the manufacturer was performed on June 20, 2014, at which time, the airplane and engine had accrued an additional 52 flight hours.

Airplane Fuel Performance 

A report furnished by the FBO indicated that the airplane was last serviced with 177 gallons of fuel on August 29, 2014. According to the manufacturer's performance calculations, the airplane would have consumed about 23 gallons of fuel in 20 minutes during its climb to cruise altitude (FL280). After reaching FL280, the airplane then flew for about 5 hours 25 minutes. Based on the manufacturer's computation, this corresponds to a mean fuel flow of about 49 gallons per hour, which is consistent with normal cruise flight fuel performance.

Bleed Air and Cabin Pressurization System 

The pilot's operating handbook (POH) states that the global air system is composed of three main subsystems: the engine bleed air system, the environmental control system, and the cabin pressure control system. These three subsystems are managed by a single-channel digital global air system controller (GASC) that receives the information from the sensors in the subsystems and from the cockpit displays and controls and issues the proper commands to the subsystem actuators and indication or warning elements. Specifically, the GASC controls the cabin pressure by modulating the amount of air dispelled from the cabin through the outflow valve. According to the POH, when the BLEED switch is set to AUTO, a ground fan cools down engine bleed air through the main heat exchanger, and the outflow valve (OFV) remains in the full open position until takeoff. After departure, the airplane's GASC controls the aperture of the OFV to reach its computed cabin altitude and rate of change. 

Cabin Pressurization Control Panel

The airplane's maintenance manual shows that, once pressurized bleed air passes ports from the engine case, the BLEED switch enables GASC control of the opening of the flow control shut-off valve (FCSOV) and other components. When the BLEED switch is set to AUTO, the pilot controls cabin pressure by the PRES MODE (pressurization mode) switch through one of two modes, AUTO and MAX DIFF. In AUTO mode, the cabin altitude will remain below 10,000 ft msl, and the cabin differential pressure will not exceed 6.2 psi. In MAX DIFF mode, the system will maintain a cabin pressure of 0 ft when the airplane's altitude is below 13,500 ft msl. When the airplane climbs above 13,500 ft msl, the cabin altitude will not exceed 10,000 ft msl or a differential pressure of 6.0 psi. The system can be reset or turned off by setting the BLEED switch to OFF/RST (off/reset). A blocking device between the AUTO and OFF/RST positions prevents the pilot from inadvertently turning the switch to the OFF/RST position.

According to the normal procedures section of the POH, the pilot sets the BLEED switch to the OFF/RST position before starting the engine. After engine start, the pilot sets the BLEED switch to AUTO once the ammeter display is less than 100 amperes. The pilot also sets the A/C and PRES MODE switches to AUTO and adjusts the cabin temperature as necessary. After the adjustments have been made, the checklist does not call for the pilot to check the pressurization system until cruise altitude is reached. 

Engine Bleed Air System 

Bleed air is supplied to the pressurization system by the engine bleed air system, which is comprised of two engine bleed air ports: the P2.5 port, a lower pressure port, and the P3 port, a higher pressure port. A non-return valve (NRV) is fitted at the outlet of the P2.5 port, and an intermediate pressure port sensor (IPPS) is housed between the engine P2.5 port and the NRV. The P3 port contains a solenoid-activated shutoff valve (SOV) installed at the outlet of the P3 port. The SOV is normally sprung-closed and requires the solenoid to open. An overheat thermal switch (OTSW) is fitted beyond the junction of the P2.5 NRV and P3 SOV and before the bleed air reaches the FCSOV. 

The GASC electronic module is designed to maintain a cabin altitude of less than 10,000 ft msl regardless of the pressurization mode setting. For most operations, the P2.5 bleed air supply is sufficient to pressurize the cabin until the airplane reaches a cruise flight altitude where it can operate with a reduced throttle setting. Should the air pressure measured by the IPPS decrease below 9.5 psig, the GASC programming laws will then automatically command the SOV to the open position, thus allowing higher pressure bleed air flow from the P3 line into the pressurization system. The increase in pressure from the P3 line will close the NRV, which isolates the P2.5 port. The GASC will command the SOV to the closed position once the P2.5 pressure returns to a value above 14.5 psig, which resumes the supply of bleed air from the P2.5 port to the pressurization system. 

OTSW Design and Function

The OTSW is a stainless steel tube with a 3-pin threaded connector at one end and a switch module at the opposing end, which contains a bimetallic disc that controls the position of an open-closed electric switch. The switch is threaded into a pneumatic bleed tube upstream of the FCSOV, so that the flow of air from the P2.5 or P3 ports will pass the OTSW. The switch module is flush with the inner wall of the tube. As the module heats to 315° C +/- 5° C, the bimetallic disc will change from a concave to a convex shape. A pin is pushed by the disc during the shape transition to move the contacts to the open position. As the switch cools to 295° C +/- 5° C, the disc is designed to revert to its concave shape, thereby closing the contacts.

Pressurization System Overheat Protection

A function of the GASC programming is to protect the cabin in the event of a bleed air overheat or engine fire. According to the pressurization system manufacturer, when the OTSW detects a temperature of 315° C, the contacts will open, which removes the electrical power that holds the spring-loaded SOV open. This causes the SOV in the P3 tube to close so that the P2.5 port becomes the primary source of bleed air for the cabin. 

The GASC indirectly determines if the OTSW contacts are open or closed by measuring voltage in a parallel circuit. When the GASC detects an open OTSW state, a BLEED_OVHT fault code is recorded in the GASC non-volatile memory (NVM), accompanied by the activation of a 30-second timer. Should the temperature drop below 295° C within 30 seconds, the OTSW will close, and the SOV will be re-energized, which returns the system to P3 mode. 

If the OTSW contact state is still detected as open after the 30 seconds have elapsed, BLEED TEMP and BLEED OFF indications will be annunciated on the CAS, and the GASC will close the FCSOV, which discontinues the flow of bleed air into the cabin. This prompts an illumination of the cockpit master caution warning annunciator light and an aural alarm. In addition, the GASC will record a BLEED_TEMP fault code in the GASC NVM.

Loss of Engine Bleed Air Input to Cabin

Reduced engine bleed air supply to the environmental control system will cause a decrease in cabin pressure that will then cause the GASC to command the OFV to close. Without a bleed air supply to maintain selected cabin pressure, the cabin altitude will continue to increase until it equalizes with the ambient altitude. The rate of cabin depressurization depends upon the difference between the cabin and atmospheric pressures and upon the cabin leakage rate. Cabin leakage is normal and unavoidable, but the rate is limited to a maximum value specified in the airplane maintenance manual. A PC_COMP_OOR fault code will be recorded in the GASC NVM when the cabin pressure is detected to be out of range (below -3,550 ft or above 15,960 ft msl).

Leak Rate Chart

The airplane manufacturer developed and published "leak rate charts" to determine the overall pressure integrity of the airplane, both during manufacture and in service operation. The airplane was equipped with an additional door located on the left side of the cockpit referenced by the airplane manufacturer as a "pilot door." The manufacturer published two separate cabin leak rate charts: one for airplanes equipped with a pilot door and one for those without a pilot door. Each chart contains a line plotted as differential pressure versus time. The line represents the threshold (minimum allowable) time for the cabin pressure to decrease from one differential pressure value to another; that time is inversely proportional to the cabin leak rate. Thus, bleed-down times faster than those defined by the line indicate unacceptably high cabin leak rates, which must be corrected to render the airplane airworthy. 

Review of the chart for airplanes equipped with a pilot door indicated that, at 28,000 ft, once pressurized air ceased to be supplied, the cabin pressure would bleed down to the ambient atmospheric pressure in about 4 minutes. The chart presumes that the cabin integrity is in compliance with the manufacturer's standards and that the OFV closes completely once pressurized air ceases to be supplied. 

Emergency Oxygen System

The airplane's emergency oxygen system is intended to provide oxygen to the flight crew and passengers in the event of a loss of cabin pressurization. Oxygen is stored under high pressure in a single cylinder mounted outside the airplane's pressure vessel and inside the right wing root fairing. The cylinder holds the equivalent of 50.3 cubic ft of oxygen at sea level pressure. 

The flight crew emergency oxygen system is comprised of two oxygen masks with smoke goggles and is manually controlled by a normally-closed OXYGEN switch-operated valve that must be turned ON in order for the system to supply oxygen to the masks. The BEFORE STARTING ENGINE procedure contains a step that calls for the pilot to turn the OXYGEN switch to the ON position. As long as the valve mounted on the physical oxygen cylinder is opened during the relevant PREFLIGHT INSPECTION procedure and the OXYGEN switch is in the ON position, both flight crewmembers will receive oxygen as they breathe if their oxygen masks have been donned.

The flight crew masks are secured in stowage cups located behind the cockpit seats, and each mask is equipped with a microphone, a three-position selector, and a button labeled PRESS TO TEST. To don a cockpit oxygen mask, the occupant must reach behind the opposite seat, remove the mask from its stowage cup, depress two vanes on the mask to inflate the harness, and then place it over their nose and mouth. The remaining oxygen quantity is transmitted by an electrical analog signal output and displayed to the flight crew on the Garmin GDU 1500 multi-function display (MFD). Once the mask is in use, the occupant can enable the mask microphone through the MICRO/MASK switch, which is normally set to MICRO via a switch guard. 

The normal checklists in the POH specified the following numbered steps regarding the emergency oxygen system:

PREFLIGHT INSPECTION Procedure

13 - Rear R.H. karman [wing root fairing]

• Oxygen cylinder – Open

• Oxygen quantity – Checked

14 - Oxygen pressure – Checked

BEFORE STARTING ENGINE Procedure

10 – MICRO/MASK micro inverter - MICRO

42 – Pilot's OXYGEN switch – ON

43 – Front oxygen masks – Checked

Press push button "PRESS TO TEST": the blinker shall turn red momentarily, then turns transparent. 

AFTER STARTING ENGINE Procedure:

4 – Oxygen supply – Available for the planned flight (see tables of paragraph "IN-FLIGHT AVAILABLE OXYGEN QUANTITY" in Chapter 4.4 and Chapter 7.10 for a FAR 135 type operation)

Oxygen Cylinder Maintenance

According to the airplane's maintenance records, a hydrostatic test was last performed in January 2013, and the airplane's oxygen cylinder was last refilled on March 28, 2014. An entry in the airplane logbook showed that the oxygen cylinder was last checked for security, corrosion, distortion, and attachment during the airplane's first inspection in June 2014. A representative of the airplane's service center stated that, at the first inspection, they would have added oxygen and recorded the work in the airplane's logbook if the service quantity was below full. 

Emergency Procedures 

According to the POH, the Emergency Descent procedures are as follows:

MAXIMUM RATE DESCENT

1 – Throttle – Flight IDLE

2 – OXYGEN – USE if necessary

3 – DESCENT - from - 10° to - 20°

Procedure in smooth air

6 - Speed 266 KIAS

Procedure in rough air or in case of structure problem

10 – Maintain IAS = kts

The POH also includes an Emergency Descent procedure for a Maximum Range Descent using the following procedures:

MAXIMUM RANGE DESCENT

1 – Throttle – CUT OFF

2 – Flaps – UP

3 – Landing gear control – UP

4 – SPEED IAS - 120 KIAS

5 – Oxygen – USE if necessary (Check oxygen duration before reaching 12,000 ft and check flow to passengers)

In the event of an anomaly, the avionics system will present warning messages in two different areas of the instrument panel; the CAS box in the MFD and lights labeled as "Master Caution" (red colored) and "Master Warning" (amber colored) located in the upper left corner of the panel between the left seat occupant's primary flight display and the glareshield. When a message appears in the CAS annunciator box, it is accompanied by the illumination of the master light that coincides with the colored CAS message and an aural tone to capture the pilot's attention. A red CAS message will be accompanied by a flashing red "Master Caution" indicator, which requires immediate action from the pilot. An amber CAS message will be accompanied by a fixed amber "Master Caution" indicator, which requires pilot action as soon as practical. The pilot must depress the corresponding red or amber light to terminate the warning tone. 

The 656-page POH includes a 96-page emergency procedures section and a separate 98-page normal procedures section. Four separate pressurization system procedures are included in the emergency section, each of which corresponds to a color-coded CAS message. BLEED TEMP, CABIN DIFF PRESS, and CABIN ALTITUDE appear in red-colored text and BLEED OFF appears in amber-colored text. 

A red BLEED TEMP CAS message, accompanied by both master and aural warnings, indicates an overheat of the bleed air system, which can lead to a termination of bleed air into the cabin and an amber warning and a BLEED OFF CAS message, also accompanied by both a master caution and aural warning. In the event of a "BLEED TEMP" indication, the pilot is instructed to do the following:

1 – If possible – REDUCE POWER

2 – HOT AIR FLOW distributor – turn to the right

3 – CONTROL selector – COCKPIT

4 – TEMP/°C selector – MINI

5 – BLEED switch – OFF/RST

6 – As soon as warning BLEED TEMP off, set BLEED switch to AUTO

When the BLEED OFF amber CAS message indication appears, the pilot is instructed to:

1 – CHECK BLEED switch position and – CORRECT

2 – If possible, reduce power

FLY THE AIRPLANE

3 – BLEED switch – OFF/RST (Reset)

4 – BLEED switch – AUTO

5 – If warning BLEED OFF displayed:

6 – Limit flight altitude to maintain cabin altitude < 10,000 feet

7 – If necessary (no oxygen available) – EMERGENCY DESCENT

8 – Continue flight

A red CABIN ALTITUDE CAS message accompanied by a master and aural warning will appear when the cabin altitude exceeds 10,000 ft ± 500 ft. The POH instructs the pilot to complete the following procedure in the event of this indication:

1 – Pressurization indicator – CHECK

If cabin altitude is greater than 10,000 feet ± 500 feet:

2 – OXYGEN – USE, if necessary

FLY THE AIRPLANE

3 – BLEED switch – CHECK AUTO

4 – DUMP switch – CHECK UNDER GUARD

5 – EMERGENCY RAM AIR control knob – CHECK PUSHED

6 – Limit flight altitude to maintain cabin altitude < 10,000 feet

7 – If necessary – EMERGENCY DESCENT

A CABIN DIFF PRESS message will appear if the cabin pressure differential is over 6.4 psi ± 0.2 psi. The POH instructs the pilot to complete the following procedure in the event of this indication:

1 – Pressurization indicator – CHECK

If pressure change is greater than 6.4 PSI ± 0.2 PSI:

2 – BLEED switch – OFF/RST

3 – Oxygen – Use, if necessary

METEOROLOGICAL INFORMATION

According to an NTSB weather study, the winds aloft at the airplane's cruising altitudes of FL280 and FL250 were from about 270° at 15 knots and 140° at 4 knots, respectively. The study found that the flight encountered some convective activity along the South Carolina coast, about 30 minutes after the pilot's final transmission to ATC. 

WRECKAGE AND IMPACT INFORMATION

According to radar data, the airplane impacted the water at more than 300 knots and separated into small fragments. The wreckage was located by an underwater search vehicle, which revealed a 984-foot-long debris field, at a depth of about 10,000 ft. The debris field included the engine and several sections of the fuselage. Fuselage and engine components of the wreckage were recovered about 4 months after the accident and transported to Panama City, Florida, where NTSB and airplane manufacturer personnel identified and sorted the recovered components. 

Among the components recovered by the investigative team were the FCSOV, the GASC, the SOV, and the Garmin G1000 primary flight display and its SD flash memory card. These items were packaged in sealed containers with distilled water to hinder corrosion before all of the recovered wreckage was transported to a secure facility in Maryland for further examination.

MEDICAL AND PATHOLOGICAL INFORMATION

A forensic examination was performed on the recovered occupant remains by the District Fourteen Medical Examiner, Panama City, Florida. The forensic report confirmed the identity of the occupants through an osteological examination. 

According to a laboratory technician at the FAA Bioaeronautical Sciences Research Laboratory, a hypoxia clinical study could not be completed due to a lack of physical specimens.

TESTS AND RESEARCH

Sound Spectrum Study

An NTSB sound spectrum study showed that the pilot's microphone release time following each statement increased significantly about 2 minutes 30 seconds after he initially reported the "abnormal" indication to ATC. Further, a spectrograph of the radioed call sign revealed that the pilot began slurring his speech about 3 minutes after his initial report of the problem to ATC. 

Non-Piloted Airplane Behavior

According to the airplane manufacturer, once the engine shuts down due to fuel starvation, the airplane will decelerate and increase its angle of attack as the autopilot continues to attempt to maintain altitude until the airplane stalls and the autopilot disengages. 

OFV Examination

The OFV modulates the discharge airflow to control the cabin pressure and is controlled by the GASC through a torque motor. During ground operations, the OFV is normally in the full open position. When the airplane is airborne, the GASC controls the aperture of the OFV to reach the target cabin altitude at an optimized control rate. The OFV and safety valve (SFV) are equipped with overpressure and negative relief safety valves that are controlled by independent pneumatic modules that override the GASC control; these are intended to prevent excessive differential pressure values. The pressurization system manufacturer stated that the OFV and SFV are designed to close within 1 second in response to a cessation of bleed airflow into the cabin. The OFV will remain closed unless negative differential pressure is encountered during a descent. 

The accident airplane's OFV was recovered from the ocean; it remained attached to the aft pressure bulkhead and was not damaged by impact. Saltwater immersion damage and accumulated organic ocean material prevented testing of the torque motor. Scars at the contact interface indicated that the valve was shut at impact. 

SFV Examination

According to the manufacturer's reference materials, the SFV ensures negative pressure relief and prevents cabin overpressure. The SFV is designed to open when the cabin altitude is greater than the outside pressure.

The accident airplane's SFV was recovered from the ocean; it remained attached to the aft pressure bulkhead, but the valve body was fractured at each of the six aluminum braces, and the center body was broken. The valve body could not be manipulated by hand due to damage and accumulated oceanic material, which precluded testing the unit in the manufacturer's air chamber. Multiple functional tests of the subcomponents were completed at the pressurization system manufacturer's facility, including leak tests of the manometric chamber overpressure relief valve, servo chamber, and cabin pressure valve. The SFV tests did not reveal any anomalies, and the component examination indicated that the valve was open about 13 mm at the time of impact. 

GASC NVM Data and Garmin G1000 primary flight display SD Flash Memory Card

According to the pressurization system manufacturer, the GASC NVM stores fault codes in its memory, which are overwritten after each take-off. The fault codes are recorded in the sequence in which they occur without time stamps.

Both the recovered GASC unit and primary flight display SD card were submitted to the NTSB Recorders laboratory for possible data download. The SD card was successfully read but did not contain any accident-related data. 

The GASC was severely damaged by impact forces. The internal NVM data was extracted using laboratory hardware and software provided by the manufacturer of the pressurization system. The data showed multiple CAS message fault codes that were generated by the GASC during the flight, in the following sequence: ECS_HEATING FAULT, BLEED_TEMP, BLEED_OVHT, and PC_COMP_OOR. 

FCSOV Examination

Examination of the recovered FCSOV revealed that the unit was in the closed position and sealed by oceanic deposits. The valve was subsequently disassembled at the pressurization system manufacturer's facility in Toulouse, France. Further examination of the unit's witness marks and actuator components confirmed that it was in a closed position at impact. 

BLEED and PRES MODE Switch Examinations

The recovered BLEED and PRES MODE switches were both found in the AUTO position. The locking gate of each switch displayed an imprint on its AUTO position, and the OFF/RST side of each switch did not display any deformation or imprints, consistent with the switches being in the AUTO position at impact. 

OTSW Examination

The OTSW was recovered from the wreckage and subsequently tested at the manufacturer's facility in Redmond, Washington. After an electrical resistance test, the switch was inserted into a mounting rack alongside an exemplar switch and placed in a static oven that was slowly heated to 336° C. The exemplar unit's contacts opened after 2 minutes 47 seconds. At 3 minutes 25 seconds, the switch burst open with a loud noise and sufficient force to bend the mounting rack, which precluded further testing as the welded area of the switch had split open. Disassembly revealed that the switch had been filled with sea water, which had turned to steam and pressurized the switch until it burst. The dielectric and insulation tests were not performed as a result of this damage.

The top of the switch module was covered in a black residue typical of corrosion and exhibited extensive surface pitting. The larger pits were near the wire terminals and proximal to different types of metal. A microscope examination revealed no evidence of heat or molten globules, but confirmed the presence of flaking, consistent with salt water corrosion. The switch module was subsequently tested inside the static oven after the wires were intentionally separated from the welds at the switch module terminals. Similar to the previous test, the unit was slowly heated until the switch contacts opened, which occurred at 326.8° C. The switch is designed to open at 315° +/- 5°C and close at 295°C +/- 5°C. 

Disassembly of the switch module revealed the presence of brown deposits and extensive rust on the interior surfaces of the module wall that were the result of long-term saltwater immersion. The sleeve that held the bimetallic thermal disc in place was rusted over. A subsequent examination of the switch contacts at the manufacturer's facility showed evidence of electrical wear and material transfer pitting on the contact surfaces. An evaluation was completed by the Air Force Research Laboratory (AFRL) Materials Integrity Branch. The AFRL reported that the wear and pitting were consistent with arc erosion. The evaluation also stated that the damage was typical for a used switch and not considered excessive. 

Examination of OTSWs from Other Airplanes

According to records supplied by the airplane manufacturer, at least 18 OTSWs had been replaced between 2008 and October 2015, including 3 that were replaced after the accident. At least 12 of the records included statements from pilots or mechanics that the cabin had depressurized in flight. 

The three OTSWs that were replaced after this accident were examined and tested at the switch manufacturer's facility. The examinations revealed small amounts of contact wear, which was consistent with having been in service. Two of the three switches passed functional testing, and it was later determined that the third switch had been improperly field tested. The contacts of this unit were not burned, welded, or otherwise abnormal.

The OTSW manufacturer provided contacts from two test switches that had accumulated 100,000 resistive load cycles. The wear area of the contacts from one of the test switches exhibited a wider area of material transfer between the contacts and a pit depth similar to the accident switch contacts. For additional details, please refer to the Systems Group Chairman Factual Report in the NTSB public docket. 

Oxygen Switch Examination

The airplane's oxygen cylinder and flight crew masks were not recovered. An examination of the cockpit OXYGEN switch revealed that it was in the OFF position, which would have prevented the flow of oxygen to the oxygen masks. A subsequent microscopic inspection of the toggle switch base did not show any indication that the switch was in a different position at impact. 

Hypoxia

The FAA's Aeronautical Information Manual (Section 8-1-2) states that "the effects of hypoxia are usually quite difficult to recognize, especially when they occur gradually."

FAA Advisory Circular (AC) 61-107B (Aircraft Operations at Altitudes Above 25,000 Feet Mean Sea Level or Mach Numbers Greater Than .75) states that altitude hypoxia is caused by "an insufficient partial pressure of oxygen in the inhaled air resulting from reduced oxygen pressure in the atmosphere at altitude. Altitude hypoxia poses the greatest potential physiological hazard to a flightcrew member when at altitude. Supplemental oxygen will combat hypoxic hypoxia within seconds. Check your oxygen systems periodically to ensure an adequate supply of oxygen and that the system is functioning properly. Perform this check frequently with increasing altitude. If supplemental oxygen is not available, initiate an emergency descent to an altitude below 10,000 ft MSL."

AC 61-107B includes the following warning concerning altitude hypoxia:

"If hypoxia is suspected, immediately don oxygen mask and breathe 100 percent oxygen slowly. Descend to a safe altitude. If supplemental oxygen is not available, initiate an emergency descent to an altitude below 10,000 ft MSL. If symptoms persist, land as soon as possible." 

AC 61-107B also describes the concept of "time of useful consciousness" (TUC) or "effective performance time" (EPT) as follows:

"This is the period of time from interruption of the oxygen supply, or exposure to an oxygen-poor environment, to the time when an individual is no longer capable of taking proper corrective and protective action. The faster the rate of ascent, the worse the impairment and the faster it happens. TUC also decreases with increasing altitude. Figure 2-3, Times of Useful Consciousness versus Altitude, shows the trend in TUC as a function of altitude. However, slow decompression is as dangerous as or more dangerous than a rapid decompression. By its nature, a rapid decompression commands attention. In contrast, a slow decompression may go unnoticed and the resultant hypoxia may be unrecognized by the pilot."

AC61-107B includes the following warning concerning TUC:

"The TUC does not mean the onset of unconsciousness. Impaired performance may be immediate. Prompt use of 100 percent oxygen is critical."

Figure 2-3 in AC 61-107B indicates that the TUC/EPT for a slow decompression at 28,000 ft is 2.5 to 3 minutes, and at 25,000 ft it is 3 to 5 minutes. The table notes that "the times provided are averages only and based on an individual at rest. Physical activity at altitude, fatigue, self-imposed stress, and individual variation will make the times vary." 

According to The Principles of Clinical Medicine for Space Flight, the "EPT tables were designed with data largely derived from young healthy military aviators seated at rest in altitude chambers." The accident pilot was typical of a more mature population of business owners and non-professional pilots that are required to hold a high altitude endorsement to act as pilot-in-command of an airplane that has a service ceiling or maximum operating altitude above 25,000 ft msl as prescribed by 14 CFR Part 61.31(g)(1). The regulation does not require the endorsement candidate to experience a simulated sudden depressurization in an altitude chamber. 

ADDITIONAL INFORMATION

Airplane Manufacturer Service Bulletin SB70-226 

About 14 months after the accident, in November 2015, the airplane manufacturer issued a service bulletin to address the reports of BLEED OFF CAS messages and the associated shutdowns of the airplane's pressurization system. The service bulletin implements a GASC software revision to maximize bleed availability through a wiring adjustment that causes the FCSOV to remain open and continue the flow of bleed air into the cabin after the OTSW contact state is detected as OPEN. The service bulletin results in the cabin losing heat without depressurizing, and the pilot will continue to receive the visual CAS warning message and aural warning alarm. 

POH Revision

Following the accident, the airplane manufacturer revised some of the emergency checklists in the POH for the TBM930 model (the model of the TBM700 currently in production) to make "Use Oxygen Mask" the first checklist item in the "relevant emergency procedures." The manufacturer plans, in 2017, to make similar revisions to the checklists in the operating handbooks of prior models.

Glazer v. Socata by David Andreatta on Scribd





Transcript of N900KN conversations with air traffic control before the pilot lost consciousness

Pilot: TBM 900KN flight level 280

ATC: November 900KN Atlanta…

Pilot: 900KN we need to descend down to about [flight level] 180, we have an indication … not correct in the plane.

ATC: 900KN descend and maintain 250.

Pilot: 250 we need to get lower 900KN.

ATC: Working on that.

Pilot: Have to get down. And reserve fuel… limit a return… thirty-three left… have to get down.

ATC: Thirty left 900KN

Pilot: 00900KN (holds transmit button)

ATC: N0KN you’re cleared direct to Taylor.

ATC: 0KN, cleared direct to Taylor.

Pilot: Direct Taylor, 900KN.

ATC: Copy that you got descent (slope?) 200…

Pilot: (mumbling)

ATC: Descent and maintain flight level 200, and you are cleared direct Taylor.

Pilot: KN900KN (sounds confused)

ATC: Understand me, descend and maintain flight level 200, flight level 200, for N900KN

ATC: TBM, TBM 0KN, descend and maintain flight level 200

ATC: 0KN, if you hear this, transmit and ident.

ATC: N900KN, Atlanta center, how do you read?

ATC: N900KN, Atlanta Center… AC5685, keep trying N900KN

AC5685: TBM900KN, this is AC5685, how do you read? (Military aircraft?)

ATC: N900KN, Atlanta Center, how do you read?

AC5685: TBM900KN, AC5685, how do you read?

ATC: N900KN, TBM, 900KN, Atlanta Center, how do you hear this…

ATC: N0KN, descent now, descent now to flight level 200.

ATC: N900KN, TBM 900KN, if you hear this transmission, contact … center 127.87

ATC: N0KN, TBM 0KN, contact … center 127.87 if you hear this…


NTSB Identification: ERA14LA424
14 CFR Part 91: General Aviation
Accident occurred Friday, September 05, 2014 in Open Water, Jamaica
Aircraft: SOCATA TBM 700, registration: N900KN
Injuries: 2 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 may not have traveled in support of this investigation and used data provided by various sources to prepare this aircraft accident report.

On September 5, 2014, about 1410 eastern daylight time (EDT), a Socata TBM700 (marketed as TBM900), N900KN, impacted open water near the coast of northeast Jamaica. The commercial pilot/owner and his passenger were fatally injured. An instrument flight rules flight plan was filed for the planned flight that originated from Greater Rochester International Airport (ROC), Rochester, New York at 0826 and destined for Naples Municipal Airport (APF), Naples, Florida. The personal flight was conducted under the provisions of 14 Code of Federal Regulations Part 91.

According to preliminary air traffic control (ATC) data received from the Federal Aviation Administration (FAA), after departing ROC the pilot climbed to FL280 and leveled off. About 1000 the pilot contacted ATC to report an "indication that is not correct in the plane" and to request a descent to FL180. The controller issued instructions to the pilot to descend to FL250 and subsequently, due to traffic, instructed him to turn 30 degrees to the left and then descend to FL200. During this sequence the pilot became unresponsive. An Air National Guard intercept that consisted of two fighter jets was dispatched from McEntire Joint National Guard Base, Eastover, South Carolina and intercepted the airplane at FL250 about 40 miles northwest of Charleston, South Carolina. The fighters were relieved by two fighter jets from Homestead Air Force Base, Homestead, Florida that followed the airplane to Andros Island, Bahamas, and disengaged prior to entering Cuban airspace. The airplane flew through Cuban airspace, eventually began a descent from FL250 and impacted open water northeast of Port Antonio, Jamaica. 

According to a review of preliminary radar data received from the FAA, the airplane entered a high rate of descent from FL250 prior to impacting the water. The last radar target was recorded over open water about 10,000 feet at 18.3547N, -76.44049W. 

The Jamaican Defense Authority and United States Coast Guard conducted a search and rescue operation. Search aircraft observed an oil slick and small pieces of debris scattered over one-quarter mile that were located near the last radar target. Both entities concluded their search on September 7, 2014.
Larry and Jane Glazer


The National Transportation Safety Board did not travel to the scene of this accident. 

Additional Participating Entities: 
Federal Aviation Administration; Washington, District of Columbia
Federal Aviation Administration; Miami, Florida
Bureau d'Enquêtes et d'Analyses; Toulouse, France

Aviation Accident Factual Report - National Transportation Safety Board:  https://app.ntsb.gov/pdf

Investigation Docket - National Transportation Safety Board: https://dms.ntsb.gov/pubdms

NEW 51LG LLC: http://registry.faa.gov/N900KN



 Larry Glazer


NTSB Identification: ERA14LA424
14 CFR Part 91: General Aviation
Accident occurred Friday, September 05, 2014 in Caribbean Sea, Unknown
Aircraft: SOCATA TBM 700, registration: N900KN
Injuries: 2 Fatal.

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

HISTORY OF FLIGHT

On September 5, 2014, about 1410 eastern daylight time (EDT), a Daher-Socata TBM700 (marketed as a TBM900 model), N900KN, was destroyed when it impacted open water in the Caribbean Sea near the northeast coast of Jamaica. The commercial pilot and the passenger were fatally injured. An instrument flight rules flight plan was filed for the cross-county flight that originated from Greater Rochester International Airport (ROC), Rochester, New York, at 0826 and was destined for Naples Municipal Airport (APF), Naples, Florida. The personal flight was conducted under the provisions of Title 14 Code of Federal Regulations (CFR) Part 91.

The pilot used a fixed based operator (FBO) at ROC, his home airport, to hangar the airplane. On the day of the accident, FBO personnel towed the airplane to the ramp in advance of the pilot's arrival. The pilot arrived at the airport before the passenger, who was his wife, and briefly spoke with two of the FBO employees, who described his demeanor as relaxed. Once his wife arrived, they loaded their bags and then boarded the airplane. An FBO employee pulled the chocks and marshalled the airplane off the FBO ramp. 

Surveillance video retrieved from the ROC airport showed that the airplane departed at 0826. According to recorded Federal Aviation Administration (FAA) air traffic control (ATC) information, a controller instructed the pilot to climb to 9,000 ft mean sea level (msl) and fly direct to a waypoint on the pilot's flight plan. Several minutes later, the controller instructed the pilot to climb to Flight Level (FL) 280, and the pilot complied. The flight proceeded without incident for about 45 minutes. 

About 0912, ATC lost communications with the airplane for a few minutes. The airplane was operating in Cleveland Center's airspace at FL280 when the pilot was instructed to contact the controller of the next sector; however, he did not acknowledge the handoff or attempt to contact the handoff controller on the provided frequency. The controllers made multiple attempts to contact the pilot, but the pilot did not respond until about 4 minutes 30 seconds after the controller's initial handoff instruction. The pilot reported to the controller that "ah something happened I don't know what happened to you but we're back." The controller subsequently issued a new frequency, which the pilot acknowledged. 

About 0917, the passenger contacted the new sector as previously instructed. The sector controller instructed the flight to contact Washington Center and provided a new frequency. The passenger acknowledged the instruction and checked in with the controller at Washington Center. All further radio communications from the airplane were made by the pilot. 

At 1003:11, the pilot checked in with an Atlanta Center controller as instructed and confirmed that the flight was level at FL280. About 1 minute later, the pilot radioed "nine hundred kilo november we need to descend ah down to about one eight zero we ah have an indication that's not correct in the plane." The controller cleared the flight to FL250, and the pilot acknowledged, "two five zero and we need to get lower nine hundred kilo november." The controller asked whether the pilot was declaring an emergency, and at 1004:50, the pilot replied, "ah not yet but we'll let you know;" radar data indicated that the airplane had started to descend from FL280 and was at FL277 when this transmission occurred. The controller instructed the flight to turn left 30°, and at 1005:02, the pilot acknowledged, "thirty left nine hundred kilo November." The pilot's speech during this period did not display any anomalies.

About 1005, the controller contacted another ATC facility to coordinate the airplane's clearance to a lower altitude. Although the pilot had not declared an emergency and had not specified the nature of his problem, the second facility agreed to redirect another airplane after the controller reported that the pilot had "a pressurization issue." By 1006, the controller had coordinated efforts to descend the airplane to FL200 and then to FL180. 

At 1006:35, while the airplane was at FL250, the controller cleared the flight to descend and maintain FL200. After receiving no acknowledgement, the controller repeated his instruction at 1006:43, and the pilot quickly acknowledged, "two zero zero nine hundred kilo november." A continuation of the carrier signal on the audio recording indicated that the airplane transmit switch remained keyed (activated) for about 4 seconds after the pilot concluded his statement. Radar data showed that the airplane remained at FL250 instead of descending as cleared by ATC and acknowledged by the pilot.

At 1007:17, the controller cleared the flight direct to the Taylor VOR. No verbal response from the flight occurred, but the audio recording contained about 2 seconds of carrier signal, indicating that the airplane's radio transmit switch was keyed. The controller repeated his clearance, and at 1007:36, the pilot immediately responded, "direct taylor nine hundred kilo november." Radar data shows the airplane did not alter its course toward the Taylor VOR. 

At 1008:10, the controller asked the flight to confirm that it had received the descent clearance to FL200. At 1008:15, the pilot replied, "two zero zero kilo November." Review of the audio recording indicated that the pilot's voice was faint during this transmission.

At 1008:40, the controller stated, "November zero kilo November descend and maintain flight level two zero zero and you are cleared direct taylor." The pilot responded immediately with, "direct kilo November nine hundred kilo November." Review of the audio recording indicated that the faintness in the pilot's voice associated with the previous call was gone. Subsequently, the controller made numerous attempts to contact the pilot, but no further radio transmissions (either verbal or carrier signal) from the flight were received. 

About 1039, two Air National Guard (ANG) F-16s from McEntire Joint National Guard Base (MMT), Eastover, South Carolina, were vectored to intercept N900KN about 40 miles southeast of MMT. Minutes later, the F-16s intercepted the airplane on a 165° magnetic heading at FL250 and 175 knots indicated airspeed. One of the ANG pilots made several radio calls to the accident airplane but did not receive a response. The F-16s completed a visual inspection of the airplane, which did not reveal any visible damage to the airplane or an accumulation of ice; however, there was a small line of condensation noted along the bottom of the right cockpit window. The engine was running, and the anti-collision lights were operating normally. According to a statement from one of the ANG pilots, he observed two occupants in the cockpit. The left seat was occupied by a male seated with his back straight, while the right seat occupant's torso and head were slouched against the fuselage aft of the right cockpit window. The ANG pilot also observed headsets on both occupants and noted that the left seat occupant's boom mic was pointed straight up. About 1 hour 20 minutes after the airplane was first intercepted, the left seat occupant's head slumped forward, which enabled the ANG pilots to see his chest rising and falling. Neither occupant was wearing an oxygen mask. 

Two F-15s from Homestead Air Reserve Base (HST), Homestead, Florida, relieved the F-16s about 70 miles east of Daytona Beach, Florida about 1 hour after the initial intercept. According to one of the F-15 pilots, the airplane maintained the same heading, airspeed, and altitude as noted by the F-16 intercept from MMT. According to one of the F-15 pilot's statement, he did not observe any signs of smoke or fluids coming from the engine, which continued to function normally. The exterior lights and instrument panel were illuminated; however, the distance between the airplanes prevented the intercept pilots from reading the indications on the glass panel display. According to one of the F-15 pilots, the intercept group disengaged from the airplane before the flight reached Cuba. 

The intercept from HST captured several digital camera photographs of the airplane that were forwarded to the NTSB. Review of the photographs confirmed that neither occupant was wearing an oxygen mask. Magnification of the photographs showed that the bottom corners of the emergency exit door on the right side of the cabin appeared to be recessed into the fuselage frame. A postaccident demonstration by the manufacturer revealed that the airplane's emergency exit door protruded out from the fuselage frame when the airplane was pressurized. 

According to a review of FAA radar data, about 1409, the airplane entered a high rate of descent from FL250. The last radar target was recorded over open water about 10,000 ft msl, about 20 nautical miles north of Port Antonio, Jamaica. 

Search aircraft and watercraft from the Jamaican Defense Authority and the United States Coast Guard observed an oil slick and small pieces of debris scattered over 1/4 mile near the last radar target. The airplane was subsequently located by an autonomous underwater vehicle and recovered by a salvage effort about 4 months after the accident.

PERSONNEL INFORMATION

Pilot

The pilot, age 68, held a commercial pilot certificate with ratings for airplane single-engine land and instrument airplane. His most recent FAA third-class medical certificate was issued on August 6, 2013, with the limitation "must wear glasses for distant [vision], [and] have glasses for near vision." A pilot data information sheet provided by SIMCOM Aviation Training showed that, at the time of his most recent training, which took place 1 week before the accident, the pilot reported a total of 7,100 flight hours with 240 hours within the preceding 12 months. The pilot's personal logbook(s) were not located after the accident. According to a friend of the pilot, the pilot had a high altitude endorsement, but he may not have received any training experience in an altitude chamber.

Before he purchased the accident airplane, the pilot had owned two other Daher-Socata TBM700 airplanes, a TBM700 "A" model (N51HT) and a TBM850 "Legacy" model (N51LG). According to a service center, the pilot purchased the A model in 1994 and accumulated about 2,700 flight hours in the airplane. He subsequently purchased the TBM850 model without a G1000 avionics suite, which he flew for about 1,250 hours before buying the accident airplane in April 2014. 

The pilot's insurance policy authorized only the pilot and one other person to act as pilot in command of the accident airplane. Maintenance records indicated that the airplane was flown about 52 hours between the time the pilot purchased it and June 20, 2014. Data retrieved from a public flight tracking service showed that the airplane had accumulated about 50 additional flight hours between June 20, 2014, and the date of the accident. A cross-check of the flight tracking service's data with the FBO's departure/arrival log validated each flight with the exception of two arrivals. Thus, the maintenance records and flight tracking service data indicated that the airplane had been flown about 102 hours since the pilot acquired it.

The pilot completed a 5-day training course on the TBM900 at SIMCOM Aviation Training Center, Orlando, Florida on August 29, 2014, to satisfy an insurance policy requirement. According to a representative of SIMCOM, the course duration would have been about 8 hours per day for the first 3 days and about 6 hours per day for the remaining 2 days. The representative stated that the course's ground training addressed the technical aspects of the TBM900's airframe, engine, and avionics and included a review of the environmental system. The course's simulator training included environmental system inspections, failures, the controls for smoke or fume elimination, and emergency descent procedures. Proper oxygen mask donning procedures were also demonstrated and discussed. The pilot's instructor at SIMCOM stated that he instructs students to don their oxygen masks before troubleshooting any pressurization problems. The instructor further stated that he likely spent 45 minutes on pressurization system training in the classroom and another 45 minutes in the simulator. The airplane manufacturer reported that, at the time of the accident, SIMCOM had the only simulator that could present crew alerting system (CAS) messages related to the TBM900 pressurization system.

The pilot attended the course with a friend who was the other named pilot on the airplane's insurance policy, frequently accompanied him during personal flights, and commonly shared crewmember duties. According to the friend, who attended the first 3 days of the 5-day course, the pilot used a Garmin G1000 simulator program on his personal computer to familiarize himself with the system in advance of the SIMCOM course as this was his first airplane with a full glass cockpit display. 

The pilot and his friend completed numerous flights together, including twelve flights in the accident airplane. He stated that the pilot was "religious" about adjusting the cabin altitude in flight; in the TBM850, the pilot would normally enter a climb and adjust cabin altitude simultaneously. During flights in the TBM900, he observed the pilot monitor cabin altitude by placing his finger on the multi-function display to verify cabin altitude during each instrument scan. 

According to the pilot's friend, the pilot completed an "external walk around" inspection of the airplane before each flight. During inspections, the pilot's friend observed him physically open the door to the oxygen bottle and verify that the oxygen cylinder's valve was on. The pilot further used a gauge in the cockpit to confirm the flow of oxygen after he turned the cockpit oxygen switch on and tested the oxygen masks. 

Family and friends indicated that the pilot was in excellent health. He was an occasional cigar smoker, took one medication for cholesterol, rarely consumed alcohol, and exercised regularly. The family did not report any unusual behaviors with the pilot or his wife in the 72 hours before the accident. A friend of the pilot stated that the pilot appeared to be in "excellent health and spirits" when he met with him the day before the accident.

Pilot-Rated Passenger

The pilot-rated passenger, age 68, held a private pilot certificate with a rating for airplane single-engine land. She reported a total flight experience of 410 hours on her latest third-class medical certificate application, dated July 1, 1992. The pilot-rated passenger's personal logbook(s) were not located after the accident.

AIRCRAFT INFORMATION

According to FAA records, the Daher-Socata TBM900 model, serial number 1003, was manufactured in 2014 and powered by a single Pratt and Whitney PT6A-66D turbo-prop engine. A standard airworthiness certificate was issued on March 6, 2014, and the airplane was subsequently registered to the pilot on April 8, 2014. 

In March 2014, the factory-new airplane was delivered from the manufacturer's facility in France to an airplane sales and service company in Connecticut with a total of 37.6 flight hours. The service center completed several flights in the airplane before the pilot took possession of it in April 2014, at a total time of 44.3 flight hours. The first in-service inspection prescribed by the manufacturer was performed on June 20, 2014, at which time, the airplane and engine had accrued an additional 52 flight hours.

Airplane Fuel Performance 

A report furnished by the FBO indicated that the airplane was last serviced with 177 gallons of fuel on August 29, 2014. According to the manufacturer's performance calculations, the airplane would have consumed about 23 gallons of fuel in 20 minutes during its climb to cruise altitude (FL280). After reaching FL280, the airplane then flew for about 5 hours 25 minutes. Based on the manufacturer's computation, this corresponds to a mean fuel flow of about 49 gallons per hour, which is consistent with normal cruise flight fuel performance.

Bleed Air and Cabin Pressurization System 

The pilot's operating handbook (POH) states that the global air system is composed of three main subsystems: the engine bleed air system, the environmental control system, and the cabin pressure control system. These three subsystems are managed by a single-channel digital global air system controller (GASC) that receives the information from the sensors in the subsystems and from the cockpit displays and controls and issues the proper commands to the subsystem actuators and indication or warning elements. Specifically, the GASC controls the cabin pressure by modulating the amount of air dispelled from the cabin through the outflow valve. According to the POH, when the BLEED switch is set to AUTO, a ground fan cools down engine bleed air through the main heat exchanger, and the outflow valve (OFV) remains in the full open position until takeoff. After departure, the airplane's GASC controls the aperture of the OFV to reach its computed cabin altitude and rate of change. 

Cabin Pressurization Control Panel

The airplane's maintenance manual shows that, once pressurized bleed air passes ports from the engine case, the BLEED switch enables GASC control of the opening of the flow control shut-off valve (FCSOV) and other components. When the BLEED switch is set to AUTO, the pilot controls cabin pressure by the PRES MODE (pressurization mode) switch through one of two modes, AUTO and MAX DIFF. In AUTO mode, the cabin altitude will remain below 10,000 ft msl, and the cabin differential pressure will not exceed 6.2 psi. In MAX DIFF mode, the system will maintain a cabin pressure of 0 ft when the airplane's altitude is below 13,500 ft msl. When the airplane climbs above 13,500 ft msl, the cabin altitude will not exceed 10,000 ft msl or a differential pressure of 6.0 psi. The system can be reset or turned off by setting the BLEED switch to OFF/RST (off/reset). A blocking device between the AUTO and OFF/RST positions prevents the pilot from inadvertently turning the switch to the OFF/RST position.

According to the normal procedures section of the POH, the pilot sets the BLEED switch to the OFF/RST position before starting the engine. After engine start, the pilot sets the BLEED switch to AUTO once the ammeter display is less than 100 amperes. The pilot also sets the A/C and PRES MODE switches to AUTO and adjusts the cabin temperature as necessary. After the adjustments have been made, the checklist does not call for the pilot to check the pressurization system until cruise altitude is reached. 

Engine Bleed Air System 

Bleed air is supplied to the pressurization system by the engine bleed air system, which is comprised of two engine bleed air ports: the P2.5 port, a lower pressure port, and the P3 port, a higher pressure port. A non-return valve (NRV) is fitted at the outlet of the P2.5 port, and an intermediate pressure port sensor (IPPS) is housed between the engine P2.5 port and the NRV. The P3 port contains a solenoid-activated shutoff valve (SOV) installed at the outlet of the P3 port. The SOV is normally sprung-closed and requires the solenoid to open. An overheat thermal switch (OTSW) is fitted beyond the junction of the P2.5 NRV and P3 SOV and before the bleed air reaches the FCSOV. 

The GASC electronic module is designed to maintain a cabin altitude of less than 10,000 ft msl regardless of the pressurization mode setting. For most operations, the P2.5 bleed air supply is sufficient to pressurize the cabin until the airplane reaches a cruise flight altitude where it can operate with a reduced throttle setting. Should the air pressure measured by the IPPS decrease below 9.5 psig, the GASC programming laws will then automatically command the SOV to the open position, thus allowing higher pressure bleed air flow from the P3 line into the pressurization system. The increase in pressure from the P3 line will close the NRV, which isolates the P2.5 port. The GASC will command the SOV to the closed position once the P2.5 pressure returns to a value above 14.5 psig, which resumes the supply of bleed air from the P2.5 port to the pressurization system. 

OTSW Design and Function

The OTSW is a stainless steel tube with a 3-pin threaded connector at one end and a switch module at the opposing end, which contains a bimetallic disc that controls the position of an open-closed electric switch. The switch is threaded into a pneumatic bleed tube upstream of the FCSOV, so that the flow of air from the P2.5 or P3 ports will pass the OTSW. The switch module is flush with the inner wall of the tube. As the module heats to 315° C +/- 5° C, the bimetallic disc will change from a concave to a convex shape. A pin is pushed by the disc during the shape transition to move the contacts to the open position. As the switch cools to 295° C +/- 5° C, the disc is designed to revert to its concave shape, thereby closing the contacts.

Pressurization System Overheat Protection

A function of the GASC programming is to protect the cabin in the event of a bleed air overheat or engine fire. According to the pressurization system manufacturer, when the OTSW detects a temperature of 315° C, the contacts will open, which removes the electrical power that holds the spring-loaded SOV open. This causes the SOV in the P3 tube to close so that the P2.5 port becomes the primary source of bleed air for the cabin. 

The GASC indirectly determines if the OTSW contacts are open or closed by measuring voltage in a parallel circuit. When the GASC detects an open OTSW state, a BLEED_OVHT fault code is recorded in the GASC non-volatile memory (NVM), accompanied by the activation of a 30-second timer. Should the temperature drop below 295° C within 30 seconds, the OTSW will close, and the SOV will be re-energized, which returns the system to P3 mode. 

If the OTSW contact state is still detected as open after the 30 seconds have elapsed, BLEED TEMP and BLEED OFF indications will be annunciated on the CAS, and the GASC will close the FCSOV, which discontinues the flow of bleed air into the cabin. This prompts an illumination of the cockpit master caution warning annunciator light and an aural alarm. In addition, the GASC will record a BLEED_TEMP fault code in the GASC NVM.

Loss of Engine Bleed Air Input to Cabin

Reduced engine bleed air supply to the environmental control system will cause a decrease in cabin pressure that will then cause the GASC to command the OFV to close. Without a bleed air supply to maintain selected cabin pressure, the cabin altitude will continue to increase until it equalizes with the ambient altitude. The rate of cabin depressurization depends upon the difference between the cabin and atmospheric pressures and upon the cabin leakage rate. Cabin leakage is normal and unavoidable, but the rate is limited to a maximum value specified in the airplane maintenance manual. A PC_COMP_OOR fault code will be recorded in the GASC NVM when the cabin pressure is detected to be out of range (below -3,550 ft or above 15,960 ft msl).

Leak Rate Chart

The airplane manufacturer developed and published "leak rate charts" to determine the overall pressure integrity of the airplane, both during manufacture and in service operation. The airplane was equipped with an additional door located on the left side of the cockpit referenced by the airplane manufacturer as a "pilot door." The manufacturer published two separate cabin leak rate charts: one for airplanes equipped with a pilot door and one for those without a pilot door. Each chart contains a line plotted as differential pressure versus time. The line represents the threshold (minimum allowable) time for the cabin pressure to decrease from one differential pressure value to another; that time is inversely proportional to the cabin leak rate. Thus, bleed-down times faster than those defined by the line indicate unacceptably high cabin leak rates, which must be corrected to render the airplane airworthy. 

Review of the chart for airplanes equipped with a pilot door indicated that, at 28,000 ft, once pressurized air ceased to be supplied, the cabin pressure would bleed down to the ambient atmospheric pressure in about 4 minutes. The chart presumes that the cabin integrity is in compliance with the manufacturer's standards and that the OFV closes completely once pressurized air ceases to be supplied. 

Emergency Oxygen System

The airplane's emergency oxygen system is intended to provide oxygen to the flight crew and passengers in the event of a loss of cabin pressurization. Oxygen is stored under high pressure in a single cylinder mounted outside the airplane's pressure vessel and inside the right wing root fairing. The cylinder holds the equivalent of 50.3 cubic ft of oxygen at sea level pressure. 

The flight crew emergency oxygen system is comprised of two oxygen masks with smoke goggles and is manually controlled by a normally-closed OXYGEN switch-operated valve that must be turned ON in order for the system to supply oxygen to the masks. The BEFORE STARTING ENGINE procedure contains a step that calls for the pilot to turn the OXYGEN switch to the ON position. As long as the valve mounted on the physical oxygen cylinder is opened during the relevant PREFLIGHT INSPECTION procedure and the OXYGEN switch is in the ON position, both flight crewmembers will receive oxygen as they breathe if their oxygen masks have been donned.

The flight crew masks are secured in stowage cups located behind the cockpit seats, and each mask is equipped with a microphone, a three-position selector, and a button labeled PRESS TO TEST. To don a cockpit oxygen mask, the occupant must reach behind the opposite seat, remove the mask from its stowage cup, depress two vanes on the mask to inflate the harness, and then place it over their nose and mouth. The remaining oxygen quantity is transmitted by an electrical analog signal output and displayed to the flight crew on the Garmin GDU 1500 multi-function display (MFD). Once the mask is in use, the occupant can enable the mask microphone through the MICRO/MASK switch, which is normally set to MICRO via a switch guard. 

The normal checklists in the POH specified the following numbered steps regarding the emergency oxygen system:

PREFLIGHT INSPECTION Procedure

13 - Rear R.H. karman [wing root fairing]

• Oxygen cylinder – Open

• Oxygen quantity – Checked

14 - Oxygen pressure – Checked

BEFORE STARTING ENGINE Procedure

10 – MICRO/MASK micro inverter - MICRO

42 – Pilot's OXYGEN switch – ON

43 – Front oxygen masks – Checked

Press push button "PRESS TO TEST": the blinker shall turn red momentarily, then turns transparent. 

AFTER STARTING ENGINE Procedure:

4 – Oxygen supply – Available for the planned flight (see tables of paragraph "IN-FLIGHT AVAILABLE OXYGEN QUANTITY" in Chapter 4.4 and Chapter 7.10 for a FAR 135 type operation)

Oxygen Cylinder Maintenance

According to the airplane's maintenance records, a hydrostatic test was last performed in January 2013, and the airplane's oxygen cylinder was last refilled on March 28, 2014. An entry in the airplane logbook showed that the oxygen cylinder was last checked for security, corrosion, distortion, and attachment during the airplane's first inspection in June 2014. A representative of the airplane's service center stated that, at the first inspection, they would have added oxygen and recorded the work in the airplane's logbook if the service quantity was below full. 

Emergency Procedures 

According to the POH, the Emergency Descent procedures are as follows:

MAXIMUM RATE DESCENT

1 – Throttle – Flight IDLE

2 – OXYGEN – USE if necessary

3 – DESCENT - from - 10° to - 20°

Procedure in smooth air

6 - Speed 266 KIAS

Procedure in rough air or in case of structure problem

10 – Maintain IAS = kts

The POH also includes an Emergency Descent procedure for a Maximum Range Descent using the following procedures:

MAXIMUM RANGE DESCENT

1 – Throttle – CUT OFF

2 – Flaps – UP

3 – Landing gear control – UP

4 – SPEED IAS - 120 KIAS

5 – Oxygen – USE if necessary (Check oxygen duration before reaching 12,000 ft and check flow to passengers)

In the event of an anomaly, the avionics system will present warning messages in two different areas of the instrument panel; the CAS box in the MFD and lights labeled as "Master Caution" (red colored) and "Master Warning" (amber colored) located in the upper left corner of the panel between the left seat occupant's primary flight display and the glareshield. When a message appears in the CAS annunciator box, it is accompanied by the illumination of the master light that coincides with the colored CAS message and an aural tone to capture the pilot's attention. A red CAS message will be accompanied by a flashing red "Master Caution" indicator, which requires immediate action from the pilot. An amber CAS message will be accompanied by a fixed amber "Master Caution" indicator, which requires pilot action as soon as practical. The pilot must depress the corresponding red or amber light to terminate the warning tone. 

The 656-page POH includes a 96-page emergency procedures section and a separate 98-page normal procedures section. Four separate pressurization system procedures are included in the emergency section, each of which corresponds to a color-coded CAS message. BLEED TEMP, CABIN DIFF PRESS, and CABIN ALTITUDE appear in red-colored text and BLEED OFF appears in amber-colored text. 

A red BLEED TEMP CAS message, accompanied by both master and aural warnings, indicates an overheat of the bleed air system, which can lead to a termination of bleed air into the cabin and an amber warning and a BLEED OFF CAS message, also accompanied by both a master caution and aural warning. In the event of a "BLEED TEMP" indication, the pilot is instructed to do the following:

1 – If possible – REDUCE POWER

2 – HOT AIR FLOW distributor – turn to the right

3 – CONTROL selector – COCKPIT

4 – TEMP/°C selector – MINI

5 – BLEED switch – OFF/RST

6 – As soon as warning BLEED TEMP off, set BLEED switch to AUTO

When the BLEED OFF amber CAS message indication appears, the pilot is instructed to:

1 – CHECK BLEED switch position and – CORRECT

2 – If possible, reduce power

FLY THE AIRPLANE

3 – BLEED switch – OFF/RST (Reset)

4 – BLEED switch – AUTO

5 – If warning BLEED OFF displayed:

6 – Limit flight altitude to maintain cabin altitude < 10,000 feet

7 – If necessary (no oxygen available) – EMERGENCY DESCENT

8 – Continue flight

A red CABIN ALTITUDE CAS message accompanied by a master and aural warning will appear when the cabin altitude exceeds 10,000 ft ± 500 ft. The POH instructs the pilot to complete the following procedure in the event of this indication:

1 – Pressurization indicator – CHECK

If cabin altitude is greater than 10,000 feet ± 500 feet:

2 – OXYGEN – USE, if necessary

FLY THE AIRPLANE

3 – BLEED switch – CHECK AUTO

4 – DUMP switch – CHECK UNDER GUARD

5 – EMERGENCY RAM AIR control knob – CHECK PUSHED

6 – Limit flight altitude to maintain cabin altitude < 10,000 feet

7 – If necessary – EMERGENCY DESCENT

A CABIN DIFF PRESS message will appear if the cabin pressure differential is over 6.4 psi ± 0.2 psi. The POH instructs the pilot to complete the following procedure in the event of this indication:

1 – Pressurization indicator – CHECK

If pressure change is greater than 6.4 PSI ± 0.2 PSI:

2 – BLEED switch – OFF/RST

3 – Oxygen – Use, if necessary

METEOROLOGICAL INFORMATION

According to an NTSB weather study, the winds aloft at the airplane's cruising altitudes of FL280 and FL250 were from about 270° at 15 knots and 140° at 4 knots, respectively. The study found that the flight encountered some convective activity along the South Carolina coast, about 30 minutes after the pilot's final transmission to ATC. 

WRECKAGE AND IMPACT INFORMATION

According to radar data, the airplane impacted the water at more than 300 knots and separated into small fragments. The wreckage was located by an underwater search vehicle, which revealed a 984-foot-long debris field, at a depth of about 10,000 ft. The debris field included the engine and several sections of the fuselage. Fuselage and engine components of the wreckage were recovered about 4 months after the accident and transported to Panama City, Florida, where NTSB and airplane manufacturer personnel identified and sorted the recovered components. 

Among the components recovered by the investigative team were the FCSOV, the GASC, the SOV, and the Garmin G1000 primary flight display and its SD flash memory card. These items were packaged in sealed containers with distilled water to hinder corrosion before all of the recovered wreckage was transported to a secure facility in Maryland for further examination.

MEDICAL AND PATHOLOGICAL INFORMATION

A forensic examination was performed on the recovered occupant remains by the District Fourteen Medical Examiner, Panama City, Florida. The forensic report confirmed the identity of the occupants through an osteological examination. 

According to a laboratory technician at the FAA Bioaeronautical Sciences Research Laboratory, a hypoxia clinical study could not be completed due to a lack of physical specimens.

TESTS AND RESEARCH

Sound Spectrum Study

An NTSB sound spectrum study showed that the pilot's microphone release time following each statement increased significantly about 2 minutes 30 seconds after he initially reported the "abnormal" indication to ATC. Further, a spectrograph of the radioed call sign revealed that the pilot began slurring his speech about 3 minutes after his initial report of the problem to ATC. 

Non-Piloted Airplane Behavior

According to the airplane manufacturer, once the engine shuts down due to fuel starvation, the airplane will decelerate and increase its angle of attack as the autopilot continues to attempt to maintain altitude until the airplane stalls and the autopilot disengages. 

OFV Examination

The OFV modulates the discharge airflow to control the cabin pressure and is controlled by the GASC through a torque motor. During ground operations, the OFV is normally in the full open position. When the airplane is airborne, the GASC controls the aperture of the OFV to reach the target cabin altitude at an optimized control rate. The OFV and safety valve (SFV) are equipped with overpressure and negative relief safety valves that are controlled by independent pneumatic modules that override the GASC control; these are intended to prevent excessive differential pressure values. The pressurization system manufacturer stated that the OFV and SFV are designed to close within 1 second in response to a cessation of bleed airflow into the cabin. The OFV will remain closed unless negative differential pressure is encountered during a descent. 

The accident airplane's OFV was recovered from the ocean; it remained attached to the aft pressure bulkhead and was not damaged by impact. Saltwater immersion damage and accumulated organic ocean material prevented testing of the torque motor. Scars at the contact interface indicated that the valve was shut at impact. 

SFV Examination

According to the manufacturer's reference materials, the SFV ensures negative pressure relief and prevents cabin overpressure. The SFV is designed to open when the cabin altitude is greater than the outside pressure.

The accident airplane's SFV was recovered from the ocean; it remained attached to the aft pressure bulkhead, but the valve body was fractured at each of the six aluminum braces, and the center body was broken. The valve body could not be manipulated by hand due to damage and accumulated oceanic material, which precluded testing the unit in the manufacturer's air chamber. Multiple functional tests of the subcomponents were completed at the pressurization system manufacturer's facility, including leak tests of the manometric chamber overpressure relief valve, servo chamber, and cabin pressure valve. The SFV tests did not reveal any anomalies, and the component examination indicated that the valve was open about 13 mm at the time of impact. 

GASC NVM Data and Garmin G1000 primary flight display SD Flash Memory Card

According to the pressurization system manufacturer, the GASC NVM stores fault codes in its memory, which are overwritten after each take-off. The fault codes are recorded in the sequence in which they occur without time stamps.

Both the recovered GASC unit and primary flight display SD card were submitted to the NTSB Recorders laboratory for possible data download. The SD card was successfully read but did not contain any accident-related data. 

The GASC was severely damaged by impact forces. The internal NVM data was extracted using laboratory hardware and software provided by the manufacturer of the pressurization system. The data showed multiple CAS message fault codes that were generated by the GASC during the flight, in the following sequence: ECS_HEATING FAULT, BLEED_TEMP, BLEED_OVHT, and PC_COMP_OOR. 

FCSOV Examination

Examination of the recovered FCSOV revealed that the unit was in the closed position and sealed by oceanic deposits. The valve was subsequently disassembled at the pressurization system manufacturer's facility in Toulouse, France. Further examination of the unit's witness marks and actuator components confirmed that it was in a closed position at impact. 

BLEED and PRES MODE Switch Examinations

The recovered BLEED and PRES MODE switches were both found in the AUTO position. The locking gate of each switch displayed an imprint on its AUTO position, and the OFF/RST side of each switch did not display any deformation or imprints, consistent with the switches being in the AUTO position at impact. 

OTSW Examination

The OTSW was recovered from the wreckage and subsequently tested at the manufacturer's facility in Redmond, Washington. After an electrical resistance test, the switch was inserted into a mounting rack alongside an exemplar switch and placed in a static oven that was slowly heated to 336° C. The exemplar unit's contacts opened after 2 minutes 47 seconds. At 3 minutes 25 seconds, the switch burst open with a loud noise and sufficient force to bend the mounting rack, which precluded further testing as the welded area of the switch had split open. Disassembly revealed that the switch had been filled with sea water, which had turned to steam and pressurized the switch until it burst. The dielectric and insulation tests were not performed as a result of this damage.

The top of the switch module was covered in a black residue typical of corrosion and exhibited extensive surface pitting. The larger pits were near the wire terminals and proximal to different types of metal. A microscope examination revealed no evidence of heat or molten globules, but confirmed the presence of flaking, consistent with salt water corrosion. The switch module was subsequently tested inside the static oven after the wires were intentionally separated from the welds at the switch module terminals. Similar to the previous test, the unit was slowly heated until the switch contacts opened, which occurred at 326.8° C. The switch is designed to open at 315° +/- 5°C and close at 295°C +/- 5°C. 

Disassembly of the switch module revealed the presence of brown deposits and extensive rust on the interior surfaces of the module wall that were the result of long-term saltwater immersion. The sleeve that held the bimetallic thermal disc in place was rusted over. A subsequent examination of the switch contacts at the manufacturer's facility showed evidence of electrical wear and material transfer pitting on the contact surfaces. An evaluation was completed by the Air Force Research Laboratory (AFRL) Materials Integrity Branch. The AFRL reported that the wear and pitting were consistent with arc erosion. The evaluation also stated that the damage was typical for a used switch and not considered excessive. 

Examination of OTSWs from Other Airplanes

According to records supplied by the airplane manufacturer, at least 18 OTSWs had been replaced between 2008 and October 2015, including 3 that were replaced after the accident. At least 12 of the records included statements from pilots or mechanics that the cabin had depressurized in flight. 

The three OTSWs that were replaced after this accident were examined and tested at the switch manufacturer's facility. The examinations revealed small amounts of contact wear, which was consistent with having been in service. Two of the three switches passed functional testing, and it was later determined that the third switch had been improperly field tested. The contacts of this unit were not burned, welded, or otherwise abnormal.

The OTSW manufacturer provided contacts from two test switches that had accumulated 100,000 resistive load cycles. The wear area of the contacts from one of the test switches exhibited a wider area of material transfer between the contacts and a pit depth similar to the accident switch contacts. For additional details, please refer to the Systems Group Chairman Factual Report in the NTSB public docket. 

Oxygen Switch Examination

The airplane's oxygen cylinder and flight crew masks were not recovered. An examination of the cockpit OXYGEN switch revealed that it was in the OFF position, which would have prevented the flow of oxygen to the oxygen masks. A subsequent microscopic inspection of the toggle switch base did not show any indication that the switch was in a different position at impact. 

Hypoxia

The FAA's Aeronautical Information Manual (Section 8-1-2) states that "the effects of hypoxia are usually quite difficult to recognize, especially when they occur gradually."

FAA Advisory Circular (AC) 61-107B (Aircraft Operations at Altitudes Above 25,000 Feet Mean Sea Level or Mach Numbers Greater Than .75) states that altitude hypoxia is caused by "an insufficient partial pressure of oxygen in the inhaled air resulting from reduced oxygen pressure in the atmosphere at altitude. Altitude hypoxia poses the greatest potential physiological hazard to a flightcrew member when at altitude. Supplemental oxygen will combat hypoxic hypoxia within seconds. Check your oxygen systems periodically to ensure an adequate supply of oxygen and that the system is functioning properly. Perform this check frequently with increasing altitude. If supplemental oxygen is not available, initiate an emergency descent to an altitude below 10,000 ft MSL."

AC 61-107B includes the following warning concerning altitude hypoxia:

"If hypoxia is suspected, immediately don oxygen mask and breathe 100 percent oxygen slowly. Descend to a safe altitude. If supplemental oxygen is not available, initiate an emergency descent to an altitude below 10,000 ft MSL. If symptoms persist, land as soon as possible." 

AC 61-107B also describes the concept of "time of useful consciousness" (TUC) or "effective performance time" (EPT) as follows:

"This is the period of time from interruption of the oxygen supply, or exposure to an oxygen-poor environment, to the time when an individual is no longer capable of taking proper corrective and protective action. The faster the rate of ascent, the worse the impairment and the faster it happens. TUC also decreases with increasing altitude. Figure 2-3, Times of Useful Consciousness versus Altitude, shows the trend in TUC as a function of altitude. However, slow decompression is as dangerous as or more dangerous than a rapid decompression. By its nature, a rapid decompression commands attention. In contrast, a slow decompression may go unnoticed and the resultant hypoxia may be unrecognized by the pilot."

AC61-107B includes the following warning concerning TUC:

"The TUC does not mean the onset of unconsciousness. Impaired performance may be immediate. Prompt use of 100 percent oxygen is critical."

Figure 2-3 in AC 61-107B indicates that the TUC/EPT for a slow decompression at 28,000 ft is 2.5 to 3 minutes, and at 25,000 ft it is 3 to 5 minutes. The table notes that "the times provided are averages only and based on an individual at rest. Physical activity at altitude, fatigue, self-imposed stress, and individual variation will make the times vary." 

According to The Principles of Clinical Medicine for Space Flight, the "EPT tables were designed with data largely derived from young healthy military aviators seated at rest in altitude chambers." The accident pilot was typical of a more mature population of business owners and non-professional pilots that are required to hold a high altitude endorsement to act as pilot-in-command of an airplane that has a service ceiling or maximum operating altitude above 25,000 ft msl as prescribed by 14 CFR Part 61.31(g)(1). The regulation does not require the endorsement candidate to experience a simulated sudden depressurization in an altitude chamber. 

ADDITIONAL INFORMATION

Airplane Manufacturer Service Bulletin SB70-226 

About 14 months after the accident, in November 2015, the airplane manufacturer issued a service bulletin to address the reports of BLEED OFF CAS messages and the associated shutdowns of the airplane's pressurization system. The service bulletin implements a GASC software revision to maximize bleed availability through a wiring adjustment that causes the FCSOV to remain open and continue the flow of bleed air into the cabin after the OTSW contact state is detected as OPEN. The service bulletin results in the cabin losing heat without depressurizing, and the pilot will continue to receive the visual CAS warning message and aural warning alarm. 

POH Revision

Following the accident, the airplane manufacturer revised some of the emergency checklists in the POH for the TBM930 model (the model of the TBM700 currently in production) to make "Use Oxygen Mask" the first checklist item in the "relevant emergency procedures." The manufacturer plans, in 2017, to make similar revisions to the checklists in the operating handbooks of prior models.

Glazer v. Socata by David Andreatta on Scribd





Transcript of N900KN conversations with air traffic control before the pilot lost consciousness

Pilot: TBM 900KN flight level 280

ATC: November 900KN Atlanta…

Pilot: 900KN we need to descend down to about [flight level] 180, we have an indication … not correct in the plane.

ATC: 900KN descend and maintain 250.

Pilot: 250 we need to get lower 900KN.

ATC: Working on that.

Pilot: Have to get down. And reserve fuel… limit a return… thirty-three left… have to get down.

ATC: Thirty left 900KN

Pilot: 00900KN (holds transmit button)

ATC: N0KN you’re cleared direct to Taylor.

ATC: 0KN, cleared direct to Taylor.

Pilot: Direct Taylor, 900KN.

ATC: Copy that you got descent (slope?) 200…

Pilot: (mumbling)

ATC: Descent and maintain flight level 200, and you are cleared direct Taylor.

Pilot: KN900KN (sounds confused)

ATC: Understand me, descend and maintain flight level 200, flight level 200, for N900KN

ATC: TBM, TBM 0KN, descend and maintain flight level 200

ATC: 0KN, if you hear this, transmit and ident.

ATC: N900KN, Atlanta center, how do you read?

ATC: N900KN, Atlanta Center… AC5685, keep trying N900KN

AC5685: TBM900KN, this is AC5685, how do you read? (Military aircraft?)

ATC: N900KN, Atlanta Center, how do you read?

AC5685: TBM900KN, AC5685, how do you read?

ATC: N900KN, TBM, 900KN, Atlanta Center, how do you hear this…

ATC: N0KN, descent now, descent now to flight level 200.

ATC: N900KN, TBM 900KN, if you hear this transmission, contact … center 127.87

ATC: N0KN, TBM 0KN, contact … center 127.87 if you hear this…


NTSB Identification: ERA14LA424
14 CFR Part 91: General Aviation
Accident occurred Friday, September 05, 2014 in Open Water, Jamaica
Aircraft: SOCATA TBM 700, registration: N900KN
Injuries: 2 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 may not have traveled in support of this investigation and used data provided by various sources to prepare this aircraft accident report.

On September 5, 2014, about 1410 eastern daylight time (EDT), a Socata TBM700 (marketed as TBM900), N900KN, impacted open water near the coast of northeast Jamaica. The commercial pilot/owner and his passenger were fatally injured. An instrument flight rules flight plan was filed for the planned flight that originated from Greater Rochester International Airport (ROC), Rochester, New York at 0826 and destined for Naples Municipal Airport (APF), Naples, Florida. The personal flight was conducted under the provisions of 14 Code of Federal Regulations Part 91.

According to preliminary air traffic control (ATC) data received from the Federal Aviation Administration (FAA), after departing ROC the pilot climbed to FL280 and leveled off. About 1000 the pilot contacted ATC to report an "indication that is not correct in the plane" and to request a descent to FL180. The controller issued instructions to the pilot to descend to FL250 and subsequently, due to traffic, instructed him to turn 30 degrees to the left and then descend to FL200. During this sequence the pilot became unresponsive. An Air National Guard intercept that consisted of two fighter jets was dispatched from McEntire Joint National Guard Base, Eastover, South Carolina and intercepted the airplane at FL250 about 40 miles northwest of Charleston, South Carolina. The fighters were relieved by two fighter jets from Homestead Air Force Base, Homestead, Florida that followed the airplane to Andros Island, Bahamas, and disengaged prior to entering Cuban airspace. The airplane flew through Cuban airspace, eventually began a descent from FL250 and impacted open water northeast of Port Antonio, Jamaica. 

According to a review of preliminary radar data received from the FAA, the airplane entered a high rate of descent from FL250 prior to impacting the water. The last radar target was recorded over open water about 10,000 feet at 18.3547N, -76.44049W. 

The Jamaican Defense Authority and United States Coast Guard conducted a search and rescue operation. Search aircraft observed an oil slick and small pieces of debris scattered over one-quarter mile that were located near the last radar target. Both entities concluded their search on September 7, 2014. NTSB Identification: ERA14LA424
14 CFR Part 91: General Aviation
Accident occurred Friday, September 05, 2014 in Open Water, Jamaica
Aircraft: SOCATA TBM 700, registration: N900KN
Injuries: 2 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 may not have traveled in support of this investigation and used data provided by various sources to prepare this aircraft accident report.

On September 5, 2014, about 1410 eastern daylight time (EDT), a Socata TBM700 (marketed as TBM900), N900KN, impacted open water near the coast of northeast Jamaica. The commercial pilot/owner and his passenger were fatally injured. An instrument flight rules flight plan was filed for the planned flight that originated from Greater Rochester International Airport (ROC), Rochester, New York at 0826 and destined for Naples Municipal Airport (APF), Naples, Florida. The personal flight was conducted under the provisions of 14 Code of Federal Regulations Part 91.

According to preliminary air traffic control (ATC) data received from the Federal Aviation Administration (FAA), after departing ROC the pilot climbed to FL280 and leveled off. About 1000 the pilot contacted ATC to report an "indication that is not correct in the plane" and to request a descent to FL180. The controller issued instructions to the pilot to descend to FL250 and subsequently, due to traffic, instructed him to turn 30 degrees to the left and then descend to FL200. During this sequence the pilot became unresponsive. An Air National Guard intercept that consisted of two fighter jets was dispatched from McEntire Joint National Guard Base, Eastover, South Carolina and intercepted the airplane at FL250 about 40 miles northwest of Charleston, South Carolina. The fighters were relieved by two fighter jets from Homestead Air Force Base, Homestead, Florida that followed the airplane to Andros Island, Bahamas, and disengaged prior to entering Cuban airspace. The airplane flew through Cuban airspace, eventually began a descent from FL250 and impacted open water northeast of Port Antonio, Jamaica.

According to a review of preliminary radar data received from the FAA, the airplane entered a high rate of descent from FL250 prior to impacting the water. The last radar target was recorded over open water about 10,000 feet at 18.3547N, -76.44049W.

The Jamaican Defense Authority and United States Coast Guard conducted a search and rescue operation. Search aircraft observed an oil slick and small pieces of debris scattered over one-quarter mile that were located near the last radar target. Both entities concluded their search on September 7, 2014.



AIRCRAFT CRASHED INTO THE CARIBBEAN SEA AFTER LOSING COMMUNICATIONS, THE 2 PERSONS ON BOARD ARE PRESUMED FATALLY INJURED, WRECKAGE DEBRIS LOCATED 14 MILES FROM PORT ANTONIO, JAMAICA

Flight Standards District Office: FAA Miami FSDO-19

NEW 51LG LLC: http://registry.faa.gov/N900KN

Any witnesses should email witness@ntsb.gov, and any friends and family who want to contact investigators about the accident should email assistance@ntsb.gov.



KINGSTON, Jamaica:   The Jamaica Civil Aviation Authority (JCAA) has sought to clear the air on its decision to delegate investigative responsibility into the crash of the TBM 900 aircraft in Jamaican waters to the United States National Transportation Safety Board (NTSB).

Nari Williams-Singh, Deputy Director General for Regulatory Affairs at the JCAA, said that given the circumstances of the particular accident, the majority of what took place occurred in US airspace.

United States real estate developer, Larry Glazer and his wife Jane perished when the small aircraft crashed in Portland on September 5.

Rescue efforts which were being conducted by Jamaican and United States authorities were discontinued after three days as they were unable to locate any debris related to the aircraft.

Asked about Jamaica’s capacity to carry out investigations of this nature, Williams-Singh suggested that local professionals were more than capable.

“It’s not that we are not capable. I think that the state have demonstrated our capability in investigating accidents as we saw in the American Airlines issue in 2009,” said Williams-Singh. “But the majority of what took place occurred in US airspace,” he added.

“There was communication with US air traffic control, there was visual contact with US military and it was a US domestic operation so we felt that the NTSB was the best to conduct the investigation,” Williams-Singh said.

He stressed that the JCAA is an accredited representative in the investigations.

Information Minister Sandrea Falconer said that after the Jamaica Defence Force and the United States Coast Guard terminated the search for the aircraft official correspondence was dispatched to the NTSB, which accepted the invitation to carry out the investigations.

She noted that the JCAA had named an accredited representative to the investigation team. He is Captain Christopher Kirkaldy, Senior Aviation Safety Inspector with the JCAA.

Chargé d'Affaires at the United States Embassy in Kingston, Elizabeth Martinez commended the Jamaican authorities for their response to the crash.

The aircraft crashed at approximately 1:10 p.m. just off the coast of Port Antonio, Portland after departing Rochester, New York heading south to Naples, Florida with the two people on board.

The aircraft bypassed Florida, flew over Cuba and into Jamaica’s airspace before crashing into the sea apparently after it ran out of fuel. 


- Source:  http://jamaica-gleaner.com

Larry and Jane Glazer


BRIGHTON — A memorial service for Larry and Jane Glazer, the real estate developer and his entrepreneur wife who are presumed dead after their small plane crashed after a ghostly journey down the U.S. East Coast and the northern Caribbean last Friday, Sept. 5, will be held on Tuesday, Sept. 16 at 11 a.m. at Temple B'rith Kodesh, 2131 Elmwood Ave., in Brighton. 

The family will receive friends on Tuesday, Sept. 16. from 2 to 4 and 7 to p.m. and Wednesday, Sept. 17 from noon to 3 p.m. and 7 to 9 p.m. at Irondequoit Country Club, 4045 East Ave.

Scott Fybush, a spokesperson for the family, said he has not confirmed a list of speakers at the memorial.

“This has been an exceptionally difficult week for the Glazers, and they, along with the rest of the family, deeply appreciate your understanding of their need to grieve privately,” said Fybush.

The Glazers’ single-engine aircraft flew 1,700 miles last Friday before running out of fuel and slamming into deep waters some 14 miles off Port Antonio on Jamaica's northeast coast.

The full obituary:


Rochester: Laurence C. Glazer, 68, and Jane L. Glazer, 68, died suddenly on Friday, September 5, 2014. Predeceased by their parents, Irwyn and Leona Glazer of Buffalo, NY and Andrew and June Lovenheim of Rochester, NY. Survived by their children, Mindy MacLaren (Tom), Richard Glazer, and Ken Glazer (Patty); siblings, Robert Lovenheim (Chris Zabih Boldu), Peter Lovenheim, and Rhonda Glazer Billick (Robert); grandchildren, Hazel Glazer, Charles Glazer, Emma Glazer, Evan Glazer, Ava MacLaren and Beatrice MacLaren; nieces and nephews Sarah Lovenheim Goldfarb (Zachary Goldfarb), Valerie Lovenheim (fiancé Oren Adaki), Ben Lovenheim, Nicole Bootel (Eshed), and Andrea Klein (Jerome); close, loving cousins and life-long friends.

In their teens, Jane and Larry met as counselors at Camp Seneca Lake. In the month before their deaths, they celebrated their 47th wedding anniversary and later returned to Seneca Lake for Family Camp with their children and grandchildren — a circle completed. In their business careers, Larry and Jane each achieved success and together contributed to the growth and prosperity of their community. By their family and friends, and by the community they enriched, they will always be remembered together.

Donations in memory of Jane and Larry Glazer may be made to the Jewish Community Center of Greater Rochester (jccrochester.org), 1200 Edgewood Ave., Rochester, NY 14618, WXXI Public Broadcasting (wxxi.org), 280 State Street, Rochester, NY 14614 or Hospice Foundation of Buffalo, PO Box 590, Buffalo, NY 14240.

Sources: http://www.brightonpittsfordpost.com


http://www.brightonmemorialchapel.com

NAPLES, Fla. - A National Transportation Safety Board investigation into the crash of a Naples-bound plane off Jamaica is stymied with the search for wreckage called off.

“We won’t start an investigation until we have the physical plane,” Kelly Nantel, director of public affairs for NTSB, said Friday. “You can’t know what happened to the airplane unless you have it.”

The private turboprop carrying New Yorkers and part-time Naples residents Jane and Larry Glazer crashed into waters north of Jamaica on Friday after it flew for four hours with an unresponsive pilot.

The NTSB will investigate should officials with the Jamaica Defence Force or anyone else stumble upon pieces of the doomed plane, but flight records of the Glazers’ final moments in the air won’t help investigators reach a final conclusion as to the cause of the crash.

Experts say the Glazer family could hire a search crew to hunt for remains or wreckage that could help investigators. Nantel said most downed aircraft are recovered.

“It’s not very common,” Nantel said of unsolved cases. “Most aircraft are recovered, but most aircraft don’t crash into the ocean. The majority are recovered and we’re able to do a comprehensive search.”

Jamaican officials ended their search for survivors and wreckage Sunday afternoon, saying they would continue to watch for debris to wash up on shore but were not actively hunting for the plane.

The U.S. Coast Guard pulled out of the search Sunday morning at 11 a.m., issuing a statement citing poor odds of finding a debris field spotted Friday but not seen again.

Petty Officer Jon-Paul Rios said the Coast Guard has no active role in any recovery efforts at this point other than to continue drawing search patterns for Jamaican officials monitoring the seas.

Former NTSB investigator Anthony Brickhouse said the Coast Guard searches for survivors of commercial or small plane crashes with the same intensity, no matter how many passengers there were.

“Whenever a plane goes down, how it hits the water will determine the breakup of the aircraft and will determine what happens to the survivors,” said Brickhouse, a professor of aerospace and occupational safety at Embry-Riddle Aeronautical University in Daytona Beach. “With any search and rescue with aircraft or a missing boater, as the hours go by, your chances of survival unfortunately go down.”

Days after the initial crash, Brickhouse said search agencies will scale back their efforts.

“If the (Glazer) family has the resources, there are companies out there to hire to try to find the wreckage or to find the remains or to keep searching for survivors,” he said.

Officials said wreckage could be as far as 6,500 feet under water, more than a mile deep. Brickhouse said the deeper the water, the bigger the effort for a recovery becomes.

“That far down, you’re going to need micro- or mini-submarines,” he said.

But Brickhouse said every scenario is different and that he’s seen seemingly impossible recovery efforts take place for wreckage thought to be long gone.

Black boxes from Air France Flight 447, which went down in the mid-Atlantic with 216 passengers and 12 crew aboard, were not recovered until two years after the 2009 crash.

“Miraculous things have happened,” Brickhouse said.

Larry Glazer, a real estate developer, and his wife Jane Glazer, an entrepreneur and former math teacher, left Rochester, New York, Friday morning in their 2014 Socata TBM900 headed for the Naples Municipal Airport.

They should have reached Southwest Florida by noon, but instead the pilot became unresponsive, veered off course and crashed at about 2:10 p.m.


-Source:   http://www.naplesnews.com

 
PORT ANTONIO, Jamaica — The Jamaica Defence Force (JDF) at 4:00 pm yesterday suspended its search and recovery operation for the missing passengers of the  Socata TBM700N (TBM900) aircraft which crashed in waters 24 nautical miles north of Portland on Friday.  
 
The US Coast Guard which was assisting the JDF - the main agency conducting the operation - had earlier ended its participation in the search.

"The decision was made based on continual re-assessment of the situation, noting the reduced probability of finding the passengers or aircraft which crashed in an area with depths of 1,500 to 2,000 metres," civil/military co-operation officer of the JDF Captain Basil Jarrett said in a press statement.

Confirming that the United States Coast Guard Cutter Bernard Webber had called off its participation in the search for the  Socata TBM700N (TBM900) and passengers, Jarrett quoted a spokesman as saying: "It is unlikely we will find any survivors at this time, so we are moving out."

The JDF and US authorities tracked the  Socata TBM700N (TBM900) aircraft into Jamaican airspace before it went off radar and crashed approximately 24 NM North of Port Antonio. Since then, a joint search and rescue effort has been underway in an area where an oil slick and small debris consistent with an aircraft crash had been spotted.

Since Friday, until yesterday, the operation continued without any success for three passengers said to include real estate developer Laurence Glazer and his wife Jane who departed from Rochester, New York, en route to Naples, Florida, but encountered problems and veered off course.

Yesterday evening before the Observer's news team left the Errol Flynn Marina, where the Command Centre for what was officially called Operation Socata is located, it was obvious that things were cooling down as JCF vessels with both police and soldiers aboard could be seen returning to base signalling that the operation was being downscaled. Official confirmation that search activities had been suspended came shortly after.

With the search and rescue operation now officially suspended any discovery of passengers or the wreckage of the aircraft might well fall within the purview of local fisherfolk.

The JCF's ground commander Senior Superintendent Terrence Bent said at a press conference on Saturday that the police had made contact with the fishing community operating in Portland and the neighboring parish of St Mary and had briefed several of them about the search. They urged them to pay attention and report any debris they found during their routine.


http://www.jamaicaobserver.com




(NaturalNews)  We’ve just published air traffic control audio and analysis of what happened to the private turbo prop aircraft that crashed yesterday after the pilot became non-responsive. The transcript of the audio is shown below, and you can hear the full audio in this YouTube video.

It’s clear from the audio that the pilot lost consciousness some time after noticing a problem that prompted him to attempt a descent to 18,000 feet. He never completed the descent, however, and he seemed to be suffering from confusion — a common symptom of hypoxia (lack of oxygen). At one point he became concerned about his plane’s reserve fuel supply and was cleared to land at “Taylor,” but he was unable to comply. 

With the pilot non-responsive, the aircraft left Atlanta airspace and flew directly toward Cuba. It crossed Cuba and then crashed into the ocean soon after, presumably due to fuel starvation of the engine (running out of fuel).

Transcript of N900KN conversations with air traffic control before the pilot lost consciousness

Pilot: TBM 900KN flight level 280

ATC: November 900KN Atlanta…

Pilot: 900KN we need to descend down to about [flight level] 180, we have an indication … not correct in the plane.

ATC: 900KN descend and maintain 250.

Pilot: 250 we need to get lower 900KN.

ATC: Working on that.

Pilot: Have to get down. And reserve fuel… limit a return… thirty-three left… have to get down.

ATC: Thirty left 900KN

Pilot: 00900KN (holds transmit button)

ATC: N0KN you’re cleared direct to Taylor.

ATC: 0KN, cleared direct to Taylor.

Pilot: Direct Taylor, 900KN.

ATC: Copy that you got descent (slope?) 200…

Pilot: (mumbling)

ATC: Descent and maintain flight level 200, and you are cleared direct Taylor.

Pilot: KN900KN (sounds confused)

ATC: Understand me, descend and maintain flight level 200, flight level 200, for N900KN

ATC: TBM, TBM 0KN, descend and maintain flight level 200

ATC: 0KN, if you hear this, transmit and ident.



ATC: N900KN, Atlanta center, how do you read?

ATC: N900KN, Atlanta Center… AC5685, keep trying N900KN

AC5685: TBM900KN, this is AC5685, how do you read? (Military aircraft?)

ATC: N900KN, Atlanta Center, how do you read?

AC5685: TBM900KN, AC5685, how do you read?

ATC: N900KN, TBM, 900KN, Atlanta Center, how do you hear this…

ATC: N0KN, descent now, descent now to flight level 200.

ATC: N900KN, TBM 900KN, if you hear this transmission, contact … center 127.87

ATC: N0KN, TBM 0KN, contact … center 127.87 if you hear this…

Learn more: http://www.naturalnews.com




The United States (US) Coast Guard Cutter has called off its search for the Socata TBM700N (TBM900) aircraft that crashed in Jamaican waters near Portland, on Friday, September 5.

Civil/Military Cooperation Officer at the Jamaica Defence Force (JDF), Major Basil Jarrett, told JIS News today (September 7), that a Spokesman from the Cutter said it is unlikely  they will find any survivors at this time, so they are moving out.

Major Jarrett said the Air Wing and  Coast  Guard of the JDF will continue  the search and recovery  operation.

The aircraft, which crashed at approximately 1:10 p.m., departed from Rochester, New York, heading south to Naples, Florida, with two persons on board.

The aircraft was reported to be non-responsive to communication from United States Air Traffic Control, and is suspected of running out of fuel and crashing somewhere over the Caribbean Sea.

Speaking at  a press briefing, held at the Office of the Prime Minister on September 6, Commanding Officer of the JDF Coast Guard, Commander Antoinette Wemyss-Gorman, informed that a debris field was spotted on Friday, September 5, in an area about 24 nautical miles north of Port Antonio, in Portland.

However, she  said the JDF was unable to confirm that the debris sighted was from the aircraft, as by the time  they got to where it was seen, they did not find it.

“At this point, we will have to assume that the debris that we spotted sank,” Commander Wemyss-Gorman said.

- Source:  http://jis.gov.jm

PORT ANTONIO, Portland — As the search continued for the private aircraft which crash-landed some 14 nautical miles off the northern coast of Portland on Friday, the main search agency, the Jamaica Defence Force (JDF) has stated that no debris from the plane has been found.

The disclosure followed a day of extensive searching by Jamaican and United States rescue agencies for the aircraft which had billionaire Laurence Glazer and his wife Janet, along with a pilot, aboard.

Addressing media representatives at the Errol Flynn Marina in Port Antonio yesterday, Lt Commander Judy Neil of the JDF said that while a calculated search-and-recovery operation was taking place, no debris from the crashed aircraft had been officially located as yet.

"The search-and-recovery operation by the JDF along with its partners started at the crack of dawn aided by additional assets from the United States Coast Guard in the form of a Cutter vessel — the USS Bernard Webber — and a helicopter.

"Debris of some sort, as can be expected at sea, was spotted from one of the aerial assets participating in the operation but nothing from the downed aircraft. That is the information at this time," Lt Commander Neil said.

Neil informed journalists that the crashed vessel, a single-engine Daher-Socata TBM-900 light business and utility aircraft, was not fitted with the customary black box which is routinely used to record in-flight voice communication on most aircraft.

"The aircraft, which crash-landed just off our coast (Jamaica) yesterday, does not carry a black box. It was fitted with a Global Positioning System (GPS)," the JDF officer said without offering any further comment on the issue.

Lt Commander Neil stated that the heavy early-morning rain with its accompanying overcast conditions in no way hampered the efforts of the search-and-recovery team although from time to time the aerial assets had to return to land for refuelling.

"It is customary to have rain in Portland but the showers this morning did little to hamper our team. We got out early and just proceeded with our work and I am giving the assurance that we will continue our work until officially told not to do so. We are prepared, we are searching and we are very committed," Neil said.

The three people feared dead left Rochester, New York, early Friday morning destined for Florida, but instead entered Cuban airspace, then flew over Jamaica before disappearing off the Portland coast around 1:10 pm, officials said. It followed concern raised by United States officials that they had tried to make contact with the aircraft's pilot, without success.

It is suspected that the six-seater aircraft, which was manufactured in France, ran out of fuel and went down in the sea.

The Jamaican Government said yesterday that the search will continue for an undetermined period.

The Government said at a news conference held at the Office of the Prime Minister yesterday that in addition to the Air Wing and Coast Guard of the JDF, the Marine Police and the United States Coast Guard were assisting in the search.

Commanding Officer of the JDF Coast Guard, Commander Antoinette Wemyss-Gorman, told journalists at the news conference that the JDF had continued its search operation throughout Friday night and into Saturday morning.

She said that the basic mission of the JDF Coast Guard was to continue the search to locate possible wreckage and/or survivors, while continuing to coordinate with all the partners in the search.

"The United States Coast Guard has deployed what is called a self-locating marker buoy and this piece of equipment will allow us further information to refine the search area," Commander Wemyss-Gorman said.

Director General of the Jamaica Civil Aviation Authority, Leroy Lindsay, said three countries will be involved in the investigation of the plane crash -- Jamaica, the United States and France.

"The depth we expect where the aircraft went in is about 2,000 metres and we might not have the assets to deal with that in Jamaica. The French have volunteered to assist, should we need equipment to go to those depths, to help us with the discovery of the aircraft," he said.

Minister with responsibility for Information, Sandrea Falconer, who chaired the news conference, said that the Office of Disaster Preparedness and Emergency Management (ODPEM) had activated its national emergency operations to provide support and coordination to key agencies.

Briefings have also been conducted with fishermen from the Portland area advising them to make contact with the police if debris is spotted by one of their boats, Falconer said.

Additional reporting by HG Helps and the Jamaica Information Service.



 Members of the Marine Police leave the Errol Flynn Marina on another search. 
(PHOTO: BRYAN CUMMINGS)



 Superintendent Wayne Cameron (right) of the Portland division goes over details with police personnel.
 (PHOTO: BRYAN CUMMINGS)


 Rescue workers brave the conditions as they search for debris.
 (PHOTO: BRYAN CUMMINGS)


 Marine Police boats docked at the Errol Flynn Marina


 Senior Superintendent of Police Terrence Bent (left) and Lt Commander Judy Neil of the JDF Coast Guard address journalists in Portland.

 A JDF helicopter flies over Port Antonio.


An aerial shot of the United States Coast Guard vessel USS Bernard Webber. 
(PHOTO: GARETH DALEY)

Search intensifies - Jamaica, US teams comb the sea off the coast of Portland but fail to find downed plane

A long, gruelling day of searching by members of a team from the Jamaica Defence Force (JDF), the Marine Police and the United States (US) Coast Guard ended yesterday without success, as the TBM900 aircraft that crashed off the coast of Portland on Friday remained buried in the sea.

Early-morning hopes that the aircraft would be found were sparked by reports from the JDF Air Wing that debris believed to be from the aircraft had been spotted and photographed. The debris field was spotted in an area about 24 nautical miles north of Port Antonio.

"While it is not yet possible to confirm that the debris sighted is from the missing TBM900, our pilots are very confident that the sighting is consistent with that of a high-impact debris field, and this has since been corroborated by a C130 aircraft involved in the operation," said the JDF in an early-morning release.

Still no luck

But by late afternoon, Lieutenant Commander Judy-Ann Neal, operations officer at the JDF Coast Guard, told reporters gathered at the marina in Port Antonio, Portland, that there was no luck, even though the local team was assisted by US Coast Guard cutter Bernard Weber, which arrived on the scene at 2:00 yesterday morning.

"No search could have been conducted then, but the official search started at daybreak," said Neal.

"Our two surface assets are still out there searching, the US Coast Guard cutter is still out there, a helicopter was also launched and has been conducting a search in the area, but nothing was found. No further evidence or debris from the wreckage has been observed from the surface assets from neither local nor overseas that have been deployed to the search area," added Neal.

Later at Jamaica House, head of the JDF Coast Guard, Antonette Wemyss-Gorman, declined to say for how long the Jamaican authorities are prepared to continue before calling off the search, which is slated to resume early this morning.

However director general of the Jamaica Civil Aviation Authority, Leroy Lindsay, said there has been an offer from overseas to assist Jamaican agencies with recovering the wreck if it proves too challenging for Jamaica.

"The depth we expect where the aircraft went in is something round about 2,000 metres, really deep, and we might not have the asset to deal with that in Jamaica. The French have volunteered that they will assist, should we need equipment to go to those depths to help us with the discovery of the aircraft," said Lindsay.

He said a lead investigating team is to be assembled to carry out a probe after the recovery effort is done.

A search-and-rescue operation resumed at first light yesterday as crews tried to solve the mystery of a small private plane carrying a prominent upstate New York couple who were taken on a ghostly 1,700-mile journey after the pilot was apparently incapacitated at the controls.

The single-engine turboprop Socata TBM900 was carrying Rochester real estate developer Laurence Glazer and his entrepreneur wife, Jane — both experienced pilots.

Unresponsive aircraft

Last Friday, US fighter pilots were launched to shadow the unresponsive aircraft; they observed the pilot slumped over and its windows frosting over. Officials say the plane slammed into the sea at least 22 kilometres (14 miles) off Jamaica's northeast coastline.

In a statement last Friday, the US Coast Guard 7th District command centre in Miami said three people were reportedly on-board the plane.

The plane's pilot had indicated there was a problem and twice asked to descend to a lower altitude before permission was granted by an air traffic controller, according to a recording of the radio conversation. Radio contact with the plane was lost a short time later.

The single-engine plane took off at 8:45 a.m. Friday from the Greater Rochester International Airport in New York en route to Naples, Florida. Air traffic controllers were last able to contact the pilot at 10 a.m., the US Federal Aviation Administration said in a statement.

- Source:   http://jamaica-gleaner.com


US personnel (from left) Pauline Kastner, Elizabeth Martinez, chargé d'affaires, and Robert Piehel as they made their way to an emergency press conference on the crashed aircraft at Jamaica House yesterday.
 - Norman Grindley/Chief Photographer 



A Jamaica Defence Force helicopter flies over the Port Antonio marina pier in Portland yesterday, as the Jamaica and US coast guards search for the missing plane that crashed at sea on Friday. 
- Norman Grindley/Chief Photographer


Norad Fighter Jets Followed Plane Until It Entered Cuban Airspace 

The U.S. military scrambled fighter jets on Friday to investigate a small private plane that became unresponsive while flying over the eastern U.S. before crashing into the Caribbean Sea.

The North American Aerospace Defense Command said it dispatched fighter aircraft late Friday morning after the plane stopped responding to calls from air-traffic control. The aircraft, a Daher-Socata TBM-900 single-propeller plane that can carry up to six adults, was flying from Rochester, N.Y., to Naples, Fla.

The plane strayed hundreds of miles from its filed flight plan, heading out over the Atlantic Ocean on a straight-line course that took it over the Bahamas before it entered Cuban airspace, where Norad said the fighter jets broke off pursuit.

At around 2:15 p.m. EDT, the plane crashed into waters about 14 miles north of Port Antonio, Jamaica, according to the Federal Aviation Administration.

Both Larry and Jane Glazer of Rochester were killed aboard the aircraft when it crashed, according to a statement from their family Friday afternoon. Mr. Glazer, a real-estate developer, was a major player in the redevelopment of faded industrial properties in downtown Rochester, city officials said.

Before losing contact with the aircraft, the TBM-900 radioed: "We need to descend to around [18,000 feet], we have an indication that's not correct in the plane," according to an air-traffic-control recording reviewed by The Wall Street Journal. The aircraft was cleared to descend to 25,000 feet by air-traffic control, but the aircraft responded, "We need to get lower."

No emergency was declared to air-traffic control, and the plane was later cleared down to 20,000 feet—an instruction it acknowledged, but it remained at 25,000 feet, where the aircraft held for the remainder of the flight before crashing.

Flightaware.com, a website that tracks civilian air traffic, showed the plane continuing to fly over the southern coast of Cuba before suddenly and sharply dropping forward speed and changing its vertical speed just north of Jamaica.

A spokesman for the National Transportation Safety Board said it is "monitoring the situation," and that its role in any investigation will be dictated by the exact location where the aircraft came down. If the plane crashed in Jamaican territorial waters, the NTSB would be a party to the investigation, since the aircraft was registered in the U.S., he added. If the aircraft crashed in U.S. or international waters, the NTSB would be responsible for the investigation, per International Civil Aviation Organization agreements.

The U.S. Coast Guard has initiated a search mission in the region, Norad said.

A tweet from Norad's official Twitter account suggested the aircraft's pilot suffered "possible hypoxia," with a lack of pressurization on board depriving the plane's occupants of oxygen and incapacitating the pilot.

"All we know is we're dealing with an unresponsive pilot," Lt. Col. Tom Crosson, a spokesman for the Pentagon, said before the plane had crashed.

Loss of pressurization and incapacitation of pilots are rare, but do happen. A Learjet carrying professional golfer Payne Stewart lost cabin pressure in 1999, incapacitating the crew during a flight from Orlando, Fla., to Dallas. The aircraft eventually ran out of fuel and crashed.

The Greater Rochester International Airport said its director, Michael Giardino, was contacted by the U.S. Air Force and the Transportation Security Administration about the aircraft at 10:45 a.m., two hours after its 8:45 a.m. departure.

An FAA statement said the pilot had stopped responding to radio calls around 10 a.m.

Initially, at approximately 10:40 a.m., two F-16 fighter jets launched from McEntire Joint National Guard Base in Richland County, S.C., to investigate, Norad said. Those jets handed off monitoring duties at around 11:30 a.m. to two F-15 fighters from Homestead Air Reserve Base in Florida, which escorted the aircraft until it entered Cuban airspace.

The two fighter jets then returned to base at roughly 2 p.m. to refuel, said John Cornelio, a Norad spokesman. Norad had a number of contingency efforts in place if the passenger plane had continued flying after the F-15s finished refueling, but it crashed during that time.

—Josh Barbanel and Felicia Schwartz contributed to this article.

Corrections & Amplifications

An aircraft carrying golfer Payne Stewart in 1999 crashed in South Dakota. An earlier online version of this article misstated it was North Dakota.


- Source:   http://online.wsj.com 

2 comments:

  1. "The pilot requests ATC "need to descend down to about (18,000 feet)...we have an indication not correct in the plane." ATC replied, "Stand by," pause, cleared descent to 25,000 feet, Pilot: "We need to get lower," ATC,"Working on that," the controller said."...

    The tragedy of this avoidable accident: a pilot wealthy enough to buy a $4+ million, high performance aircraft, not knowledgeable enough to understand his Pilot in Command authority to declare "EMERGENCY, DESCENDING" and commence an off-airway descent to altitude necessary without "asking" ATC. One may also wonder if he ever bother to spend a few hundred dollars for an Isobaric Chamber session and some ground school instruction, a responsible education cost when you have enough money to buy a high performance aircraft capable of flying at 31,000 ft.

    At least the aircraft did not crash into an area that could have resulted in innocent loss of life or that fighter pilots were not required to shoot it out of the sky.

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  2. There are a lot of Monday morning quarter backs,that have never experienced hypoxia and it's effects and how quick it comes on. My thoughts are do some homework before you condemn the dead and yes I am a pilot commercial rating and 10,000 hrs. Military and civilian in high performance aircraft!

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