Thursday, January 8, 2015

Jet Maker Bombardier Finds Bigger Proves Far From Better • Missteps Shake CSeries Project in Bid to Go Head-to-Head With Boeing and Airbus

The Wall Street Journal
By JON OSTROWER and  PAUL VIEIRA

Updated Jan. 8, 2015 8:35 p.m. ET


MIRABEL, Quebec—Just after he became Bombardier Inc. ’s chief executive in 2008, Pierre Beaudoin bet the future of the company his grandfather founded on a pair of passenger jets rivaling those from the two titans of global aerospace.

Bombardier had long produced smaller planes for wealthy individuals, companies and regional airlines. The technologically advanced, more fuel efficient CSeries would be its first jets capable of seating well over 100 passengers, aiming at a slice of the market dominated by Boeing Co. and Airbus Group NV.

But more than six years after the CSeries’ first orders, Mr. Beaudoin is revamping Bombardier and retaking control of the project to keep it from becoming a multibillion-dollar albatross.

In the latest blow, Bombardier said Thursday it was parting ways with its chief commercial-aircraft salesman. A series of missteps have shaken the project, starting with development problems that delayed the first model’s planned late-2013 delivery date by as much as two years, and continuing through software-development snags and a major engine failure last May that halted test flights for 100 days.

The cost of the CSeries has mushroomed, and the Swedish carrier lined up to be the first operator of CSeries planes declined the role in August—the second customer to do so. Bombardier said it has secured a new launch airline, though it isn’t yet naming it.

Meanwhile, Airbus and Boeing, as well as Brazil’s Embraer SA, have sharpened competition in the broader single-aisle market—the industry’s workhorse planes of 100 to 240 seats—that the CSeries must contend with. The other jet makers are upgrading existing models to offer improved fuel efficiency—which makes planes cheaper per seat to operate—while aggressively discounting sales prices.

Combined with other savings for airlines that come from only making incremental changes in their fleets, the moves have eaten into the cost efficiency of Bombardier’s new jets.

In an interview, Bombardier’s 52-year-old scion says he is confident the efforts will pay off. A major restructuring announced in July culled an entire layer of senior managers at the aerospace unit and gave Mr. Beaudoin a much more hands-on role, which he says is necessary to monitor the large investments Bombardier has made. After more than six years of marketing, Bombardier has about 80% of the 300 firm orders it plans to have when the jet is scheduled to be delivered.

“We’re getting there now, but it’s long and it takes a long time, so it needs a lot of patience,” he says. “It gives opportunities for a lot of people to question.”

Industry observers say Mr. Beaudoin has left himself with little room for error. “This is a really crucial window for the CSeries right now,” said Jerrold T. Lundquist, former head of McKinsey & Co.’s aerospace and defense practice who now runs his own consultancy, Lundquist Group. If it fails to win more orders soon and deliver the CSeries on time, Bombardier could be burdened for years with a program that churns out little or no profit, he said. “The choice to go with an aircraft…right into the competitive domain of Boeing and Airbus was very, very risky, and I think they’re paying the price for that now.”

Bombardier, its suppliers and governments in Canada and the U.K., where the wings are built, are now on track to plow at least $4.4 billion into the CSeries program—up from an original plan of $3.4 billion and equal to nearly two thirds of Bombardier’s total market value.

Bombardier’s aerospace sales have picked up recently, but revenue in 2013 was roughly flat with the level five years earlier, at $9.39 billion, while profit before interest and taxes fell by more than 53% to $418 million in the period. Results for 2014 are due out in February.

More is at stake than Bombardier’s bottom line. Founded in 1937 by Joseph-Armand Bombardier, Mr. Beaudoin’s grandfather and the man widely regarded as the inventor of the modern snowmobile, the company represents one of Canada’s few manufacturing success stories on the global stage. Bombardier Inc. no longer makes snowmobiles, but its products are omnipresent in Canada, from turboprop planes to commuter trains to subway cars, and it remains one of the country’s largest employers, with roughly 25,000 on home soil. Revenue at Bombardier’s transportation division, which builds the trains and rail systems, slipped over the past five years to $8.77 billion in 2013.

Mr. Beaudoin set the CSeries in motion in 2004, when he was heading the aerospace division. Bombardier faced a major challenge from Embraer, and sales of its commercial planes, after rapid growth in the 1990s, were slowing. He tapped Gary Scott, a former Boeing executive, to develop the CSeries, giving him a team that grew to 600 people. In 2006, with the engine it needed still years from becoming available, Mr. Beaudoin scaled the team back to 50 but kept the project going.

“This was Pierre’s baby,” said Mr. Scott, who retired from Bombardier in 2011. Mr. Scott likened the project to Boeing’s development in the 1960s of the 747, then its largest jet by far. “We all kind of loosely used ‘betting the company’,” when describing the Bombardier project, he said, and the board “saw it as the biggest bet the company ever made.”

Mr. Beaudoin said the big investment in the CSeries isn’t unusual for Bombardier and other aerospace companies.

Mr. Beaudoin became CEO on June 4, 2008, replacing his father, Laurent, who remains chairman. Less than six weeks later, Bombardier announced its first airline commitment for the planes, and its board voted to proceed with producing it. The new CEO said the planes would “revolutionize the economics and network strategies for airline operations in the 100- to 149-seat commercial market.”

In a way, the CSeries already has reshaped the industry. The jets were designed to be 20% more fuel-efficient than similarly sized planes, in part thanks to a new engine from United Technologies Corp. ’s Pratt & Whitney unit, as well as quieter and less-polluting. With up to 125 seats for the smaller CS100 model and up to 160 for the CS300, which list for $63.4 million to $72.4 million each, the jets would go head-to-head with the less-efficient, smallest versions of the popular single-aisle offerings from Boeing, the 737, and Airbus, the A320.

Bombardier estimated in 2014 that the market for jets of 100 to 149 seats over the coming 20 years would be 7,100 aircraft, worth more than $465 billion. It said it expected to capture half of that.

Alarmed by the CSeries, Bombardier’s rivals soon responded—leading to what has become a record jet sales binge. In December 2010, Airbus launched its A320neo line—three single-aisle jets that now range from 124 to 240 seats—boasting 15% or more fuel savings from its previous models and scheduled for delivery in November. Boeing in August 2011 launched its 737 Max line—three jets ranging from 126 to 220 seats—slated for delivery in 2017, also touting fuel savings. Embraer in June 2013 decided to add new wings, engines and longer bodies to its regional jets for 2018, though it stopped short of directly challenging Boeing and Airbus. Both Airbus and Embraer offered the same Pratt engine used on the CSeries.

Bombardier was blindsided. “We did not fully expect and prepare” for the competitive response led by Airbus, said a Bombardier executive.

It had thought Airbus and Boeing would discount their existing aircraft, and later make all-new, pricier jets, according to two people familiar with Bombardier’s planning. But it didn’t think it was likely the duo would simply put better engines on existing models, they said. The move meant Airbus and Boeing avoided the expensive and risky investment in developing new models.

Boeing and Airbus, in competition with each other, cut prices in deals for their upgraded models, and further blunted Bombardier because their larger planes spread fuel and other operating costs across more seats. The larger planes are attractive as airlines, even in smaller markets, opt to fly bigger jets with more passengers, rather than add more flights at congested hubs.

A Boeing spokeswoman said the company competes “based on the best combination of price and value” in all its sales campaigns for single-aisle jets. John Leahy, Airbus’s chief salesman, dismissed the idea that it engaged in a price war, and said customers prefer jets with more seats than the CSeries offers. “I don’t want to upset my friends in Montreal, but we do not take them very seriously as a competitive threat,” he said.

Bombardier officials say that they relish their underdog status and that the company also was discounted by rivals when building its first business and regional jets. Bombardier says that in addition to the increased fuel efficiency, its new planes are quieter and more useful at small airports with shorter runways, and offer more comfortable cabins.

Defenders say not all routes can accommodate the bigger single-aisle jets, and the size of the CSeries aircraft will be needed by airlines.

Global airlines in the market for the single-aisle jets have snapped up the Airbus and Boeing upgraded planes, eating away at the potential market for Bombardier. Airbus has more than 3,400 firm orders for the A320neo family, and Boeing has over 2,600 for its 737 Max jets. “A lot of the market is already taken,” says Scotia Capital Inc. analyst Turan Quettawala. He estimated in September about 75% of the market for single-aisle jets for the next 10 years is already sold to Airbus, Boeing and Embraer.

While Bombardier’s 243 orders for its CSeries jets equal about half the 457 disclosed orders for the smaller models in the next-generation single-aisle market, the vast majority of orders so far are for the larger planes.

Mr. Beaudoin says they would rather have a small number of orders to be delivered now so they can command a higher price later, once the jet is certified and the performance is proven. “There’s no advantage for us to go build the next 10 years of production at launch price,” Mr. Beaudoin said.

Mr. Lundquist, the aerospace consultant, says Bombardier should be focusing on securing orders from large established airlines that act as a validating force for the jet’s new technology.

Bombardier has secured orders from large airlines like Deutsche Lufthansa AG and Korean Air Lines Co. , but it is challenged by the power of incumbency. A readily available pool of pilots for Boeing and Airbus aircraft and a global technical infrastructure built for the more than 10,000 single-aisle jets from those makers in service make acquiring the European and American models comparatively less risky or expensive for airlines.

A Bombardier spokesman said the CSeries is the right aircraft and that Airbus and Boeing have “neglected” this market segment.

The company said Thursday that Raymond Jones, the former senior vice president of global sales, marketing and asset management for its commercial-aircraft business, was leaving for personal reasons. He was appointed in December 2013, following the abrupt departure of his predecessor, who also struggled to reel in big airlines for the new CSeries jets. A replacement hasn’t been named. Mr. Jones didn’t respond to a request for comment.

Jure Dubravica, head of portfolio management at KBM Infond, a Slovenian fund manager, sold his entire Bombardier holding of 121,350 shares last year and invested in rival Embraer. Bombardier is “still a great company…but we didn’t like the delays in the CSeries and the [lack] of orders,” he said.

Bombardier’s most important shareholders won’t likely follow suit. The four living children of founder Joseph-Armand Bombardier, including Mr. Beaudoin’s mother, together own 79% of the supervoting A class shares, giving them 54% of the total voting rights. There has never been a serious push by shareholders to collapse the company’s share structure. Bombardier’s B-share price has fallen about 14% since the end of 2009.

Bombardier also has the backing of the Canadian government, which through last year had disbursed 350 million Canadian dollars, or about US$300 million, in low-interest loans to Bombardier to help develop technology for the CSeries. A Canadian government official declined to make details of the financing available.

Bombardier hopes its hardest days are behind it. The CS100 test fleet is again airborne, having flown more than 750 of the 2,400 hours needed to certify the new jet after Pratt developed a fix for the engine’s oil system. Its software snags are also in the past, and it is flying jets with a version representative of what airline pilots will experience. The first CS300 jet is readying for air trials.

At the same time, Bombardier is juggling other major aviation challenges that are consuming attention and resources. It is developing a pair of larger corporate jets as part of its successful Global line to be delivered in 2016 and 2017, including the longest-range business jet ever designed.

It is also working on an all-new carbon fiber model for its Learjet unit originally due in late 2013, which has struggled with design issues and has no new delivery target. Meanwhile, political tension caused it to shelve plans for an assembly line in Russia tied to up to 100 orders for its turboprop aircraft, now in limbo.

The restructuring of the aerospace operations started in July, with the division’s CEO, Guy Hachey, abruptly retiring and some 1,800 jobs cut. Mr. Hachey declined to comment through Hexcel Corp., where he now serves on the board of directors. Top executives for marketing, strategy, communications and some CSeries sales staff were let go. Unit presidents now all report directly to Mr. Beaudoin, who says Bombardier needs the new structure “to be able to be agile with all the growth that’s coming up.”

Mr. Beaudoin continues to believe the investment will pay off and his focus today is completing the jet’s certification. “I’m very confident that the market will be there” when the CSeries is done, he said. “I’d like to think it’s not a bet, I think we’ve done our homework.”

—Alistair MacDonald contributed to this article.

Original article can be found at: http://www.wsj.com


Key Lime Air: Piper PA-31-350 Navajo Chieftain, N66906 • Fairchild SA227-AC Metro III, N31171 • Cessna 404 Titan, N404MG

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

Additional Participating Entity:
Federal Aviation Administration / Flight Standards District Office; Wichita, Kansas

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

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

Registered Owner: CBG LLC
Operator: Key Lime Air

http://registry.faa.gov/N66906




NTSB Identification: CEN15LA117
Nonscheduled 14 CFR Part 135: Air Taxi & Commuter
Accident occurred Wednesday, January 21, 2015 in Goodland, KS
Probable Cause Approval Date: 04/26/2016
Aircraft: PIPER PA-31-350, registration: N66906
Injuries: 1 Uninjured.

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

The commercial pilot was conducting a cargo flight in the airplane. The operator reported that, during taxi and takeoff, the pilot noted no issues with the airplane. During cruise flight, the left engine lost total power. The right engine then also lost total power, but the pilot failed to complete any of the required engine failure emergency procedures. He chose to perform a forced landing, during which the airplane impacted power lines and then a field, which resulted in substantial damage to the airplane. 

On-scene examination revealed that there was no apparent fuel smell nor fuel on the ground. During postaccident examination of the airplane, no useable fuel was found in the left and right outboard fuel tanks; however, 35 gallons of fuel were found in each of the two inboard fuel tanks. The fuel selectors were found in the “off” position. Further examination of the fuel system revealed that there was no fuel in the fuel lines leading to the left engine and that only about 2 teaspoons of fuel was present in the fuel inlet line to the right engine fuel strainer, indicating that the pilot had not properly managed the fuel, which led to fuel starvation to both engines. The examination revealed no mechanical anomalies that would have precluded normal operation.

Further, postaccident examination of the airplane revealed that the pilot had not feathered both propellers, which would have increased the airplane’s glide distance, and that he had not extended the flaps, which would have resulted in a slower touchdown speed and lower impact energy during the forced landing. Therefore, the pilot did not properly configure the airplane for the forced landing, which resulted in its high-energy impact with power lines and terrain. 

The pilot was on duty all night the day before the accident and had to reposition a flight at 0330, at which point he had been awake for about 15 hours. The pilot reported that, about 40 minutes into the flight, he was definitely starting to feel fatigued. Shortly later, the engine issues began. The pilot reported that he believed that a high level of fatigue, previous issues with another airplane he had flown that day, and a recent company airplane accident had "caused him to not think straight and not perform the proper emergency procedures for engine failure in flight."

The National Transportation Safety Board determines the probable cause(s) of this accident as follows:
The pilot’s improper fuel management and failure to conduct the engine failure emergency procedures and his improper conduct of the forced landing, which resulted in fuel starvation, a total loss of engine power, and the subsequent high-energy impact with power lines and terrain. Contributing to the accident was pilot fatigue.

On January 21, 2015, at 0754 mountain standard time, a Piper PA-31-350, N66906, experienced a total loss of engine power of both engines during cruise flight. The pilot performed a forced landing to a field where the airplane impacted terrain about 10 miles west of Goodland, Kansas. The airplane sustained substantial damage. The pilot was uninjured. The airplane was operated by Key Lime Air as [Key Lime Air] LYM flight 169 under the provisions of Title 14 Code of Federal Regulations Part 135 as a cargo flight and was operating on an instrument rules flight plan. Visual meteorological conditions prevailed for the flight that originated from Denver International Airport (DEN), Denver, Colorado, and was destined to Shalz Field Airport (CBK), Colby, Kansas.

On February 1, 2015, the National Transportation Safety Board Investigator-In-Charge (IIC) requested that the pilot complete the required NTSB Pilot/Operator Accident/Incident Report, NTSB Form 6120.1 and return to the IIC within 10 days. Form 6120.1 was not received from the pilot, and the pilot stated that he provided a statement to the company. 

After not receiving Form 6120.1 from the pilot, the IIC requested and received the Form 6120.1 from Key Lime Air, which had a Narrative History of Flight, the 'majority' of which was taken from the pilot's personal statement that he gave after the accident.

"On Tuesday, January 20th, the pilot woke up at 0330 and arrived at work at 0430 for his flight to Trinidad (LYM1961). That flight went without incident and the pilot was off duty at 0830. From 1000 to 1200, he was able to take a nap in the hotel where he was staying during the day. At 1745, he reported to work at [Perry Stokes Airport] (TAD), [Trinidad, Colorado]. During the preflight/run-up of aircraft N313RA, he discovered the battery was almost dead and the engines would not start. The airport did not have a [ground power unit] available to start the aircraft. Instead, the ground crew had two 12-volt car batteries that were linked together. The pilot unsuccessfully attempted to use these to help give the plane power. He then called Key Lime Air dispatch, told them of the problem, and called the [fixed base operator] for assistance. The pilot started the plane at 2100, and [proceeded] back to DEN. He blocked back in at 2222. When all post flight actions and maintenance write-ups were completed, he called dispatch to go off duty at 2300. Dispatch informed him that due to scheduling issues with his Wednesday morning flight, he would have to stay on duty all night and then reposition a plane from [Centennial Airport] (APA), [Denver, Colorado] to DEN at 0330. Once arriving home at 2345 on Tuesday night after the flight back to DEN, the pilot ate dinner. He decided that if he had to wake up at 0200 to drive to APA, two hours of sleep would make it difficult to wake up and he would have a good chance of oversleeping. He remained awake until it was time to drive to APA. On the drive there he realized that he was fatigued and had issues keeping his eyes open. Once arriving at the Key Lime ramp, he called the DEN ramp supervisor and said he was there but very tired. However, he did not use the word 'Fatigued.' The ramp supervisor asked if he was okay. The pilot replied that he was. The ramp supervisor told him to fly up to DEN, drink some coffee, and once done with the flight to CBK, he could nap before flying back to DEN. Once arriving at DEN and completing post-flight actions, the pilot realized that the nose wheel was losing air quickly. He assumed that it must have happened while taxiing to the UPS ramp. At this time, he wondered why he kept having issues when he got into a plane. He then conducted the preflight N66906 for the flight to CBK and noticed nothing unusual. While waiting for freight to be brought out, he walked towards another pilot's plane to talk to him, bumped a fire extinguisher, knocked the pin loose, and discharged the unit. He stated that he now felt jinxed and was going to cause an issue with the plane he was to fly to CBK. After the freight was brought out and loaded into N66906, he started up but realized both taxi and landing lights were inoperative. He turned back to the ramp and called maintenance. After roughly 45 minutes of troubleshooting maintenance could not find the cause of the issue and the lights were [a minimum equipment list item]. He then waited for daylight and taxied out for the flight. During taxi and takeoff there were no issues with the plane. Once he reached cruise altitude and configured the plane, he did not notice any issues and completed the aircraft trend, which read normal. After roughly 40 minutes into the flight, he stated that he was definitely starting to feel fatigued. Once 25-30 miles from the [Renner Field (Goodland Municipal Airport)] (GLD) [very high frequency omni-directional range navigation aid], he asked Denver Center to go direct to CBK to shorten the flight. Approximately five minutes later, he noticed the Left Boost Pump [Inoperative] light came on. He thought that turning on the Left Auxiliary Pump could fix the problem. However, soon after that the left engine failed. The pilot thought that it was a mechanical issue and radioed [air traffic control] (ATC) to report an engine failure. He then turned toward GLD. ATC reported the weather and asked what approach he wanted. The pilot stated that what he really should have been doing was troubleshooting the cause of the left engine failure. He believed the high level of fatigue, issues with the previous aircraft, and the fact that the company had just lost a pilot due to a crash a month ago caused him to not think straight and do the proper emergency procedures for engine failure in flight. He failed to complete any of the required emergency procedures and concentrated solely on getting to GLD. The Right Boost Pump [Inoperative] light then came on. The pilot turned on the Right Aux Pump but the engine started to fail. Now the pilot stated that he really started to feel stressed and that "his head was out of it." He thought he was not going to make it, and the fear of death clouded all decision making. He once again did not conduct the required emergency procedures and just thought of just getting to the airport. He was losing altitude quickly and told ATC he was not going to make it. ATC told him to find a road to put the plane down. At this time, the aircraft was roughly 2000 feet [above ground level]. The pilot located a gravel road (County Road 71). At roughly 1000 feet [above ground level], he put the landing gear in the down position, but did not get a chance to verify it was down. He was planning on landing to the left side of the road to avoid the power lines running along the south side of the road. At roughly 300 feet [above ground level], he saw a power line to the left (north) side of the road. At the last minute, he tried to pull up to miss the power line to the right but realized was going to hit it. The aircraft hit the power line. The pilot stated that he must have blacked out for the next few seconds. The next thing he knew was that he was stopped in a field to the north of County Road 71. Fearing an engine fire, he put the [fuel] tanks in the off position, pulled mixtures, turned off the [fuel] boost pumps"

According to a Federal Aviation Administration (FAA) Inspector from the Wichita Flight Standards District Office, the airplane was located in a field approximately 645 feet east of a second power line pole north of the intersection of County Road 10 and County Road 71. From the power line pole, in the direction of the aircraft, the left main gear torque links were at 50 feet, the left main landing gear door was at 72 feet, the initial impact of the airplane from the left main landing gear was at 236 feet, a left propeller strike at 267 feet, right propeller strike at 275 feet, nose landing gear impact at 269 feet, pieces of power line pole and power wires at 420 feet, left gear trunnion assembly and wheel at 440 feet, airplane at 645 feet. Approximately 6 feet of the power line was wrapped around the left gear trunnion assembly. Airplane antennas were found at various locations from the aircraft impact to where the airplane came to rest. The left and right propellers strikes were found to indicate they were rotating.

There was no damage to the primary flight controls with the exception of the left aileron. Flight control continuity was checked and all flight controls were able to fully travel, including the trim controls. All engine controls were checked for travel and the left and right engine controls were operational and checked at the engine compartment for continuity. All controls were fully functional.

At the airplane location, there was no apparent fuel smell or any indication of fuel found on the ground. The airplane was sitting at a slight left wing down angle. The left and right outboard fuel tanks were placarded for a 40 gallon capacity; no fuel was visible from looking into the tank from the fuel cap. Approximately two inches of fuel was found in the left inboard fuel tank, placarded for a 56 gallon capacity, and no fuel was visible in the right inboard fuel tank, also placarded for a 56 gallon capacity. 

Cockpit switches and fuel selectors were found in the off position. When power was turned on, the left and right outboard fuel tank indicated empty when selected, the right inboard fuel tank indicated empty when selected and the left inboard fuel tank indicated half full when selected. All circuit breakers were found in and no other abnormalities were found in the cockpit. The left engine throttle control was found in the cutoff position and propeller in the feather position. The right engine throttle controls was found forward in the power position and the propeller control was found forward in the power position. The gear handle was found in the down selected position.

Following the airplane's recovery to a salvage facility, further examination of the airplane fuel system revealed that there was no fuel found in the fuel lines leading to the left engine, however there was approximately two teaspoon of fuel found in the inlet line to the fuel strainer for the right engine. Fuel was sumped from the left and right outboard fuel tanks; approximately one quart of fuel was found in each tank. The inboard fuel tanks were sumped; approximately 35 gallons of fuel was found in each tank. There was a very minute amount of water found in the left inboard tank sump and very minute dirt/contamination found in each sump. The fuel selector valves were checked for continuity from the cockpit, there was no abnormalities found, the selector would allow each tank position to physically be selected.

The FAA Inspector stated that at no point did the pilot indicate he tried to restart either engine, check fuel gauges, or check the fuel selector position.

The FAA Inspector stated that the airplane landing gear was extended, the flaps were fully retracted, and both propellers were not in the feathered position.

NTSB Identification: CEN15LA117
Nonscheduled 14 CFR Part 135: Air Taxi & Commuter
Accident occurred Wednesday, January 21, 2015 in Goodland, KS
Aircraft: PIPER PA-31-350, registration: N66906
Injuries: 1 Uninjured.

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 January 21, 2015, about 0754 mountain standard time, a Piper PA-31-350, N66906, experienced a total loss of engine power of both engines during cruise flight. The pilot performed a forced landing to a field where the airplane impacted terrain about 10 miles west of Goodland, Kansas. The pilot was uninjured. The airplane sustained substantial damage. The airplane was registered to and operated by Key Lime Air as LYM169 under the provisions of Title 14 Code of Federal Regulations Part 135 as a cargo flight and was operating on an instrument rules flight plan. Visual meteorological conditions prevailed for the flight that originated from Denver International Airport, Denver, Colorado, and was destined to Shalz Field Airport, Colby, Kansas. The National Transportation Safety Board did not travel to the scene of this accident.

Additional Participating Entity:
Federal Aviation Administration / Flight Standards District Office; Wichita, Kansas

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

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

Registered Owner: CBG LLC
Operator: Key Lime Air

http://registry.faa.gov/N66906




NTSB Identification: CEN15LA117
Nonscheduled 14 CFR Part 135: Air Taxi & Commuter
Accident occurred Wednesday, January 21, 2015 in Goodland, KS
Probable Cause Approval Date: 04/26/2016
Aircraft: PIPER PA-31-350, registration: N66906
Injuries: 1 Uninjured.

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

The commercial pilot was conducting a cargo flight in the airplane. The operator reported that, during taxi and takeoff, the pilot noted no issues with the airplane. During cruise flight, the left engine lost total power. The right engine then also lost total power, but the pilot failed to complete any of the required engine failure emergency procedures. He chose to perform a forced landing, during which the airplane impacted power lines and then a field, which resulted in substantial damage to the airplane. 

On-scene examination revealed that there was no apparent fuel smell nor fuel on the ground. During postaccident examination of the airplane, no useable fuel was found in the left and right outboard fuel tanks; however, 35 gallons of fuel were found in each of the two inboard fuel tanks. The fuel selectors were found in the “off” position. Further examination of the fuel system revealed that there was no fuel in the fuel lines leading to the left engine and that only about 2 teaspoons of fuel was present in the fuel inlet line to the right engine fuel strainer, indicating that the pilot had not properly managed the fuel, which led to fuel starvation to both engines. The examination revealed no mechanical anomalies that would have precluded normal operation.

Further, postaccident examination of the airplane revealed that the pilot had not feathered both propellers, which would have increased the airplane’s glide distance, and that he had not extended the flaps, which would have resulted in a slower touchdown speed and lower impact energy during the forced landing. Therefore, the pilot did not properly configure the airplane for the forced landing, which resulted in its high-energy impact with power lines and terrain. 

The pilot was on duty all night the day before the accident and had to reposition a flight at 0330, at which point he had been awake for about 15 hours. The pilot reported that, about 40 minutes into the flight, he was definitely starting to feel fatigued. Shortly later, the engine issues began. The pilot reported that he believed that a high level of fatigue, previous issues with another airplane he had flown that day, and a recent company airplane accident had "caused him to not think straight and not perform the proper emergency procedures for engine failure in flight."

The National Transportation Safety Board determines the probable cause(s) of this accident as follows:
The pilot’s improper fuel management and failure to conduct the engine failure emergency procedures and his improper conduct of the forced landing, which resulted in fuel starvation, a total loss of engine power, and the subsequent high-energy impact with power lines and terrain. Contributing to the accident was pilot fatigue.

On January 21, 2015, at 0754 mountain standard time, a Piper PA-31-350, N66906, experienced a total loss of engine power of both engines during cruise flight. The pilot performed a forced landing to a field where the airplane impacted terrain about 10 miles west of Goodland, Kansas. The airplane sustained substantial damage. The pilot was uninjured. The airplane was operated by Key Lime Air as [Key Lime Air] LYM flight 169 under the provisions of Title 14 Code of Federal Regulations Part 135 as a cargo flight and was operating on an instrument rules flight plan. Visual meteorological conditions prevailed for the flight that originated from Denver International Airport (DEN), Denver, Colorado, and was destined to Shalz Field Airport (CBK), Colby, Kansas.

On February 1, 2015, the National Transportation Safety Board Investigator-In-Charge (IIC) requested that the pilot complete the required NTSB Pilot/Operator Accident/Incident Report, NTSB Form 6120.1 and return to the IIC within 10 days. Form 6120.1 was not received from the pilot, and the pilot stated that he provided a statement to the company. 

After not receiving Form 6120.1 from the pilot, the IIC requested and received the Form 6120.1 from Key Lime Air, which had a Narrative History of Flight, the 'majority' of which was taken from the pilot's personal statement that he gave after the accident.

"On Tuesday, January 20th, the pilot woke up at 0330 and arrived at work at 0430 for his flight to Trinidad (LYM1961). That flight went without incident and the pilot was off duty at 0830. From 1000 to 1200, he was able to take a nap in the hotel where he was staying during the day. At 1745, he reported to work at [Perry Stokes Airport] (TAD), [Trinidad, Colorado]. During the preflight/run-up of aircraft N313RA, he discovered the battery was almost dead and the engines would not start. The airport did not have a [ground power unit] available to start the aircraft. Instead, the ground crew had two 12-volt car batteries that were linked together. The pilot unsuccessfully attempted to use these to help give the plane power. He then called Key Lime Air dispatch, told them of the problem, and called the [fixed base operator] for assistance. The pilot started the plane at 2100, and [proceeded] back to DEN. He blocked back in at 2222. When all post flight actions and maintenance write-ups were completed, he called dispatch to go off duty at 2300. Dispatch informed him that due to scheduling issues with his Wednesday morning flight, he would have to stay on duty all night and then reposition a plane from [Centennial Airport] (APA), [Denver, Colorado] to DEN at 0330. Once arriving home at 2345 on Tuesday night after the flight back to DEN, the pilot ate dinner. He decided that if he had to wake up at 0200 to drive to APA, two hours of sleep would make it difficult to wake up and he would have a good chance of oversleeping. He remained awake until it was time to drive to APA. On the drive there he realized that he was fatigued and had issues keeping his eyes open. Once arriving at the Key Lime ramp, he called the DEN ramp supervisor and said he was there but very tired. However, he did not use the word 'Fatigued.' The ramp supervisor asked if he was okay. The pilot replied that he was. The ramp supervisor told him to fly up to DEN, drink some coffee, and once done with the flight to CBK, he could nap before flying back to DEN. Once arriving at DEN and completing post-flight actions, the pilot realized that the nose wheel was losing air quickly. He assumed that it must have happened while taxiing to the UPS ramp. At this time, he wondered why he kept having issues when he got into a plane. He then conducted the preflight N66906 for the flight to CBK and noticed nothing unusual. While waiting for freight to be brought out, he walked towards another pilot's plane to talk to him, bumped a fire extinguisher, knocked the pin loose, and discharged the unit. He stated that he now felt jinxed and was going to cause an issue with the plane he was to fly to CBK. After the freight was brought out and loaded into N66906, he started up but realized both taxi and landing lights were inoperative. He turned back to the ramp and called maintenance. After roughly 45 minutes of troubleshooting maintenance could not find the cause of the issue and the lights were [a minimum equipment list item]. He then waited for daylight and taxied out for the flight. During taxi and takeoff there were no issues with the plane. Once he reached cruise altitude and configured the plane, he did not notice any issues and completed the aircraft trend, which read normal. After roughly 40 minutes into the flight, he stated that he was definitely starting to feel fatigued. Once 25-30 miles from the [Renner Field (Goodland Municipal Airport)] (GLD) [very high frequency omni-directional range navigation aid], he asked Denver Center to go direct to CBK to shorten the flight. Approximately five minutes later, he noticed the Left Boost Pump [Inoperative] light came on. He thought that turning on the Left Auxiliary Pump could fix the problem. However, soon after that the left engine failed. The pilot thought that it was a mechanical issue and radioed [air traffic control] (ATC) to report an engine failure. He then turned toward GLD. ATC reported the weather and asked what approach he wanted. The pilot stated that what he really should have been doing was troubleshooting the cause of the left engine failure. He believed the high level of fatigue, issues with the previous aircraft, and the fact that the company had just lost a pilot due to a crash a month ago caused him to not think straight and do the proper emergency procedures for engine failure in flight. He failed to complete any of the required emergency procedures and concentrated solely on getting to GLD. The Right Boost Pump [Inoperative] light then came on. The pilot turned on the Right Aux Pump but the engine started to fail. Now the pilot stated that he really started to feel stressed and that "his head was out of it." He thought he was not going to make it, and the fear of death clouded all decision making. He once again did not conduct the required emergency procedures and just thought of just getting to the airport. He was losing altitude quickly and told ATC he was not going to make it. ATC told him to find a road to put the plane down. At this time, the aircraft was roughly 2000 feet [above ground level]. The pilot located a gravel road (County Road 71). At roughly 1000 feet [above ground level], he put the landing gear in the down position, but did not get a chance to verify it was down. He was planning on landing to the left side of the road to avoid the power lines running along the south side of the road. At roughly 300 feet [above ground level], he saw a power line to the left (north) side of the road. At the last minute, he tried to pull up to miss the power line to the right but realized was going to hit it. The aircraft hit the power line. The pilot stated that he must have blacked out for the next few seconds. The next thing he knew was that he was stopped in a field to the north of County Road 71. Fearing an engine fire, he put the [fuel] tanks in the off position, pulled mixtures, turned off the [fuel] boost pumps"

According to a Federal Aviation Administration (FAA) Inspector from the Wichita Flight Standards District Office, the airplane was located in a field approximately 645 feet east of a second power line pole north of the intersection of County Road 10 and County Road 71. From the power line pole, in the direction of the aircraft, the left main gear torque links were at 50 feet, the left main landing gear door was at 72 feet, the initial impact of the airplane from the left main landing gear was at 236 feet, a left propeller strike at 267 feet, right propeller strike at 275 feet, nose landing gear impact at 269 feet, pieces of power line pole and power wires at 420 feet, left gear trunnion assembly and wheel at 440 feet, airplane at 645 feet. Approximately 6 feet of the power line was wrapped around the left gear trunnion assembly. Airplane antennas were found at various locations from the aircraft impact to where the airplane came to rest. The left and right propellers strikes were found to indicate they were rotating.

There was no damage to the primary flight controls with the exception of the left aileron. Flight control continuity was checked and all flight controls were able to fully travel, including the trim controls. All engine controls were checked for travel and the left and right engine controls were operational and checked at the engine compartment for continuity. All controls were fully functional.

At the airplane location, there was no apparent fuel smell or any indication of fuel found on the ground. The airplane was sitting at a slight left wing down angle. The left and right outboard fuel tanks were placarded for a 40 gallon capacity; no fuel was visible from looking into the tank from the fuel cap. Approximately two inches of fuel was found in the left inboard fuel tank, placarded for a 56 gallon capacity, and no fuel was visible in the right inboard fuel tank, also placarded for a 56 gallon capacity. 

Cockpit switches and fuel selectors were found in the off position. When power was turned on, the left and right outboard fuel tank indicated empty when selected, the right inboard fuel tank indicated empty when selected and the left inboard fuel tank indicated half full when selected. All circuit breakers were found in and no other abnormalities were found in the cockpit. The left engine throttle control was found in the cutoff position and propeller in the feather position. The right engine throttle controls was found forward in the power position and the propeller control was found forward in the power position. The gear handle was found in the down selected position.

Following the airplane's recovery to a salvage facility, further examination of the airplane fuel system revealed that there was no fuel found in the fuel lines leading to the left engine, however there was approximately two teaspoon of fuel found in the inlet line to the fuel strainer for the right engine. Fuel was sumped from the left and right outboard fuel tanks; approximately one quart of fuel was found in each tank. The inboard fuel tanks were sumped; approximately 35 gallons of fuel was found in each tank. There was a very minute amount of water found in the left inboard tank sump and very minute dirt/contamination found in each sump. The fuel selector valves were checked for continuity from the cockpit, there was no abnormalities found, the selector would allow each tank position to physically be selected.

The FAA Inspector stated that at no point did the pilot indicate he tried to restart either engine, check fuel gauges, or check the fuel selector position.

The FAA Inspector stated that the airplane landing gear was extended, the flaps were fully retracted, and both propellers were not in the feathered position.

NTSB Identification: CEN15LA117
Nonscheduled 14 CFR Part 135: Air Taxi & Commuter
Accident occurred Wednesday, January 21, 2015 in Goodland, KS
Aircraft: PIPER PA-31-350, registration: N66906
Injuries: 1 Uninjured.

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 January 21, 2015, about 0754 mountain standard time, a Piper PA-31-350, N66906, experienced a total loss of engine power of both engines during cruise flight. The pilot performed a forced landing to a field where the airplane impacted terrain about 10 miles west of Goodland, Kansas. The pilot was uninjured. The airplane sustained substantial damage. The airplane was registered to and operated by Key Lime Air as LYM169 under the provisions of Title 14 Code of Federal Regulations Part 135 as a cargo flight and was operating on an instrument rules flight plan. Visual meteorological conditions prevailed for the flight that originated from Denver International Airport, Denver, Colorado, and was destined to Shalz Field Airport, Colby, Kansas. National Transportation Safety Board - Aviation Accident Final Report: http://app.ntsb.gov/pdf

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

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

http://registry.faa.gov/N404MG

FAA Flight Standards District Office: FAA Denver FSDO-03

NTSB Identification: CEN15FA090 
14 CFR Part 91: General Aviation
Accident occurred Tuesday, December 30, 2014 in Englewood, CO
Probable Cause Approval Date: 02/08/2016
Aircraft: CESSNA 404, registration: N404MG
Injuries: 1 Fatal.

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

The pilot was conducting an early morning repositioning flight of the cargo airplane. Shortly after takeoff, the pilot reported to air traffic control that he had “lost an engine” and would return to the airport. Several witnesses reported that the engines were running rough and one witness reported that he did not hear any engine sounds just before the impact. The airplane impacted trees, a wooden enclosure, a chain-linked fence, and shrubs in a residential area and was damaged by the impact and postimpact fire. 

The airplane had been parked outside for 5 days before the accident flight and had been plugged in to engine heaters the night before the flight. It was dark and snowing lightly at the time of the accident. The operator reported that no deicing services were provided before the flight and that the pilot mechanically removed all of the snow and ice accumulation. The wreckage and witness statements were consistent with the airplane being in a right-wing-low descent but the airplane did not appear to be out of control. Neither of the propellers were at or near the feathered position. The emergency procedures published by the manufacturer for a loss of engine power stated that pilots should first secure the engine and feather the propeller following a loss of engine power and then turn the fuel selector for that engine to “off.” The procedures also cautioned that continued flight might not be possible if the propeller was not feathered. The right fuel selector valve and panel were found in the off position. Investigators were not able to determine why an experienced pilot did not follow the emergency procedures and immediately secure the engine following the loss of engine power. It is not known how much snow and ice had accumulated on the airplane leading up to the accident flight or if the pilot was successful in removing all of the snow and ice with only mechanical means. The on-scene examination of the wreckage and the teardown of both engines did not reveal any preimpact mechanical malfunctions or failures. While possible, it could not be determined if water or ice ingestion lead to the loss of engine power at takeoff.

The National Transportation Safety Board determines the probable cause(s) of this accident as follows:
The loss of power to the right engine for reasons that could not be determined during postaccident examination and teardown and the pilot’s failure to properly configure the airplane for single-engine flight.

HISTORY OF FLIGHT

On December 30, 2014, about 0429 mountain standard time a Cessna 404, N404MG, was substantially damaged when it impacted a residential area north of Centennial Airport (KAPA), Englewood, Colorado. A post impact fire ensued. The airline transport pilot was fatally injured. The airplane was operated by Key Lime Air under the provisions of 14 Code of Federal Regulations Part 91 as a positioning flight. Night visual meteorological conditions prevailed for the flight, which operated on an instrument flight rules flight plan. The flight was originating at the time of the accident and was en route to Denver International Airport (KDEN), Denver, Colorado

According to representatives from Key Lime Air, the pilot was positioning the airplane from KAPA to KDEN for a potential 14 Code of Federal Regulations Part 135 freight flight. The airplane was parked outside and uphill from their facility at KAPA since December 25, 2014. The night before the accident the airplane was towed to a parking space outside of their hangar so that the engine heaters could be plugged in.

On the morning of the accident, the pilot was observed removing the blankets from the engine and the snow and ice on the airframe. The pilot used mechanical means to deice the airplane and was not assisted with a chemical deice or deicing services. Key Lime Air estimated that the airplane had 800 pounds of fuel on board. There were no services requested or received by the pilot on the morning of the accident.

A Key Lime Air employee estimated that the pilot started his number 1 engine about 0408. The engine started immediately and ran for 5 to 10 minutes before the pilot started the number two engine. This engine also started immediately and ran for several minutes. The airplane taxied from its parking spot several minutes later.

According to air traffic control (ATC) recordings the pilot requested clearance from ATC and was cleared to the Denver Airport at an altitude of 8,000 feet. At 0419:11 the pilot announced his taxi and was cleared to runway 35 right via the alpha taxiway. At 0425 the pilot was cleared for takeoff.

At 0427:22 the pilot reported to the tower controller that he had "lost an engine" and needed to return to the airport. The controller responded that any runway was available and provided a wind of 030 degrees at 3 knots. At 0427:38 the controller asked the pilot if he would be able to make "that left turn." At 0427:42 the pilot responded by saying "standby".

Radar data indicated the accident airplane departed from runway 17L/35R to the north – the field elevation at KAPA was 5,885 feet mean sea level (msl). The radar track was consistent with a slight right turn to the northeast. Radar data indicated an altitude of 6,125 feet msl when the turn to the right was initiated. The highest altitude indicated was 6,225 feet msl. The last recorded radar return indicated an altitude of 5,975 feet msl, and was coincident with ATC's loss of radar and voice communications.

One witness observed the airplane in a right turn. Several other witnesses heard the airplane and described a rough-running engine. One witness stated that he did not hear either engine running just prior to the accident.

The airplane impacted several trees, a wooden trash enclosure, a fence, and hedges in a residential area. The trees, hedges, and grass were all damaged during the impact and the post impact fire. The driveway was damaged during the impact and the siding and roof of one house was damaged by flying debris and the post impact fire.

PERSONNEL INFORMATION

The pilot, age 55, held an airline transport pilot certificate with an airplane multiengine land rating and a commercial pilot certificate with an airplane single engine land rating. He held type ratings for the Dornier 328 and the Fairchild SA227. He also held a flight instructor certificate with airplane single, multiengine, and instrument airplane ratings. He was issued a special issuance second class airman medical certificate on May 23, 2014. The certificate contained the limitation "Not valid for any class after 05/31/2015."

According to Key Lime Air records, the pilot had flown 89 hours in the last 90 days; 4 hours of which were logged in the make and model of the accident airplane. The pilot had flown 24 hours in the past 30 days; 3 hours of which were at night, 5 hours in actual instrument conditions, and 24 hours were logged in a twin-engine Piper. Key Lime Air estimated the pilot's total flight time as 2,566 hours; 676 hours of which were at night.

Neither Key Lime Air nor the family had the pilot's flight logbook. On an insurance form dated June 22, 2014, the pilot reported 4,280 hours total time. About 3,760 hours were logged in multiengine airplanes and 800 hours at night.

A company flight log, dated from July 1, 2014, through December 30, 2014, indicated the last time the pilot flew the accident airplane was September 2, 2014, on a flight between Alamosa and KAPA. The flight duration was one hour at night. Key Lime records showed that the pilot was first assigned to the Cessna 404 on August 16, 2004, as pilot in command. He was assigned as a flight instructor for the Cessna 404 on October 18, 2004, and a check airman on March 7, 2005.

The pilot's airman competency/proficiency check for CFR 135.293 (Initial and recurrent pilot testing), CFR 135.299 (Pilot in command: Line checks: Routes and Airports), and CFR 135.297 (Instrument Proficiency) was completed with a satisfactory rating in all tested areas on December 22, 2014. A company check-airman conducted the flight check in a Piper PA31-350 in daylight conditions. The flight lasted for 1.7 hours. During this check, he received simulation in instrument meteorological conditions and emergencies including engine failures. The check-airman reported no concerns with the pilot or his performance during the flight check.

The pilot was the Director of Safety at Key Lime Air. According to his family, he had been flying and working since Thanksgiving. Depending on the day and the need for an additional aircraft and activities in the office he would fly in the morning and then return to the office to work in the afternoon. He usually returned from flying around 1030. Workload permitting, he would nap until 1300 and then return to the office and work until 1600 or 1700. On the Monday prior to the accident, he flew in the morning and then went into the office. He had dinner around 1800 and fell asleep in his chair in the living room. He went to bed around 1930 and slept well through the night. On the morning of the accident he likely got up between 0300 and 0305 and left the house about 0330.

AIRCRAFT INFORMATION

The accident airplane, a Cessna 404 (serial number 404-0813), was manufactured in 1980. It was registered with the Federal Aviation Administration (FAA) on a standard airworthiness certificate for normal operations. Two Teledyne Continental Motors GTSIO-520-M engines rated at 375 horsepower at 3,350 rpm each powered the airplane. The engines were equipped with McCauley 3-blade, controllable pitch propellers.

The airplane was registered to EDB Air, Inc., operated by Key Lime Air Corporation, and was maintained under an annual inspection program. An annual inspection had been completed on December 15, 2014, at an airframe total time of 16,681.7 hours.

A review of the maintenance records indicated the number 1, or left engine, was overhauled by RAM Aircraft and was installed on August 14, 2012. The number 2, or right engine, was overhauled by RAM Aircraft and was installed on March 20, 2014.

In the Aircraft Flight/Maintenance Log for N404MG, two discrepancies were reported by the accident pilot on the right engine. The first discrepancy (not dated) stated that the right engine "Floods when aux pump turned on. Appears to be in high position. Fuel flow touchy @ 1500." The corrective action was completed on December 18, 2014. The log contained the following entry "adjusted … fuel hi and low pressure on fuel pump, adjusted fuel mixture and adjusted turbo controller linkage, ground run ops check good." The second discrepancy (not dated, same page) stated that the right engine "prop feathers way before detent." The corrective action was completed on December 18, 2014. The log contained the following entry: "adjust … governor control cable, ground run ops check good."

The airplane was flown on December 19, 2014, from KAPA, to KDEN, to KCOD, and then back to KAPA. The pilot for that day did not report any issues or anomalies with the airplane or specifically the right engine. The last pilot to fly the airplane, 4 or 5 days prior to the accident, reported that there were no anomalies or concerns with the airplane. He parked the airplane on the hill, to the south of the Key Lime Air hangar. The airplane remained in that location until the night prior to the accident when it was towed to the Key Lime Air Hangar and parked just outside of the hangar until the morning of the accident.

METEOROLOGICAL INFORMATION

The closest official weather observation station was Centennial Airport (KAPA), Englewood, Colorado, located 1.8 nautical miles (nm) southwest of the accident site. The elevation of the weather observation station was 5,885 feet msl. The routine aviation weather report (METAR) for KAPA issued at 0353 reported wind 050 degrees at 3 knots, visibility 6 miles in light snow and mist, ceiling of broken clouds at 3,100 feet, temperature minus 19 degrees Celsius (C), dew point temperature minus 22 degrees C, altimeter 30.36 inches.

The special METAR for KAPA issued at 0406 reported wind calm, visibility 7 miles in light snow, ceiling of broken clouds at 2,900 feet, temperature minus 19 degrees C, dew point temperature minus 22 degrees C, altimeter 30.37 inches.

The special METAR for KAPA issued at 0451 reported wind 040 at 4 knots, visibility 9 miles, few clouds at 1,300 feet, scattered clouds at 12,000 feet, temperature minus 20 degrees C, dew point temperature minus 22 degrees C, altimeter 30.37 inches. The snow had ended at 45 minutes after the hour.

Snow totals for the 60 hours prior to the accident ranged between 1.9 and 4.2 inches of snow – the liquid equivalent of between 0.10 and 0.30 inches.

Airman's Meteorological Information (AIRMETs) for mountain obscuration, instrument flight rules conditions, moderate icing conditions, and moderate turbulence were all valid at the time of the accident for the accident location.

According to the United States Naval Observatory, Astronomical Applications Department Sun and Moon Data, sunrise was at 0720 on the morning of the accident. The moon rose at 1258.

AIRPORT INFORMATION

Centennial Airport (KAPA), is a public, tower- controlled airport (Class D airspace), at a surveyed elevation of 5,885 feet. Class B, E, and G airspace surround the area immediately outside of the Class D airspace at KAPA. The airport had 3 open runways, runway 17L/35R (10,001 feet by 100 feet, asphalt), runway 17R/35L (7,001 feet by 75 feet, asphalt), and runway 10/28 (4,800 feet by 75 feet, asphalt).

WRECKAGE AND IMPACT INFORMATION

The accident site was located in a residential area. The airplane impacted several trees, a wooden enclosure, a fence, and shrubs, and came to rest oriented on a northeast heading. The accident site was at an elevation of 5,680 feet msl and the airplane impacted on a magnetic heading of 160 degrees.

The initial impact point was located at the tops of two pine trees, approximately 30 feet high, to the north of the main wreckage. Broken tree branches were located directly beneath the trees. The outboard tip of the right wing, paint chips, torn metal, and a light panel with green lens fragments were located between the two trees in the snow.

Debris continued for 23 feet from the trees to the start of the ground impact scar. Dirt and snow was pushed in the direction of the main wreckage to the south. A propeller blade was located to the west of the first ground scar. The blade had penetrated a wooden fence. The chain linked fence surrounding the back yard, to the south of the initial impact point, was impact damaged.

The ground scar continued 12 feet to the propeller hub. The face of the propeller hub assembly, including two propeller blades, was embedded in the ground.

Impact damage and witness marks continued along the ground, chain linked fence and through the bushes (located along the east edge of the fence) 56 feet to the main wreckage. Torn metal, Plexiglas, fiberglass, radios, instruments, and propeller blades were all located throughout the debris field. The right engine cowling and one propeller blade were located in the back yard, to the west of the debris field. The rear face of the house exhibited damage consistent with impact from the propeller blade.

The debris along this path and the bushes exhibited exposure to heat and fire.

The main wreckage came to rest oriented on an approximate heading of east. The wreckage included the left wing, the right wing, the fuselage, and the empennage. The forward fuselage, including the cabin and instrument panel, and the cargo area exhibited impact damage and was charred, melted, and partially consumed by fire.

The left wing included the left engine, left main landing gear assembly, the left aileron, and the left flap. The left engine had partially separated and exhibited impact and fire damage. The left main landing gear was located within the wheel well. The leading edge of the wing exhibited impact damage and the entire upper surface of the wing exhibited exposure to heat and fire. The left aileron cable was continuous from the aileron inboard to the forward cabin.

The right wing included the right main landing gear assembly and the right flap. The right main landing gear was located within the wheel well. The wing was bent and torn and exhibited exposure to heat and fire. The right engine separated from the right wing and was located to the south of the main wreckage, adjacent a tree.

The empennage remained partially attached to the fuselage and included the horizontal and vertical stabilizers, elevator, and rudder. The right horizontal stabilizer exhibited leading edge impact damage. The left horizontal stabilizer was buckled. The vertical stabilizer and rudder were unremarkable. The flight control cables were continuous from the empennage forward to the forward cabin.

No preaccident mechanical malfunctions or failures were found that would have precluded normal operation.

MEDICAL AND PATHOLOGICAL INFORMATION

The autopsy was performed by the Arapahoe County – Office of the Coroner on December 30, 2014, as authorized by the Arapahoe County Coroner's office. The autopsy concluded that the manner of death was accident and the report listed the specific injuries.

The FAA's Civil Aerospace Medical Institute, Oklahoma City, Oklahoma, performed toxicological tests on specimens that were collected during the autopsy (CAMI Reference #201500004001). Results were negative for carbon monoxide and ethanol. Tests for cyanide were not performed. Tests of the blood and liver tissue were positive for loratadine. The FAA Forensic Toxicology Website indicates that loratadine is a non-sedating tricyclic antihistamine.

TESTS AND RESEARCH

The flight control cables for ailerons, the elevator, and rudder were examined. Breaks or points of separation through these cables were consistent with impact damage or wreckage recovery efforts. The impact damage on the right stabilizer was consistent with an impact with the chain link fence post. A film of yellow colored engine oil was located along the entire right side of the empennage including the horizontal and vertical stabilizer.

Shop air was applied to the deice air lines. The left horizontal stabilizer boot inflated. The right stabilizer boot was impact damaged and could not be tested. The vertical stabilizer boot inflated. The boots along both wings were impact damaged and could not be tested.

The rudder trim was measured at 1.3 inches. When compared to the Cessna Charts, this measurement is considered unreliable/beyond limits. The elevator trim was measured at 1.2 inches on the right and 1.3 inches on the left. The aileron trim was measured at 0.8 inches. When compared to the Cessna Charts, this measurement is considered unreliable/beyond limits.

Engine control quadrant - were not restricted or bound in movement. The following measurements were taken:
Throttles - L 1 3/4 " up from closed R 2 9/16" up from closed
Propellers - L 2 7/16" up from detent R 1 13/16" up from detent
Mixture - L 2 3/4 R 1 3/4 rich

The fuel selector panel exhibited the following positions:
Right engine – "off"
Left engine – "left main"

Fuel selector valves within the wing assemblies exhibited the following positions:
Right engine - "off"
Left engine - "left main"

Field Engine Examination

All 3 blades from the right propeller separated from the propeller hub. The hub was fragmented.
The propeller blades were labeled R1, R2, and R3 for identification purposes. Blade R1 exhibited leading edge scoring along the first 2.5" of the blade, and face scoring along the entire span of the blade. Otherwise the blade was visually unremarkable. Blade R2 exhibited scoring along the outboard trailing edge of the blade. Otherwise the blade was visually unremarkable. Blade R3 exhibited scoring on the face of the blade leading edge nicks and was bowed aft and twisted.

One blade separated from the left propeller assembly. The propeller hub was impact damaged.
The propeller blades were labeled L1, L2, and L3 for identification purposes. Blade L1 exhibited leading edge gouges and nicks. Otherwise the blade was visually unremarkable. BladeL2 was bowed forward. Otherwise the blade was visually unremarkable. Blade L3 separated from the propeller hub and exhibited leading edge gouges and nicks. Otherwise the blade was visually unremarkable.

The left engine exhibited exposure to heat and fire and impact damage. The top bank of spark plugs and the valve covers were removed. The spark plugs exhibited worn out normal signatures when compared to Champion spark plug chart. The p-leads were damaged by fire and could not be functionally tested. A lighted bore scope was used to examine the engine through the upper spark plug orifice at each cylinder. The examination revealed no anomalies. The engine was rotated through at the accessory housing. Air movement was noted on all cylinders at the upper spark plug orifice. Valve train continuity was observed on all cylinders.

The right engine forward gear case was impact damaged. The intake and exhaust valve arms on the No. 5 cylinder separated. The oil sump was impact damaged. The top bank of spark plugs and valve covers were removed. The spark plugs exhibited worn out normal signatures when compared to Champion spark plug chart. A lighted bore scope was used to examine the engine through the upper spark plug orifice at each cylinder. The examination revealed no anomalies.
The engine could not be rotated through by hand.

Lab Engine Examination

Left engine
The vacuum pump was disassembled and no anomalies were noted. The fuel pump spline was intact and the fuel pump rotated without hesitation. Disassembly of the pump revealed no preimpact anomalies.

A slave harness was placed on the right magneto and it was operated on a test bench. No spark was noted on any of the leads. Internal heat damage to the capacitor terminals and the points prevented normal operation. Examination of the left magneto revealed similar internal heat damage to the capacitor terminals and the points.

Examination of the cylinders, pistons, crankshaft, crankcase, sparkplugs, valves, and other components revealed signatures of exposure to heat and fire and impact damage. No mechanical anomalies were noted that would have precluded normal operation.

Right Engine
The left and right magnetos were equipped with a slave harness and ran on a test bench. A blue spark was observed on each lead at varying rpm. The vacuum pump was disassembled and no anomalies were noted.

The fuel pump spline was intact and the fuel pump rotated. The fuel pump was impact damaged and epoxy was applied at a fitting for bench testing purposes. An additional fitting in the vapor tower was impact damaged and replaced for testing purposes. The fuel pump was installed on a test stand and ran at rpms between 700 and 3,200 for five minutes. The pressure was high and the unit test results were out of limits.

Scoring was noted on the rear propeller reduction gear bolt and the aft propeller gear reduction journal. This scoring was consistent with rotation at the time of impact. The intake and exhaust valve rockers were impact damage and separated.

Examination of the cylinders, pistons, crankshaft, crankcase, sparkplugs, valves, crank case halves, and other components revealed signatures of impact damage. No mechanical anomalies were noted that would have precluded normal operation.

ORGANIZATIONAL AND MANAGEMENT INFORMATION

The FAA issued Key Lime Air a Part 135 operating certificate in 1997 to conduct on demand cargo and passenger flights. They also hold a Part 121 certificate for scheduled operations between KAPA, Rocky Mountain Metropolitan Airport (KBJC) Broomfield, Colorado, and Grand Junction (KGJT), Colorado. At the time of the accident, Key Lime Air conducted cargo operations in six states. The corporate headquarters, including training, the Director of Operations, Chief Pilot, and Director of Safety were located in Englewood, Colorado. The FAA Flight Standards District Office in Denver, Colorado managed the operating certificate.

The company operated six different make and models of airplane and employed about 35 pilots. Prior to employment, each pilot was required to meet the minimum flight time and experience requirements per the Federal Aviation Regulations for Part 135 operations.

ADDITIONAL INFORMATION

De-Icing Procedures

According to Key Lime Air, the method for deicing airplanes is dependent on the extent and thickness of the ice and is left to pilot's discretion for requesting deicing services. Generally pilots will physically remove frost, ice, snow, and surface contaminations. If the contamination is thicker or a jet is being operated the pilot can use chemicals for deicing.

The Cessna Pilot Safety And Warning Supplement – Airframe Icing – discusses that the "inflight ice protection equipment is not designed to remove ice, snow or frost accumulation on a parked airplane… Other means … must be employed to ensure that all wing, tail, control, propeller, windshield, static port surfaces and fuel vents are free of ice, snow, and frost accumulations, and that there are no internal accumulations of ice or debris in the control surfaces, engine intakes, brakes, pitot-static system ports, and fuel vents prior to takeoff."

Engine Inoperative Procedures

The Cessna Model 404 single-engine airspeeds for safe operation were as follows:

VX – 98 knots (takeoff and approach flaps) 105 knots (flaps up)
VY - 102 knots (takeoff and approach flaps) 109 knots (flaps up)

The Engine Inoperative Procedures for an engine failure after takeoff were as follows:

Mixture – Full Rich
Propellers – Full Forward
Throttles – Full Forward
Landing gear – up
Inoperative Engine – Throttle closed, mixture idle cutoff, propeller feather.
The pilot is then guided to establish a 5 degree bank into the operative engine, establish climb airspeed, raise the flaps, and then secure the inoperative engine.

The amplified procedures stated in part that "…climb or continued level flight at moderate altitude is improbable with the landing gear extended and the propeller windmilling…" The procedures warn that "The propeller on the inoperative engine must be feathered, landing gear retracted, and wing flaps up or continued flight may be impossible."

The Rate-of-Climb chart estimated that the airplane would have been able to sustain a 540 foot-per-minute climb with the airplane properly configured for single-engine operations. The chart subtracts 350 feet per minute for a windmilling propeller, 300 feet-per-minute with the landing gear down, and 100 feet-per-minute with the flaps in a takeoff or approach configuration.

NTSB Identification: CEN15FA090 
14 CFR Part 91: General Aviation
Accident occurred Tuesday, December 30, 2014 in Englewood, CO
Probable Cause Approval Date: 02/08/2016
Aircraft: CESSNA 404, registration: N404MG
Injuries: 1 Fatal.

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

The pilot was conducting an early morning repositioning flight of the cargo airplane. Shortly after takeoff, the pilot reported to air traffic control that he had “lost an engine” and would return to the airport. Several witnesses reported that the engines were running rough and one witness reported that he did not hear any engine sounds just before the impact. The airplane impacted trees, a wooden enclosure, a chain-linked fence, and shrubs in a residential area and was damaged by the impact and postimpact fire. 

The airplane had been parked outside for 5 days before the accident flight and had been plugged in to engine heaters the night before the flight. It was dark and snowing lightly at the time of the accident. The operator reported that no deicing services were provided before the flight and that the pilot mechanically removed all of the snow and ice accumulation. The wreckage and witness statements were consistent with the airplane being in a right-wing-low descent but the airplane did not appear to be out of control. Neither of the propellers were at or near the feathered position. The emergency procedures published by the manufacturer for a loss of engine power stated that pilots should first secure the engine and feather the propeller following a loss of engine power and then turn the fuel selector for that engine to “off.” The procedures also cautioned that continued flight might not be possible if the propeller was not feathered. The right fuel selector valve and panel were found in the off position. Investigators were not able to determine why an experienced pilot did not follow the emergency procedures and immediately secure the engine following the loss of engine power. It is not known how much snow and ice had accumulated on the airplane leading up to the accident flight or if the pilot was successful in removing all of the snow and ice with only mechanical means. The on-scene examination of the wreckage and the teardown of both engines did not reveal any preimpact mechanical malfunctions or failures. While possible, it could not be determined if water or ice ingestion lead to the loss of engine power at takeoff.

The National Transportation Safety Board determines the probable cause(s) of this accident as follows:
The loss of power to the right engine for reasons that could not be determined during postaccident examination and teardown and the pilot’s failure to properly configure the airplane for single-engine flight.
 
HISTORY OF FLIGHT


On December 30, 2014, about 0429 mountain standard time a Cessna 404, N404MG, was substantially damaged when it impacted a residential area north of Centennial Airport (KAPA), Englewood, Colorado. A post impact fire ensued. The airline transport pilot was fatally injured. The airplane was operated by Key Lime Air under the provisions of 14 Code of Federal Regulations Part 91 as a positioning flight. Night visual meteorological conditions prevailed for the flight, which operated on an instrument flight rules flight plan. The flight was originating at the time of the accident and was en route to Denver International Airport (KDEN), Denver, Colorado

According to representatives from Key Lime Air, the pilot was positioning the airplane from KAPA to KDEN for a potential 14 Code of Federal Regulations Part 135 freight flight. The airplane was parked outside and uphill from their facility at KAPA since December 25, 2014. The night before the accident the airplane was towed to a parking space outside of their hangar so that the engine heaters could be plugged in.


On the morning of the accident, the pilot was observed removing the blankets from the engine and the snow and ice on the airframe. The pilot used mechanical means to deice the airplane and was not assisted with a chemical deice or deicing services. Key Lime Air estimated that the airplane had 800 pounds of fuel on board. There were no services requested or received by the pilot on the morning of the accident.


A Key Lime Air employee estimated that the pilot started his number 1 engine about 0408. The engine started immediately and ran for 5 to 10 minutes before the pilot started the number two engine. This engine also started immediately and ran for several minutes. The airplane taxied from its parking spot several minutes later.


According to air traffic control (ATC) recordings the pilot requested clearance from ATC and was cleared to the Denver Airport at an altitude of 8,000 feet. At 0419:11 the pilot announced his taxi and was cleared to runway 35 right via the alpha taxiway. At 0425 the pilot was cleared for takeoff.


At 0427:22 the pilot reported to the tower controller that he had "lost an engine" and needed to return to the airport. The co
ntroller responded that any runway was available and provided a wind of 030 degrees at 3 knots. At 0427:38 the controller asked the pilot if he would be able to make "that left turn." At 0427:42 the pilot responded by saying "standby".

Radar data indicated the accident airplane departed from runway 17L/35R to the north – the field elevation at KAPA was 5,885 feet mean sea level (msl). The radar track was consistent with a slight right turn to the northeast. Radar data indicated an altitude of 6,125 feet msl when the turn to the right was initiated. The highest altitude indicated was 6,225 feet msl. The last recorded radar return indicated an altitude of 5,975 feet msl, and was coincident with ATC's loss of radar and voice communications.

One witness observed the airplane in a right turn. Several other witnesses heard the airplane and described a rough-running engine. One witness stated that he did not hear either engine running just prior to the accident.

The airplane impacted several trees, a wooden trash enclosure, a fence, and hedges in a residential area. The trees, hedges, and grass were all damaged during the impact and the post impact fire. The driveway was damaged during the impact and the siding and roof of one house was damaged by flying debris and the post impact fire.

PERSONNEL INFORMATION

The pilot, age 55, held an airline transport pilot certificate with an airplane multiengine land rating and a commercial pilot certificate with an airplane single engine land rating. He held type ratings for the Dornier 328 and the Fairchild SA227. He also held a flight instructor certificate with airplane single, multiengine, and instrument airplane ratings. He was issued a special issuance second class airman medical certificate on May 23, 2014. The certificate contained the limitation "Not valid for any class after 05/31/2015."

According to Key Lime Air records, the pilot had flown 89 hours in the last 90 days; 4 hours of which were logged in the make and model of the accident airplane. The pilot had flown 24 hours in the past 30 days; 3 hours of which were at night, 5 hours in actual instrument conditions, and 24 hours were logged in a twin-engine Piper. Key Lime Air estimated the pilot's total flight time as 2,566 hours; 676 hours of which were at night.

Neither Key Lime Air nor the family had the pilot's flight logbook. On an insurance form dated June 22, 2014, the pilot reported 4,280 hours total time. About 3,760 hours were logged in multiengine airplanes and 800 hours at night.

A company flight log, dated from July 1, 2014, through December 30, 2014, indicated the last time the pilot flew the accident airplane was September 2, 2014, on a flight between Alamosa and KAPA. The flight duration was one hour at night. Key Lime records showed that the pilot was first assigned to the Cessna 404 on August 16, 2004, as pilot in command. He was assigned as a flight instructor for the Cessna 404 on October 18, 2004, and a check airman on March 7, 2005.

The pilot's airman competency/proficiency check for CFR 135.293 (Initial and recurrent pilot testing), CFR 135.299 (Pilot in command: Line checks: Routes and Airports), and CFR 135.297 (Instrument Proficiency) was completed with a satisfactory rating in all tested areas on December 22, 2014. A company check-airman conducted the flight check in a Piper PA31-350 in daylight conditions. The flight lasted for 1.7 hours. During this check, he received simulation in instrument meteorological conditions and emergencies including engine failures. The check-airman reported no concerns with the pilot or his performance during the flight check.

The pilot was the Director of Safety at Key Lime Air. According to his family, he had been flying and working since Thanksgiving. Depending on the day and the need for an additional aircraft and activities in the office he would fly in the morning and then return to the office to work in the afternoon. He usually returned from flying around 1030. Workload permitting, he would nap until 1300 and then return to the office and work until 1600 or 1700. On the Monday prior to the accident, he flew in the morning and then went into the office. He had dinner around 1800 and fell asleep in his chair in the living room. He went to bed around 1930 and slept well through the night. On the morning of the accident he likely got up between 0300 and 0305 and left the house about 0330.

AIRCRAFT INFORMATION

The accident airplane, a Cessna 404 (serial number 404-0813), was manufactured in 1980. It was registered with the Federal Aviation Administration (FAA) on a standard airworthiness certificate for normal operations. Two Teledyne Continental Motors GTSIO-520-M engines rated at 375 horsepower at 3,350 rpm each powered the airplane. The engines were equipped with McCauley 3-blade, controllable pitch propellers.

The airplane was registered to EDB Air, Inc., operated by Key Lime Air Corporation, and was maintained under an annual inspection program. An annual inspection had been completed on December 15, 2014, at an airframe total time of 16,681.7 hours.

A review of the maintenance records indicated the number 1, or left engine, was overhauled by RAM Aircraft and was installed on August 14, 2012. The number 2, or right engine, was overhauled by RAM Aircraft and was installed on March 20, 2014.

In the Aircraft Flight/Maintenance Log for N404MG, two discrepancies were reported by the accident pilot on the right engine. The first discrepancy (not dated) stated that the right engine "Floods when aux pump turned on. Appears to be in high position. Fuel flow touchy @ 1500." The corrective action was completed on December 18, 2014. The log contained the following entry "adjusted … fuel hi and low pressure on fuel pump, adjusted fuel mixture and adjusted turbo controller linkage, ground run ops check good." The second discrepancy (not dated, same page) stated that the right engine "prop feathers way before detent." The corrective action was completed on December 18, 2014. The log contained the following entry: "adjust … governor control cable, ground run ops check good."

The airplane was flown on December 19, 2014, from KAPA, to KDEN, to KCOD, and then back to KAPA. The pilot for that day did not report any issues or anomalies with the airplane or specifically the right engine. The last pilot to fly the airplane, 4 or 5 days prior to the accident, reported that there were no anomalies or concerns with the airplane. He parked the airplane on the hill, to the south of the Key Lime Air hangar. The airplane remained in that location until the night prior to the accident when it was towed to the Key Lime Air Hangar and parked just outside of the hangar until the morning of the accident.

METEOROLOGICAL INFORMATION

The closest official weather observation station was Centennial Airport (KAPA), Englewood, Colorado, located 1.8 nautical miles (nm) southwest of the accident site. The elevation of the weather observation station was 5,885 feet msl. The routine aviation weather report (METAR) for KAPA issued at 0353 reported wind 050 degrees at 3 knots, visibility 6 miles in light snow and mist, ceiling of broken clouds at 3,100 feet, temperature minus 19 degrees Celsius (C), dew point temperature minus 22 degrees C, altimeter 30.36 inches.

The special METAR for KAPA issued at 0406 reported wind calm, visibility 7 miles in light snow, ceiling of broken clouds at 2,900 feet, temperature minus 19 degrees C, dew point temperature minus 22 degrees C, altimeter 30.37 inches.

The special METAR for KAPA issued at 0451 reported wind 040 at 4 knots, visibility 9 miles, few clouds at 1,300 feet, scattered clouds at 12,000 feet, temperature minus 20 degrees C, dew point temperature minus 22 degrees C, altimeter 30.37 inches. The snow had ended at 45 minutes after the hour.

Snow totals for the 60 hours prior to the accident ranged between 1.9 and 4.2 inches of snow – the liquid equivalent of between 0.10 and 0.30 inches.

Airman's Meteorological Information (AIRMETs) for mountain obscuration, instrument flight rules conditions, moderate icing conditions, and moderate turbulence were all valid at the time of the accident for the accident location.

According to the United States Naval Observatory, Astronomical Applications Department Sun and Moon Data, sunrise was at 0720 on the morning of the accident. The moon rose at 1258.

AIRPORT INFORMATION

Centennial Airport (KAPA), is a public, tower- controlled airport (Class D airspace), at a surveyed elevation of 5,885 feet. Class B, E, and G airspace surround the area immediately outside of the Class D airspace at KAPA. The airport had 3 open runways, runway 17L/35R (10,001 feet by 100 feet, asphalt), runway 17R/35L (7,001 feet by 75 feet, asphalt), and runway 10/28 (4,800 feet by 75 feet, asphalt).

WRECKAGE AND IMPACT INFORMATION

The accident site was located in a residential area. The airplane impacted several trees, a wooden enclosure, a fence, and shrubs, and came to rest oriented on a northeast heading. The accident site was at an elevation of 5,680 feet msl and the airplane impacted on a magnetic heading of 160 degrees.

The initial impact point was located at the tops of two pine trees, approximately 30 feet high, to the north of the main wreckage. Broken tree branches were located directly beneath the trees. The outboard tip of the right wing, paint chips, torn metal, and a light panel with green lens fragments were located between the two trees in the snow.

Debris continued for 23 feet from the trees to the start of the ground impact scar. Dirt and snow was pushed in the direction of the main wreckage to the south. A propeller blade was located to the west of the first ground scar. The blade had penetrated a wooden fence. The chain linked fence surrounding the back yard, to the south of the initial impact point, was impact damaged.

The ground scar continued 12 feet to the propeller hub. The face of the propeller hub assembly, including two propeller blades, was embedded in the ground.

Impact damage and witness marks continued along the ground, chain linked fence and through the bushes (located along the east edge of the fence) 56 feet to the main wreckage. Torn metal, Plexiglas, fiberglass, radios, instruments, and propeller blades were all located throughout the debris field. The right engine cowling and one propeller blade were located in the back yard, to the west of the debris field. The rear face of the house exhibited damage consistent with impact from the propeller blade.

The debris along this path and the bushes exhibited exposure to heat and fire.

The main wreckage came to rest oriented on an approximate heading of east. The wreckage included the left wing, the right wing, the fuselage, and the empennage. The forward fuselage, including the cabin and instrument panel, and the cargo area exhibited impact damage and was charred, melted, and partially consumed by fire.

The left wing included the left engine, left main landing gear assembly, the left aileron, and the left flap. The left engine had partially separated and exhibited impact and fire damage. The left main landing gear was located within the wheel well. The leading edge of the wing exhibited impact damage and the entire upper surface of the wing exhibited exposure to heat and fire. The left aileron cable was continuous from the aileron inboard to the forward cabin.

The right wing included the right main landing gear assembly and the right flap. The right main landing gear was located within the wheel well. The wing was bent and torn and exhibited exposure to heat and fire. The right engine separated from the right wing and was located to the south of the main wreckage, adjacent a tree.

The empennage remained partially attached to the fuselage and included the horizontal and vertical stabilizers, elevator, and rudder. The right horizontal stabilizer exhibited leading edge impact damage. The left horizontal stabilizer was buckled. The vertical stabilizer and rudder were unremarkable. The flight control cables were continuous from the empennage forward to the forward cabin.

No preaccident mechanical malfunctions or failures were found that would have precluded normal operation.

MEDICAL AND PATHOLOGICAL INFORMATION

The autopsy was performed by the Arapahoe County – Office of the Coroner on December 30, 2014, as authorized by the Arapahoe County Coroner's office. The autopsy concluded that the manner of death was accident and the report listed the specific injuries.

The FAA's Civil Aerospace Medical Institute, Oklahoma City, Oklahoma, performed toxicological tests on specimens that were collected during the autopsy (CAMI Reference #201500004001). Results were negative for carbon monoxide and ethanol. Tests for cyanide were not performed. Tests of the blood and liver tissue were positive for loratadine. The FAA Forensic Toxicology Website indicates that loratadine is a non-sedating tricyclic antihistamine.

TESTS AND RESEARCH

The flight control cables for ailerons, the elevator, and rudder were examined. Breaks or points of separation through these cables were consistent with impact damage or wreckage recovery efforts. The impact damage on the right stabilizer was consistent with an impact with the chain link fence post. A film of yellow colored engine oil was located along the entire right side of the empennage including the horizontal and vertical stabilizer.

Shop air was applied to the deice air lines. The left horizontal stabilizer boot inflated. The right stabilizer boot was impact damaged and could not be tested. The vertical stabilizer boot inflated. The boots along both wings were impact damaged and could not be tested.

The rudder trim was measured at 1.3 inches. When compared to the Cessna Charts, this measurement is considered unreliable/beyond limits. The elevator trim was measured at 1.2 inches on the right and 1.3 inches on the left. The aileron trim was measured at 0.8 inches. When compared to the Cessna Charts, this measurement is considered unreliable/beyond limits.

Engine control quadrant - were not restricted or bound in movement. The following measurements were taken:
Throttles - L 1 3/4 " up from closed R 2 9/16" up from closed
Propellers - L 2 7/16" up from detent R 1 13/16" up from detent
Mixture - L 2 3/4 R 1 3/4 rich

The fuel selector panel exhibited the following positions:
Right engine – "off"
Left engine – "left main"

Fuel selector valves within the wing assemblies exhibited the following positions:
Right engine - "off"
Left engine - "left main"

Field Engine Examination

All 3 blades from the right propeller separated from the propeller hub. The hub was fragmented.
The propeller blades were labeled R1, R2, and R3 for identification purposes. Blade R1 exhibited leading edge scoring along the first 2.5" of the blade, and face scoring along the entire span of the blade. Otherwise the blade was visually unremarkable. Blade R2 exhibited scoring along the outboard trailing edge of the blade. Otherwise the blade was visually unremarkable. Blade R3 exhibited scoring on the face of the blade leading edge nicks and was bowed aft and twisted.

One blade separated from the left propeller assembly. The propeller hub was impact damaged.
The propeller blades were labeled L1, L2, and L3 for identification purposes. Blade L1 exhibited leading edge gouges and nicks. Otherwise the blade was visually unremarkable. BladeL2 was bowed forward. Otherwise the blade was visually unremarkable. Blade L3 separated from the propeller hub and exhibited leading edge gouges and nicks. Otherwise the blade was visually unremarkable.

The left engine exhibited exposure to heat and fire and impact damage. The top bank of spark plugs and the valve covers were removed. The spark plugs exhibited worn out normal signatures when compared to Champion spark plug chart. The p-leads were damaged by fire and could not be functionally tested. A lighted bore scope was used to examine the engine through the upper spark plug orifice at each cylinder. The examination revealed no anomalies. The engine was rotated through at the accessory housing. Air movement was noted on all cylinders at the upper spark plug orifice. Valve train continuity was observed on all cylinders.

The right engine forward gear case was impact damaged. The intake and exhaust valve arms on the No. 5 cylinder separated. The oil sump was impact damaged. The top bank of spark plugs and valve covers were removed. The spark plugs exhibited worn out normal signatures when compared to Champion spark plug chart. A lighted bore scope was used to examine the engine through the upper spark plug orifice at each cylinder. The examination revealed no anomalies.
The engine could not be rotated through by hand.

Lab Engine Examination

Left engine
The vacuum pump was disassembled and no anomalies were noted. The fuel pump spline was intact and the fuel pump rotated without hesitation. Disassembly of the pump revealed no preimpact anomalies.

A slave harness was placed on the right magneto and it was operated on a test bench. No spark was noted on any of the leads. Internal heat damage to the capacitor terminals and the points prevented normal operation. Examination of the left magneto revealed similar internal heat damage to the capacitor terminals and the points.

Examination of the cylinders, pistons, crankshaft, crankcase, sparkplugs, valves, and other components revealed signatures of exposure to heat and fire and impact damage. No mechanical anomalies were noted that would have precluded normal operation.

Right Engine
The left and right magnetos were equipped with a slave harness and ran on a test bench. A blue spark was observed on each lead at varying rpm. The vacuum pump was disassembled and no anomalies were noted.

The fuel pump spline was intact and the fuel pump rotated. The fuel pump was impact damaged and epoxy was applied at a fitting for bench testing purposes. An additional fitting in the vapor tower was impact damaged and replaced for testing purposes. The fuel pump was installed on a test stand and ran at rpms between 700 and 3,200 for five minutes. The pressure was high and the unit test results were out of limits.

Scoring was noted on the rear propeller reduction gear bolt and the aft propeller gear reduction journal. This scoring was consistent with rotation at the time of impact. The intake and exhaust valve rockers were impact damage and separated.

Examination of the cylinders, pistons, crankshaft, crankcase, sparkplugs, valves, crank case halves, and other components revealed signatures of impact damage. No mechanical anomalies were noted that would have precluded normal operation.

ORGANIZATIONAL AND MANAGEMENT INFORMATION

The FAA issued Key Lime Air a Part 135 operating certificate in 1997 to conduct on demand cargo and passenger flights. They also hold a Part 121 certificate for scheduled operations between KAPA, Rocky Mountain Metropolitan Airport (KBJC) Broomfield, Colorado, and Grand Junction (KGJT), Colorado. At the time of the accident, Key Lime Air conducted cargo operations in six states. The corporate headquarters, including training, the Director of Operations, Chief Pilot, and Director of Safety were located in Englewood, Colorado. The FAA Flight Standards District Office in Denver, Colorado managed the operating certificate.

The company operated six different make and models of airplane and employed about 35 pilots. Prior to employment, each pilot was required to meet the minimum flight time and experience requirements per the Federal Aviation Regulations for Part 135 operations.

ADDITIONAL INFORMATION

De-Icing Procedures

According to Key Lime Air, the method for deicing airplanes is dependent on the extent and thickness of the ice and is left to pilot's discretion for requesting deicing services. Generally pilots will physically remove frost, ice, snow, and surface contaminations. If the contamination is thicker or a jet is being operated the pilot can use chemicals for deicing.

The Cessna Pilot Safety And Warning Supplement – Airframe Icing – discusses that the "inflight ice protection equipment is not designed to remove ice, snow or frost accumulation on a parked airplane… Other means … must be employed to ensure that all wing, tail, control, propeller, windshield, static port surfaces and fuel vents are free of ice, snow, and frost accumulations, and that there are no internal accumulations of ice or debris in the control surfaces, engine intakes, brakes, pitot-static system ports, and fuel vents prior to takeoff."

Engine Inoperative Procedures

The Cessna Model 404 single-engine airspeeds for safe operation were as follows:

VX – 98 knots (takeoff and approach flaps) 105 knots (flaps up)
VY - 102 knots (takeoff and approach flaps) 109 knots (flaps up)

The Engine Inoperative Procedures for an engine failure after takeoff were as follows:

Mixture – Full Rich
Propellers – Full Forward
Throttles – Full Forward
Landing gear – up
Inoperative Engine – Throttle closed, mixture idle cutoff, propeller feather.
The pilot is then guided to establish a 5 degree bank into the operative engine, establish climb airspeed, raise the flaps, and then secure the inoperative engine.

The amplified procedures stated in part that "…climb or continued level flight at moderate altitude is improbable with the landing gear extended and the propeller windmilling…" The procedures warn that "The propeller on the inoperative engine must be feathered, landing gear retracted, and wing flaps up or continued flight may be impossible."

The Rate-of-Climb chart estimated that the airplane would have been able to sustain a 540 foot-per-minute climb with the airplane properly configured for single-engine operations. The chart subtracts 350 feet per minute for a windmilling propeller, 300 feet-per-minute with the landing gear down, and 100 feet-per-minute with the flaps in a takeoff or approach configuration.

NTSB Identification: CEN15LA117
Nonscheduled 14 CFR Part 135: Air Taxi & Commuter
Accident occurred Wednesday, January 21, 2015 in Goodland, KS
Aircraft: PIPER PA-31-350, registration: N66906
Injuries: 1 Uninjured.

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 January 21, 2015, about 0754 mountain standard time, a Piper PA-31-350, N66906, experienced a total loss of engine power of both engines during cruise flight. The pilot performed a forced landing to a field where the airplane impacted terrain about 10 miles west of Goodland, Kansas. The pilot was uninjured. The airplane sustained substantial damage. The airplane was registered to and operated by Key Lime Air as LYM169 under the provisions of Title 14 Code of Federal Regulations Part 135 as a cargo flight and was operating on an instrument rules flight plan. Visual meteorological conditions prevailed for the flight that originated from Denver International Airport, Denver, Colorado, and was destined to Shalz Field Airport, Colby, Kansas.


Piper PA-31 Navajo Chieftain, N66906, Key Lime Air: Accident occurred January 21, 2015 in Goodland, Sherman County, Kansas

Fairchild SA227-AC Metro III,  N31171,    Key Lime Air:    Incident occurred January 08, 2015 at Centennial Airport   (KAPA),  Denver, Colorado  


Cessna 404 Titan, N404MG, Key Lime Air: Fatal accident occurred December 30, 2014 near Centennial Airport (KAPA), Arapahoe County, Colorado 



N66906 KEY LIME FLIGHT LYM169 PIPER PA 31 AIRCRAFT STRUCK POWERLINES AND FORCE LANDED IN A FIELD, 10 MILES FROM GOODLAND, KS


FAA Flight Standards District Office: FAA Wichita FSDO-64

CBG LLC: http://registry.faa.gov/N66906

GOODLAND, Kan. — Emergency crews are on scene of a plane crash that happened Wednesday morning in northwest Kansas.

Kansas Highway Patrol Trooper Tod Hileman said a twin engine plane crashed in Sherman County just before 9 a.m. The scene is near the intersection of County Roads 10 and 71.

Trooper Hileman said the pilot is okay.

He said the plane was carrying UPS cargo and was registered to Key Lime Air out of Englewood, Colorado.

The company released the following statement:

Key Lime Air received confirmation that one of our twin engine cargo aircraft experienced an unexpected engine anomaly in flight. The flight was operated with a single pilot and no passengers. The aircraft landed safely at an off-airport location close to Goodland, KS, without incident. There are no injuries to the pilot. Key Lime Air will be conducting a thorough examination of the aircraft in order to determine the cause of the anomaly.




One week after fatal crash, Key Lime Air plane lands with only one engine

CENTENNIAL, Colo. - Key Lime Air, the air cargo company that lost a pilot in a fatal crash last week, had another plane make an emergency landing Thursday morning.

Dispatchers with the South Metro Fire Department confirmed to 7NEWS that their teams were alerted to an in-flight emergency. Specifically, they said the plane was landing without one engine.

AIRTRACKER7 was overhead at 7:43 a.m. when the green plane touched down safely at the Centennial Airport. As the plane taxied from left to right across the screen, it was clear to see that the engine propellers on the near side were not turning.

After originally telling 7NEWS to expect a press release, a spokesperson said Key Lime Air decided not to comment. They reversed their decision again, after 7NEWS published our original version of this story. 

"Key Lime Air confirms that a leased aircraft conducting a cargo flight experienced an engine malfunction in flight. The flight was operated with a single pilot and no passengers. The aircraft safely returned to the Key Lime Air maintenance facility at Centennial Airport in Colorado and landed without incident. There were no injuries to the pilot and no damage to the aircraft. Key Lime Air is conducting a thorough examination of the engine to determine the cause of the malfunction," Key Lime Air wrote in a statement issued via email at 1:27 p.m.

Key Lime Air pilot and retired police officer Daniel Steitz lost his life in the crash last week on December 30, after departing the Centennial Airport. According to the NTSB's preliminary report, he had also lost engine power.

"According to air traffic control recordings at KAPA, the pilot reported that he had lost an engine and needed to return to the airport," the preliminary report said. "Several witnesses observed the airplane in a right turn as it descended towards terrain. Several other witnesses heard the airplane and described a rough-running engine. One witness stated that he did not hear either engine running just prior to the accident."

Steve Cowell, a former commercial pilot and FAA accident prevention counselor, said Key Lime Air began flying cargo routes, and now also flies commercial passengers.

He says it is not uncommon for companies to have reported incidents.

"Is it alarming to have two engine failures from one company in a couple of weeks?" asked 7NEWS Reporter Jennifer Kovaleski.

"It's very alarming, it's alarming to the public … the FAA issues a certificate that basically says that we're going to put the public trust in your ability to fly safely and now you've had these two incidents, why? We don't know yet," he said.

Cowell said the FAA will look at whether or not there's a pattern or link between the two incidents.

"They're going to undergo a white glove inspection most likely from the FAA because we have a series of incidents so closely together," he said. "The FAA's going to be looking at is whether there's a pattern, is something wrong with maintenance procedures, is something wrong with the training."

Cowell said the FAA requires these types of plane engines to undergo thorough inspections every 50 to 100 hours of flight. However,until the investigation is complete, he says it's too early to conclude anything.

"Whether those incidents are coincidental or whether they are linked remains to be seen," he said.

7NEWS checked FAA and NTSB records and found Key Lime Air has three dozen reported incidents since 2000. FAA records list several minor issues, like pilot errors. Two reported in 2010 detail engine failures on two different planes. 

Story, Videos and Photo:   http://www.thedenverchannel.com

http://registry.faa.gov/N31171



Fairchild SA227-AC Metro III, N31171, Key Lime Air: Incident occurred January 08, 2015 at Centennial Airport (KAPA), Denver, Colorado




http://registry.faa.gov/N404MG

NTSB Identification: CEN15FA090

14 CFR Part 91: General Aviation
Accident occurred Tuesday, December 30, 2014 in Englewood, CO
Aircraft: CESSNA 404, registration: N404MG
Injuries: 1 Fatal.

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

On December 30, 2014, about 0429 mountain standard time a Cessna 404, N404MG, was substantially damaged when it impacted a residential area north of the Centennial Airport (KAPA), Englewood, Colorado. A post impact fire ensued. The airline transport pilot was fatally injured. The airplane was operated by Key Lime Air under the provisions of 14 Code of Federal Regulations Part 91 as positioning flight. Night visual meteorological conditions prevailed for the flight, which operated on an instrument flight rules flight plan. The flight was originating at the time of the accident and was en route to Denver International Airport (KDEN), Denver, Colorado

According to air traffic control recordings at KAPA, the pilot reported that he had lost an engine and needed to return to the airport. Several witnesses observed the airplane in a right turn as it descended towards terrain. Several other witnesses heard the airplane and described a rough-running engine. One witness stated that he did not hear either engine running just prior to the accident. 

The airplane impacted several trees, a fence, and hedges in a residential area and came to rest oriented on a northeast heading. Portions of the right wing, right engine, and the propellers from both engine assemblies were located within the debris field. Both engines separated partially from the airplane during the impact sequence and were located immediately adjacent the main wreckage. 

The routine aviation weather report for KAPA, issued at 0406, reported, wind calm, visibility 7 miles in light snow, sky condition, ceiling broken clouds at 2,900 feet, temperature minus 19 degrees Celsius (C), dew point temperature minus 22 degrees C, altimeter 30.37 inches.













CENTENNIAL, Colo. (CBS4) – The coroner has identified the pilot who died when his small plane went down after taking off from Centennial Airport early Tuesday morning. 

Daniel Lee Steitz, 55, from Aurora, worked for Key Lime Air. The National Transportation Safety Board says the plane he was flying cartwheeled after crashing and then came to stop on a homeowner’s lawn.

CBS4’s Howard Nathan spoke with a veteran pilot who says it may have been both skill and luck that kept the plane from crashing into homes.

The Cessna 404 cargo plane was ripped open by the time it stopped tumbling on Jim Siffring’s front lawn before dawn.

“Big crash and then the room just lit up like daylight … our bedroom is facing right there at the crash scene,” Siffring said.

Flames were so intense the siding melted on his house.

Bob Doubek has been flying small planes for 68 years and knows what a pilot is thinking when a problem erupts during the flight.

“Fly the aircraft, fly it all the way to the scene of the accident,” he said.

In this case the accident scene was just several feet from Siffring’s house in a residential neighborhood. A neighbor explained what an eyewitness saw.

“He said the plane just dropped like a rock, it was kind of sitting at an angle … and just dropped like a rock,” the neighbor said.


No matter what a pilot will try, they’ll sometimes crash into property. Earlier this month six people died when a plane crashed into a home in Maryland. Three of the victims, a mother and two children, were inside their house.

Last May in Northglenn a small plane crashed into a home, but luckily nobody died.

“(It’s a) matter of self-preservation. You’re looking for the best spot to put it down. It may be a highway, it may be a golf course, if you’re lucky,” Doubek said.

The plane was removed Tuesday night. The NTSB says the engine lost power, but they also say they will not know the cause behind the crash for another 10 months.

Story, video and photos:  http://denver.cbslocal.com

Daniel Lee Steitz 





Daniel Steitz
Aurora Police Department



ARAPAHOE COUNTY, Colo. - A plane belonging to a charter and cargo company crashed Tuesday morning in Centennial after the pilot reported a loss of engine power. 

 The pilot, later identified by the Coroner's Office as Daniel Steitz, was killed by blunt force injuries during the crash. He was a former detective sergeant with the Aurora Police Department, working for the department between 1987 and his retirement in 2011.

"It is with sincere sorrow that we have confirmed a Key Lime Air aircraft, a Cessna 404 has been involved in an accident," company president Cliff Honeycutt said in a statement sent to 7NEWS. "The flight was a cargo flight repositioning empty from Centennial airport to Denver International. (Sic)"

The plane crashed minutes after take-off in the 6600 block of South Billings Way. That's near Arapahoe Road, between Potomac Drive and Jordan Road, about 1.5 miles from the airport.

"He had just taken off and reported to air traffic control he had suffered a loss of engine power," NTSB Senior Air Safety Investigator Jennifer Rodi said, who added that the NTSB's team was still arriving to the crash scene.

The plane hit a trash structure outside of Jim Siffring's home. It did not directly hit the house, but the NTSB said there was some fire damage to one side of the structure. 

Siffring said the flames "just lit up like daylight."

"We rolled up the curtain and there's an airplane on fire outside of our house," said Siffring, who said he and his wife ran outside and emptied their fire extinguishers onto the wreckage. 

Siffring also extended his family's regrets about the loss of the pilot. 

South Metro Fire dispatchers told 7NEWS that only one person was on board the twin-prop Cessna when the plane crashed and that pilot died.

A man driving in the area said he saw the plane pass over Centennial Airport, heading east, and flying extremely low.

"He veered right and went straight down," Steven R. told 7NEWS. "I knew something was not right."

Rodi said the pilot reported a perceived loss of engine power. 

"The airplane came in in a somewhat nose low, wing low, sort of a banked angle if you will, but not completely nose low, not in a stalled position," said Rodi. "It cartwheeled for a couple of feet."

The plane slid through two yards and came close to two homes, but did not hit the homes. No one on the ground was injured.

"We will be documenting the wreckage, the debris field and we will be recovering the airplane and the engines to a location up in Greeley Colorado for the furtherance of our investigation," Rodi said. 

Story and Video: http://www.thedenverchannel.com

A National Transportation Safety Board investigator said the pilot reported a loss of engine power shortly before crashing into the neighborhood. There was light snow falling at the time of the crash and whether the engine was preheated before takeoff could have had an effect on the accident, the NTSB said.

A homeowner in the neighborhood called 911 and said the plane did not hit any structures and was fully engulfed. There were no injuries reported on the ground.

“We were asleep and heard a a huge crash,” the homeowner where the plane crashed said. “It was a big crash and just lit up like daylight. We rolled open the curtain and there’s an airplane on fire in front of our house.”

A neighbor who did not want to be identified or interviewed on camera captured cellphone video of the plane fully engulfed moments after it crashed and provided it to FOX31 Denver reporter Chris Jose.

“It was just really loud all of a sudden and then there was a crash,” another homeowner who did not want to be identified said. “It was one of those crashes that you can’t explain really well. And then I looked out the window and you could see the smoke come over the top of the houses.

“It was only a block or so away. And I thought it was the house right behind us, but apparently it was in the yard. And then all of a sudden there was just a loud explosion.”

Authorities said the pilot was the only person on the plane, which took off about 4:27 a.m. from the airport. According to FlightAware, Key Lime Air Flight 182 was flying to Denver International Airport.

Key Lime Air is a Centennial Airport-based aircraft rental service that transports passengers and cargo in North America, the Caribbean and South America.

“Dedication to safety is our highest priority and is paramount in our airplanes, strict pilot training, as well as our stringent operational and maintenance programs,” a statement reads on Key Lime Air’s website.

“It is with sincere sorrow that we have confirmed a Key Lime Air aircraft, a Cessna 404 has been involved in an accident,” Key Lime Air President Cliff Honeycutt said in a statement. “The flight was a cargo flight repositioning empty from Centennial airport to Denver International. There were no passengers, only the pilot on board.  Sadly, we have received confirmation from the Arapahoe County Sheriff Department that there were no survivors in this accident.

“Our focus at this time is on supporting the family of the pilot.”

The identity of the pilot has not been released by Arapahoe County officials or by Key Lime Air.















































CENTENNIAL, Colo. — A small plane crashed into the front yard of a home moments after taking off from Centennial Airport early Tuesday morning, killing the pilot, South Metro Fire Rescue said. 


The crash happened about 4:50 a.m. in the 6600 block of South Billings Way, near East Arapahoe Road and South Jordan Road, about 2 miles northeast of Centennial Airport.

A homeowner in the neighborhood called authorities and said the plane did not hit any structures and was fully engulfed.

Authorities said the pilot was the only person on the Cessna 404.