Friday, November 30, 2018

Cessna 550 Citation II, N941JM; accident occurred November 30, 2018 at Hector International Airport (KFAR), Fargo, Cass County, North Dakota -and- Beech 200 Super King Air, N80RT, accident occurred November 23, 2016 near Moorhead Municipal Airport (KJKJ), Clay County, Minnesota

























Aviation Accident Final Report - National Transportation Safety Board 

Additional Participating Entities:
Federal Aviation Administration / Flight Standards District Office; Fargo, North Dakota
Textron Aviation; Wichita, Kansas 

Investigation Docket - National Transportation Safety Board:

Location: Fargo, North Dakota 
Accident Number: CEN19LA039
Date & Time: November 30, 2018, 13:53 Local 
Registration: N941JM
Aircraft: Cessna 550 
Aircraft Damage: Substantial
Defining Event: Aerodynamic stall/spin 
Injuries: 9 Minor, 2 None
Flight Conducted Under: Part 91: General aviation

Analysis

The commercial pilot was conducting a cross-country, business flight with 10 passengers onboard the 8-passenger airplane. He reported that air traffic control cleared the flight for an instrument landing system (ILS) approach to the runway. While descending, the airplane entered instrument meteorological conditions (IMC) at 3,100 ft mean sea level (msl), and ice started to accumulate on the wing's leading edges, empennage, and windshield. The pilot activated the pneumatic deice boots multiple times during the approach and slowed the airplane to 120 knots. The airplane then exited the clouds about 400 ft above ground level (agl), and the pilot maintained 120 knots as the airplane flew over the airport fence; all indications for landing were normal. About 100 ft agl, the airplane started to pull right. He applied left correction inputs, but the airplane continued to pull right. He applied engine power to conduct a goaround, but the airplane landed in grass right of the runway, sustaining damage to the wings and landing gear. Witnesses and passengers reported that the airplane stalled.

During examination of the airplane immediately after the accident, about 1/2 to 1 inch of mixed ice was found on the right wing's leading edge, the vertical and horizontal stabilizers, and the angle of attack probe. Ice was also observed on the windshield. The flaps were found in the "up" position. Flight control continuity was established.

Although the airplane was originally certificated for two-pilot operation, the pilot was flying the airplane under a single-pilot exemption. The pilot received a logbook endorsement indicating that he had received single-pilot training and was properly qualified under the single-pilot exemption. However, he had not met the turbine flight time qualifications (1,000 hours) to be properly authorized to conduct the flight under the single-pilot exemption because he only had 500 hours.

A review of cockpit voice recorder information indicated that, although the pilot verbalized that the landing gear was "all green," followed by stating "check, check, check," he did not verbalize all the approach or landing checklist items nor did he make any audible comments about activating the pneumatic deice boots or windshield anti-ice.

A review of radar data for the flight indicated that, during the last 2 minutes of flight, while the airplane was on final approach to the runway, the indicated airspeed got as low as 99 knots. The last recorded radar return indicated that the airplane had an airspeed of 104 knots at 900 ft msl. The pilot's lack of minimum flight experience required to fly the airplane without a copilot likely led to task saturation as he flew the airplane entered IMC and icing conditions while on an ILS approach. He subsequently failed to lower the flaps during the approach, which resulted in a no-flap approach instead of a full-flap landing. The ice on the leading edges of the wings, the no-flap approach, and the low airspeed likely led to the exceedance of the airplane's critical angle of attack, which resulted in an aerodynamic stall.

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The pilot's failure to lower the flaps during the approach and maintain sufficient airspeed while flying in instrument meteorological and icing conditions and the accumulation of ice on the wings' leading edges, which resulted in the exceedance of the airplane's critical angle of attack and subsequent aerodynamic stall. Contributing to the accident was the pilot's lack of proper qualification to operate the airplane under a single-pilot exemption due to his lack of total turbine time, which led to task saturation and his failure to properly configure the flaps for landing.

Findings

Aircraft Configuration - Incorrect use/operation
Aircraft Airspeed - Not attained/maintained
Aircraft Angle of attack - Capability exceeded
Personnel issues Use of equip/system - Pilot
Environmental issues Conducive to structural icing - Effect on operation
Personnel issues Qualification/certification - Pilot
Personnel issues Task overload - Pilot

Factual Information

History of Flight

On November 30, 2018, about 1353 central standard time, a Cessna 550, N941JM, departed controlled flight and impacted terrain while on approach at the Hector International Airport (FAR), Fargo, North Dakota. The pilot and one of the passengers were not injured, and 9 passengers received minor injuries. The airplane sustained substantial damage. The airplane was registered to Slice of the 406 LLC and operated by the pilot under the provisions of the Title 14 Code of Federal Regulations Part 91 as a business flight. Instrument meteorological conditions prevailed at the time of the accident and the flight was operating on an instrument flight plan. The flight departed from the Sloulin Field International Airport (ISN), Williston, North Dakota, about 1250 with FAR as the destination.

The pilot reported that after departure, the flight was cleared direct as filed on the instrument flight plan. He obtained the destination weather when the flight was 100 nautical miles (nm) and 30 nm from FAR. Air traffic control (ATC) provided radar vectors to the inbound course for the FAR ILS RWY 18 approach and subsequently cleared the flight for the approach. He stated that he completed the approach checklist, activated the deicing equipment, and started a descent to 2,500 ft mean sea level (msl). The airplane was about 10 nm from FAR when it entered a layer of clouds, which were at 3,100 ft msl, at an airspeed of 160 kts. He stated that ice started to accumulate on the wings, so he activated the de-ice boots. While inbound to FAR from the final approach fix, he switched the radio to the tower frequency, maintained 140 kts airspeed, completed the landing checklist, and was cleared to land. He reported that he activated the de-ice boots several times on the approach and slowed the airplane to 120 kts airspeed for the final approach. The airplane exited the clouds at 400 ft above ground level (agl), and it was right of centerline with the airport and runway in sight. He reported that he turned the autopilot and yaw damper off, corrected to the left to line up with the centerline, and maintained 120 kts airspeed over the airport fence. He stated that all indications were normal for landing. He stated that at approximately 100 ft agl, the airplane started to pull to the right. He applied left corrective control inputs, but the airplane continued to pull to the right. He applied engine power to perform a go-around, but the airplane landed in the grass just right of runway 18. He shut the engines down, turned the battery off, and conducted an emergency evacuation through the main cabin door.

A witness, who observed the accident from his office window which faced the approach threshold for runway 18, reported that he "watched the airplane fall out of the sky." He explained that he saw the wings slowly "fluttering" back and forth and recognized that the airplane was about to stall from an altitude of 130 to 140 ft agl. He said the airplane's nose pitched up and then the right wing went down. He could see the belly of the airplane and he estimated that the angle of bank was possibly 80°.

Another witness said that he saw the airplane as it was on final approach over the runway threshold. He said the airplane looked "odd." The airplane was over the runway, but it was 30 – 50 ft high. He said it was way too high for the flare. The nose was high and then it leveled off. Then the nose rose up and the wings started "waffling" and was about to stall. The right wing dropped and hit the ground about 2 seconds later. He estimated that the angle of bank was about 40°.

The passenger, who was sitting in the right seat of the cockpit, reported that the airplane started to take on ice on the windshield and the deicing boot on the right wing while they were on the approach in the clouds. He reported that the approach was normal until they neared the ground when the tail started "fishtailing." He saw the pilot push the throttles forward; however, the left wing climbed and the airplane "pulled hard to the right." The airplane impacted the ground on its right wing and then impacted back on its belly.

The passenger who was sitting on the couch directly behind the copilot's seat reported that the airplane was in the clouds for about 15 minutes and she saw ice forming on the windshield. When they were about to land, she said the pilot had the control wheel all the way toward him. She did not see any lights or hear any "bells," but she did see the pilot holding the control yoke as hard as he could and as close to his chest as he could. She said his arms were shaking because he was pulling back so hard. She said the pilot said an expletive, and then the airplane crashed seconds later.

PERSONNEL INFORMATION

The 41-year-old pilot held a commercial pilot certificate with single-engine land, multi-engine land, and airplane instrument ratings. He held a second-class airman medical certificate that was issued on July 12, 2018 with no limitations. The pilot reported that he had a total of 1,513 flight hours with 263 hours in a Cessna 550, and a total turbine time of 432.9 hours

The pilot's flight logbook indicted that he passed his commercial, multi-engine check ride on July 31, 2016, when he had a total of 479.1 flight hours. On May 11, 2017, he passed a check ride in a Cessna 550 when he had a total of 1,071.8 flight hours with 69.6 hours of turbojet time and 85.1 hours of turboprop time. On June 28, 2018, he passed the Pilot Proficiency Check 14 CFR 61.58 check ride for single-pilot operation in a Cessna 550 when he had a total of 1,420.5 flight hours with 257.5 hours of turbojet time and 85.1 hours of turboprop time.

Single-pilot Exemption

The logbook entry for single-pilot exemption #9917 stated that the pilot, "… has met all requirements for FAA exemption No. 9917 published at docket No. FAA-2009-0373, received training and review of the Practical Test Standards listed in FAA-S-8081-5F, and has completed the FAA Approved Training Course by 'VUE, Inc.'"

The pilot received single-pilot exemption training through VUE, Inc., the company which held the Exemption No. 9917. The exemption was from FAR 91.9 (a), and 91.531 (a) (1) and (2) of Title 14, CFR to the extent possible to allow VUE to train and check pilots of certain Cessna Citation airplanes covered by the CE-500 type rating to operate those airplanes with a single pilot, rather than with two as required by their type certificate sheets, subject to certain conditions and limitations.

One of the pilot requirements was that the pilot must have logged at least 1,000 hours of total pilot flight time, including at least 50 hours of night flight time; 75 hours of instrument flight time; 40 hours of which are in actual instrument meteorological conditions; and 500 hours as pilot-in-command (PIC), second-in-command (SIC), or both, in turbine-powered airplanes.

A review of the pilot's flight logbook indicated that he had less than 500 hours as PIC or SIC in turbine-powered aircraft which was required to exercise the single-pilot exemption.

AIRCRAFT INFORMATION

The Cessna 550 is a low-wing airplane powered by two Pratt & Whitney Canada JT-15B-4 turbofan engines which produced 2,500 lbs of thrust each. It is equipped with straight wings with integral wet-wing fuel tanks, a conventional tail, and retractable tricycle landing gear. The accident airplane was manufactured in 1980 and had a seating capacity of seven passengers and two pilots and had a maximum gross weight was 13,500 lbs.

According to the Cessna Citation Model 500 Airplane Flight Manual (AFM), the airplane was originally certificated under 14 CFR Part 25, which requires that a two-pilot crew operate the airplane. However, the FAA subsequently allowed for certain exemptions, including the VUE, Inc. No.9917 exemption, which allowed for single-pilot operation of the CE-500 and other specific airplanes.

A Federal Aviation Administration (FAA) inspector reported that according to the airplane's maintenance records, in 1986, two of the regular forward-facing passenger seats were removed from the cabin and replaced with a 3-person couch. The installation of the couch was installed without approved data for the accident airplane. During the accident, the cable for the seat belt attachment for the mid and aft passenger failed during ground impact.

The FAA inspector also reported that the factory installed toilet seat (and bench that covered the toilet seat) was a non-belted seat. It was not designed to be used as a passenger seat during takeoffs and landings. The seat belt installation for the toilet seat on the accident airplane was not approved and did not meet FAR Part 25 requirements.

During the accident flight, one of the passengers was sitting in the copilot's seat, 5 passengers were sitting in the originally installed cabin passenger seats, 3 passengers were sitting on the side facing couch located on the right, front side of the cabin, and 1 passenger was sitting on the bench which was over the toilet seat located in the rear of the cabin. All the passengers were wearing the seatbelts that were provided with the seats.

The Cessna 550 AFM had the following description of the airplane's stall warning system:

"Stall warning is achieved aerodynamically, aided by stall strips on the inboard section of each wing. The strips disrupt airflow over the wing, causing that area to stall first accentuating prestall buffet. The pilot is alerted to impending stall by aerodynamic buffeting which occurs at approximately VS1 + 10 in the clean configuration and VS0 + 5 in the landing configuration."

The airplane was also equipped with an optional Teledyne Angle-of-Attack System. The Supplement to the AFM stated that "the angle-of-attack system can be used as a reference for approach speed (1.3 VS1) at all airplane weights and center-of-gravity locations at zero, takeoff/approach, and landing flap positions.

Flaps

The airplane had three flaps settings: Flaps UP, Takeoff and Approach (T.O. & APPR), and LAND. The Before Landing checklist found in the Cessna Citation II Operating Manual Performance Section states that the flaps should be extended to the T.O. & APPR below 202 knots indicated airspeed (KIAS) and to verify the flap indicator position during the approach. Prior to landing, the manual states that the flaps LAND should be selected. The manual states:

"Flaps may be extended to T.O. & APPR below 202 KIAS and LAND below 176 KIAS. Should be in LAND position for all normal landings. Check indicator to verify position. Handle must be pushed in to clear T.O. & APPR detent when LAND flaps are desired."

The manual further states:

"After passing the instrument approach fix outbound or nearing the airport traffic area, airspeed should be reduced below 202 KIAS and the flaps extended to the APPR (15°) position. Approaching the final instrument fix inbound (one dot from glideslope intercept, on an ILS), or a downwind abeam position, extend the landing gear below 176 KIAS. At the point where final descent to landing is begun, extend FULL flaps, establish the desired vertical rate, and adjust power to maintain VREF to VREF + 10 KIAS indicated airspeed."

The Cessna AFM Performance section indicated that at a gross weight of 12,100 lbs, the VREF speed was about 106 KIAS. The landing performance charts are predicated on full flaps (LAND).

Ice Protection

The Cessna 550 Citation II was equipped with an anti-ice system to prevent ice on the windshield and a separate de-ice system that provided for removal of ice on the leading edge of the wing and tail by pneumatically expanding boots.

METEOROLOGICAL INFORMATION

At 1353, FAR reported a wind at from 200° at 10 knots, visibility of 5 statute miles, mist, ceiling overcast at 400 feet above ground level, temperature of -1° Celsius (C) and a dew point temperature of -1°C, altimeter setting of 29.91 inches of mercury; remarks: station with a precipitation discriminator, sea level pressure of 1014.2 hectopascals (hPa), temperature of -1.1°C and a dew point temperature of -1.1°C.

The Terminal Aerodrome Forecast (TAF) issued at 1133 CST for FAR forecasted for the accident time: a variable wind at 6 knots, visibility of 5 statute miles, mist, ceiling overcast at 300 feet agl.

At 0845 CST, an AIRMET ZULU was issued for moderate icing below 10,000 feet.

Images provided by the National Center for Atmospheric Research included the Current Icing Potential (CIP) and the Forecast Icing Potential (FIP) valid between 1300 and 1400 CST. Both the CIP and FIP indicated a 60% to 70% chance of light icing below 3,000 ft mean sea level (msl) in the vicinity of the accident. In addition, about 30 minutes after the accident, the pilot of a Citation Excel at 3,000 ft and close to FAR reported overcast skies and moderate rime ice with a temperature of -2°C. See the NTSB Meteorology Weather Study for more details about the accident weather conditions.

FLIGHT RECORDERS

Multiple Electronic Devices Examination

The National Transportation Safety Board's (NTSB) Vehicle Recorders Division examined the following electronic devices: 1) Sandel ST3400 Terrain Awareness Warning System, 2) Honeywell KLM 900, 3) Garmin AT MX20 Chart View. The data downloaded from the devices did not have pertinent data concerning the accident airplane while it was flying the ILS RWY 18 approach to FAR.

Cockpit Voice Recorder

The airplane was equipped with a Fairchild GA-100 cockpit voice recorder (CVR) designed to record 30 minutes of analog audio, including channels for each flight crewmember and the cockpit area microphone, on a continuous loop tape. The magnetic tape was retrieved from the crash-protected case and was successfully read out. A CVR group was not convened, and a summary of the recording was made and is included with the docket material associated with this investigation.

The summary CVR report indicated that the pilot did not verbalize out loud the approach and landing checklist responses. Approximately 45 seconds after ATC instructed the pilot to switch to the tower frequency and subsequently cleared to land on runway 18, the CVR recorded a sound consistent with landing gear extension and a voice stating, "all green." The pilot responded, "check, check, check," followed by the "outer marker, four miles." There was no other indication on the CVR that the pilot verbalized any checklist items, nor did the pilot make any audible comments about activating the pneumatic de-ice boots or windshield anti-ice.

Flight Data Recorder

The airplane was not equipped, and was not required to be equipped, with a flight data recorder.

WRECKAGE AND IMPACT INFORMATION

The examination of the accident site revealed that the airplane's right wingtip impacted the right edge of runway 18. After the initial impact, the airplane bounced and skidded on the grass infield for about 635 ft before coming to a stop resting on its belly. There was no ground fire. Immediately after the accident, about ½ - 1 inch of mixed ice was found on the leading edge of the right wing, vertical stabilizer, horizontal stabilizer, and the angle of attack (AOA) probe. Ice was also observed on the windshield. The ice accretion found on the leading edge of the vertical stabilizer was the same size and shape on the de-icing boots as that of the ice on the unprotected surfaces.

The initial examination of the airplane revealed that the right wing's outboard section was pushed up and aft. The nose wheel landing gear assembly was bent to the right, and the nose wheel trunnion assembly was broken in two pieces. The nose wheel assembly was separated from the fuselage with part of the trunnion attached to the wheel assembly. The left main landing gear was found folded into the gear wheel well, and the landing gear components were pushed upwards through the upper wing surface above the gear well. The left and right pitot tubes located on the left and right side of the nose of the airplane were broken. The AOA probe on the right side of the fuselage was intact; however, the operation of the AOA's heat element could not be verified when tested. The wing flaps were found in the up (0.0 degrees) position. The limited damage to the bottom surface or trailing edge of the flaps was consistent with the flaps being in the UP position. The examination of the cockpit revealed that the flap handle was found in the LAND (down) position, but the flap indicator was found in the UP position.

FAA inspectors examined the wreckage to verify the flap position based on the cable and drive chain position. The number of chain links visible confirmed that the flaps were in the full up position at the time of the accident. Both primary and secondary cables for the left and right flaps were both in the same position and the cables and surrounding structure did not show signs of damage. The continuity of the flap indicator cable was confirmed.

TESTS AND RESEARCH INFORMATION

NTSB Radar Performance Study

The NTSB Vehicle Performance Division conducted a radar performance study of the accident flight. Radar track data indicated that the airplane approached FAR from the west and was receiving vectors from air traffic control to capture the instrument landing system (ILS) signal for runway 18. The airplane encountered icing conditions for about 9 - 10 minutes while it was flying the ILS approach. The radar data indicated that during the last 2 minutes while the airplane was on final approach to the runway, the indicated airspeed was as low as 99 kts. The last radar return recorded indicated 104 kts airspeed and was at an altitude of 900 ft msl, the same as the touchdown zone elevation for runway 18.

The radar study included a simulation using models that were used to match altitude and position data from radar. The simulation indicated that during the last 2 minutes of flight, the angle-of-attack (AOA) approached angles very close to the stall AOA, and the AOA momentarily exceeded the linear portion of the Cessna 550 "no-ice" lift curve with flaps in the retracted position. When the lift coefficient was reduced by 5% to model the effect of ice accretions on the airplane's wings in the simulation, the AOA with the lift reduction was consistently into the non-linear portion of the no-ice lift curve for the last 30 seconds of flight.

ADDITIONAL INFORMATION

Operational Control of the Flight

FAA inspectors interviewed the passengers of the accident flight to determine who had operational control of the airplane. The passenger who made the flight arrangements reported that he contacted the pilot via text message and made all the arrangements for the flight with the pilot. He stated that the pilot was responsible for operation of the flight, to include fuel, maintenance, pilot qualifications and weather. He stated that the pilot was the single source provider for the flight. He was not informed that it was a charter flight, or that there was a separate lease for the airplane and for the pilot services. The passenger stated that he would be billed for the flight, and then he would sub-bill the cost of the flight to the other parties (passengers).

Pilot Information

Certificate: Commercial
Age: 41, Male
Airplane Rating(s): Multi-engine Land; Single-engine Land
Seat Occupied: Left
Other Aircraft Rating(s): None
Restraint Used:
Instrument Rating(s): Airplane
Second Pilot Present: No
Instructor Rating(s): None
Toxicology Performed: No
Medical Certification: Class 2 Without Waivers/Limitations
Last FAA Medical Exam: 07/12/2018
Occupational Pilot: Yes
Last Flight Review or Equivalent: 09/02/2018
Flight Time:  1513 hours (Total, all aircraft), 263 hours (Total, this make and model), 649 hours (Pilot In Command, all aircraft), 57 hours (Last 90 days, all aircraft), 10 hours (Last 30 days, all aircraft) 

Aircraft and Owner/Operator Information

Aircraft Make: Cessna
Registration: N941JM
Model/Series: 550 No Series
Aircraft Category: Airplane
Year of Manufacture: 1980
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: 550-0146
Landing Gear Type: Retractable - Tricycle
Seats: 11
Date/Type of Last Inspection: 03/23/2017, Continuous Airworthiness
Certified Max Gross Wt.: 13500 lbs
Time Since Last Inspection:
Engines: 2 Turbo Jet
Airframe Total Time: 7180 Hours as of last inspection
Engine Manufacturer: Pratt & Whitney
ELT: Installed
Engine Model/Series: JT 15B-4
Registered Owner: Slice Of The 406 Llc
Rated Power: 2500 lbs
Operator: On file
Operating Certificate(s) Held: None

Meteorological Information and Flight Plan

Conditions at Accident Site: Instrument Conditions
Condition of Light: Day
Observation Facility, Elevation: FAR, 901 ft msl
Distance from Accident Site: 0 Nautical Miles
Observation Time: 1353 CST
Direction from Accident Site: 0°
Lowest Cloud Condition:
Visibility:  5 Miles
Lowest Ceiling: Overcast / 400 ft agl
Visibility (RVR):
Wind Speed/Gusts: 10 knots /
Turbulence Type Forecast/Actual:
Wind Direction: 200°
Turbulence Severity Forecast/Actual:
Altimeter Setting: 29.91 inches Hg
Temperature/Dew Point: -1°C / -1°C
Precipitation and Obscuration: Mist
Departure Point: Williston, ND (ISN)
Type of Flight Plan Filed: IFR
Destination: Fargo, ND (FAR)
Type of Clearance: IFR
Departure Time: 1250 CST
Type of Airspace:

Airport Information

Airport: Hector International (FAR)
Runway Surface Type: Concrete
Airport Elevation: 901 ft
Runway Surface Condition: Wet
Runway Used: 18
IFR Approach: ILS
Runway Length/Width: 9001 ft / 150 ft
VFR Approach/Landing: Full Stop

Wreckage and Impact Information

Crew Injuries: 1 None
Aircraft Damage: Substantial
Passenger Injuries: 9 Minor, 1 None
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 9 Minor, 2 None

Latitude, Longitude: 46.920556, -96.815833 (est)

Location: Fargo, ND
Accident Number: CEN19LA039
Date & Time: 11/30/2018, 1353 CST
Registration: N941JM
Aircraft: Cessna 550
Injuries: 9 Minor, 2 None
Flight Conducted Under: Part 91: General Aviation - Business 

On November 30, 2018, about 1353 central standard time, a Cessna 550, N941JM, departed controlled flight while on approach at the Hector International Airport (FAR), Fargo, North Dakota, and impacted the terrain to the right of the runway. The pilot and one passenger were not injured, and 9 passengers received minor injuries. The airplane sustained substantial damage. The airplane was registered to the Slice of the 406 LLC and operated by Dirt Dynamics, Inc. under the provisions of the Title 14 Code of Federal Regulations Part 91 as a business flight. Instrument meteorological conditions prevailed at the time of the accident and the flight was operating on an instrument flight plan. The flight departed from the Sloulin Field International Airport (ISN), Williston, North Dakota, about 1250 with FAR as the destination.

The pilot reported that the airplane encountered a cloud layer that was about 2,500 ft thick while he was on the approach to FAR. He stated that there was ice buildup on the wing surfaces, but he activated the deice boots several times during the approach to runway 18 (9,001 ft by 150 ft, concrete) and the airplane's performance was normal. The airplane became clear of the clouds about 400 ft above the ground (agl) and it was right of centerline. He flew back onto the centerline maintaining 120 kts during the descent. About 100 ft agl, the airplane started "pulling to the right." He applied left aileron and left rudder, and advanced the throttle to go-around. The airplane continued to the right and impacted the terrain seconds later.

A witness, who observed the accident from his office window which faced the approach threshold for runway 18, reported that he "watched the airplane fall out of the sky." He explained that he saw the wings slowly "fluttering" back and forth and recognized that the airplane was about to stall from an altitude of 130 to 140 ft agl. He said the airplane's nose pitched up and then the right wing went down. He could see the belly of the airplane and he estimated that the angle of bank was possibly 80°.

The passenger, who was sitting in the right seat of the cockpit, reported that the airplane started to take on ice on the windshield and the deicing boot on the right wing while they were on the approach in the clouds. He reported that the approach was normal until they neared the ground when the tail started "fish tailing." He saw the pilot push the throttles forward; however, the left wing climbed and the airplane "pulled hard to the right." The airplane impacted the ground on its right wing and then impacted back on its belly.

The initial examination of the airplane revealed that the right wing's outboard section was pushed up and aft. The nose wheel landing gear assembly was bent to the right, and the nose wheel trunnion assembly was broken in two pieces. The nose wheel assembly was separated from the fuselage with part of the trunnion attached to the wheel assembly. The left main landing gear was found folded into the gear wheel well, and the landing gear components were pushed upwards through the upper wing surface above the gear well.

The examination of the wreckage revealed that there was about ½ inch of mixed ice on the leading edge of the right wing, vertical stabilizer, horizontal stabilizer, and on the angle of attack (AOA) indicator.

At 1353, the surface weather observation at FAR was wind 200° at 10 kts; 5 miles visibility; mist; overcast ceiling at 400 ft; temperature -1° C; dew point -1° C; and an altimeter setting of 29.91 inches of mercury.

Aircraft and Owner/Operator Information

Aircraft Make: Cessna
Registration: N941JM
Model/Series: 550 No Series
Aircraft Category: Airplane
Amateur Built: No
Operator: Dirt Dynamics, Inc.
Operating Certificate(s) Held: None 

Meteorological Information and Flight Plan

Conditions at Accident Site: Instrument Conditions
Condition of Light: Day
Observation Facility, Elevation: FAR, 901 ft msl
Observation Time: 1353 CST
Distance from Accident Site: 0 Nautical Miles
Temperature/Dew Point: -1°C / -1°C
Lowest Cloud Condition:
Wind Speed/Gusts, Direction: 10 knots / , 200°
Lowest Ceiling: Overcast / 400 ft agl
Visibility:  5 Miles
Altimeter Setting: 29.91 inches Hg
Type of Flight Plan Filed: IFR
Departure Point: Williston, ND (ISN)
Destination: Fargo, ND (FAR)

Wreckage and Impact Information

Crew Injuries: 1 None
Aircraft Damage: Substantial
Passenger Injuries: 9 Minor, 1 None
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion:None 
Total Injuries: 9 Minor, 2 None
Latitude, Longitude: 46.920556, -96.815833 (est)


Cessna 550 Citation II, N941JM



FARGO — No one was hurt when a plane veered off a runway at Hector International Airport and crashed at the north end of the airfield just before 2 p.m. Friday, November 30th, an airport official said.

Shawn Dobberstein, executive director of Fargo's Municipal Airport Authority, said it appeared the Cessna 550 Citation II had been in the process of landing on the airport's primary runway when the small jet veered off the runway before coming to a stop.

Dobberstein said he did not know how many people were aboard the plane, but he said everyone was safe after the incident and those who had been on the plane waited at the nearby Jet Center, 3802 20th St. N., for transportation.

He said the plane, which had flown from Williston, suffered significant damage and will remain at the crash site until federal investigators arrive.

At least two fire trucks, a handful of police vehicles and an ambulance responded to the crash site, according to a WDAY-TV reporter at the scene.

Federal Aviation Administration records indicate that based on the plane's "N" number it is registered to Slice of the 406 LLC, of Helena, Montana.

The Montana Secretary of State's website lists the registered agent of Slice of the 406 as Deer Creek Corporate Services Inc., of Helena, which describes itself on its company website as a registered agent and legal services company.

A woman who answered the phone at Deer Creek Services said she could release no information.

A plane that made a crash landing in a field near Moorhead Municipal Airport on November 23rd, 2016, was also registered to Slice of the 406 LLC.

In that incident, the plane involved was a Beech King Air 200 that suffered substantial damage when it hit the ground during a missed approach at night.

According to the FAA's final report on the Moorhead incident, the airplane was operated by Flight Development LLC, an air taxi company.

The report stated the probable cause of the Moorhead crash was pilot failure to attain a positive climb rate during an attempted missed approach at night, "which resulted in a controlled flight into terrain."

The pilot in that crash suffered injuries to his face as did one of six passengers on the flight, the report regarding the 2016 crash said.

Original article can be found here ➤ http://www.bemidjipioneer.com

Beech 200 Super King Air, N80RT, registered to Slice of the 406 LLC and operated by Flight Development LLC: Accident occurred November 23, 2016 near Moorhead Municipal Airport (KJKJ), Clay County, Minnesota 


Beech 200 Super King Air, N80RT




Aviation Accident Final Report - National Transportation Safety Board 

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

Investigation Docket - National Transportation Safety Board:

Location: Moorhead, MN
Accident Number: CEN17LA043
Date & Time: 11/23/2016, 1759 CST
Registration: N80RT
Aircraft: BEECH 200
Aircraft Damage: Substantial
Defining Event: Controlled flight into terr/obj (CFIT)
Injuries: 3 Minor, 4 None
Flight Conducted Under: Part 135: Air Taxi & Commuter - Non-scheduled

Analysis

The commercial pilot was conducting an on-demand passenger flight at night in instrument meteorological conditions that were at/near straight-in approach minimums for the runway. The pilot flew the approach as a nonprecision LNAV approach, and he reported that the approach was stabilized and that he did not notice anything unusual. A few seconds after leveling the airplane at the missed approach altitude, he saw the runway end lights, the strobe lights, and the precision approach path indicator. He then disconnected the autopilot and took his hand off the throttles to turn on the landing lights. However, before he could turn on the landing lights, the runway became obscured by clouds. The pilot immediately decided to conduct a missed approach and applied engine power, but the airplane subsequently impacted terrain short of the runway in a nose-up level attitude. The pilot reported that there were no mechanical anomalies with the airplane that would have precluded normal operation. It is likely the pilot lost sight of the runway due to the visibility being at/near the straight-in approach minimums and that the airplane got too low for a missed approach, which resulted in controlled flight into terrain.

A passenger stated that he and the pilot were not wearing available shoulder harnesses. The passenger said that he was not informed that the airplane was equipped with shoulder harnesses or told how to adjust the seats. The pilot sustained injuries to his face in the accident.

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The pilot's failure to attain a positive climb rate during an attempted missed approach in night instrument meteorological conditions that were at/near approach minimums, which resulted in controlled flight into terrain.

Findings

Aircraft
Climb rate - Not attained/maintained (Cause)
Emergency equipment - Not used/operated

Personnel issues
Aircraft control - Pilot (Cause)
Issuing instructions - Pilot

Environmental issues
Ceiling/visibility/precip - Effect on operation (Cause)



Factual Information

On November 23, 2016, at 1759 central standard time, a Beech 200, N80RT, impacted terrain during a missed approach from runway 30 at Moorhead Municipal Airport (JKJ), Moorhead, Minnesota. The pilot initiated a missed approach after losing visual reference of the runway environment during the final segment of a GPS instrument approach. The pilot and two passengers sustained minor injuries and four passengers were uninjured. The airplane received substantial damage. The airplane was operated by Flight Development, LLC under the provisions of 14 Code of Federal Regulations Part 135 as a single-pilot on-demand passenger flight. The flight was operating on an instrument rules flight plan. Night instrument meteorological conditions prevailed at the time of the accident. The flight departed from Baudette International Airport (BDE), Baudette, Minnesota, at 1714 and was destined to JKJ.

A passenger stated that he and his work crew had been flying between Baudette and Moorhead on a weekly basis for the past 5-6 weeks to build agricultural storage facilities. The passenger stated that the pilot had flown the work crew on one of the previous flights, and the remainder of the flights were flown by the company chief pilot and the company director of operations.

The passenger stated that the accident flight was the first flight in which he was seated in the copilot seat. The passenger stated that he and the pilot were not wearing a shoulder harness. The passenger stated that he was not informed that the airplane was equipped with shoulder harnesses, how to use them, and how to adjust the seats. The passenger stated that he would have adjusted the seat if he would have known that was an option and used his shoulder harness, as he is a safety conscious person.

The pilot stated that before he was handed off from Minneapolis Center to Fargo Approach, he listened to the automated weather observing system (AWOS) at JKJ, which reported that light north winds, a ceiling of 300 feet above ground level, and 1.25 statute mile visibility. He checked in with Fargo Approach and informed them that he had the weather at JKJ and requested the area navigation (RNAV) approach to runway 30 starting at IVEJE, the initial approach fix (IAF). N80RT was not equipped with a wide area augmentation system (WAAS) GPS so he flew the approach as a non-precision lateral navigation (LNAV) approach (straight-in approach minima were: 300 feet above ground level and 1 statute mile visibility). He told Fargo Approach that he realized the weather was deteriorating and would make one attempt at JKJ and then divert to Hector International Airport (FAR), Fargo, North Dakota. Fargo Approach issued a clearance to the IAF, and initial approach altitude, and provided missed approach instructions. The pilot stated that he had flown this approach numerous times and briefed the approach. He stated that the approach was stabilized with the appropriate altitudes and airspeeds throughout and did not notice anything unusual. Upon leveling off at the missed approach altitude of 1,300 feet mean sea level, he looked for the runway. After what seemed like just a few seconds he saw the runway end lights, the strobe lights, and the precision approach path indicator. He disconnected the autopilot and took his hand off the throttles to turn on the landing lights for landing. Before he could even turn on the landing lights, the runway disappeared from sight due to the clouds. He immediately decided to perform a missed approach and applied engine power. He said that he referenced the flight director, but did not recall what it was indicating. He did not feel any sinking feeling indicating that he was losing altitude. He said that It seemed like just a few seconds before the airplane impacted the ground. The airplane struck the ground in somewhat of a nose-up, level bank attitude. The airplane slid along the ground and turned slightly to the right before coming to rest.

The passenger stated that prior to departure, the pilot said they needed to get going because the weather was getting bad in Fargo. While en route, the passenger heard Fargo Air Traffic Control Tower advise weather was not good, and the pilot stated he would try to fly to JKJ first and then fly to FAR, if that did not work. The passenger said the pilot asked him to be on the lookout for the runway and about 3,600 feet the airplane banked to line up for the approach. The passenger said he heard an audible "too low" warning three times, saw some runway lights at eye level, and then the airplane impacted the ground. The passenger said he did not think the pilot initiated a go-around, and he did not see him adjust engine power settings or move the control yoke. The passenger stated that he received facial injuries that required stitches.

The pilot reported that there was no mechanical malfunction/failure with the airplane.

The pilot's safety recommendation on how the accident could have been prevented was:

"Stick to my normal personal weather minimums and not attempt a non-precision approach to minimums. It would of been so easy to go to Fargo and do the ILS. I have always lectured to my students on the advantage of having two pilots when things are challenging. This is a prime example of such [an accident]. Over confidence is always something that we have to try to keep in check."

A review of the pilot's training records showed that the pilot completed the company's Federal Aviation Administration (FAA) approved ground and flight training program, dated August 17, 2016. The ground training was conducted by the company director of operations and the company chief pilot. The pilot's flight training, which was 10.8 hours in duration, was conducted by the company chief pilot. The pilot received and passed his most recent Part 135.293 Airman Proficiency Check, dated August 18, 2016, which was conducted by an FAA inspector from the Fargo Flight Standards District Office. The check was performed using a Beech 200 and was 1.7 hours in flight duration. The pilot received a grade of satisfactory for all of the check's maneuvers/procedures.

FAA Advisory Circular 91-65, Use of Shoulder Harnesses in Passenger Seats, states in part:

On December 17, 1985, the National Transportation Safety Board (NTSB) issued safety recommendation A-85-124, recommending issuance of advisory circular to provide information on crash survivability aspects of small aircraft. The recommendation was the result of an NTSB general aviation airplane crashworthiness project. In the project, the safety board examined 500 relatively severe general aviation airplane accident, to determine what proportion of the occupants would have benefited from the use of shoulder harnesses and energy-absorbing seats. The safety board found that 20 percent of the fatally-injured occupants in these accidents could have survived with shoulder harnesses (assuming the seat belt was fastened) and 88 percent of the seriously injured could have had significantly less severe injuries with the use of shoulder harnesses. Energy-absorbing seats could have benefited 34 percent

of the seriously injured. The safety board concluded that shoulder harness use is the most effective way of reducing fatalities and serious injuries in general aviation accidents.

Part 135.117, Briefing of Passengers Before Flight, states that before each takeoff each pilot in command of an aircraft carrying passengers shall ensure that all passengers have been orally briefed on: the use of seat belts, the placement of seat backs in an upright position before takeoff and landing, location and means for opening the passenger entry door and emergency exits, location of survival equipment, if the flight involves extended overwater operation, ditching procedures and the use of required flotation equipment, if the flight involves operations above 12,000 feet MSL, the normal and emergency use of oxygen, and location and operation of fire extinguishers. 

History of Flight

Approach-IFR final approach
Loss of visual reference

Approach-IFR missed approach
Controlled flight into terr/obj (CFIT) (Defining event)
Collision with terr/obj (non-CFIT) 

Pilot Information

Certificate: Airline Transport; Flight Instructor; Commercial
Age: 59, Male
Airplane Rating(s): Multi-engine Land; Single-engine Land; Single-engine Sea
Seat Occupied: Left
Other Aircraft Rating(s): None
Restraint Used: 3-point
Instrument Rating(s): Airplane
Second Pilot Present: No
Instructor Rating(s):  Airplane Multi-engine; Airplane Single-engine; Instrument Airplane
Toxicology Performed: No
Medical Certification: Class 1 None
Last FAA Medical Exam: 09/20/2016
Occupational Pilot: Yes
Last Flight Review or Equivalent: 08/18/2016
Flight Time:  5630 hours (Total, all aircraft), 89 hours (Total, this make and model), 5345 hours (Pilot In Command, all aircraft), 149 hours (Last 90 days, all aircraft), 46 hours (Last 30 days, all aircraft), 0 hours (Last 24 hours, all aircraft)



Aircraft and Owner/Operator Information

Aircraft Make: BEECH
Registration: N80RT
Model/Series: 200
Aircraft Category: Airplane
Year of Manufacture: 1978
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: BB-370
Landing Gear Type: Tricycle
Seats: 11
Date/Type of Last Inspection:  100 Hour
Certified Max Gross Wt.: 12500 lbs
Time Since Last Inspection:
Engines: 2 Turbo Prop
Airframe Total Time:
Engine Manufacturer: Pratt & Whitney
ELT: Installed, activated, did not aid in locating accident
Engine Model/Series: PT6A-41
Registered Owner: SLICE OF THE 406 LLC
Rated Power: 1050 hp
Operator: Flight Development, LLC
Operating Certificate(s) Held: On-demand Air Taxi (135)
Operator Does Business As:
Operator Designator Code: VOXA

Meteorological Information and Flight Plan

Conditions at Accident Site: Instrument Conditions
Condition of Light: Night
Observation Facility, Elevation: JKJ, 918 ft msl
Distance from Accident Site: 1 Nautical Miles
Observation Time: 1754 CST
Direction from Accident Site: 120°
Lowest Cloud Condition: Clear
Visibility:  0.5 Miles
Lowest Ceiling: Overcast / 300 ft agl
Visibility (RVR):
Wind Speed/Gusts: 7 knots /
Turbulence Type Forecast/Actual: / None
Wind Direction: 350°
Turbulence Severity Forecast/Actual: / N/A
Altimeter Setting: 30.1 inches Hg
Temperature/Dew Point: 1°C / 1°C
Precipitation and Obscuration: Moderate - Fog; No Precipitation
Departure Point: Baudette, MN (BDE)
Type of Flight Plan Filed: IFR
Destination: Moorhead, MN (JKJ)
Type of Clearance: IFR
Departure Time: 1714 CDT
Type of Airspace:

Airport Information

Airport: Moorhead Municipal Airport (JKJ)
Runway Surface Type: Asphalt
Airport Elevation: 918 ft
Runway Surface Condition:
Runway Used: 30
IFR Approach: Global Positioning System
Runway Length/Width: 4300 ft / 75 ft
VFR Approach/Landing: 

Wreckage and Impact Information

Crew Injuries: 1 Minor
Aircraft Damage: Substantial
Passenger Injuries: 2 Minor, 4 None
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 3 Minor, 4 None
Latitude, Longitude: 46.839167, -96.664167 (est)

Flight Control System Malfunction/Failure: Cessna 525A CitationJet CJ2+, N525EG; fatal accident occurred November 30, 2018 in Memphis, Clark County, Indiana

The estates of three people who died in a 2018 plane crash in Southern Indiana have reached a settlement with the aviation company behind a winglet system scrutinized in the incident. 

Family and representatives of the three victims — Louisville City FC founder Wayne Estopinal, his architecture firm’s vice president, Sandra Holland Johnson, and pilot Andrew Davis — had sued Tamarack Aerospace Group in connection with the Nov. 30, 2018, crash of the Cessna 525A CitationJet CJ2+ in a field near Memphis, Indiana. 

The wrongful death suit, filed in 2020 in U.S. District Court for the Eastern District of Washington, accused Idaho-based Tamarack of making a winglet system that “was not reasonably safe as designed” and claimed “adequate warnings or instructions were not provided.” 

Winglets are the raised pieces at the edge of wings that reduce drag and help control the plane. 

Following an investigation, the National Transportation Safety Board said in a 2021 report on the crash that six pins in the wingtip extensions of the Cessna were “curled” and two pins were not aligned, which could have disrupted power. 

Without definitively blaming Tamarack, the NTSB described the official cause of the crash as “asymmetric deployment of the left wing load alleviation system for undetermined reasons.” 

Claims made in a lawsuit represent only one side of a case. 

Tamarack Aerospace Group said in a statement Thursday it “has reached a confidential resolution of all claims evolving from the November 30, 2018 Cessna mishap near Memphis, Indiana.” 

The company declined to provide further details in the statement to The Courier Journal. 

Online records in the case before U.S. District Judge Mary K. Dimke also confirmed the “parties have informed the Court that this matter settled during mediation.” Attorneys for the plaintiffs did not immediately return phone calls and emails seeking comment.

Each plaintiff sought to recover, at a minimum, $75,000 from Tamarack Aerospace Group and Cranfield Aerospace Solutions Limited, along with prejudgment interest, attorney fees and costs. 

The suit is separate from Tamarack’s pending petition to the NTSB that asks the federal board to reconsider its conclusion the 2018 crash was likely caused by the winglet system. 

Tamarack defends its winglets 

Tamarack previously argued its Active Winglets installed on the Cessna in the 2018 crash “were fully operational and did not cause or contribute to the accident.” 

Roughly six months after the crash, the Federal Aviation Administration announced it was grounding Cessna planes equipped with Tamarack's ATLAS winglets, mentioning reports of incidents in which the winglets appeared to have malfunctioned. 

The FAA alluded to the Indiana plane crash without specifically naming it, and the agency also cited a similar emergency directive issued a month earlier by the European Aviation Safety Agency. 

The European agency and FAA lifted the winglet directives in the summer of 2019 after Tamarack Aerospace Group announced it had found a fix to the system that improves reliability and safety. Since then, no accidents or crashes involving the Cessna fleet with the Tamarack winglet system have been reported.

Remembering the victims 

Davis, 32, Estopinal, 63, and Johnson, 54, died when the  Cessna 525A CitationJet CJ2+ crashed a few minutes after its 10:25 a.m. takeoff from Clark Regional Airport on the way to Chicago's Midway International Airport. 

Davis lived in Sellersburg and was an associate corporate pilot for TEG. He left behind a wife and two young children. 

Johnson was vice president of TEG and based in the firm's Shreveport, Louisiana, office. A mother of two sons, she was remembered as a caring friend and an energetic person with a zest for life. 

Estopinal was president of Jeffersonsville-based TEG Architects, where Davis and Johnson also worked, and Estopinal’s EstoAir LLC firm owned the plane. 

Estopinal was also behind the effort to bring a United Soccer League franchise to Louisville in 2014, with LouCity since becoming one of the USL's most successful clubs, and he was the architectural leader behind several local projects, including the University of Louisville’s Lynn Stadium and Jeffersonville’s Big Four Station Park.


Aviation Accident Final Report - National Transportation Safety Board

Investigator In Charge (IIC): Aguilera, Jason

The National Transportation Safety Board traveled to the scene of this accident.

Additional Participating Entities:
Chris House; Federal Aviation Administration / Flight Standards District Office; Indianapolis, Indiana
Textron Aviation; Wichita, Kansas
Williams International; Pontiac, Michigan
Tamarack Aerospace Group; Sandpoint, Idaho
Rockwell Collins; Cedar Rapids, Iowa
Lee Air; Wichita, Kansas

Investigation Docket - National Transportation Safety Board:



Location: Memphis, Indiana 
Accident Number: CEN19FA036
Date and Time: November 30, 2018, 10:28 Local 
Registration: N525EG
Aircraft: Cessna 525
Aircraft Damage: Destroyed
Defining Event: Flight control sys malf/fail 
Injuries: 3 Fatal
Flight Conducted Under: Part 91: General aviation - Business

Analysis

The pilot and two passengers departed in instrument meteorological conditions on a crosscountry flight. According to the airplane’s automatic dependent surveillance–broadcast (ADSB) data, the airplane climbed to about 1,400 ft mean sea level (msl) before it turned left onto a track toward the assigned fix and continued to climb. The pilot contacted air traffic control and was assigned 10,000 ft; he turned the autopilot on and adjusted the selected altitude to 10,000 ft. The airplane passed 3,000 ft, with airspeed between 230 and 240 kts, and continued to climb. The airplane then began to bank to the left at a rate of about 5° per second. After the
onset of the roll, the airplane maintained airspeed and continued to climb for 12 seconds, which indicated that engine power was not reduced in response to the roll onset.

When the airplane reached about 30° of left bank, about 3 seconds after the onset of the roll, the autopilot disconnected accompanied by an aural alert. About 1 second later, the cockpit voice recorder (CVR) recorded a statement by the pilot consistent with surprise, likely made in response to the autopilot disconnect and/or the bank angle. Based on the pilot’s statement of surprise, it is unlikely that the pilot commanded the left bank. The airplane continued its climb and reached a maximum altitude of about 6,100 ft msl before it began to rapidly descend, with its left bank angle reaching near 90°. During the descent, the airplane’s enhanced ground proximity warning system announced eight “bank angle” annunciations and one “overspeed warning” annunciation.

About 23 seconds after the autopilot disconnected, the pilot made a mayday call shouting that he was “…in an emergency descent unable to gain control of the aircraft.” At the final ADS-B data point, the airplane was at an altitude of about 1,000 ft msl, at an airspeed of about 380 kts, and in a 53° left bank. The airplane impacted a wooded area about 8.5 miles northwest of the departure airport. The total time from the beginning of the left bank until ground impact was about 35 seconds.

The airplane was modified with a Tamarack Aerospace Group Active Technology Load Alleviation System (ATLAS), which operated independently of other airplane systems. The system included the installation of Tamarack Active Camber Surfaces (TACS), which are
aerodynamic control surfaces mounted on the wing extensions that either hold their position in trail with the wing or symmetrically deploy trailing edge up or trailing edge down to alleviate structural loads. The TACS are actuated by the TACS control units (TCUs) and are not controlled by the pilot.

Postaccident examination of the airplane’s left TACS control linkage assemblies revealed a witness mark on the bellcrank, consistent with contact with the trailing-edge-up mechanical stop and, thus, the TACS being in a trailing-edge-up position at the time of ground impact. Additional damage on the TACS inboard hinge fitting, consistent with over-deflection in the trailing-edge-up direction, was also consistent with the TACS being in a trailing-edge-up position at the time of ground impact. Examination of the left TCU showed contact marks on the ram guide housing and on the extend hard stop plate, which were consistent with the actuator being at a maximum extension position at the time of ground impact. These marks are not expected during normal operation of the actuator. The evidence indicates that the left TACS was in a position consistent with full trailing edge up position at the time of ground impact.

Examination of the right TACS control linkage assemblies revealed damage to the trailing edge-down bolt/stop. The drive that positions the TACS was found in the neutral position. Damage to the bolt was consistent with the bell-crank impacting the bolt with sufficient force to shear the bolt at the nut, which is consistent with the TACS moving to a trailing-edge-down position during the impact sequence. Additional damage on the TACS inboard hinge fitting, consistent with over-deflection in the trailing-edge-down direction, was consistent with the TACS being in a trailing-edge-down position. The forces required to cause this damage would likely be due to the control system moving with some speed toward the trailing-edge-down position.

Examination of the right TCU, which was found detached from its mounting location, did not find contact marks on the retract hard stop that would have been consistent with a full trailing edge-down position. Additionally, marks on the ram guide housing were consistent with the actuator being in a midtravel position, or a more neutral position of the TACS. These marks are not expected during normal operation of the actuator. The evidence indicates that the right TACS was in a neutral position at the time of ground impact. Because the right TCU and TACS were found separated from the control linkage assembly, it is likely that the TACS was able to move freely after initial ground impact and then cause the damage to the trailing-edge-down bolt/stop.

An asymmetric deployment of the TACS, with the left TACS likely in a position consistent with trailing edge up and the right TACS likely in a position consistent with neutral, would have induced a left rolling moment to the airplane.

Postaccident examination revealed that the left TCU’s 40-pin connector had 6 pins that were curled, with 2 of the pins not continuous, which could indicate an intermittent electrical connection in the left TACS that could interrupt power to the TACS, leading the left TACS to remain in a trailing-edge-up position while the right TACS floated to a neutral position.

However, it could not be determined how or when the pins had been curled, and the lack of fault recording capability in the ATLAS precluded the detection of any problems with the system.

According to the airplane performance study, certification failure assessment flight testing for the ATLAS found that at a speed of 240 kts, an initial bank angle of 30°, and a maximum unfavorable fuel imbalance (critical failure condition), a near full asymmetric deflection of the TACS resulted in a roll rate of greater than 20° per second. For the accident flight, at the start of the left roll, the airplane’s airspeed was calculated to be 240 kts with the wings about level. In the flight test, the pilot reacted to the full asymmetric TACS deflection within 3 seconds and was able to counteract the roll induced by the asymmetric TACS deflection.

The accident roll rate of 5° per second was significantly less than the flight test data provided for a fully asymmetric TACS deflection at a critical failure initial condition. It is possible that the system was not experiencing a full asymmetric failure or that the full possible roll rate could not be induced because the airplane was not in the critical failure condition. The roll rate
did change from negative to positive, and the roll angle did recover from 90° left wing down to about 53° left wing down before ground impact.

If an asymmetric TACS deflection caused the left roll, it is possible the pilot was able to roll the airplane back to the right but not enough to fully recover and arrest the descent. However, because the airplane was not equipped with a flight recorder, control surface deflections and pilot input are unknown. Further, the ATLAS is independent of other airplane systems, and it does not record any information about TCU actuation or TACS deflection.

The investigation found that five uncommanded roll incidents have been reported to either the European Union Aviation Safety Agency or the Federal Aviation Administration involving airplanes equipped with ATLAS. After this accident, the ATLAS manufacturer issued a service bulletin (SB) applicable to all TACS units in response to uncommanded roll events related to ATLAS failures. The SB stated that the aerodynamic overbalance of the TACS allowed for the TACS to remain deployed when power was removed from the TCU while the TACS are deployed or if unique aerodynamic conditions were encountered causing the TACS to deploy with the TCUs in an unpowered state. The SB specified the application of centering strips attached to the upper and lower trailing edge of the TACS that, in the event of a system fault, would aerodynamically force the TACS back to their faired position and reduce the impact of the fault. Because the SB was released after this accident occurred, the accident airplane was not equipped with these centering strips.

The investigation also examined the pilot’s actions before the left bank and his response to it. The CVR transcript showed that before the autopilot disconnected, the pilot had consistently verbalized his actions. These statements and the pilot’s exchanges with controllers were consistent with a pilot fully engaged in routine operations and did not suggest performance deficiency or impairment. In the moments before the autopilot disconnect, the pilot had been conducting a checklist, which was interrupted by a routine exchange with a controller to change frequencies. After the exchange, the pilot resumed the checklist and subsequently responded with surprise after the autopilot disconnect aural annunciation.

For about 15 seconds, while the bank angle warning sounded and the overspeed warning began to annunciate, the pilot did not make any statements. However, about 2 seconds after the onset of the overspeed warning, the pilot shouted three expletives followed about 6 seconds later by a mayday call. After the autopilot disconnect, the pilot’s statements were consistent with startle and surprise and, although he made no statements that described actions he was taking, his statement in the mayday call of “unable to gain control” is likely consistent with the pilot having taken some actions to regain control but an increasing recognition that they were not effective.

According to a supplement to the flight manual emergency procedures, during an ATLAS inoperative condition in flight, the pilot is to move the throttles to idle and extend the speed brakes to reach an airspeed below 161 kts. Warnings indicate that “LARGE AILERON INPUT MAY BE REQUIRED IF AN ATLAS FAILURE AT HIGH INDICATED AIRSPEED INCLUDES A TACS RUNAWAY” and “SPEED REDUCTION IS THE FIRST PRIORITY IN THESE FAILURE CONDITIONS.”

The airplane performance study found that after the autopilot disconnect, the airplane continued to climb, consistent with the engine at a high power setting. During the descent, airplane systems warned of an overspeed condition, and the last data point revealed that the airplane was traveling about 380 kts. Thus, it is unlikely that the pilot moved the throttles to the idle position as directed by the flight manual supplement. The ATLAS INOP button was not located in the wreckage, and it could not be determined if the button illuminated in flight to help the pilot identify a malfunction with the ATLAS.

In summary, the circumstances of the accident are consistent with asymmetric or trailing edge up deployment of the left TACS for reasons that could not be determined. The resultant roll rate, although above the nominal threshold for detection by the human vestibular system, likely went unrecognized by the pilot, due primarily to the pilot’s attention being directed toward a checklist and communications with a controller, a lack of visible horizon because the airplane was in the clouds, and the autopilot engagement. After the autopilot disconnected, the pilot was audibly surprised and did not reduce engine power or deploy the speed brakes. The pilot was not able to regain control before collision with terrain.

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The asymmetric deployment of the left wing load alleviation system for undetermined reasons, which resulted in an in-flight upset from which the pilot was not able to recover.

Findings

Aircraft Control surface (fitting on wing) - Malfunction

Factual Information

History of Flight

Initial climb Flight control sys malf/fail (Defining event)
Initial climb Loss of control in flight
Uncontrolled descent Collision with terr/obj (non-CFIT)

**This report was modified on October 6, 2021. Please see the public docket for this investigation to view the original factual report.**

On November 30, 2018, about 1028 central standard time, a Cessna 525A (Citation) airplane, N525EG, was destroyed when it was involved in an accident near Memphis, Indiana. The pilot and two passengers were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 business flight.

The cross-country flight originated from Clark Regional Airport (JVY), Jeffersonville, Indiana, and was en route to Chicago Midway International Airport (MDW), Chicago, Illinois. The airplane was equipped with automatic dependent surveillance–broadcast (ADS-B), which recorded latitude and longitude from GPS, pressure and geometric altitude, and selected altitude and heading. The airplane was also equipped with a cockpit voice recorder (CVR), which recorded the accident flight and annunciations from the enhanced ground proximity warning system (EGPWS). It was not equipped with a flight data recorder (FDR) nor was it required to be.

Review of the CVR transcript showed that the pilot operated as a single pilot but verbalized his actions as he configured the airplane before departure. He referenced items from the Before Taxi checklist and included in his crew briefing that in the event of a problem after takeoff decision speed, he would handle it as an in-flight emergency and “fly the airplane, address the problem, get the autopilot on, talk on the radios, divert over to Stanford.” The air traffic controller provided initial clearance for the pilot to fly direct to the STREP intersection and to climb and maintain 3,000 ft mean sea level. Before the departure from JVY, the pilot announced on the common traffic advisory frequency that he was departing runway 36 and verbalized in the cockpit “this is three six” before he advanced the throttles.

The flight departed JVY about 1024:36 into instrument meteorological conditions. The CVR recorded the pilot state that he set power to maximum cruise thrust, switched the engine sync on, and turned on the yaw dampers. The pilot also verbalized his interaction with the autopilot, including navigation mode, direct STREP, and vertical speed climb up to 3,000 ft. According to the National Transportation Safety Board’s (NTSB) airplane performance study, the airplane climbed to about 1,400 ft msl before it turned left onto a course of 330° and continued to climb. The CVR recorded the pilot state he was turning on the autopilot at 1025:22.

At 1025:39, the pilot was cleared up to 10,000 ft and asked to “ident,” and the airplane was subsequently identified on radar. The pilot verbalized setting the autopilot for 10,000 ft and read items on the After Takeoff/Climb checklist. The performance study indicated that the airplane passed 3,000 ft about 1026, with an airspeed between 230 and 240 kts, and continued to climb steadily.

At 1026:29, while the pilot was conducting the checklist, the controller instructed him to contact the Indianapolis Air Route Traffic Control Center; the pilot acknowledged. At 1026:38, the pilot resumed the checklist and stated, “uhhh lets seeee. Pressurization pressurizing anti ice de-ice systems are not required at this time.” The performance study indicated that, at 1026:45, the airplane began to bank to the left at a rate of about 5° per second and that after the onset of the roll, the airplane maintained airspeed while it continued to climb for 12 seconds, consistent with engine power not being reduced in response to the roll onset.

At 1026:48, the CVR recorded the airplane’s autopilot disconnect annunciation, “autopilot.” The performance study indicated that about this time, the airplane was in about a 30° left bank. About 1 second later, the pilot stated, “whooooaaaaah.” Over the next 8 seconds, the airplane’s EGPWS annunciated six “bank angle” alerts. At 1026:57, the airplane reached its maximum altitude of about 6,100 ft msl and then began to descend rapidly, in excess of 11,000 ft per minute. At 1026:58, the bank angle was about 70° left wing down, and by 1027:05, the airplane was near 90° left wing down.

At 1027:04, the CVR recorded a sound similar to an overspeed warning alert, which continued to the end of the flight. The performance study indicated that about the time of the overspeed warning, the airplane passed about 250 kts calibrated airspeed at an altitude of about 5,600 ft. After the overspeed warning, the pilot shouted three expletives, and the bank angle alert sounded two more times. According to the performance study, at 1027:18, the final ADS-B data point, the airplane was about 1,000 ft msl, with the airspeed about 380 kts and in a 53° left bank. At 1027:11, the CVR recorded the pilot shouting a radio transmission, “mayday mayday mayday citation five two five echo golf is in an emergency descent unable to gain control of the aircraft.” At 1027:16, the CVR recorded the EGPWS annunciating “terrain terrain.” The sound of impact was recorded about 1027:20. The total time from the beginning of the left roll until ground impact was about 35 seconds.

The accident site was located about 8.5 miles northwest of JVY.

Pilot Information

Certificate: Airline transport; Flight instructor 
Age: 32, Male
Airplane Rating(s): Single-engine land; Multi-engine land
Seat Occupied: Left
Other Aircraft Rating(s): None
Restraint Used: Unknown
Instrument Rating(s): Airplane
Second Pilot Present: No
Instructor Rating(s): Airplane multi-engine; Airplane single-engine; Instrument airplane
Toxicology Performed: No
Medical Certification: Class 1 Without waivers/limitations 
Last FAA Medical Exam: March 15, 2018
Occupational Pilot: Yes
Last Flight Review or Equivalent:
Flight Time: 3500 hours (Total, all aircraft)

The pilot received his single-pilot Cessna 525 type rating to his airline transport pilot certificate on February 28, 2018, after completing training at Simuflite and prior to the installation of the Tamarack Aerospace Group Active Technology Load Alleviation System (ATLAS) on the accident airplane. On his application to add the Cessna 525 type rating, the pilot reported 3,291 total hours of flight experience and 453 hours of instrument experience. On previous applications filed on February 14, 2017, and on August 29, 2016, the pilot reported the same hours. On his application for a Federal Aviation Administration (FAA) medical certificate dated March 15, 2018, the pilot reported 3,500 total hours. Logbooks for the pilot were not located, and no online logbook was discovered during the investigation. The pilot’s total hours and experience could not be verified.

Aircraft and Owner/Operator Information

Aircraft Make: Cessna 
Registration: N525EG
Model/Series: 525 A
Aircraft Category: Airplane
Year of Manufacture: 2009 
Amateur Built:
Airworthiness Certificate: Normal 
Serial Number: 525A0449
Landing Gear Type: Retractable - Tricycle
Seats: 10
Date/Type of Last Inspection: 
Certified Max Gross Wt.: 12500 lbs
Time Since Last Inspection:
Engines: 2 Turbo fan
Airframe Total Time: 3306.5 Hrs at time of accident
Engine Manufacturer: Williams International
ELT: C126 installed, not activated 
Engine Model/Series: FJ44-3A-24
Registered Owner: 
Rated Power: 2490 Lbs thrust
Operator: 
Operating Certificate(s) Held: None

Autopilot

The airplane was equipped with an autopilot system. The pilot can disengage the autopilot, and the autopilot can also disengage during abnormal situations. Abnormal disconnects can occur if the stick shaker activates, there is a yaw damper or internal autopilot failure (such as an excessive autopilot roll rate of 10°/second into a bank), there is an attitude heading reference system failure or miscompare, there is a loss of power to the normal (main) DC buses, or excessive attitudes are reached (25° nose up, 15° nose down, or 45° left or right wing down).

EGPWS

The airplane was equipped with a Honeywell Mark VIII EGPWS that interfaced with various airplane systems and provided six modes of alerts for the flight crew, including advisory callouts through the cockpit audio system for “bank angle” to alert the pilot to excessive bank angles. According to the Citation Aircraft Flight Manual, the aural advisory for bank angle above 2,450 ft above ground level occurs at 55°.

Aircraft Recording System

The airplane was equipped with an aircraft recording system (AReS), which recorded aircraft system maintenance data to help with maintenance troubleshooting procedures. Data were stored on a compact flash card installed in the AReS recording unit. The unit was not required to be installed, nor was it certified to FDR regulatory standards for crashworthy data storage or required parameters.

Active Technology Load Alleviation System

Tamarack Aerospace Group designed and manufactured the ATLAS and used Cranfield Aerospace Solutions Ltd. (CAeS) to provide support for a European Union Aviation Safety Agency (EASA) supplemental type certificate (STC). On December 22, 2015, EASA approved STC 10056170, and on December 27, 2016, the FAA issued STC SA03842NY after validation of the EASA STC.

Tamarack modified the original airplane design by removing the wing tip assemblies and adding winglets and wing extensions that contain active aerodynamic surfaces. The system was designed to provide increased aerodynamic efficiency without adverse structural effects due to the winglet installation. ATLAS operates independently of all other airplane systems. The main components of ATLAS consist of two wing extensions and two winglets with an ATLAS control unit (ACU), two Tamarack active camber surfaces (TACS), two TACS control units (TCUs), an annunciator line replaceable unit (LRU), and an ATLAS INOP button.

The TACS are active aerodynamic control surfaces mounted on the wingtip extensions that either hold their position in trail with the wing or deploy symmetrically to alleviate structural loads. The TACS attach to the wing-tip extensions through two hinges and connect to the TCUs via pushrods, a bellcrank, and a walking beam. The ACU, which was mounted to the fuselage near the airplane’s center of gravity, is an analog device with no software or nonvolatile memory, , contains two accelerometers to measure acceleration along the vertical axis, and provides commands to the TCUs to actuate the TACS symmetrically as required based on varying loading conditions.

The TCU communicates with the ACU for fault monitoring and system operation. In the event of a fault being detected, the ACU signals the TCU to depower the motor. The TCUs contain electronic limits to actuator travel (soft stops) and hardware limits (hard/mechanical stops).  (These hard stops are internal to the TCU; additional hard stops are located within the bellcrank.) When power is not applied to the TCUs, the TACS are free to move with an applied force of 10 lbs or less. The ATLAS installation allows the TACS to travel 21° ±1° trailing edge up and 10° ±1° trailing edge down to mechanical stops located in the bellcrank assembly. The nominal operational travel is 20° trailing edge up and 9° trailing edge down using the electronic stops within the TCU. During normal operations, due to the electronic limits, the bellcrank should not contact the hard stops. The bellcrank contains a TCU return spring and two hard stops, one in the trailing-edge-up direction and one in the trailing-edge-down direction.

The annunciator LRU contains relays to trigger the annunciation of the ATLAS INOP button, which was installed on the main instrument panel, in the event of a system fault signal or loss of power from the ACU. The ATLAS INOP button, illuminates in the event of a fault condition and provides the flight crew with a primary means of resetting the system during a faulted condition. The illumination of the ATLAS INOP button would not result in an aural annunciation.

Logic within the system depowers the TCUs if an asymmetric deployment of the TACS is sensed. In this situation, the TACS would be able to free float and could aerodynamically move to their full deflection hard stop. Centering strips introduced several months after the accident in a service bulletin (SB) would use aerodynamic forces to move the TACS to a streamlined position (see Additional Information section).

On May 27, 2018, the accident airplane was modified via STC SA03842NY to install the ATLAS. None of the installed components for the ATLAS were capable of recording a fault history, nor were they required to do so.

Maintenance

The left TCU, manufactured on December 18, 2017, and the right TCU, manufactured on November 14, 2017, were initially installed on the airplane on May 27, 2018. Both TCUs had been returned to the manufacturer per SB CAS/SB1467, which corrected the potential for a metal fastener inside the TCU to become loose and detach and were reinstalled on the airplane on July 13, 2018.

The last maintenance performed on the airplane occurred on November 20, 2018; at that time, the airplane had a total of 3,296.7 flight hours. At the time of the accident, the ATLAS had accrued about 250 flight hours and about 193 flight hours since SB CAS/1467 was accomplished. There were no reported discrepancies concerning the flight controls, autopilot, or ATLAS before the accident.

Meteorological Information and Flight Plan

Conditions at Accident Site: Instrument (IMC) 
Condition of Light: Day
Observation Facility, Elevation: KLOU, 540 ft msl
Distance from Accident Site: 16 Nautical Miles
Observation Time: 15:53 Local
Direction from Accident Site: 155°
Lowest Cloud Condition: 
Visibility: 9 miles
Lowest Ceiling: Overcast / 800 ft AGL 
Visibility (RVR):
Wind Speed/Gusts: 4 knots / 
Turbulence Type
Forecast/Actual: None / Clear air
Wind Direction: 50° 
Turbulence Severity Forecast/Actual: N/A / Moderate
Altimeter Setting: 30 inches Hg 
Temperature/Dew Point: 12°C / 8°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Jeffersonville, IN (JVY)
Type of Flight Plan Filed: IFR
Destination: Chicago, IL (MDW) 
Type of Clearance: IFR
Departure Time: 10:25 Local
Type of Airspace:

A review of weather information for the accident flight revealed instrument flight rules conditions in the vicinity of the accident site. Sounding data revealed that conditions were conducive for light turbulence from the surface to about 2,500 ft, where the intensity increased to moderate through about 7,000 ft. Cloud coverage was present between about 1,200 ft to 10,000 ft msl.

Wreckage and Impact Information

Crew Injuries: 1 Fatal 
Aircraft Damage: Destroyed
Passenger Injuries: 2 Fatal
Aircraft Fire: On-ground
Ground Injuries: 
Aircraft Explosion: None
Total Injuries: 3 Fatal
Latitude, Longitude: 38.475276,-85.811111(est)

The debris field measured about 400 yards on an easterly heading through a wooded area. The first impact point consisted of treetops. The airplane was found fragmented in numerous pieces with the right engine being the farthest piece of wreckage. All major airplane components were accounted for at the accident site. There was evidence of a postimpact fire.

A layout reconstruction of the primary flight controls was conducted on scene. All flight control cables were broken in multiple locations, and all breaks displayed broom-strawing at the fracture points. No preimpact anomalies were noted with the flight controls.

Both engines’ full authority digital engine control units, which do not record continuous engine data, were recovered from the accident site and sent to the manufacturer for download. Data extracted from both units revealed that neither recorded any faults on the day of the accident. Each unit recorded a single data point at takeoff for the accident flight; no anomalies were recorded during the takeoff.

A portion of the EGPWS outer case was found along the wreckage path, but its internal components were not located. The AReS unit was also found along the wreckage path. The outer case of the unit was compromised, and the outer case of the compact flash card was breeched. Further examination revealed that the memory chip had separated from the compact flash card circuit board and was not located.

ATLAS Components

The ACU was found detached from its mounting location in the wing root fairing. The unit case showed signs of crush damage consistent with impact. The ACU cover screws were not present, and removal of the cover revealed multiple loose electrical components in the unit and missing components from the main circuit card. Damage to the ACU precluded any functional testing.

The ATLAS INOP button and annunciator LRU were not located in the wreckage.

Left TACS and TCU

Portions of the left TACS were located in the recovered wreckage. The recovered control linkages exhibited failures consistent with overload. A visual examination showed a witness mark on the bellcrank, which was consistent with contact with the trailing-edge-up mechanical stop. Additional damage consistent with overdeflection in the trailing-edge-up direction was noted to the inboard hinge fitting.

The left TCU was still attached to its wing-mounted location. Due to impact forces, an outline consistent with the TCU was impressed into the wing access panel. The unit’s case did not exhibit any signs of deformation, and the top and bottom covers were secured to the unit. A computed tomography (CT) scan found five screw heads loose within the unit. The screws were part of the linear variable differential transformer and motor cover assemblies, and the screw head damage was consistent with shearing due to the deformation of the actuator housing. In addition, the CT scan found 6 pins bent near the end of the 40-pin connector in the unit. The six bent pins corresponded with the following:

• 29 – Ground
• 31 – Ground
• 33 – Servo Enable
• 35 – Servo Command
• 37 – Servo Fault
• 39 – Position Output

Of the six bent pins, electrical continuity testing showed open connections between 33 – Servo Enable and the board and 35 – Servo Command and the board. As of August 10, 2021, the manufacturer had inspected 30% of the in-service TCUs and had not found any bent pins like those found in the accident unit.

The ram tube was bent and could not be removed using normal disassembly procedures without applying excessive force. There were visible markings on the retract hard stop consistent with acceptance testing, but no marks were visible that were consistent with a high-force impact. Examination of the extend hard stop found witness marks consistent with a high-energy impact.

A set of witness marks was found on the upper ram guide housing, consistent with contact from the ball screw nut that positions the TACS, in an area consistent with an intermediate extension position (left TACS trailing edge up). Another set of witness marks corresponded with a full extension position of the actuator. Additional marks were observed on the bottom ram guide housing, which would not normally be in contact with the ball nut. Due to damage, functional testing could not be performed.

Right TACS and TCU

Portions of the right TACS were located in the recovered wreckage. The recovered control linkages exhibited failures consistent with overload. A visual examination of the trailing-edge down mechanical stop revealed that the bolt/stop was deformed, and the nut and cotter pin were not located. The damage to the bolt was consistent with shear loading at the lower attachment fitting. Additional damage consistent with over-deflection in the trailing-edge-down direction was noted to the inboard hinge fitting.

The right TCU was found in the wreckage path, detached from its wing-mounted location. Its case was deformed and twisted, and the upper-case cover was found partially separated from the unit, consistent with impact damage. Internal components were found damaged. The ram tube assembly was fractured at the ball screw, and the remaining portion of the ram tube, internal to the actuator assembly, was bent. There were no discernable marks on the retract hard stop indicative of a high-force impact.

Witness marks were found on the upper ram guide housing consistent with contact from the ball screw nut. The location of the witness marks corresponded to a position of approximate mid-travel of the actuator (an intermediate extension position). An additional mark was observed on the bottom ram guide housing, which would not normally be in contact with the ball nut. There were no discernable markings on the extend hard stop plate. Due to damage, functional testing could not be performed.

Additional Information

Citation CJ2+ Operating Manual Unusual Attitude Recoveries

The Citation CJ2+ Operating Manual states that “unusual attitudes do not have to be severe to be unusual; they are simply not what you expected.” The recovery is to “recognize the attitude by looking at all three attitude indicators.” Reference airspeed, altitude, and heading changes and use the best instrument available to control the recovery. Return to wings-level flight before chasing command bars. For a “Nose High” recovery, the manual states “if needed, add power to preserve airspeed. Do not push the nose down. Relax any back pressure you may be applying. Consider using some bank to help lower the nose.”

ATLAS Emergency Procedures

According to an ATLAS supplement to the Cessna 525A flight manual, section V, ATLAS inoperative (ATLAS INOP button light on), in-flight procedures have the following warnings:

“LARGE AILERON INPUT MAY BE REQUIRED IF AN ATLAS FAILURE AT HIGH INDICATED AIRSPEED INCLUDES A TACS RUNAWAY” and “SPEED REDUCTION IS THE FIRST PRIORITY IN THESE FAILURE CONDITIONS.”

The first 5 steps of the Emergency Procedures are as follows:

1. Throttles - IDLE
2. Speed Brakes - EXTEND
3. AP/TRIM DISC Button - PUSH
4. Maintain lateral control
5. Airspeed - REDUCE TO 161 KIAS [kts indicated airspeed] OR LESS

Of note, the ATLAS INOP procedures differ with regard to power settings. On the CVR, the pilot did not mention the ATLAS INOP light, and due to impact damage, the light was not available for testing to determine whether the ATLAS INOP light illuminated.

Service Bulletins and Airworthiness Directives Related to ATLA

On April 25, 2018, CAeS/Tamarack issued SB CAS/SB1467, which required the removal and rework of the TCUs. The rework required an existing screw and split lockwasher to be removed and a new screw, split lockwasher, and flat washer to be installed. As previously noted, this SB was accomplished on the accident airplane’s TCUs.

On March 1, 2019, CAeS/Tamarack issued SB CAS/SB1475, applicable to all TACS units, in response to “three uncommanded roll events related to Tamarack ATLAS failures.” The SB stated the following:

The aerodynamic over balance of the Tamarack Active Camber Surface (TACS) is a primary contribution in all three [events] since the TACS will stay deployed if power is removed from the TACS CONTROL UNIT (TCU) while the TACS are deployed; or in unique aerodynamic conditions the TACS will aerodynamically deploy if the TCU is unpowered.

According to Tamarack’s website (https://tamarackaero.com/EASA-EAD-Resolution, accessed Dec. 21, 2020), CAS/SB1475: consists of centering strips attached to the upper and lower trailing edge of the… TACS. In the unlikely event of a system fault, the centering strips aerodynamically force the TACS back to their faired position, reducing the impact of the fault.

The SB was released after this accident occurred; thus, the accident airplane was not equipped with these centering strips.

On April 19, 2019, as an interim action, EASA issued Emergency Airworthiness Directive (EAD) 2019-0086-E due to reported occurrences of the ATLAS system experiencing malfunctions resulting in upset events; in some cases, the pilots had difficulty recovering the aircraft. The EAD included additional preflight inspection procedures and flight envelope limitations. Compliance was required before the next flight.

On May 24, 2019, the FAA issued AD 2019-08-13, applicable to all Cessna airplanes with the ATLAS system installed. The AD prohibited operation of the airplane with the ATLAS system installed until “a modification has been incorporated in accordance with an FAA-approved method” to address the malfunctions that prompted the EASA EAD.

On July 4, 2019, CAeS/Tamarack issued SB CAS/SB1480, which required operators to verify/modify their airplanes to be in accordance with SB CAS/SB1467 and SB CAS/SB1475.Operator compliance with the SB was mandatory, “[b]efore flight with the Tamarack ATLAS winglets installed.”

On July 10, 2019, the FAA issued an alternate means of compliance for AD 2019-08-13, which, if complied with, removed the flight restrictions put in place by the FAA AD and required operators to follow the instructions in SB CAS/SB1480.

On August 9, 2019, EASA issued a revision to EAD 2019-0086-E, effective August 23, 2019, that removed the restrictions put in place by the EASA EAD if operators complied with the instructions in SB CAS/SB1480. The original STC was also revised to include the modifications outlined in CAS/SB1480.

Additional Fleet Events

A review of manufacturer and FAA records was conducted to note any uncommanded roll events in the fleet of Cessna CitationJet 525 airplanes without the ATLAS installed; for the history of the airplane, without ATLAS installed, there have not been any reported events of uncommanded rolls.

Five incidents have been reported to either EASA or the FAA through the service difficulty reporting system for airplanes with the ATLAS system installed. None of the listed events reported injuries or airframe damage. The events are summarized as follows:
February 2018: The airplane banked to the right in cruise, achieving about 30° of bank as the pilot recovered. ATLAS would not reset in the air.

August 2018: The left-seat pilot was being trained by the right-seat pilot. The right-seat pilot told the left-seat pilot to recover, and the left-seat pilot did without the right-seat pilot touching controls. The left-seat pilot reported full aileron input for recovery. The right-seat pilot reported that he “was never out of training mode.”

February 2019: The pilot reported a “violent roll” input. The passenger did not notice the event until notified on landing.

March 2019: The pilot reported a roll input he assumed was an autopilot hard over: less than 45° bank during recovery, using 1/4 to 1/3 roll input.

April 2019: The pilot reported a large roll input with 75° bank during recovery and large yoke forces. This event was investigated by the Air Accident Investigation Branch as AAIB-25698. The final report (available at https://www.gov.uk/aaib-reports/aaib-investigation-to-cessnacitation-cj1-n680kh, accessed on January 4, 2021) notes the following:

The aircraft had been modified with a system intended to enhance its performance, which included supplementary control surfaces designed to deflect symmetrically and automatically to alleviate gust loads. Shortly after takeoff, an electrical failure in this system caused one of these control surfaces to deploy separately, causing an uncommanded roll. The resulting aircraft upset caused the pilot significant surprise and difficulty in controlling the aircraft. The pilot was not aware of supplementary procedures associated with the modification. The procedures did not adequately characterise the significance of the system failure, nor address the failure in all anticipated flight conditions. Certification flight tests of the system did not reveal the severity of possible outcomes.

Flight recorders

The airplane’s CVR, an L-3/Fairchild FA2100-1020, is a solid-state CVR that records 120 minutes of digital audio. Specifically, it contains a 2-channel recording of the last 120 minutes of operation and separately contains a 4-channel recording of the last 30 minutes of operation. The CVR sustained significant structural damage; the outer case was removed, and the interior crash-protected case did not appear to have any heat or structural damage. Digital audio was successfully downloaded from the crash-survivable memory unit at the NTSB Vehicle Recorder Division, and a transcript was prepared.

Medical and Pathological Information

The Clark County Coroner's Office, Jefferson, Indiana, recovered the remains of the pilot but was unable to perform an autopsy or obtain suitable samples for toxicology testing. The coroner ruled the cause of death as blunt force trauma.

Tests and Research

Airplane Performance

The airplane performance study compared the roll rate in the accident scenario to roll rates related to a possible ATLAS malfunction. Certification failure assessment flight tests for the system found that at speeds of 240 kts, an initial bank angle of 30°, and a maximum unfavorable fuel imbalance (critical failure condition), a near full asymmetric deflection of the TACS resulted in a roll rate of greater than 20° per second, but it was recoverable. In the flight test, the pilot reacted to the full asymmetric TACS deflection within 3 seconds and was able to counteract the roll induced by the asymmetric TACS deflection.

For the accident flight, at the start of the left roll, the airplane’s airspeed was calculated to be about 240 kts with the wings approximately level. The accident roll rate of 5° per second was significantly less than the flight test data provided for a fully asymmetric TACS deflection at a critical failure initial condition. It is possible that the system was not experiencing a full asymmetric failure or that the full possible roll rate could not be induced because the airplane was not initially in the critical failure condition. The roll rate did change from negative to positive, and the roll angle did recover from 90° left wing down to 60° left wing down before impact. If an asymmetric TACS deflection caused the left roll, it is possible the pilot was able to roll the airplane back to the right but not enough to fully recover and arrest the descent. Because the airplane was not equipped with a flight recorder, control surface deflections and pilot inputs are unknown.


 
Wayne Estopinal, Sandy Johnson and Andrew Davis

















The National Transportation Safety Board traveled to the scene of this accident.

Additional Participating Entities:
Federal Aviation Administration / Flight Standards District Office; Indianapolis, Indiana
Textron Aviation; Wichita, Kansas
Williams International; Pontiac, Michigan
Tamarack Aerospace Group; Sandpoint, Idaho
Rockwell Collins; Cedar Rapids, Iowa
Lee Air; Wichita, Kansas

Investigation Docket - National Transportation Safety Board:

https://registry.faa.gov/N525EG

Location: Memphis, IN
Accident Number: CEN19FA036
Date & Time: 11/30/2018, 1028 EST
Registration: N525EG
Aircraft: Cessna 525
Injuries: 3 Fatal
Flight Conducted Under:  Part 91: General Aviation - Business 

On November 30, 2018, about 1028 eastern standard time, a Cessna 525A (Citation) airplane, N525EG, collided with trees and terrain near Memphis, Indiana. The airline transport certificated pilot and 2 passengers were fatally injured, and the airplane was destroyed. The airplane was owned and operated by EstoAir LLC under the provisions of 14 Code of Federal Regulations Part 91 as a business flight. Visual meteorological conditions prevailed for the flight which operated on an instrument flight rules flight plan. The cross-country flight departed Clark Regional Airport (JVY), Jeffersonville, Indiana, about 1025, with Chicago Mid-way Airport (MDW), Chicago, Illinois, as the intended destination.

According to preliminary information from radar data and air traffic controllers, the airplane was climbing through 6,000 ft mean sea level when it began a left turn, descended, and disappeared from radar. The pilot had previously been given a frequency change, which was acknowledge, however the pilot never reported to the next controller and no distress message was heard on either frequency. An alert notice (ALNOT) was issued for the airplane.

According to local law enforcement, residents near the accident site heard an airplane flying low followed by a loud noise. The airplane wreckage was in slightly rugged, wooded area and the debris field was oriented on a heading of east. The first impact point was identified at the tops of several trees. A large divot was located beneath and to the east of the trees and then the airplane was found fragmented in numerous pieces. The right engine was measured almost 400 from the initial impact point. All major airplane components were accounted for at the accident site. There was evidence of a post-impact fire.

The wreckage was documented on-scene and recovered to a secure facility for further examination. 

Aircraft and Owner/Operator Information

Aircraft Make: Cessna
Registration: N525EG
Model/Series: 525 A
Aircraft Category: Airplane
Amateur Built: No
Operator: Estoair Llc
Operating Certificate(s) Held: None 

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: KSDF, 488 ft msl
Observation Time: 1056 EST
Distance from Accident Site: 18 Nautical Miles
Temperature/Dew Point: 11°C / 9°C
Lowest Cloud Condition: 
Wind Speed/Gusts, Direction:  6 knots / , 50°
Lowest Ceiling: Overcast / 700 ft agl
Visibility:  6 Miles
Altimeter Setting: 29.99 inches Hg
Type of Flight Plan Filed: IFR
Departure Point: Jeffersonville, IN (JVY)
Destination: Chicago, IL (MDW)

Wreckage and Impact Information

Crew Injuries: 1 Fatal
Aircraft Damage: Destroyed
Passenger Injuries: 2 Fatal
Aircraft Fire: On-Ground
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 3 Fatal
Latitude, Longitude: 38.475278, -85.811111 (est)

Andrew Dale Davis 






For Immediate release
‍November 3, 2021

Tamarack Aerospace Group Strongly Disputes Findings of Probable Cause by the National Transportation Safety Board Concerning the 2018 Citation Jet Accident which Killed Three People Near Memphis, Indiana

(Sandpoint, Idaho) - Tamarack cites facts and evidence showing that Tamarack’s Active Winglets, installed on the CitationJet involved in the November 30, 2018, fatal accident, were fully operational and did not cause or contribute to the accident. We disagree with the National Transportation Safety Board’s (NTSB’s) Final Report today that concludes Active Winglets installed on the aircraft N525EG were the probable cause of the accident, alleging there was, “asymmetric deployment of the leftwing load alleviation system for undetermined reasons.”  The forensic evidence collected in the investigation indicates that the load alleviation system was indeed operational, and deployed symmetrically, upon impact. There are inconsistencies within the report that do not support the conclusion published by the NTSB. 

Of particular note, the NTSB Final Report acknowledges that the aircraft was rolling at 5 degrees per second when the autopilot automatically disconnected at 30 degrees of bank, not at 45 degrees as would be the case for an excessive bank condition caused by an uncommanded roll. The investigation fails to explain or address the fact that the autopilot disconnected for other reasons. 

Tamarack has fully cooperated with the NTSB during the investigation. The NTSB published a revised Factual Report on October 5, 2021, and just one month later published the Final Report, without taking into consideration facts that indicate other causes could have caused the accident, as the Active Winglet modification was fully operating. Tamarack addressed this in a recent submission, that was ignored by the NTSB. The submission can be read here:‍


The NTSB Final Report also includes information that the pilot was able to attempt some corrective action late in the flight at very high speeds, but fails to address that an Active Winglet failure would have been easier to recover at slower speeds. These inconsistencies and missing factual elements could be material clues for understanding what caused or contributed to the accident, which could ultimately help the industry prevent other similar accidents. 

Tamarack extends its deepest condolences to the families and friends of those who died in the 2018 tragic accident. That said, we believe all parties and aviation as a whole are interested in considering all the facts of the accident, resulting in an accurate probable cause finding by the NTSB that will lead to preventing future accidents involving aircraft. Tamarack intends to request the NTSB reconsider its finding, as per its own procedures. Tamarack will provide a more detailed response after further consideration of the NTSB’s recent announcement. 

Details about ActiveWinglet modification safety and aviation expert testimonials can be found on the Tamarack Website

Please direct questions to:

Scott Sobel
202-264-0200
Media@TamarackAero.com


Location: Memphis, Indiana 
Accident Number: CEN19FA036
Date & Time: November 30, 2018, 10:28 Local
Registration: N525EG
Aircraft: Cessna 525 
Aircraft Damage: Destroyed
Defining Event: Flight control sys malf/fail
Injuries: 3 Fatal
Flight Conducted Under: Part 91: General aviation - Business

On November 30, 2018, about 1028 central standard time, a Cessna 525A (Citation) airplane, N525EG, was destroyed when it was involved in an accident near Memphis, Indiana. The pilot and two passengers were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 business flight.

The cross-country flight originated from Clark Regional Airport (JVY), Jeffersonville, Indiana, and was en route to Chicago Midway International Airport (MDW), Chicago, Illinois. The airplane was equipped with automatic dependent surveillance–broadcast (ADS-B), which recorded latitude and longitude from GPS, pressure and geometric altitude, and selected altitude and heading. The airplane was also equipped with a cockpit voice recorder (CVR), which recorded the accident flight and annunciations from the enhanced ground proximity warning system (EGPWS). It was not equipped with a flight data recorder (FDR) nor was it required to be.

Review of the CVR transcript showed that the pilot operated as a single pilot but verbalized his actions as he configured the airplane before departure. He referenced items from the Before Taxi checklist and included in his crew briefing that in the event of a problem after takeoff decision speed, he would handle it as an in-flight emergency and “fly the airplane, address the problem, get the autopilot on, talk on the radios, divert over to Stanford.” The air traffic controller provided initial clearance for the pilot to fly direct to the STREP intersection and to climb and maintain 3,000 ft mean sea level. Before the departure from JVY, the pilot announced on the common traffic advisory frequency that he was departing runway 36 and verbalized in the cockpit “this is three six” before he advanced the throttles.

The flight departed JVY about 1024:36 into instrument meteorological conditions. The CVR recorded the pilot state that he set power to maximum cruise thrust, switched the engine sync on, and turned on the yaw dampers. The pilot also verbalized his interaction with the autopilot, including navigation mode, direct STREP, and vertical speed climb up to 3,000 ft. According to the National Transportation Safety Board’s (NTSB) airplane performance study, the airplane climbed to about 1,400 ft msl before it turned left onto a course of 330° and continued to climb. The CVR recorded the pilot state he was turning on the autopilot at 1025:22.

At 1025:39, the pilot was cleared up to 10,000 ft and asked to “ident,” and the airplane was subsequently identified on radar. The pilot verbalized setting the autopilot for 10,000 ft and read items on the After Takeoff/Climb checklist. The performance study indicated that the airplane passed 3,000 ft about 1026, with an airspeed between 230 and 240 kts, and continued to climb steadily.

At 1026:29, while the pilot was conducting the checklist, the controller instructed him to contact the Indianapolis Air Route Traffic Control Center; the pilot acknowledged. At 1026:38, the pilot resumed the checklist and stated, “uhhh lets seeee. Pressurization pressurizing anti ice de-ice systems are not required at this time.” The performance study indicated that, at 1026:45, the airplane began to bank to the left at a rate of about 5° per second and that after the onset of the roll, the airplane maintained airspeed while it continued to climb for 12 seconds, consistent with engine power not being reduced in response to the roll onset.

At 1026:48, the CVR recorded the airplane’s autopilot disconnect annunciation, “autopilot.” The performance study indicated that about this time, the airplane was in about a 30° left bank. About 1 second later, the pilot stated, “whooooaaaaah.” Over the next 8 seconds, the airplane’s EGPWS annunciated six “bank angle” alerts. At 1026:57, the airplane reached its maximum altitude of about 6,100 ft msl and then began to descend rapidly, in excess of 11,000 ft per minute. At 1026:58, the bank angle was about 70° left wing down, and by
1027:05, the airplane was near 90° left wing down.

At 1027:04, the CVR recorded a sound similar to an overspeed warning alert, which continued to the end of the flight. The performance study indicated that about the time of the overspeed warning, the airplane passed about 250 kts calibrated airspeed at an altitude of about 5,600 ft. After the overspeed warning, the pilot shouted three expletives, and the bank angle alert sounded two more times. According to the performance study, at 1027:18, the final ADS-B data point, the airplane was about 1,000 ft msl, with the airspeed about 380 kts and in a 53° left bank. At 1027:11, the CVR recorded the pilot shouting a radio transmission, “mayday mayday mayday citation five two five echo golf is in an emergency descent unable to gain control of the aircraft.” At 1027:16, the CVR recorded the EGPWS annunciating “terrain terrain.” The sound of impact was recorded about 1027:20. The total time from the beginning of the left roll until ground impact was about 35 seconds.

The accident site was located about 8.5 miles northwest of JVY.

Pilot Information

Certificate: Airline transport; Flight instructor
Age: 32, Male
Airplane Rating(s): Single-engine land; Multi-engine land
Seat Occupied: Left
Other Aircraft Rating(s): Non
e Restraint Used: Unknown
Instrument Rating(s): Airplane 
Second Pilot Present: No
Instructor Rating(s): Airplane multi-engine; Airplane single-engine; Instrument airplane
Toxicology Performed: No
Medical Certification: Class 1 Without waivers/limitations
Last FAA Medical Exam: March 15, 2018
Occupational Pilot: Yes 
Last Flight Review or Equivalent:
Flight Time: 3500 hours (Total, all aircraft)

The pilot received his single-pilot Cessna 525 type rating to his airline transport pilot certificate on February 28, 2018, after completing training at Simuflite and prior to the installation of the Tamarack Aerospace Group Active Technology Load Alleviation System (ATLAS) on the accident airplane. On his application to add the Cessna 525 type rating, the pilot reported 3,291 total hours of flight experience and 453 hours of instrument experience. On previous applications filed on February 14, 2017, and on August 29, 2016, the pilot reported the same hours. On his application for a Federal Aviation Administration (FAA) medical certificate dated March 15, 2018, the pilot reported 3,500 total hours. Logbooks for the pilot were not located, and no online logbook was discovered during the investigation. The pilot’s total hours and experience could not be verified.

Aircraft and Owner/Operator Information

Aircraft Make: Cessna 
Registration: N525EG
Model/Series: 525 A 
Aircraft Category: Airplane
Year of Manufacture: 2009 
Amateur Built:
Airworthiness Certificate: Normal 
Serial Number: 525A0449
Landing Gear Type: Retractable - Tricycle
Seats: 10
Date/Type of Last Inspection: Certified 
Max Gross Wt.: 12500 lbs
Time Since Last Inspection: 
Engines: 2 Turbo fan
Airframe Total Time: 3306.5 Hrs at time of accident
Engine Manufacturer: Williams International
ELT: C126 installed, not activated 
Engine Model/Series: FJ44-3A-24
Registered Owner: 
Rated Power: 2490 Lbs thrust
Operator: 
Operating Certificate(s) Held: None

Autopilot

The airplane was equipped with an autopilot system. The pilot can disengage the autopilot, and the autopilot can also disengage during abnormal situations. Abnormal disconnects can occur if the stick shaker activates, there is a yaw damper or internal autopilot failure (such as an excessive autopilot roll rate of 10°/second into a bank), there is an attitude heading reference system failure or miscompare, there is a loss of power to the normal (main) DC buses, or excessive attitudes are reached (25° nose up, 15° nose down, or 45° left or right wing down).

EGPWS

The airplane was equipped with a Honeywell Mark VIII EGPWS that interfaced with various airplane systems and provided six modes of alerts for the flight crew, including advisory callouts through the cockpit audio system for “bank angle” to alert the pilot to excessive bank angles. According to the Citation Aircraft Flight Manual, the aural advisory for bank angle above 2,450 ft above ground level occurs at 55°.

Aircraft Recording System

The airplane was equipped with an aircraft recording system (AReS), which recorded aircraft system maintenance data to help with maintenance troubleshooting procedures. Data were stored on a compact flash card installed in the AReS recording unit. The unit was not required to be installed, nor was it certified to FDR regulatory standards for crashworthy data storage or required parameters.

Active Technology Load Alleviation System

Tamarack Aerospace Group designed and manufactured the ATLAS and used Cranfield Aerospace Solutions Ltd. (CAeS) to provide support for a European Union Aviation Safety Agency (EASA) supplemental type certificate (STC). On December 22, 2015, EASA approved STC 10056170, and on December 27, 2016, the FAA issued STC SA03842NY after validation of the EASA STC.

Tamarack modified the original airplane design by removing the wing tip assemblies and adding winglets and wing extensions that contain active aerodynamic surfaces. The system was designed to provide increased aerodynamic efficiency without adverse structural effects due to the winglet installation. ATLAS operates independently of all other airplane systems. The main components of ATLAS consist of two wing extensions and two winglets with an ATLAS control unit (ACU), two Tamarack active camber surfaces (TACS), two TACS control units (TCUs), an annunciator line replaceable unit (LRU), and an ATLAS INOP button.

The TACS are active aerodynamic control surfaces mounted on the wingtip extensions that either hold their position in trail with the wing or deploy symmetrically to alleviate structural loads. The TACS attach to the wing-tip extensions through two hinges and connect to the TCUs via pushrods, a bellcrank, and a walking beam. The ACU, which was mounted to the fuselage near the airplane’s center of gravity, is an analog device with no software or nonvolatile memory, , contains two accelerometers to measure acceleration along the vertical axis, and provides commands to the TCUs to actuate the TACS symmetrically as required based on varying loading conditions.

The TCU communicates with the ACU for fault monitoring and system operation. In the event of a fault being detected, the ACU signals the TCU to depower the motor. The TCUs contain electronic limits to actuator travel (soft stops) and hardware limits (hard/mechanical stops). (These hard stops are internal to the TCU; additional hard stops are located within the bellcrank.) When power is not applied to the TCUs, the TACS are free to move with an applied force of 10 lbs or less. The ATLAS installation allows the TACS to travel 21° ±1° trailing edge up and 10° ±1° trailing edge down to mechanical stops located in the bellcrank assembly. The nominal operational travel is 20° trailing edge up and 9° trailing edge down using the electronic stops within the TCU. During normal operations, due to the electronic limits, the bellcrank should not contact the hard stops. The bellcrank contains a TCU return spring and two hard stops, one in the trailing-edge-up direction and one in the trailing-edge-down direction.

The annunciator LRU contains relays to trigger the annunciation of the ATLAS INOP button, which was installed on the main instrument panel, in the event of a system fault signal or loss of power from the ACU. The ATLAS INOP button, illuminates in the event of a fault condition and provides the flight crew with a primary means of resetting the system during a faulted condition. The illumination of the ATLAS INOP button would not result in an aural annunciation.

Logic within the system depowers the TCUs if an asymmetric deployment of the TACS is sensed. In this situation, the TACS would be able to free float and could aerodynamically move to their full deflection hard stop. Centering strips introduced several months after the accident in a service bulletin (SB) would use aerodynamic forces to move the TACS to a streamlined position (see Additional Information section).

On May 27, 2018, the accident airplane was modified via STC SA03842NY to install the ATLAS. None of the installed components for the ATLAS were capable of recording a fault history, nor were they required to do so. 

Maintenance

The left TCU, manufactured on December 18, 2017, and the right TCU, manufactured on November 14, 2017, were initially installed on the airplane on May 27, 2018. Both TCUs had been returned to the manufacturer per SB CAS/SB1467, which corrected the potential for a metal fastener inside the TCU to become loose and detach and were reinstalled on the airplane on July 13, 2018.

The last maintenance performed on the airplane occurred on November 20, 2018; at that time, the airplane had a total of 3,296.7 flight hours. At the time of the accident, the ATLAS had accrued about 250 flight hours and about 193 flight hours since SB CAS/1467 was accomplished. There were no reported discrepancies concerning the flight controls, autopilot, or ATLAS before the accident.

Meteorological Information and Flight Plan

Conditions at Accident Site: Instrument (IMC)
Condition of Light: Day
Observation Facility, Elevation: KLOU,540 ft msl 
Distance from Accident Site: 16 Nautical Miles
Observation Time: 15:53 Local
Direction from Accident Site: 155°
Lowest Cloud Condition: 
Visibility: 9 miles
Lowest Ceiling: Overcast / 800 ft AGL
Visibility (RVR):
Wind Speed/Gusts: 4 knots / 
Turbulence Type Forecast/Actual: None / Clear air
Wind Direction: 50° 
Turbulence Severity Forecast/Actual: N/A / Moderate
Altimeter Setting: 30 inches Hg 
Temperature/Dew Point: 12°C / 8°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Jeffersonville, IN (JVY)
Type of Flight Plan Filed: IFR
Destination: Chicago, IL (MDW)
Type of Clearance: IFR
Departure Time: 10:25 Local 
Type of Airspace:

A review of weather information for the accident flight revealed instrument flight rules conditions in the vicinity of the accident site. Sounding data revealed that conditions were conducive for light turbulence from the surface to about 2,500 ft, where the intensity increased to moderate through about 7,000 ft. Cloud coverage was present between about 1,200 ft to 10,000 ft msl.

Wreckage and Impact Information

Crew Injuries: 1 Fatal
Aircraft Damage: Destroyed
Passenger Injuries: 2 Fatal 
Aircraft Fire: On-ground
Ground Injuries: 
Aircraft Explosion: None
Total Injuries: 3 Fatal
Latitude, Longitude: 38.475276,-85.811111(est)

The debris field measured about 400 yards on an easterly heading through a wooded area. The first impact point consisted of treetops. The airplane was found fragmented in numerous pieces with the right engine being the farthest piece of wreckage. All major airplane components were accounted for at the accident site. There was evidence of a postimpact fire.

A layout reconstruction of the primary flight controls was conducted on scene. All flight control cables were broken in multiple locations, and all breaks displayed broomstrawing at the fracture points. No preimpact anomalies were noted with the flight controls.

Both engines’ full authority digital engine control units, which do not record continuous engine data, were recovered from the accident site and sent to the manufacturer for download. Data extracted from both units revealed that neither recorded any faults on the day of the accident. Each unit recorded a single data point at takeoff for the accident flight; no anomalies were recorded during the takeoff.

A portion of the EGPWS outer case was found along the wreckage path, but its internal components were not located. The AReS unit was also found along the wreckage path. The outer case of the unit was compromised, and the outer case of the compact flash card was breeched. Further examination revealed that the memory chip had separated from the compact flash card circuit board and was not located.

ATLAS Components

The ACU was found detached from its mounting location in the wing root fairing. The unit case showed signs of crush damage consistent with impact. The ACU cover screws were not present, and removal of the cover revealed multiple loose electrical components in the unit and missing components from the main circuit card. Damage to the ACU precluded any functional testing.

The ATLAS INOP button and annunciator LRU were not located in the wreckage.

Left TACS and TCU

Portions of the left TACS were located in the recovered wreckage. The recovered control linkages exhibited failures consistent with overload. A visual examination showed a witness mark on the bellcrank, which was consistent with contact with the trailing-edge-up mechanical stop. Additional damage consistent with overdeflection in the trailing-edge-up direction was noted to the inboard hinge fitting.

The left TCU was still attached to its wing-mounted location. Due to impact forces, an outline consistent with the TCU was impressed into the wing access panel. The unit’s case did not exhibit any signs of deformation, and the top and bottom covers were secured to the unit. A computed tomography (CT) scan found five screw heads loose within the unit. The screws were part of the linear variable differential transformer and motor cover assemblies, and the screw head damage was consistent with shearing due to the deformation of the actuator housing. In addition, the CT scan found 6 pins bent near the end of the 40-pin connector in the unit. The six bent pins corresponded with the following:

• 29 – Ground
• 31 – Ground
• 33 – Servo Enable
• 35 – Servo Command
• 37 – Servo Fault
• 39 – Position Output

Of the six bent pins, electrical continuity testing showed open connections between 33 – Servo Enable and the board and 35 – Servo Command and the board. As of August 10, 2021, the manufacturer had inspected 30% of the in-service TCUs and had not found any bent pins like those found in the accident unit.

The ram tube was bent and could not be removed using normal disassembly procedures without applying excessive force. There were visible markings on the retract hard stop consistent with acceptance testing, but no marks were visible that were consistent with a highforce impact. Examination of the extend hard stop found witness marks consistent with a highenergy impact.

A set of witness marks was found on the upper ram guide housing, consistent with contact from the ball screw nut that positions the TACS, in an area consistent with an intermediate extension position (left TACS trailing edge up). Another set of witness marks corresponded with a full extension position of the actuator. Additional marks were observed on the bottom ram guide housing, which would not normally be in contact with the ball nut. Due to damage, functional testing could not be performed.

Right TACS and TCU

Portions of the right TACS were located in the recovered wreckage. The recovered control linkages exhibited failures consistent with overload. A visual examination of the trailing-edgedown mechanical stop revealed that the bolt/stop was deformed, and the nut and cotter pin were not located. The damage to the bolt was consistent with shear loading at the lower attachment fitting. Additional damage consistent with overdeflection in the trailing-edge-down direction was noted to the inboard hinge fitting.

The right TCU was found in the wreckage path, detached from its wing-mounted location. Its case was deformed and twisted, and the upper-case cover was found partially separated from the unit, consistent with impact damage. Internal components were found damaged. The ram tube assembly was fractured at the ball screw, and the remaining portion of the ram tube, internal to the actuator assembly, was bent. There were no discernable marks on the retract hard stop indicative of a high-force impact.

Witness marks were found on the upper ram guide housing consistent with contact from the ball screw nut. The location of the witness marks corresponded to a position of approximate midtravel of the actuator (an intermediate extension position). An additional mark was observed on the bottom ram guide housing, which would not normally be in contact with the ball nut. There were no discernable markings on the extend hard stop plate. Due to damage, functional testing could not be performed.

Additional Information

Citation CJ2+ Operating Manual Unusual Attitude Recoveries

The Citation CJ2+ Operating Manual states that “unusual attitudes do not have to be severe to be unusual; they are simply not what you expected.” The recovery is to “recognize the attitude by looking at all three attitude indicators.” Reference airspeed, altitude, and heading changes and use the best instrument available to control the recovery. Return to wings-level flight before chasing command bars. For a “Nose High” recovery, the manual states “if needed, add power to preserve airspeed. Do not push the nose down. Relax any back pressure you may be applying. Consider using some bank to help lower the nose.”

ATLAS Emergency Procedures

According to an ATLAS supplement to the Cessna 525A flight manual, section V, ATLAS

inoperative (ATLAS INOP button light on), in-flight procedures have the following warnings:
“LARGE AILERON INPUT MAY BE REQUIRED IF AN ATLAS FAILURE AT HIGH INDICATED AIRSPEED INCLUDES A TACS RUNAWAY” and “SPEED REDUCTION IS THE FIRST PRIORITY IN THESE FAILURE CONDITIONS.”

The first 5 steps of the Emergency Procedures are as follows:

1. Throttles - IDLE
2. Speed Brakes - EXTEND
3. AP/TRIM DISC Button - PUSH
4. Maintain lateral control
5. Airspeed - REDUCE TO 161 KIAS [kts indicated airspeed] OR LESS

Of note, the ATLAS INOP procedures differ with regard to power settings. On the CVR, the pilot did not mention the ATLAS INOP light, and due to impact damage, the light was not available for testing to determine whether the ATLAS INOP light illuminated.

Service Bulletins and Airworthiness Directives Related to ATLAS 

On April 25, 2018, CAeS/Tamarack issued SB CAS/SB1467, which required the removal and rework of the TCUs. The rework required an existing screw and split lockwasher to be removed and a new screw, split lockwasher, and flat washer to be installed. As previously noted, this SB was accomplished on the accident airplane’s TCUs.

On March 1, 2019, CAeS/Tamarack issued SB CAS/SB1475, applicable to all TACS units, in response to “three uncommanded roll events related to Tamarack ATLAS failures.” The SB stated the following:

The aerodynamic over balance of the Tamarack Active Camber Surface (TACS) is a primary contribution in all three [events] since the TACS will stay deployed if power is removed from the TACS CONTROL UNIT (TCU) while the TACS are deployed; or in unique aerodynamic conditions the TACS will aerodynamically deploy if the TCU is unpowered.

According to Tamarack’s website (https://tamarackaero.com/EASA-EAD-Resolution, accessed Dec. 21, 2020), CAS/SB1475:

consists of centering strips attached to the upper and lower trailing edge of the … TACS. In the unlikely event of a system fault, the centering strips aerodynamically force the TACS back to their faired position, reducing the impact of the fault.

The SB was released after this accident occurred; thus, the accident airplane was not equipped with these centering strips.

On April 19, 2019, as an interim action, EASA issued Emergency Airworthiness Directive (EAD) 2019-0086-E due to reported occurrences of the ATLAS system experiencing malfunctions resulting in upset events; in some cases, the pilots had difficulty recovering the aircraft. The EAD included additional preflight inspection procedures and flight envelope limitations. Compliance was required before the next flight.

On May 24, 2019, the FAA issued AD 2019-08-13, applicable to all Cessna airplanes with the ATLAS system installed. The AD prohibited operation of the airplane with the ATLAS system installed until “a modification has been incorporated in accordance with an FAA-approved method” to address the malfunctions that prompted the EASA EAD.

On July 4, 2019, CAeS/Tamarack issued SB CAS/SB1480, which required operators to verify/modify their airplanes to be in accordance with SB CAS/SB1467 and SB CAS/SB1475. Operator compliance with the SB was mandatory, “[b]efore flight with the Tamarack ATLAS
winglets installed.” 

On July 10, 2019, the FAA issued an alternate means of compliance for AD 2019-08-13, which, if complied with, removed the flight restrictions put in place by the FAA AD and required operators to follow the instructions in SB CAS/SB1480.

On August 9, 2019, EASA issued a revision to EAD 2019-0086-E, effective August 23, 2019, that removed the restrictions put in place by the EASA EAD if operators complied with the instructions in SB CAS/SB1480. The original STC was also revised to include the modifications outlined in CAS/SB1480.

Additional Fleet Events

A review of manufacturer and FAA records was conducted to note any uncommanded roll events in the fleet of Cessna CitationJet 525 airplanes without the ATLAS installed; for the history of the airplane, without ATLAS installed, there have not been any reported events of uncommanded rolls.

Five incidents have been reported to either EASA or the FAA through the service difficulty reporting system for airplanes with the ATLAS system installed. None of the listed events reported injuries or airframe damage. The events are summarized as follows:

February 2018: The airplane banked to the right in cruise, achieving about 30° of bank as the pilot recovered. ATLAS would not reset in the air.

August 2018: The left-seat pilot was being trained by the right-seat pilot. The right-seat pilot told the left-seat pilot to recover, and the left-seat pilot did without the right-seat pilot touching controls. The left-seat pilot reported full aileron input for recovery. The right-seat pilot reported that he “was never out of training mode.”

February 2019: The pilot reported a “violent roll” input. The passenger did not notice the event until notified on landing.

March 2019: The pilot reported a roll input he assumed was an autopilot hard over: less than 45° bank during recovery, using 1/4 to 1/3 roll input.

April 2019: The pilot reported a large roll input with 75° bank during recovery and large yoke forces. This event was investigated by the Air Accident Investigation Branch as AAIB-25698.

The final report (available at https://www.gov.uk/aaib-reports/aaib-investigation-to-cessnacitation-cj1-n680kh, accessed on January 4, 2021) notes the following:

The aircraft had been modified with a system intended to enhance its performance, which included supplementary control surfaces designed to deflect symmetrically and automatically to alleviate gust loads. Shortly after takeoff, an electrical failure in this system caused one of these control surfaces to deploy separately, causing an uncommanded roll.

The resulting aircraft upset caused the pilot significant surprise and difficulty in controlling the aircraft. The pilot was not aware of supplementary procedures associated with the modification. The procedures did not adequately characterise the significance of the system failure, nor address the failure in all anticipated flight conditions. Certification flight tests of the system did not reveal the severity of possible outcomes.

Flight recorders

The airplane’s CVR, an L-3/Fairchild FA2100-1020, is a solid-state CVR that records 120 minutes of digital audio. Specifically, it contains a 2-channel recording of the last 120 minutes of operation and separately contains a 4-channel recording of the last 30 minutes of operation. The CVR sustained significant structural damage; the outer case was removed, and the interior crash-protected case did not appear to have any heat or structural damage. Digital audio was successfully downloaded from the crash-survivable memory unit at the NTSB Vehicle Recorder Division, and a transcript was prepared.

Medical and Pathological Information

The Clark County Coroner's Office, Jefferson, Indiana, recovered the remains of the pilot but was unable to perform an autopsy or obtain suitable samples for toxicology testing. The coroner ruled the cause of death as blunt force trauma.

Tests and Research

Airplane Performance

The airplane performance study compared the roll rate in the accident scenario to roll rates related to a possible ATLAS malfunction. Certification failure assessment flight tests for the system found that at speeds of 240 kts, an initial bank angle of 30°, and a maximum unfavorable fuel imbalance (critical failure condition), a near full asymmetric deflection of the TACS resulted in a roll rate of greater than 20° per second, but it was recoverable. In the flight test, the pilot reacted to the full asymmetric TACS deflection within 3 seconds and was able to counteract the roll induced by the asymmetric TACS deflection.

For the accident flight, at the start of the left roll, the airplane’s airspeed was calculated to be about 240 kts with the wings approximately level. The accident roll rate of 5° per second was significantly less than the flight test data provided for a fully asymmetric TACS deflection at a critical failure initial condition. It is possible that the system was not experiencing a full asymmetric failure or that the full possible roll rate could not be induced because the airplane was not initially in the critical failure condition. The roll rate did change from negative to positive, and the roll angle did recover from 90° left wing down to 60° left wing down before impact. If an asymmetric TACS deflection caused the left roll, it is possible the pilot was able to roll the airplane back to the right but not enough to fully recover and arrest the descent.  Because the airplane was not equipped with a flight recorder, control surface deflections and pilot inputs are unknown.

The National Transportation Safety Board traveled to the scene of this accident.

Additional Participating Entities:
Federal Aviation Administration / Flight Standards District Office; Indianapolis, Indiana
Textron Aviation; Wichita, Kansas
Williams International; Pontiac, Michigan
Tamarack Aerospace Group; Sandpoint, Idaho
Rockwell Collins; Cedar Rapids, Iowa
Lee Air; Wichita, Kansas

Investigation Docket - National Transportation Safety Board:


Location: Memphis, Indiana 
Accident Number: CEN19FA036
Date & Time: November 30, 2018, 10:28 Local
Registration: N525EG
Aircraft: Cessna 525 
Aircraft Damage: Destroyed
Defining Event: Flight control sys malf/fail
Injuries: 3 Fatal
Flight Conducted Under: Part 91: General aviation - Business

On November 30, 2018, about 1028 central standard time, a Cessna 525A (Citation) airplane, N525EG, was destroyed when it was involved in an accident near Memphis, Indiana. The pilot and two passengers were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 business flight.

The cross-country flight originated from Clark Regional Airport (JVY), Jeffersonville, Indiana, and was en route to Chicago Midway International Airport (MDW), Chicago, Illinois. The airplane was equipped with automatic dependent surveillance–broadcast (ADS-B), which recorded latitude and longitude from GPS, pressure and geometric altitude, and selected altitude and heading. The airplane was also equipped with a cockpit voice recorder (CVR), which recorded the accident flight and annunciations from the enhanced ground proximity warning system (EGPWS). It was not equipped with a flight data recorder (FDR) nor was it required to be.

Review of the CVR transcript showed that the pilot operated as a single pilot but verbalized his actions as he configured the airplane before departure. He referenced items from the Before Taxi checklist and included in his crew briefing that in the event of a problem after takeoff decision speed, he would handle it as an in-flight emergency and “fly the airplane, address the problem, get the autopilot on, talk on the radios, divert over to Stanford.” The air traffic controller provided initial clearance for the pilot to fly direct to the STREP intersection and to climb and maintain 3,000 ft mean sea level. Before the departure from JVY, the pilot announced on the common traffic advisory frequency that he was departing runway 36 and verbalized in the cockpit “this is three six” before he advanced the throttles.

The flight departed JVY about 1024:36 into instrument meteorological conditions. The CVR recorded the pilot state that he set power to maximum cruise thrust, switched the engine sync on, and turned on the yaw dampers. The pilot also verbalized his interaction with the autopilot, including navigation mode, direct STREP, and vertical speed climb up to 3,000 ft. According to the National Transportation Safety Board’s (NTSB) airplane performance study, the airplane climbed to about 1,400 ft msl before it turned left onto a course of 330° and continued to climb. The CVR recorded the pilot state he was turning on the autopilot at 1025:22.

At 1025:39, the pilot was cleared up to 10,000 ft and asked to “ident,” and the airplane was subsequently identified on radar. The pilot verbalized setting the autopilot for 10,000 ft and read items on the After Takeoff/Climb checklist. The performance study indicated that the airplane passed 3,000 ft about 1026, with an airspeed between 230 and 240 kts, and continued to climb steadily.

At 1026:29, while the pilot was conducting the checklist, the controller instructed him to contact the Indianapolis Air Route Traffic Control Center; the pilot acknowledged. At 1026:38, the pilot resumed the checklist and stated, “uhhh lets seeee. Pressurization pressurizing anti ice de-ice systems are not required at this time.” The performance study indicated that, at 1026:45, the airplane began to bank to the left at a rate of about 5° per second and that after the onset of the roll, the airplane maintained airspeed while it continued to climb for 12 seconds, consistent with engine power not being reduced in response to the roll onset.

At 1026:48, the CVR recorded the airplane’s autopilot disconnect annunciation, “autopilot.” The performance study indicated that about this time, the airplane was in about a 30° left bank. About 1 second later, the pilot stated, “whooooaaaaah.” Over the next 8 seconds, the airplane’s EGPWS annunciated six “bank angle” alerts. At 1026:57, the airplane reached its maximum altitude of about 6,100 ft msl and then began to descend rapidly, in excess of 11,000 ft per minute. At 1026:58, the bank angle was about 70° left wing down, and by
1027:05, the airplane was near 90° left wing down.

At 1027:04, the CVR recorded a sound similar to an overspeed warning alert, which continued to the end of the flight. The performance study indicated that about the time of the overspeed warning, the airplane passed about 250 kts calibrated airspeed at an altitude of about 5,600 ft. After the overspeed warning, the pilot shouted three expletives, and the bank angle alert sounded two more times. According to the performance study, at 1027:18, the final ADS-B data point, the airplane was about 1,000 ft msl, with the airspeed about 380 kts and in a 53° left bank. At 1027:11, the CVR recorded the pilot shouting a radio transmission, “mayday mayday mayday citation five two five echo golf is in an emergency descent unable to gain control of the aircraft.” At 1027:16, the CVR recorded the EGPWS annunciating “terrain terrain.” The sound of impact was recorded about 1027:20. The total time from the beginning of the left roll until ground impact was about 35 seconds.

The accident site was located about 8.5 miles northwest of JVY.

Pilot Information

Certificate: Airline transport; Flight instructor
Age: 32, Male
Airplane Rating(s): Single-engine land; Multi-engine land
Seat Occupied: Left
Other Aircraft Rating(s): Non
e Restraint Used: Unknown
Instrument Rating(s): Airplane 
Second Pilot Present: No
Instructor Rating(s): Airplane multi-engine; Airplane single-engine; Instrument airplane
Toxicology Performed: No
Medical Certification: Class 1 Without waivers/limitations
Last FAA Medical Exam: March 15, 2018
Occupational Pilot: Yes 
Last Flight Review or Equivalent:
Flight Time: 3500 hours (Total, all aircraft)

The pilot received his single-pilot Cessna 525 type rating to his airline transport pilot certificate on February 28, 2018, after completing training at Simuflite and prior to the installation of the Tamarack Aerospace Group Active Technology Load Alleviation System (ATLAS) on the accident airplane. On his application to add the Cessna 525 type rating, the pilot reported 3,291 total hours of flight experience and 453 hours of instrument experience. On previous applications filed on February 14, 2017, and on August 29, 2016, the pilot reported the same hours. On his application for a Federal Aviation Administration (FAA) medical certificate dated March 15, 2018, the pilot reported 3,500 total hours. Logbooks for the pilot were not located, and no online logbook was discovered during the investigation. The pilot’s total hours and experience could not be verified.

Aircraft and Owner/Operator Information

Aircraft Make: Cessna 
Registration: N525EG
Model/Series: 525 A 
Aircraft Category: Airplane
Year of Manufacture: 2009 
Amateur Built:
Airworthiness Certificate: Normal 
Serial Number: 525A0449
Landing Gear Type: Retractable - Tricycle
Seats: 10
Date/Type of Last Inspection: Certified 
Max Gross Wt.: 12500 lbs
Time Since Last Inspection: 
Engines: 2 Turbo fan
Airframe Total Time: 3306.5 Hrs at time of accident
Engine Manufacturer: Williams International
ELT: C126 installed, not activated 
Engine Model/Series: FJ44-3A-24
Registered Owner: 
Rated Power: 2490 Lbs thrust
Operator: 
Operating Certificate(s) Held: None

Autopilot

The airplane was equipped with an autopilot system. The pilot can disengage the autopilot, and the autopilot can also disengage during abnormal situations. Abnormal disconnects can occur if the stick shaker activates, there is a yaw damper or internal autopilot failure (such as an excessive autopilot roll rate of 10°/second into a bank), there is an attitude heading reference system failure or miscompare, there is a loss of power to the normal (main) DC buses, or excessive attitudes are reached (25° nose up, 15° nose down, or 45° left or right wing down).

EGPWS

The airplane was equipped with a Honeywell Mark VIII EGPWS that interfaced with various airplane systems and provided six modes of alerts for the flight crew, including advisory callouts through the cockpit audio system for “bank angle” to alert the pilot to excessive bank angles. According to the Citation Aircraft Flight Manual, the aural advisory for bank angle above 2,450 ft above ground level occurs at 55°.

Aircraft Recording System

The airplane was equipped with an aircraft recording system (AReS), which recorded aircraft system maintenance data to help with maintenance troubleshooting procedures. Data were stored on a compact flash card installed in the AReS recording unit. The unit was not required to be installed, nor was it certified to FDR regulatory standards for crashworthy data storage or required parameters.

Active Technology Load Alleviation System

Tamarack Aerospace Group designed and manufactured the ATLAS and used Cranfield Aerospace Solutions Ltd. (CAeS) to provide support for a European Union Aviation Safety Agency (EASA) supplemental type certificate (STC). On December 22, 2015, EASA approved STC 10056170, and on December 27, 2016, the FAA issued STC SA03842NY after validation of the EASA STC.

Tamarack modified the original airplane design by removing the wing tip assemblies and adding winglets and wing extensions that contain active aerodynamic surfaces. The system was designed to provide increased aerodynamic efficiency without adverse structural effects due to the winglet installation. ATLAS operates independently of all other airplane systems. The main components of ATLAS consist of two wing extensions and two winglets with an ATLAS control unit (ACU), two Tamarack active camber surfaces (TACS), two TACS control units (TCUs), an annunciator line replaceable unit (LRU), and an ATLAS INOP button.

The TACS are active aerodynamic control surfaces mounted on the wingtip extensions that either hold their position in trail with the wing or deploy symmetrically to alleviate structural loads. The TACS attach to the wing-tip extensions through two hinges and connect to the TCUs via pushrods, a bellcrank, and a walking beam. The ACU, which was mounted to the fuselage near the airplane’s center of gravity, is an analog device with no software or nonvolatile memory, , contains two accelerometers to measure acceleration along the vertical axis, and provides commands to the TCUs to actuate the TACS symmetrically as required based on varying loading conditions.

The TCU communicates with the ACU for fault monitoring and system operation. In the event of a fault being detected, the ACU signals the TCU to depower the motor. The TCUs contain electronic limits to actuator travel (soft stops) and hardware limits (hard/mechanical stops). (These hard stops are internal to the TCU; additional hard stops are located within the bellcrank.) When power is not applied to the TCUs, the TACS are free to move with an applied force of 10 lbs or less. The ATLAS installation allows the TACS to travel 21° ±1° trailing edge up and 10° ±1° trailing edge down to mechanical stops located in the bellcrank assembly. The nominal operational travel is 20° trailing edge up and 9° trailing edge down using the electronic stops within the TCU. During normal operations, due to the electronic limits, the bellcrank should not contact the hard stops. The bellcrank contains a TCU return spring and two hard stops, one in the trailing-edge-up direction and one in the trailing-edge-down direction.

The annunciator LRU contains relays to trigger the annunciation of the ATLAS INOP button, which was installed on the main instrument panel, in the event of a system fault signal or loss of power from the ACU. The ATLAS INOP button, illuminates in the event of a fault condition and provides the flight crew with a primary means of resetting the system during a faulted condition. The illumination of the ATLAS INOP button would not result in an aural annunciation.

Logic within the system depowers the TCUs if an asymmetric deployment of the TACS is sensed. In this situation, the TACS would be able to free float and could aerodynamically move to their full deflection hard stop. Centering strips introduced several months after the accident in a service bulletin (SB) would use aerodynamic forces to move the TACS to a streamlined position (see Additional Information section).

On May 27, 2018, the accident airplane was modified via STC SA03842NY to install the ATLAS. None of the installed components for the ATLAS were capable of recording a fault history, nor were they required to do so. 

Maintenance

The left TCU, manufactured on December 18, 2017, and the right TCU, manufactured on November 14, 2017, were initially installed on the airplane on May 27, 2018. Both TCUs had been returned to the manufacturer per SB CAS/SB1467, which corrected the potential for a metal fastener inside the TCU to become loose and detach and were reinstalled on the airplane on July 13, 2018.

The last maintenance performed on the airplane occurred on November 20, 2018; at that time, the airplane had a total of 3,296.7 flight hours. At the time of the accident, the ATLAS had accrued about 250 flight hours and about 193 flight hours since SB CAS/1467 was accomplished. There were no reported discrepancies concerning the flight controls, autopilot, or ATLAS before the accident.

Meteorological Information and Flight Plan

Conditions at Accident Site: Instrument (IMC)
Condition of Light: Day
Observation Facility, Elevation: KLOU,540 ft msl 
Distance from Accident Site: 16 Nautical Miles
Observation Time: 15:53 Local
Direction from Accident Site: 155°
Lowest Cloud Condition: 
Visibility: 9 miles
Lowest Ceiling: Overcast / 800 ft AGL
Visibility (RVR):
Wind Speed/Gusts: 4 knots / 
Turbulence Type Forecast/Actual: None / Clear air
Wind Direction: 50° 
Turbulence Severity Forecast/Actual: N/A / Moderate
Altimeter Setting: 30 inches Hg 
Temperature/Dew Point: 12°C / 8°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Jeffersonville, IN (JVY)
Type of Flight Plan Filed: IFR
Destination: Chicago, IL (MDW)
Type of Clearance: IFR
Departure Time: 10:25 Local 
Type of Airspace:

A review of weather information for the accident flight revealed instrument flight rules conditions in the vicinity of the accident site. Sounding data revealed that conditions were conducive for light turbulence from the surface to about 2,500 ft, where the intensity increased to moderate through about 7,000 ft. Cloud coverage was present between about 1,200 ft to 10,000 ft msl.

Wreckage and Impact Information

Crew Injuries: 1 Fatal
Aircraft Damage: Destroyed
Passenger Injuries: 2 Fatal 
Aircraft Fire: On-ground
Ground Injuries: 
Aircraft Explosion: None
Total Injuries: 3 Fatal
Latitude, Longitude: 38.475276,-85.811111(est)

The debris field measured about 400 yards on an easterly heading through a wooded area. The first impact point consisted of treetops. The airplane was found fragmented in numerous pieces with the right engine being the farthest piece of wreckage. All major airplane components were accounted for at the accident site. There was evidence of a postimpact fire.

A layout reconstruction of the primary flight controls was conducted on scene. All flight control cables were broken in multiple locations, and all breaks displayed broomstrawing at the fracture points. No preimpact anomalies were noted with the flight controls.

Both engines’ full authority digital engine control units, which do not record continuous engine data, were recovered from the accident site and sent to the manufacturer for download. Data extracted from both units revealed that neither recorded any faults on the day of the accident. Each unit recorded a single data point at takeoff for the accident flight; no anomalies were recorded during the takeoff.

A portion of the EGPWS outer case was found along the wreckage path, but its internal components were not located. The AReS unit was also found along the wreckage path. The outer case of the unit was compromised, and the outer case of the compact flash card was breeched. Further examination revealed that the memory chip had separated from the compact flash card circuit board and was not located.

ATLAS Components

The ACU was found detached from its mounting location in the wing root fairing. The unit case showed signs of crush damage consistent with impact. The ACU cover screws were not present, and removal of the cover revealed multiple loose electrical components in the unit and missing components from the main circuit card. Damage to the ACU precluded any functional testing.

The ATLAS INOP button and annunciator LRU were not located in the wreckage.

Left TACS and TCU

Portions of the left TACS were located in the recovered wreckage. The recovered control linkages exhibited failures consistent with overload. A visual examination showed a witness mark on the bellcrank, which was consistent with contact with the trailing-edge-up mechanical stop. Additional damage consistent with overdeflection in the trailing-edge-up direction was noted to the inboard hinge fitting.

The left TCU was still attached to its wing-mounted location. Due to impact forces, an outline consistent with the TCU was impressed into the wing access panel. The unit’s case did not exhibit any signs of deformation, and the top and bottom covers were secured to the unit. A computed tomography (CT) scan found five screw heads loose within the unit. The screws were part of the linear variable differential transformer and motor cover assemblies, and the screw head damage was consistent with shearing due to the deformation of the actuator housing. In addition, the CT scan found 6 pins bent near the end of the 40-pin connector in the unit. The six bent pins corresponded with the following:

• 29 – Ground
• 31 – Ground
• 33 – Servo Enable
• 35 – Servo Command
• 37 – Servo Fault
• 39 – Position Output

Of the six bent pins, electrical continuity testing showed open connections between 33 – Servo Enable and the board and 35 – Servo Command and the board. As of August 10, 2021, the manufacturer had inspected 30% of the in-service TCUs and had not found any bent pins like those found in the accident unit.

The ram tube was bent and could not be removed using normal disassembly procedures without applying excessive force. There were visible markings on the retract hard stop consistent with acceptance testing, but no marks were visible that were consistent with a highforce impact. Examination of the extend hard stop found witness marks consistent with a highenergy impact.

A set of witness marks was found on the upper ram guide housing, consistent with contact from the ball screw nut that positions the TACS, in an area consistent with an intermediate extension position (left TACS trailing edge up). Another set of witness marks corresponded with a full extension position of the actuator. Additional marks were observed on the bottom ram guide housing, which would not normally be in contact with the ball nut. Due to damage, functional testing could not be performed.

Right TACS and TCU

Portions of the right TACS were located in the recovered wreckage. The recovered control linkages exhibited failures consistent with overload. A visual examination of the trailing-edgedown mechanical stop revealed that the bolt/stop was deformed, and the nut and cotter pin were not located. The damage to the bolt was consistent with shear loading at the lower attachment fitting. Additional damage consistent with overdeflection in the trailing-edge-down direction was noted to the inboard hinge fitting.

The right TCU was found in the wreckage path, detached from its wing-mounted location. Its case was deformed and twisted, and the upper-case cover was found partially separated from the unit, consistent with impact damage. Internal components were found damaged. The ram tube assembly was fractured at the ball screw, and the remaining portion of the ram tube, internal to the actuator assembly, was bent. There were no discernable marks on the retract hard stop indicative of a high-force impact.

Witness marks were found on the upper ram guide housing consistent with contact from the ball screw nut. The location of the witness marks corresponded to a position of approximate midtravel of the actuator (an intermediate extension position). An additional mark was observed on the bottom ram guide housing, which would not normally be in contact with the ball nut. There were no discernable markings on the extend hard stop plate. Due to damage, functional testing could not be performed.

Additional Information

Citation CJ2+ Operating Manual Unusual Attitude Recoveries

The Citation CJ2+ Operating Manual states that “unusual attitudes do not have to be severe to be unusual; they are simply not what you expected.” The recovery is to “recognize the attitude by looking at all three attitude indicators.” Reference airspeed, altitude, and heading changes and use the best instrument available to control the recovery. Return to wings-level flight before chasing command bars. For a “Nose High” recovery, the manual states “if needed, add power to preserve airspeed. Do not push the nose down. Relax any back pressure you may be applying. Consider using some bank to help lower the nose.”

ATLAS Emergency Procedures

According to an ATLAS supplement to the Cessna 525A flight manual, section V, ATLAS

inoperative (ATLAS INOP button light on), in-flight procedures have the following warnings:
“LARGE AILERON INPUT MAY BE REQUIRED IF AN ATLAS FAILURE AT HIGH INDICATED AIRSPEED INCLUDES A TACS RUNAWAY” and “SPEED REDUCTION IS THE FIRST PRIORITY IN THESE FAILURE CONDITIONS.”

The first 5 steps of the Emergency Procedures are as follows:

1. Throttles - IDLE
2. Speed Brakes - EXTEND
3. AP/TRIM DISC Button - PUSH
4. Maintain lateral control
5. Airspeed - REDUCE TO 161 KIAS [kts indicated airspeed] OR LESS

Of note, the ATLAS INOP procedures differ with regard to power settings. On the CVR, the pilot did not mention the ATLAS INOP light, and due to impact damage, the light was not available for testing to determine whether the ATLAS INOP light illuminated.

Service Bulletins and Airworthiness Directives Related to ATLAS 

On April 25, 2018, CAeS/Tamarack issued SB CAS/SB1467, which required the removal and rework of the TCUs. The rework required an existing screw and split lockwasher to be removed and a new screw, split lockwasher, and flat washer to be installed. As previously noted, this SB was accomplished on the accident airplane’s TCUs.

On March 1, 2019, CAeS/Tamarack issued SB CAS/SB1475, applicable to all TACS units, in response to “three uncommanded roll events related to Tamarack ATLAS failures.” The SB stated the following:

The aerodynamic over balance of the Tamarack Active Camber Surface (TACS) is a primary contribution in all three [events] since the TACS will stay deployed if power is removed from the TACS CONTROL UNIT (TCU) while the TACS are deployed; or in unique aerodynamic conditions the TACS will aerodynamically deploy if the TCU is unpowered.

According to Tamarack’s website (https://tamarackaero.com/EASA-EAD-Resolution, accessed Dec. 21, 2020), CAS/SB1475:

consists of centering strips attached to the upper and lower trailing edge of the … TACS. In the unlikely event of a system fault, the centering strips aerodynamically force the TACS back to their faired position, reducing the impact of the fault.

The SB was released after this accident occurred; thus, the accident airplane was not equipped with these centering strips.

On April 19, 2019, as an interim action, EASA issued Emergency Airworthiness Directive (EAD) 2019-0086-E due to reported occurrences of the ATLAS system experiencing malfunctions resulting in upset events; in some cases, the pilots had difficulty recovering the aircraft. The EAD included additional preflight inspection procedures and flight envelope limitations. Compliance was required before the next flight.

On May 24, 2019, the FAA issued AD 2019-08-13, applicable to all Cessna airplanes with the ATLAS system installed. The AD prohibited operation of the airplane with the ATLAS system installed until “a modification has been incorporated in accordance with an FAA-approved method” to address the malfunctions that prompted the EASA EAD.

On July 4, 2019, CAeS/Tamarack issued SB CAS/SB1480, which required operators to verify/modify their airplanes to be in accordance with SB CAS/SB1467 and SB CAS/SB1475. Operator compliance with the SB was mandatory, “[b]efore flight with the Tamarack ATLAS
winglets installed.” 

On July 10, 2019, the FAA issued an alternate means of compliance for AD 2019-08-13, which, if complied with, removed the flight restrictions put in place by the FAA AD and required operators to follow the instructions in SB CAS/SB1480.

On August 9, 2019, EASA issued a revision to EAD 2019-0086-E, effective August 23, 2019, that removed the restrictions put in place by the EASA EAD if operators complied with the instructions in SB CAS/SB1480. The original STC was also revised to include the modifications outlined in CAS/SB1480.

Additional Fleet Events

A review of manufacturer and FAA records was conducted to note any uncommanded roll events in the fleet of Cessna CitationJet 525 airplanes without the ATLAS installed; for the history of the airplane, without ATLAS installed, there have not been any reported events of uncommanded rolls.

Five incidents have been reported to either EASA or the FAA through the service difficulty reporting system for airplanes with the ATLAS system installed. None of the listed events reported injuries or airframe damage. The events are summarized as follows:

February 2018: The airplane banked to the right in cruise, achieving about 30° of bank as the pilot recovered. ATLAS would not reset in the air.

August 2018: The left-seat pilot was being trained by the right-seat pilot. The right-seat pilot told the left-seat pilot to recover, and the left-seat pilot did without the right-seat pilot touching controls. The left-seat pilot reported full aileron input for recovery. The right-seat pilot reported that he “was never out of training mode.”

February 2019: The pilot reported a “violent roll” input. The passenger did not notice the event until notified on landing.

March 2019: The pilot reported a roll input he assumed was an autopilot hard over: less than 45° bank during recovery, using 1/4 to 1/3 roll input.

April 2019: The pilot reported a large roll input with 75° bank during recovery and large yoke forces. This event was investigated by the Air Accident Investigation Branch as AAIB-25698.

The final report (available at https://www.gov.uk/aaib-reports/aaib-investigation-to-cessnacitation-cj1-n680kh, accessed on January 4, 2021) notes the following:

The aircraft had been modified with a system intended to enhance its performance, which included supplementary control surfaces designed to deflect symmetrically and automatically to alleviate gust loads. Shortly after takeoff, an electrical failure in this system caused one of these control surfaces to deploy separately, causing an uncommanded roll.

The resulting aircraft upset caused the pilot significant surprise and difficulty in controlling the aircraft. The pilot was not aware of supplementary procedures associated with the modification. The procedures did not adequately characterise the significance of the system failure, nor address the failure in all anticipated flight conditions. Certification flight tests of the system did not reveal the severity of possible outcomes.

Flight recorders

The airplane’s CVR, an L-3/Fairchild FA2100-1020, is a solid-state CVR that records 120 minutes of digital audio. Specifically, it contains a 2-channel recording of the last 120 minutes of operation and separately contains a 4-channel recording of the last 30 minutes of operation. The CVR sustained significant structural damage; the outer case was removed, and the interior crash-protected case did not appear to have any heat or structural damage. Digital audio was successfully downloaded from the crash-survivable memory unit at the NTSB Vehicle Recorder Division, and a transcript was prepared.

Medical and Pathological Information

The Clark County Coroner's Office, Jefferson, Indiana, recovered the remains of the pilot but was unable to perform an autopsy or obtain suitable samples for toxicology testing. The coroner ruled the cause of death as blunt force trauma.

Tests and Research

Airplane Performance

The airplane performance study compared the roll rate in the accident scenario to roll rates related to a possible ATLAS malfunction. Certification failure assessment flight tests for the system found that at speeds of 240 kts, an initial bank angle of 30°, and a maximum unfavorable fuel imbalance (critical failure condition), a near full asymmetric deflection of the TACS resulted in a roll rate of greater than 20° per second, but it was recoverable. In the flight test, the pilot reacted to the full asymmetric TACS deflection within 3 seconds and was able to counteract the roll induced by the asymmetric TACS deflection.

For the accident flight, at the start of the left roll, the airplane’s airspeed was calculated to be about 240 kts with the wings approximately level. The accident roll rate of 5° per second was significantly less than the flight test data provided for a fully asymmetric TACS deflection at a critical failure initial condition. It is possible that the system was not experiencing a full asymmetric failure or that the full possible roll rate could not be induced because the airplane was not initially in the critical failure condition. The roll rate did change from negative to positive, and the roll angle did recover from 90° left wing down to 60° left wing down before impact. If an asymmetric TACS deflection caused the left roll, it is possible the pilot was able to roll the airplane back to the right but not enough to fully recover and arrest the descent.  Because the airplane was not equipped with a flight recorder, control surface deflections and pilot inputs are unknown.

 
Wayne Estopinal, Sandy Johnson and Andrew Davis

















The National Transportation Safety Board traveled to the scene of this accident.

Additional Participating Entities:
Federal Aviation Administration / Flight Standards District Office; Indianapolis, Indiana
Textron Aviation; Wichita, Kansas
Williams International; Pontiac, Michigan
Tamarack Aerospace Group; Sandpoint, Idaho
Rockwell Collins; Cedar Rapids, Iowa
Lee Air; Wichita, Kansas

Investigation Docket - National Transportation Safety Board:

https://registry.faa.gov/N525EG

Location: Memphis, IN
Accident Number: CEN19FA036
Date & Time: 11/30/2018, 1028 EST
Registration: N525EG
Aircraft: Cessna 525
Injuries: 3 Fatal
Flight Conducted Under:  Part 91: General Aviation - Business 

On November 30, 2018, about 1028 eastern standard time, a Cessna 525A (Citation) airplane, N525EG, collided with trees and terrain near Memphis, Indiana. The airline transport certificated pilot and 2 passengers were fatally injured, and the airplane was destroyed. The airplane was owned and operated by EstoAir LLC under the provisions of 14 Code of Federal Regulations Part 91 as a business flight. Visual meteorological conditions prevailed for the flight which operated on an instrument flight rules flight plan. The cross-country flight departed Clark Regional Airport (JVY), Jeffersonville, Indiana, about 1025, with Chicago Mid-way Airport (MDW), Chicago, Illinois, as the intended destination.

According to preliminary information from radar data and air traffic controllers, the airplane was climbing through 6,000 ft mean sea level when it began a left turn, descended, and disappeared from radar. The pilot had previously been given a frequency change, which was acknowledge, however the pilot never reported to the next controller and no distress message was heard on either frequency. An alert notice (ALNOT) was issued for the airplane.

According to local law enforcement, residents near the accident site heard an airplane flying low followed by a loud noise. The airplane wreckage was in slightly rugged, wooded area and the debris field was oriented on a heading of east. The first impact point was identified at the tops of several trees. A large divot was located beneath and to the east of the trees and then the airplane was found fragmented in numerous pieces. The right engine was measured almost 400 from the initial impact point. All major airplane components were accounted for at the accident site. There was evidence of a post-impact fire.

The wreckage was documented on-scene and recovered to a secure facility for further examination. 

Aircraft and Owner/Operator Information

Aircraft Make: Cessna
Registration: N525EG
Model/Series: 525 A
Aircraft Category: Airplane
Amateur Built: No
Operator: Estoair Llc
Operating Certificate(s) Held: None 

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: KSDF, 488 ft msl
Observation Time: 1056 EST
Distance from Accident Site: 18 Nautical Miles
Temperature/Dew Point: 11°C / 9°C
Lowest Cloud Condition: 
Wind Speed/Gusts, Direction:  6 knots / , 50°
Lowest Ceiling: Overcast / 700 ft agl
Visibility:  6 Miles
Altimeter Setting: 29.99 inches Hg
Type of Flight Plan Filed: IFR
Departure Point: Jeffersonville, IN (JVY)
Destination: Chicago, IL (MDW)

Wreckage and Impact Information

Crew Injuries: 1 Fatal
Aircraft Damage: Destroyed
Passenger Injuries: 2 Fatal
Aircraft Fire: On-Ground
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 3 Fatal
Latitude, Longitude: 38.475278, -85.811111 (est)

Andrew Dale Davis 






















The National Transportation Safety Board traveled to the scene of this accident.

Additional Participating Entities:
Federal Aviation Administration / Flight Standards District Office; Indianapolis, Indiana
Textron Aviation; Wichita, Kansas
Williams International; Pontiac, Michigan

Investigation Docket - National Transportation Safety Board:

https://registry.faa.gov/N525EG

Location: Memphis, IN
Accident Number: CEN19FA036
Date & Time: 11/30/2018, 1028 EST
Registration: N525EG
Aircraft: Cessna 525
Injuries: 3 Fatal
Flight Conducted Under:  Part 91: General Aviation - Business 

On November 30, 2018, about 1028 eastern standard time, a Cessna 525A (Citation) airplane, N525EG, collided with trees and terrain near Memphis, Indiana. The airline transport certificated pilot and 2 passengers were fatally injured, and the airplane was destroyed. The airplane was owned and operated by EstoAir LLC under the provisions of 14 Code of Federal Regulations Part 91 as a business flight. Visual meteorological conditions prevailed for the flight which operated on an instrument flight rules flight plan. The cross-country flight departed Clark Regional Airport (JVY), Jeffersonville, Indiana, about 1025, with Chicago Mid-way Airport (MDW), Chicago, Illinois, as the intended destination.

According to preliminary information from radar data and air traffic controllers, the airplane was climbing through 6,000 ft mean sea level when it began a left turn, descended, and disappeared from radar. The pilot had previously been given a frequency change, which was acknowledge, however the pilot never reported to the next controller and no distress message was heard on either frequency. An alert notice (ALNOT) was issued for the airplane.

According to local law enforcement, residents near the accident site heard an airplane flying low followed by a loud noise. The airplane wreckage was in slightly rugged, wooded area and the debris field was oriented on a heading of east. The first impact point was identified at the tops of several trees. A large divot was located beneath and to the east of the trees and then the airplane was found fragmented in numerous pieces. The right engine was measured almost 400 from the initial impact point. All major airplane components were accounted for at the accident site. There was evidence of a post-impact fire.

The wreckage was documented on-scene and recovered to a secure facility for further examination. 

Aircraft and Owner/Operator Information

Aircraft Make: Cessna
Registration: N525EG
Model/Series: 525 A
Aircraft Category: Airplane
Amateur Built: No
Operator: Estoair Llc
Operating Certificate(s) Held: None 

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: KSDF, 488 ft msl
Observation Time: 1056 EST
Distance from Accident Site: 18 Nautical Miles
Temperature/Dew Point: 11°C / 9°C
Lowest Cloud Condition: 
Wind Speed/Gusts, Direction:  6 knots / , 50°
Lowest Ceiling: Overcast / 700 ft agl
Visibility:  6 Miles
Altimeter Setting: 29.99 inches Hg
Type of Flight Plan Filed: IFR
Departure Point: Jeffersonville, IN (JVY)
Destination: Chicago, IL (MDW)

Wreckage and Impact Information

Crew Injuries: 1 Fatal
Aircraft Damage: Destroyed
Passenger Injuries: 2 Fatal
Aircraft Fire: On-Ground
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 3 Fatal
Latitude, Longitude: 38.475278, -85.811111 (est)

Andrew Dale Davis 

A Celebration of Life for Andrew Dale Davis, 32, of Jeffersonville, Indiana will be held at 11 AM on Saturday, December 8, 2018 at Northside Christian Church, 4407 Charlestown Road, New Albany, Indiana. Visitation will be held prior to the service on Saturday at the church. He passed away on Friday, November 30, 2018. Cremation was chosen and Scott Funeral Home has been entrusted with his care.

Andrew was born on January 15, 1986 in Corydon, Indiana.  He was a graduate of Graceland Christian and then received his Bachelor’s Degree from Indiana State University.  He was currently working as Chief Pilot for TEG Architects and a member of Northside Christian Church in New Albany. Andrew loved life and lived his days with anticipation and a childlike faith.  Each day was an opportunity to make memories.  He didn’t see limitations, but dreams to be pursued. 

Andrew is survived by his loving wife of 7 years, Erica Davis; two children, Jackson and Sophia Davis; his parents, Tony and Teresa Davis; a sister, Sarah Barlowe (Daniel); grandfather, Robert Davis; In-laws, Gerardo and Ana Quiroz; brother and sister-in-laws, Christian Quiroz; Gerica Davis (Chris); Vaytta Arroyo; Mailee Quiroz; three nieces, Emma Barlowe, Sadie Barlowe, Kiley Davis; and a nephew, Lincoln Davis.      

In lieu of flowers, memorial contributions can be made in care of the children’s college fund.  Envelopes will be available at the church on Saturday.  To leave a special message for the family, please visit: www.scottfuneralhome.com



Wreckage from a fatal plane crash in Southern Indiana last week began to emerge Monday as investigators continued to search for evidence.

Several massive bags filled with twisted and scorched metal were seen outside of a wooded area where the jet crashed Friday near Memphis, Indiana. Other parts, which had loose wires poking out of sharp edges of airline aluminum, were left uncovered. 

An ATV was also seen dragging an entire cart of twisted metal up a hill, the entry point to a roughly 300-yard area that investigators are examining for the wreckage. 

The crash killed the pilot, Andrew Davis, as well as architect Wayne Estopinal and marketing executive Sandra Johnson who were traveling to Chicago. Investigators are still determining what caused the Cessna Citation 525 to crash just a few minutes after taking off from Clark Regional Airport. 

It appears the jet hit the ground at a relatively high angle and relatively high speed, said Bill Waldock, professor of safety science at Embry-Riddle Aeronautical University in Prescott, Arizona. He reviewed photos from the scene and told the Courier Journal that it does not appear that it was an in-flight breakup. 

Investigators with the National Transportation Safety Board had left the scene already, said Indiana State Trooper Phil D'Angelo, who was on scene Monday. ISP spokesman Jerry Goodin did not return a request for comment left Monday afternoon.  

On Friday morning, air traffic control chatter around the time of the crash appears to show a normal takeoff for the Cessna. But a few minutes later, a Louisville air controller is heard asking the plane to call back. There was no answer. 

The plane crashed in a wooded area 16 miles north of Louisville. 

All three victims were mourned in the following days. 

On Sunday, members of Northside Christian Church in New Albany rallied around Davis' family and his wife, Erica. 

"Just the fact that they came to church after a tragedy like this shows that they know where Andrew is now," executive pastor Sam Thomas told the Courier Journal.

Johnson, 54, was a marketing executive based in TEG's Shreveport, Louisiana, office. A friend, Kasey DeLucia, said Johnson "filled the world with laughter and kindness."

Estopinal helped design the University of Louisville sports facilities and also brought the Louisville City FC soccer team to town. 

“He’s responsible for bringing something here in Louisville City FC that has become part of thousands of people’s lives,” former LouCity spokesman Jonathan Lintner said. “He had left his mark on Louisville and the region even before that, but with that team, that’s a heck of a legacy.”

Original article ➤ https://www.courier-journal.com





A funeral mass for Robert Wayne Estopinal, 63, of Jeffersonville, Indiana will be held at 11 AM on Monday, December 10, 2018 at St. Augustine Catholic Church, 315 E. Chestnut Street in Jeffersonville, with burial to follow in Walnut Ridge Cemetery.  Visitation will be held on Sunday December 9, 2018 from 11-8 PM at Scott Funeral Home, 2515 Veterans Pkwy in Jeffersonville and prior to the service on Monday from 10-11 AM at the church.  A Celebration of Wayne’s Life including live music and memories from his close friends and colleagues will be held on Sunday at 4:30 PM at Scott Funeral Home.  Wayne passed away on Friday, November 30, 2018.  

He was preceded in death by his son, Christopher Wayne Estopinal; his parents, Robert Jules Estopinal and Martha Jane Bennett Driver; grandparents, Edna Harrell Bennett and Wentworth (Buttons) Bennett; and a brother, Mark Bennett Estopinal.

Wayne is survived by his wife of 40 years, Thresa Taylor Estopinal; a daughter, Ashley Nicole Estopinal; a son, Andrew Wayne Estopinal; a brother, Steven Wentworth Driver (Linda Jackson); a niece, Kendra Bennett Driver; and a nephew, Gregory Wentworth Driver.

Read more here ➤ https://scottfuneralhome.com

Plane crash victims Wayne Estopinal, Sandy Johnson and Andrew Davis.


Andrew Dale Davis, the pilot killed in a small jet crash in Southern Indiana last week, was conscientious about safety and had a clean flight record free of any accidents or enforcement actions, according to fellow pilots and Federal Aviation Administration records.

Davis, 32, was flying two passengers Friday when the Cessna 525A crashed minutes after takeoff from Clark Regional Airport. Flight tracking site FlightAware shows it was at about 6,000 feet when it suddenly changed course and then disappeared from radar.

Davis was a corporate pilot at TEG Architects. He was flying Wayne Estopinal, 63, the head of the Jeffersonville firm and a founder of the Louisville City FC soccer team, and TEG vice president Sandra Holland Johnson, 54, of Shreveport, Louisiana. All three were killed.

Workers Monday were hauling parts of the demolished plane from a densely wooded area west of unincorporated Memphis, about 16 miles north of Louisville.

Pilots, safety experts and others have cautioned against early speculation about the cause of the crash. The National Transportation Safety Board will spend months studying the crash before determining a likely cause.

The FAA said Monday that it had no records of accidents, incidents or enforcement actions related to Davis.

Davis had been with TEG Architects since February 2018, according to the company. Before that, he had worked as a corporate pilot at Soin International and Muncie Aviation Co., according to TEG.

Davis graduated in 2008 from Indiana State University with a bachelor's degree in aerospace administration and professional aviation flight technology, the university confirmed Monday.

At TEG, Davis worked alongside Mike Vollmer, the company's other corporate pilot.

The two had previously worked together at Soin. When Davis switched to TEG, he encouraged Vollmer to join him at the Jeffersonville architectural firm. Soin did not immediately responded to questions emailed Monday afternoon.

"He was a relentless father and husband," Vollmer said of Davis. "Everything he did focused around his family and his faith."

Vollmer said Davis was easy to get along with and was always telling stories. "I used to joke with him that he wasn’t old enough to have that many stories," he said.

He said Davis was always focused on safety and procedure. "He had checklists for checklists." 

Vollmer said the Cessna 525A had recently been in for minor routine maintenance. He said he and Davis in November held a safety training "stand-down" and had invited other tenants at Clark Regional to join.

Paul Lucas, a TEG pilot from 2007 to 2014, said he flew the Cessna for more than five years, beginning when it was delivered new from the factory in 2009. He said the plane had two crew seats and seven seats for passengers.

He said the corporate jet "has a history of being a very safe, reliable aircraft."

Lucas stressed that he has been gone from the company for four years but said the plane was reliable and doesn’t remember significant problems.

Estopinal, himself a private pilot, was focused on safety, Lucas said.

"He was a hard-charging guy, but when it came to airplanes, we were in charge," Lucas said. "He got the things that sometimes as a corporate pilot are difficult to convey to your management team."

Lucas spoke reverently of Estopinal, praising his former boss for giving him an opportunity to be chief pilot at age 24.

"I swore I would never let that man and his family down," Lucas said.

Lucas said he used to fly 300 to 400 hours per year in the Cessna 525A. He said the typical flight was within about 600 miles of Clark County, although "we had the airplane all over the country, all four corners of continental U.S."

Lucas said there's a "natural human reaction to try to rationalize" what could have happened in the crash but he said he hopes people will wait to speculate and allow investigators to do their jobs.

Original article → https://www.courier-journal.com

Sandra Holland Johnson, the vice president of locally owned TEG Architects and one of three victims in Friday's tragic plane crash in Southern Indiana, was remembered as a caring friend and an energetic person with a zest for life.

Johnson, 54, was a marketing executive based in TEG's Shreveport, Louisiana, office. She was aboard the flight that also killed the pilot, 32-year-old Andrew Davis, and prominent architect Wayne Estopinal, president of the Jeffersonville, Indiana-based company and a founding member of Louisville City FC. 

The small corporate jet owned by a subsidiary company of TEG, Estoair LLC, crashed after takeoff at a Southern Indiana airport. The craft scorched a path through dense woods in western Clark County, Indiana, about 16 miles north of Louisville. 

The cause of the crash, just minutes after the Cessna Citation took off with no indications of problems from Clark Regional Airport, is still under investigation. Officials from the National Transportation Safety Board responded to the scene Friday afternoon and had worked through the night to examine the wreckage, located off Crone Road, west of unincorporated Memphis.

Johnson was a native of Shreveport and had worked for TEG since the late 1990s. Facebook accounts showed that Estopinal and Johnson traveled together previously and had taken a trip together to London last summer.

A photo posted by Estopinal from overseas dated July 4 shows the two toasting with sparkling white wine flutes on what appears to be a balcony overlooking the Thames River.

"Enjoying London! Great times! Love being here with Sandy!" Estopinal wrote in the caption. Several friends, including Jeffersonville lawyer Larry Wilder, wrote back to joke with Estopinal and to cheer the getaway.

Johnson's work centered on developing leads for the company with health care clients. The firm did several projects in Louisiana and Texas, and recently designed new Norton Cancer Center in eastern Jefferson County.

Johnson, the mother of two sons, was involved in the National Association of Women in Construction, Greater Shreveport Leadership Program, Rotary International, Rescue Mission and Food Bank of Northwest Louisiana. 

Johnson was part of a "small group of friends who enjoy running, cycling and working out," according to a profile on her in the May 2016 issue of Shreveport's City Life magazine. She was also involved in the Society of Marketing Professional Services. 

Michelle Skupin, senior director of marketing and communications at RetailMeNot in Austin, Texas, said Saturday morning that she's still trying to process the shock over Johnson's death. The two met at a Society for Marketing Professional Services conference in Denver a decade ago and became fast friends.

Johnson was "caring and beautiful inside and out," Skupin wrote in an email. "I was always impressed with her dedication to her work and her family. Sandy lived life to the fullest, and her enthusiasm and energy were infectious." 

Another friend, Kasey DeLucia, director of corporate marketing at DKS Associates in Portland, Oregon, said she hopes people remember Johnson as the "beautiful amazing and strong woman she was." 

She added: "It’s hard for me to adequately convey what an incredibly funny, kind and bright light she was to all of those lucky enough to be in her presence. I want the world to know we lost a woman that filled the world with laughter and kindness."

Original article ➤ https://www.courier-journal.com

Andrew Davis



Andrew Davis with his wife Erica and their children.


Andrew and Erica Davis

Andrew Davis
Associate – Corporate Pilot
September 2018

Andrew, a seasoned pilot, will also join the firm to provide support for the firm’s aviation needs. He obtained a B.S. in Professional Aviation Flight Technology, as well as a B.S. in Aerospace Administration from Indiana State University.  His past experience as a lead captain and corporate pilot at Soin International and Muncie Aviation Company will allow the firm to provide exceptional customer service for our clients across the nation.
http://www.teg123.com

The pilot killed in a small jet crash in Southern Indiana with two others had just started working for the architectural firm that owned the plane.

Andrew Davis, 32, was the pilot of the small plane that crashed on its way to Chicago from Clark Regional Airport. Passengers Wayne Estopinal and Sandra Holland Johnson were also killed. 

The Sellersburg resident was an associate corporate pilot at TEG Architects, a firm led by Estopinal. He joined the firm in September, according to a news release on the company's website. 

He was married and had two young children, according to a Facebook post by a friend. 

Earlier this year Andrew Davis traveled on a mission trip to Salcedo, Dominican Republic, with a group from the New Albany-based Northside Christian Church, according to a post on his Facebook page. 

Davis was part of a team of 300 people that helped build homes and host sports camps, among other activities. According to a Facebook post by his wife, his project was to help build a house in four days.  

Her Facebook page is filled with loving pictures and videos of her husband and children and odes to his support. In October, she wrote: 

"He brings balance to my life, what more could I ask for. He is a rare kind."

And in September: "I'll fly with you till the ends of the Earth."

Davis graduated from Indiana State University with a degree in professional aviation flight technology and aerospace administration. Previously, he was a lead captain and corporate pilot at Soin International and Muncie Aviation Co., according to TEG.

He was taking Estopinal — an influential local figure who helped design University of Louisville sports facilities and bring Louisville City FC to the city — and Johnson to Chicago's Midway International Airport from Clark County Regional Airport.

The plane, which was based in Clark County, never made it. Some six minutes after taking off, the plane turned back for the airport shortly before crashing near Memphis, Indiana. There were no survivors.

It still isn't clear why the plane went down. Air traffic control chatter around the time of the crash appears to show a normal takeoff for the Cessna from Clark County Regional Airport. A few minutes later, though, a Louisville air controller is heard asking the plane to call back. Only silence followed.

Original article ➤ https://www.courier-journal.com

Sandy Johnson and Wayne Estopinal

Ball State Board of Trustees member Wayne Estopinal talks with other board members during a committee meeting on Friday on Ball State's campus.

A Cessna 525A CitationJet CJ2+ crashed about 15 miles north of the Louisville International Airport Friday morning, according to the Federal Aviation Administration. Authorities said the aircraft was flying "to Chicago Midway Airport when it disappeared from air traffic radar."

Police agencies in Clark County, Indiana, were alerted to the crash near Borden, Indiana, at about 11:30 a.m. Clark County authorities confirmed that a flight left the Clark County Airport in Sellersburg, Indiana, at about 11:24 a.m. en route to Chicago with three people aboard, including the pilot. The Indiana State Police confirmed that those three people are dead.

The I-Team has learned the plane apparently took off about 90 minutes late and reached an altitude of several thousand feet before the crash. The weather in the area was misty and overcast Friday morning. The area that the plane went down in is densely wooded, making it difficult for authorities to reach by any method except foot.

"Our whole house shook," said Breanna Beswick, who lives near the crash site. "We have trails in our backyard so we were just, like, walking around, trying to see what was going on, if we could see anything."

Wayne Estopinal, CEO of TEG Architects, is among the dead, the ABC7 I-Team has confirmed. A man who answered the phone at one of the company's offices confirmed that Estopinal was on the way to Chicago. The company declined to confirm the identities of the other people on the flight.

FlightAware shows the tail number of the aircraft to be N525EG, which is registered to another company owned by Estopinal. Estopinal did have his pilot's license, but it was unclear if he was the one flying the plane.

Estopinal, 63, was an alumnus of Ball State University and sat on its board of trustees, according to his professional biography. The school released a statement upon Estopinal's death calling him "an exceptional leader and passionate supporter of the university." Estopinal was reportedly coming to Chicago for a Ball State-related event, the I-Team has learned.

He also founded several professional soccer teams, including the Louisville City Football Club. Brad Estes, president of the soccer club, and John Neace, principal owner, released statements upon Estopinal's identification as a victim of the crash.

"We at LouCity are deeply saddened to hear of the passing of club founder Wayne Estopinal," Estes said. "We would not be the club we are today without his innovation, leadership, and hard work, and his contributions to the community are something for which we are incredibly grateful. Our hearts are with Wayne's family and loved ones at this time."

"Greater Louisville lost a great corporate citizen today. Wayne was very active in the soccer community and will be missed by us all. We mourn this inexpressible loss and today acknowledge his contribution to Louisville City FC and the entire Louisville soccer community," Neace said.

No information on memorial or funeral services for Estopinal was available.

Local authorities handed the crash investigation over to Federal Aviation Administration investigators and the National Transportation Safety Board.

Original article can be found here ➤ https://abc7chicago.com


Clark County Sheriff Jamey Noel speaks to members of the media.


Major James Haehl, Chief Detective to the Clark County Sheriff's Office.








Ball State Board of Trustees member Wayne Estopinal talks with other board members during a committee meeting on Friday on Ball State's campus.










MUNCIE, Indiana — Architect R. Wayne Estopinal, who just this week was appointed by the governor to another term on the board of trustees at Ball State University, his alma mater, died Friday in a plane crash in southern Indiana.

A proud Cardinal, he was en route to Chicago for a Ball State alumni event Friday night and a gala on Saturday.

Estopinal had served on the board since 2011 and had earned two bachelor's degrees from Ball State in 1979 — one in architecture and one in environmental design. 

The soccer club for which Estopinal was a founder, Louisville City FC, confirmed his death.

He was on board a Cessna 525A CitationJet CJ2+ that crashed in rural Clark County just outside of Louisville around 11:30 a.m. Emergency responders arrived at a rural wooded area to find a debris field from the reported crash.

The flight was en route to Chicago, where Ball State is being recognized this weekend, at the Renaissance Chicago Downtown Hotel, as the Indiana Society of Chicago Foundation’s Institution of the Year.

Three people were aboard the flight, including the pilot, according to state police. None survived.

Ball State President Geoffrey S. Mearns, board of trustees' Chairman Rick Hall, other trustees and senior administration staff from the university were among a large Ball State contingent in Chicago for an alumni event Friday night. The Indiana Society of Chicago's gala is Saturday.

"He was an exceptional leader and passionate supporter of the university," Mearns and Hall said in a statement. "As we mourn this loss to our Ball State family, we ask that you keep Wayne’s family and friends in your thoughts and prayers."

"He was a good friend of mine," said Tom Bracken, a fellow trustee. "He was a good friend of Ball State. ... It's a tremendous loss for all of us."

During Estopinal's tenure on the board, Ball State stopped burning coal, banned smoking on campus, took over governance of distressed Muncie Community Schools and hired two presidents: Paul Ferguson and current President Geoffrey S. Mearns.

Estopinal chaired the search committee that led to the hiring of Ferguson, then-president of the University of Maine, a fact that made Estopinal proud of BSU.

Ball State's ability to hire "the sitting president of a land grant university says a lot about this university," he told The Star Press in 2014.

"I can't wait to see what you do," Estopinal told new Muncie school board members appointed by trustees earlier this year to replace an elected school board.

He had an ability to see and express the funny side of things, which helped lighten up what traditionally had been pretty humorless trustee meetings.

Estopinal cooperated with The Star Press on news coverage of Ball State, though he kept the hiring of Ferguson a secret until the moment Ferguson walked on stage during an announcement at Sursa Performance Hall. Estopinal had stressed the importance to committee members of keeping the names of candidates for the presidency confidential.

It always seemed like Estopinal — a frequent air traveler because of his business — was at an airport when the newspaper called for comment.

During an interview in 2016, he was asked to respond to criticism that board of trustee actions were almost always unanimous.

"Much of the controversy or dissenting commentary occurs in executive session," Estopinal told The Star Press. "We don't vote in executive session but we have that robust discussion privately and everyone presents their position. I am one of the most dissenting voices on the board. At times, that puts me at odds with the other trustees, but I don't worry about that because ... I am the one who has to look back on my service and say I put my viewpoint forward. I am not anyone's yes man."

He saw nothing to be gained by airing dissenting opinions in public. "We're not running for office," he went on. "We don't have to create sound bites. I don't think that serves much of a purpose."

Estopinal was president of TEG Architects, a firm that specializes in providing architectural, planning, virtual reality imaging and interior design services to national clients, according to a biography provided by Ball State. The firm is based in Jeffersonville, with offices in Louisville, Kentucky and Shreveport, Louisiana.

He of course voiced his opinion and asked questions at public trustee meetings about the design of numerous construction projects undertaken by Ball State in the past eight years.

For example, at a meeting during which drawings were revealed for a multi-million-dollar makeover of the front of Emens Auditorium, he said, "I would like to see (architectural consultant) MSKTD look at the facade, and look at the facade of Sursa (Performance Hall), and get other contextual clues from around it. I think possibly it could be a little more transparent, because the idea is, from the street we should show the entrance, the excitement, the gatherings inside."

The university's geothermal heat pump system, which replaced an old coal-burning plant, uses the Earth's ability to store heat in the ground. It uses the Earth as either a heat source, when operating in heating mode, or a heat sink, when operating in cooling mode. The ground in Muncie a few feet below the surface has a stable temperature of 55 degrees.

In addition to being an active Ball State alumnus, Estopinal was deeply involved in his hometown community, serving on the Louisville Sports Commission Board of Directors, Louisville Zoo Foundation Board of Directors, Lincoln Heritage Council Boy Scouts of America Board of Directors, Community Bankshares of Indiana Board of Directors and the Your Community Bank Board of Directors.

His specialty was health care construction, but his lasting contributions include founding the Louisville City FC soccer franchise and designing the University of Louisville’s Lynn Stadium. 

Estopinal spearheaded efforts to move a United Soccer League franchise from Orlando, Florida, to Louisville in 2014, after that team was displaced by a Major League Soccer franchise. While retaining his minority stake in the Orlando ownership group, Estopinal took charge of the startup Louisville effort.

His personal interests included distance running, soccer and inspiring in others a passion for excellence.

Estopinal’s new term on Ball State's board of trustees would have lasted until Dec. 31, 2022.

Original article ➤ https://www.thestarpress.com