Monday, November 26, 2018

Cape Air, Cessna 402: Incident occurred November 26, 2018 at Rutland Southern Vermont Regional Airport (KRUT), Clarendon, Vermont

CLARENDON — No one was injured Friday when a Cape Air flight on its way into Rutland Southern Vermont Regional Airport from Boston had to make an emergency landing.

Airport Manager Christopher Beitzel said Monday that the Cessna 402 aircraft reported having engine trouble at around 3:43 p.m. It landed safely, carrying five passengers and two crew members. Three fire trucks from the Clarendon Fire Department and one from the City of Rutland Fire Department responded, along with a truck from the airport’s fire service.

Beitzel said about two gallons of fuel spilled as a result. He’s not sure if that was related to the engine problem itself or a byproduct of addressing said problem.

The emergency landing didn’t interrupt scheduled flights, Beitzel said, however a “Notice to Airmen” or a “NOTAM” was issued and for a few hours no one could land.

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

Robinson R22 BETA, VH-KZV: Fatal accident occurred November 24, 2018 in Alice Springs, Australia

NTSB Identification: WPR19WA032
14 CFR Non-U.S., Non-Commercial
Accident occurred Saturday, November 24, 2018 in Alice Springs, Australia
Aircraft: ROBINSON R22, registration:
Injuries: 1 Fatal, 1 Serious.

The foreign authority was the source of this information.

On November 24, 2018, at 1200 local time, a Robinson R22 BETA, VH-KZV, collided with terrain near Alice Springs, NT, Australia. The helicopter sustained substantial damage. The pilot sustained serious injuries and the passenger was fatally injured. The flight was operated under the pertinent civil regulations of the Government of Australia.

The investigation is under the jurisdiction of the Government of Australia and authority of the Australian Transport Safety Bureau. This report is for information purposes only and contains only information released by the Government of Australia. Further information pertaining to this accident may be obtained from:

Australian Transport Safety Bureau (ATSB)
P.O. Box 967, Civic Square
Canberra A.C.T. 2608
Australia
Tel: (61) 2 6257-4150
http://www.atsb.gov.au

Collision with terrain involving Robinson R22 Beta, VH-KZV, 130km ENE of Alice Springs, Northern Territory, on November 24, 2018

Investigation number: AO-2018-077

Summary

The ATSB is investigating a collision with terrain involving a Robinson R22 Beta, VH-KZV, 130km ENE of Alice Springs Airport, Northern Territory on 24 November 2018.

The helicopter collided with terrain about 130km ENE of Alice Springs Airport. A passenger and pilot were on board. The passenger sustained serious injuries and the pilot was fatally injured. The helicopter was destroyed.

A final report will be released at the end of the investigation.

Should a critical safety issue be identified during the course of the investigation, the ATSB will immediately notify those affected and seek safety action to address the issue.

https://www.atsb.gov.au

An Australian Transport Safety Bureau (ATSB) team has begun its investigation of a helicopter crash in Central Australia on Saturday, which left one man dead and another with critical injuries.

The crash occurred approximately 125 kilometres north east of Alice Springs near the Old Ambalindum station in the East MacDonnell Ranges. The Robinson R22 helicopter, which is commonly used for cattle mustering, crashed into a riverbed.

An ATSB spokesman said it was too early to speculate on what could have caused the accident.

“At team of three ATSB transport safety investigators travelling from Canberra are anticipated to arrive in the Northern Territory on Sunday afternoon to begin the evidence collection phase of the investigation,” he said.

The spokesman said the investigators are expected to spend several days inspecting the scene.

“The evidence collection phase will define the size and scope of the investigation and determine the expected time frame for the completion of a final report,” he said.

“Should a critical safety issue be identified during the course of an investigation, the ATSB will immediately communicate it to relevant parties so that appropriate safety action can be taken.”

St John Ambulance spokesman Craig Garraway said paramedics had a tough job in transporting the critically injured patient to the hospital in Alice Springs.

“Where they could land the responding helicopter was about a 10 minute walk to where the crash site was. They had to walk into the site and then had to stretcher the patient, once he was stabilised, back to the helicopter where there was a doctor waiting,” he said.

“The weather was apparently not very good there so what they had to do is one responding helicopter had to take off to get the patient back out and the other helicopter had to stay there because it couldn’t take off.”

NT Police are preparing a report for the coroner and their investigations are also ongoing.


https://www.ntnews.com.au

Chicago, Illinois: Curious About The Cessna Caravan Circling Overhead Recently? It’s Researching City’s Construction Boom



DOWNTOWN — For over a week, a low-flying small aircraft making daily flights over the city and surrounding suburbs was spotted by residents throughout Chicago.

The plane, a Cessna Caravan owned and operated by the commercial real estate information database CoStar, was gathering data and images of new construction in the greater Chicago metro area.

The team wrapped up its latest assignment in Chicago prior to Thanksgiving.

Overseeing the effort is aerial research photographer Amber Surrency, a United States Marine Corps veteran based in Florida.

For the Chicago assignment, the team was tasked with updating imagery and information on over 400 sites.

“We’ll fly each market gathering construction data while verifying the status and collecting images on known construction properties,” Surrency said. “Anything new we find is submitted to the research gatherers.”



Surrency and crew complete two three-hour flights each day and document high-resolution images and other data utilizing a 6K RED Dragon camera mounted to a carbon fiber Cineflex stabilization system.

Surrency, who was in Chicago for an assignment at the same time last year, said she has documented a noticeable increase in new multi-unit buildings and hotels. And with numerous mega-developments in advanced planning stages, the city’s landscape will continue to change dramatically in the coming years.

Chicago’s notoriously unpredictable weather and congested airspace presents challenges to completing the entire assignment in the alloted time. However, Surrency said the team does typically complete a market on schedule.

Despite the growing popularity of drones for video and imagery, Surrency said that using a small aircraft is much more efficient, allowing the team to cover more territory and ultimately complete more research. Small aircrafts are also more conducive to covering data points in both developed urban and rural areas, she adds.

“We fly in the plane for five to six hours per day, while a drone can only fly for about 20 to 30 minutes per battery,” Surrency said. “With pilots, you can also coordinate with restricted airspace while drones are limited to line of sight.”

Covering 136 different metro areas throughout the country, Surrency said Chicago is one of the most unique markets to document.

“Flying over the lakefront and Sears Tower is always an amazing experience,” she said.

Story and photo gallery ➤ https://blockclubchicago.org

Business use of Grand Haven Memorial Airpark (3GM)



Have you ever wondered how the Grand Haven Memorial Airport is used by Grand Haven's business community?

Although we don't see airlines or charter services regularly flying into our airport, there's lots of "business" going on at our local airport.

Electro-Media, Inc., headquartered in Spring Lake, provides technology, communication, and security services for customers throughout Michigan and the Midwest. The company employs 22 people, who work in Spring Lake and Mishawaka, Indiana.

Local resident Pete Boon is the president of Electro-Media, Inc., and like many small business owners, he often needs to be in two places at once, in order to be accessible to his customers and employees. Since Pete can't clone himself, he does the next best thing – he uses his 2006 Cessna Skylane, based at the Grand Haven airport, to get quickly from place to place.

Pete says he uses his airplane in almost every aspect of his business – traveling between offices, visiting customers, making sales calls, delivering parts, attending conferences, taking employees to job sites, and turning two-day trips into one-day trips. Pete says that his Skylane and the Grand Haven airport allow him to support his 22 employees and to live and work in the community he loves.

Jamie Abraham owns Universal Tool & Engineering in Johnson City, Tennessee. Earlier this year, Jamie flew his beautiful red, black and silver Cirrus SR22 GTS into Grand Haven to meet with local manufacturing executives regarding the CNC tube bending machines his company produces.

Jamie says he uses his airplane for business travel about every other week, making trips as short as 100 miles and as far away as 1,200 miles. He says local airports like Grand Haven's are a key community and business resource.

"For me, the biggest advantage of flying a private plane to a local airport is time savings. To make a trip to Grand Haven, flying commercial or driving, would be a two- or three-day endeavor. Flying myself to the Grand Haven airport, I can turn this into an overnight or day trip."

Visitors to Grand Haven also arrive hungry and eager to shop. Did you ever consider that the couple sitting next to you at one of our iconic local restaurants or retail stores may have arrived via airplane? Pilots love to use their airplanes to visit their favorite beaches, parks, stores, and restaurants.

Earlier this summer, I ran into a couple of beach bums who had flown from Indiana to Grand Haven to buy a kiteboard from MACkite on Hayes Street. Just a few weeks later, I sat next to a couple at Porto Bello who had flown in from Chicago because they love the variety, atmosphere, and food at our local restaurants.

All in all, Grand Haven enjoys a thriving business community, and our local airport is a one-of-a kind gateway for our vibrant city businesses.

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

Van's RV-6. LN-AAL: Fatal accident occurred November 07, 2018 near Meråker-Øyan airstrip, Trøndelag, Norway

NTSB Identification: CEN19WA027
14 CFR Non-U.S., Non-Commercial
Accident occurred Wednesday, November 07, 2018 in Meraaker, Norway
Aircraft: Vans (EX) RV-6, registration:
Injuries: 2 Fatal.

The foreign authority was the source of this information.

On November 7, 2018, about 1410 hours central European standard time, a Vans RV-6 airplane, Norwegian registration LN-AAL, impacted terrain under unknown circumstances near Meråker, Norway. The pilot and passenger were fatally injured. The flight departed from the Værnes Airport (ENVA), Trondheim, Norway.

The accident investigation is under the jurisdiction of the Accident Investigation Board Norway (AIBN). This report is for informational purposes and contains only information released by or obtained from the government of Norway.

Further information pertaining to this accident may be obtained from:
Accident Investigation Board Norway
P. O. Box 213
N-2001 Lillestrøm
Norway
Tel: + 47 63 89 63 00
Website: http://www.aibn.no
Email: post@aibn.no


Stig Harald Hoff (t.v.) og Espen Andreas Holdnes Hoff (t.h.) døde i flystyrten i Meråker.




Politiet har frigitt navnene på de omkomne i flystyrten i Meråker. De to omkomne er brødre, Espen Andreas Holdnes Hoff, 54 år gammel, bosatt i Trondheim, og Stig Harald Hoff, 59 år gammel, bosatt i Ørland. Begge etterlater seg familie og barn.

Lensmann i Stjørdal, Kjetil Ravlo, forteller til NRK at det trolig var Espen Andreas Holdnes Hoff som var pilot på flyet.

Han skal ha vært en meget erfaren flyver, med bakgrunn som flykaptein i Widerøe. Det opplyser Tor Andre Weiseth, leder i Værnes Flyklubb, hvor også Espen Andreas Holdnes Hoff var medlem. Ifølge Weiseth var Holdnes Hoff eieren av flyet som styrtet.

– De fleste i klubben har flyving som hobby, men Espen var yrkespilot. Vi har ingen å miste i flyklubbmiljøet, sier Weiseth til NRK.

Leteaksjonen i Meråker i Trøndelag ble satt i gang etter at et småfly av typen Vans Aircraft RV-6 utløste nødsignal onsdag ettermiddag. Halvannen time senere ble flyet funnet i et skogholt en snau kilometer fra Øian flyplass sørøst for Meråker sentrum i Trøndelag.

Politiet har ventet med å hente dem ut av hensyn til de krimtekniske undersøkelsene, og fordi det var svært vanskelig å få dem ut.

Begravelsesbiler har fraktet dem til St. Olavs hospital, hvor de skal obduseres fredag.

https://www.nrk.no

Airdrome Aeroplanes Sopwith Pup, N1916Z: Accident occurred November 26, 2018 at Rio Vista Municipal Airport (O88), Solano County, California

Federal Aviation Administration / Flight Standards District Office; Sacramento, California

https://registry.faa.gov/N1916Z

NTSB Identification: GAA19CA075
14 CFR Part 91: General Aviation
Accident occurred Monday, November 26, 2018 in Rio Vista, CA
Aircraft: Darren M. Vinelli Sopwith PUP, registration: N1916Z

NTSB investigators will use data provided by various entities, including, but not limited to, the Federal Aviation Administration and/or the operator, and will not travel in support of this investigation to prepare this aircraft accident report.

Aircraft veered off runway and overturned.

Date: 26-NOV-18
Time: 20:35:00Z
Regis#: N1916Z
Aircraft Make: SOPWITH
Aircraft Model: PUP
Event Type: ACCIDENT
Highest Injury: NONE
Aircraft Missing: No
Damage: SUBSTANTIAL
Activity: UNKNOWN
Flight Phase: LANDING (LDG)
City: RIO VISTA
State: CALIFORNIA




RIO VISTA — A escaped without injury after a small plane overturned during landing at an airport, authorities said.

The plane, an Airdrome Sopwith Pup with a tail number of N1916Z, was landing at Rio Vista Municipal Airport about 12:30 p.m. Monday, Federal Aviation Administration spokesman Ian Gregor said.

Federal Aviation Administration records list the plane as a fixed-wing single-engine model built from a kit.

No information was immediately available about the circumstances that led to the crash or any plane damage, but Gregor said the FAA will investigate.

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

RIO VISTA (CBS13) — A man flying a World War I replica biplane flipped over Monday while practicing landing in crosswinds at Rio Vista Municipal Airport, police said.

Police said the plane caught a gust of wind and flipped over in the landing, but the pilot was able to walk away unharmed.

Both Rio Vista police and firefighters responded to the incident. Officials closed the runway for two hours while righting the plane and moving it to a hangar.

The man was flying an Airdrome Aeroplanes Sopwith Pup.

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

Beech B36TC Bonanza, N6453C: Incident occurred November 26, 2018 at North Platte Regional Airport (KLBF), Lincoln County, Nebraska

Federal Aviation Administration / Flight Standards District Office; Lincoln, Nebraska

Aircraft nose gear collapsed during landing.

Advanced Systems Group Inc

https://registry.faa.gov/N6453C


Date: 26-NOV-18
Time: 16:30:00Z
Regis#: N6453C
Aircraft Make: BEECH
Aircraft Model: BE36
Event Type: INCIDENT
Highest Injury: NONE
Aircraft Missing: No
Damage: MINOR
Activity: UNKNOWN
Flight Phase: LANDING (LDG)
City: NORTH PLATTE
State: NEBRASKA





Part of the landing gear of a single-engine airplane collapsed Monday morning after a plane landed at the North Platte Regional Airport, bringing the plane to a sudden stop on the side of the runway.

No one was injured.

The pilot was arriving from Tulsa to provide an “Angel Flight” — to pick up someone who needs medical attention, Airport Manager Sam Seafeldt said.

Angel Flights provide free air transportation for legitimate, charitable, medically related needs.

Operations Supervisor Justin Gosnell was the first to respond, driving the airport’s firefighting unit. Gosnell alerted the North Platte fire and rescue department as he drove to the crash site, but was able to tell them not to come after finding the pilot was okay and there was no fire.

The right-side landing gear collapsed as the plane was slowing on the runway. The nose gear also collapsed.

The runway was clean. Ice was not immediately suspected to be a contributing factor, Gosnell said.

The accident happened shortly after 10 a.m.

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




NORTH PLATTE, Neb. – Emergency crews responded to the North Platte Regional Airport on Monday morning after a Beechcraft Bonanza B36TC suffered a collapsed landing gear while arriving at the airport.

The call came in around 10 a.m.

The pilot walked away unharmed.

The plane was lifted by a crane, put on a flatbed and towed to the onsite mechanic shop for further inspection.

According to FlightAware, the plane took off from Tulsa, Oklahoma around 7 a.m. and was scheduled to land in North Platte at 10:09 a.m

Original article can be found here ➤ https://www.knopnews2.com

Bellanca 7GCBC, N50340: Accident occurred November 23, 2018 at Benson Municipal Airport (E95), Cochise County, Arizona

Federal Aviation Administration / Flight Standards District Office;  Scottsdale, Arizona

Plane Folks LLC

https://registry.faa.gov/N50340

NTSB Identification: GAA19CA072
14 CFR Part 91: General Aviation
Accident occurred Friday, November 23, 2018 in Benson, AZ
Aircraft: Champion 7GCBC, registration: N50340

NTSB investigators will use data provided by various entities, including, but not limited to, the Federal Aviation Administration and/or the operator, and will not travel in support of this investigation to prepare this aircraft accident report.

Ground looped.

Date: 23-NOV-18
Time: 15:30:00Z
Regis#: N50340
Aircraft Make: BELLANCA
Aircraft Model: 7GCBC
Event Type: ACCIDENT
Highest Injury: NONE
Aircraft Missing: No
Damage: SUBSTANTIAL
Activity: UNKNOWN
Flight Phase: LANDING (LDG)
Operation: 91
City: BENSON
State: ARIZONA

Beech C23 Sundowner 180, N66710: Accident occurred November 25, 2018 at Porterville Municipal Airport (KPTV), Tulare County, California

Additional Participating Entity:
Federal Aviation Administration / Flight Standards District Office; Fresno, California

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

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

https://registry.faa.gov/N66710

Location: Porterville, CA
Accident Number: GAA19CA073
Date & Time: 11/25/2018, 1320 PST
Registration: N66710
Aircraft: Beech C23
Aircraft Damage: Substantial
Defining Event: Loss of control on ground
Injuries: 1 None
Flight Conducted Under: Part 91: General Aviation - Personal 

The pilot reported that, during the landing flare the airplane touched down on the main gear and ballooned a few feet off the ground. Subsequently, the airplane porpoised, the nose wheel collapsed, and the airplane came to rest nose down on the runway.

The airplane sustained substantial damage to the engine mount.

The pilot reported that there were no preimpact mechanical failures or malfunctions with the airplane that would have precluded normal operation. 

Pilot Information

Certificate: Private
Age: 71, Male
Airplane Rating(s): Single-engine Land
Seat Occupied: Left
Other Aircraft Rating(s): None
Restraint Used: 3-point
Instrument Rating(s): None
Second Pilot Present: No
Instructor Rating(s): None
Toxicology Performed: No
Medical Certification: Class 3 With Waivers/Limitations
Last FAA Medical Exam: 03/07/2018
Occupational Pilot: No
Last Flight Review or Equivalent: 05/22/2017
Flight Time:  (Estimated) 242 hours (Total, all aircraft), 220 hours (Total, this make and model), 132 hours (Pilot In Command, all aircraft), 4 hours (Last 90 days, all aircraft)

Aircraft and Owner/Operator Information

Aircraft Make: Beech
Registration: N66710
Model/Series: C23
Aircraft Category: Airplane
Year of Manufacture: 1983
Amateur Built: No
Airworthiness Certificate: Normal; Utility
Serial Number: M-2387
Landing Gear Type: Tricycle
Seats: 4
Date/Type of Last Inspection: 11/20/2017, Annual
Certified Max Gross Wt.: 2450 lbs
Time Since Last Inspection:
Engines: 1 Reciprocating
Airframe Total Time: 6109 Hours as of last inspection
Engine Manufacturer: Lycoming
ELT: C91  installed, not activated
Engine Model/Series: O-360-A4K
Registered Owner: Donald Uttenreither, Rickey Cooksey
Rated Power: 180 hp
Operator: On file
Operating Certificate(s) Held: Fractional Ownership 

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: KPTV, 442 ft msl
Distance from Accident Site: 0 Nautical Miles
Observation Time: 2156 UTC
Direction from Accident Site: 177°
Lowest Cloud Condition: Clear
Visibility:  10 Miles
Lowest Ceiling: None
Visibility (RVR):
Wind Speed/Gusts: 6 knots /
Turbulence Type Forecast/Actual: None / None
Wind Direction: 300°
Turbulence Severity Forecast/Actual: N/A / N/A
Altimeter Setting: 30.06 inches Hg
Temperature/Dew Point: 21°C / 12°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Porterville, CA (PTV)
Type of Flight Plan Filed: None
Destination: Porterville, CA (PTV)
Type of Clearance: None
Departure Time: 1250 PST
Type of Airspace: Class G

Airport Information

Airport: PORTERVILLE MUNI (PTV)
Runway Surface Type: Asphalt
Airport Elevation: 443 ft
Runway Surface Condition: Dry
Runway Used: 30
IFR Approach: None
Runway Length/Width: 5960 ft / 150 ft
VFR Approach/Landing: Full Stop; Traffic Pattern 

Wreckage and Impact Information

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

Latitude, Longitude:  36.030000, -119.063056 (est)

Powrachute Airwolf, N2487N: Incident occurred November 23, 2018 in Pierson, Volusia County, Florida

Federal Aviation Administration / Flight Standards District Office; Orlando, Florida

Crashed into tree.

https://registry.faa.gov/N2487N

Date: 23-NOV-18
Time: 14:30:00Z
Regis#: N2487N
Aircraft Make: EXPERIMENTAL
Aircraft Model: AIRWOLF
Event Type: INCIDENT
Highest Injury: MINOR
Aircraft Missing: No
Damage: UNKNOWN
Activity: UNKNOWN
Flight Phase: UNKNOWN (UNK)
Operation: 91
City: PIERSON
State: FLORIDA

Beech A36 Bonanza, N41VK: Accident occurred November 23, 2018 at Summerland Key Cove Airport (FD51), Monroe County, Florida

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

Additional Participating Entity: 

Federal Aviation Administration / Flight Standards District Office; Miramar, Florida 

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


https://registry.faa.gov/N41VK

Location: Summerland Key, FL
Accident Number: ERA19TA067
Date & Time: 11/23/2018, 0820 EST
Registration: N41VK
Aircraft: Beech A36
Injuries: 1 None
Flight Conducted Under: Part 91: General Aviation - Personal 

On November 23, 2018, about 0820 eastern standard time, a Beech A36, N41VK, operated by the private pilot, was substantially damaged during landing at Summerland Key Cove Airport (FD51), Summerland Key, Florida. The private pilot was not injured. The personal flight was conducted under the provisions of Title 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed and an instrument flight rules flight plan was filed for the flight that departed Pompano Beach Airpark (PMP), Pompano Beach, Florida.

The pilot reported that during taxi after landing, he intended to retract the flaps, but accidently retracted the landing gear, resulting in the nose gear and right main landing gear collapsing. The pilot also reported that there were no preimpact mechanical malfunctions with the airplane.

Examination of the airplane by a Federal Aviation Administration inspector revealed damage to the right wing and lower fuselage.

Aircraft and Owner/Operator Information


Aircraft Make: Beech
Registration: N41VK
Model/Series: A36 UNDESIGNATED
Aircraft Category: Airplane
Amateur Built: No
Operator: On file
Operating Certificate(s) Held: None 

Meteorological Information and Flight Plan


Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: NQX, 5 ft msl
Observation Time: 0753 EST
Distance from Accident Site: 14 Nautical Miles
Temperature/Dew Point: 24°C / 21°C
Lowest Cloud Condition: Clear
Wind Speed/Gusts, Direction: 8 knots / , 40°
Lowest Ceiling: None
Visibility:  10 Miles
Altimeter Setting: 30.02 inches Hg
Type of Flight Plan Filed: IFR
Departure Point: Pompano Beach, FL (PMP)
Destination: Summerland Key, FL (FD51) 

Wreckage and Impact Information


Crew Injuries: 1 None
Aircraft Damage: Substantial
Passenger Injuries: N/A
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 1 None
Latitude, Longitude: 25.795278, -80.290000 (est)

Learjet 60, N174FP: Incident occurred November 23, 2018 at Cobb County International Airport (KRYY), Kennesaw, Georgia

Federal Aviation Administration / Flight Standards District Office; Atlanta, Georgia

Bird strike on short final.

Ponsol Group LLC

https://registry.faa.gov/N174FP

Date: 23-NOV-18
Time: 19:22:00Z
Regis#: N174FP
Aircraft Make: LEARJET
Aircraft Model: 60
Event Type: INCIDENT
Highest Injury: NONE
Aircraft Missing: No
Damage: UNKNOWN
Activity: UNKNOWN
Flight Phase: APPROACH (APR)
Operation: 91
City: ATLANTA
State: GEORGIA

Piper PA-46-350P Malibu, N369CG: Incident occurred November 23, 2018 at Oakland/Troy Airport (KVLL), Oakland County, Michigan

Federal Aviation Administration / Flight Standards District Office; East Michigan

Landed gear up.

SVP LLC

https://registry.faa.gov/N369CG

Date: 23-NOV-18
Time: 15:40:00Z
Regis#: N369CG
Aircraft Make: PIPER
Aircraft Model: PA 46 350P
Event Type: INCIDENT
Highest Injury: NONE
Aircraft Missing: No
Damage: UNKNOWN
Activity: PERSONAL
Flight Phase: LANDING (LDG)
Operation: 91
City: TROY
State: MICHIGAN

Lancair 360, N360XT: Incident occurred November 25, 2018 in St. Louis, Missouri

Federal Aviation Administration / Flight Standards District Office; St. Louis, Missouri

Nose gear collapsed.

https://registry.faa.gov/N360XT

Date: 25-NOV-18
Time: 03:15:00Z
Regis#: N360XT
Aircraft Make: EXPERIMENTAL
Aircraft Model: LANCAIR 360
Event Type: INCIDENT
Highest Injury: NONE
Aircraft Missing: No
Damage: UNKNOWN
Activity: UNKNOWN
Flight Phase: LANDING (LDG)
Operation: 91
City: ST LOUIS
State: MISSOURI

Piper PA-28-140, N6311W: Incident occurred November 23, 2018 in Reidsville, Rockingham County, North Carolina

Federal Aviation Administration / Flight Standards District Office; Greensboro, North Carolina

Nose gear collapsed and veered off the runway.

https://registry.faa.gov/N6311W

Date: 23-NOV-18
Time: 17:00:00Z
Regis#: N6311W
Aircraft Make: PIPER
Aircraft Model: PA 28 140
Event Type: INCIDENT
Highest Injury: UNKNOWN
Aircraft Missing: No
Damage: UNKNOWN
Activity: OTHER
Flight Phase: UNKNOWN (UNK)
Operation: 91
City: REIDSVILLE
State: NORTH CAROLINA

Piper PA-28-180, N7212W: Incident occurred November 23, 2018 at North Central State Airport (KSFZ), Pawtucket, Providence County, Rhode Island

Federal Aviation Administration / Flight Standards District Office; Boston, Massachusetts

Struck a deer on departure roll.

https://registry.faa.gov/N7212W

Date: 23-NOV-18
Time: 15:35:00Z
Regis#: N7212W
Aircraft Make: PIPER
Aircraft Model: PA 28 180
Event Type: INCIDENT
Highest Injury: NONE
Aircraft Missing: No
Damage: UNKNOWN
Activity: UNKNOWN
Flight Phase: TAKEOFF (TOF)
Operation: 91
City: PAWTUCKET
State: RHODE ISLAND

Allegiant Air, Airbus A320: Incident occurred November 25, 2018 at Austin–Bergstrom International Airport (KAUS), Austin, Texas

Federal Aviation Administration / Flight Standards District Office; San Antonio, Texas

Allegiant Air flight number 1819: Struck unidentified object on departure, possible bird strike.

Date: 25-NOV-18
Time: 01:29:00Z
Regis#: UNK
Aircraft Make: AIRBUS
Aircraft Model: 320
Event Type: INCIDENT
Highest Injury: UNKNOWN
Aircraft Missing: No
Damage: UNKNOWN
Activity: COMMERCIAL
Flight Phase: TAKEOFF (TOF)
Operation: 121
Aircraft Operator: ALLEGIANT
Flight Number: 1819
City: AUSTIN
State: TEXAS

Cessna 172L Skyhawk, owned and operated by Carolina Aviation of Aiken LLC, N7081Q: Accident occurred November 23, 2018 at Grand Strand Airport (KCRE), North Myrtle Beach, South Carolina

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

Additional Participating Entity:

Federal Aviation Administration / Flight Standards District Office; West Columbia, South Carolina

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


https://registry.faa.gov/N7081Q

Location: North Myrtle Beach, SC
Accident Number: ERA19LA055
Date & Time: 11/23/2018, 1105 EST
Registration: N7081Q
Aircraft: Cessna 172
Injuries: 1 None
Flight Conducted Under: Part 91: General Aviation - Personal 

On November 23, 2018, about 1105 eastern standard time, a Cessna 172L, N7081Q, owned and operated by Carolina Aviation of Aiken LLC, collided with a parked, unoccupied airplane while taxiing after landing at Grand Strand Airport (CRE), North Myrtle Beach, South Carolina. The commercial pilot was not injured, and the airplane was substantially damaged. The airplane was being operated under the provisions of title 14 Code of Federal Regulations Part 91 as a personal flight. Visual meteorological conditions prevailed at the time, for the flight that originated about 1 hour 36 minutes earlier from Aiken Regional Airport (AIK), Aiken, South Carolina.

The pilot stated that there were no discrepancies with the brakes at the departure airport. After landing on taxiway A (NOTAM 11/005 specified the taxiway was runway 05/23) the airplane slowed aerodynamically requiring him to add some power. He turned off at the first taxiway and taxied to the ramp while following a van that was escorting him to parking. While taxiing about 4 to 5 miles-per-hour (mph), he felt a wind gust push the tail to the right, which was not corrected with full right rudder. While turning to the left he applied right brake, and at that time the right brake failed. He then applied both brakes to stop but the left turn became exaggerated. He released the left brake and pulled the mixture control to stop the propeller but while rolling about 1-2 mph, the airplane impacted a parked Beech Baron.

The owner/operator of the airplane, who is an airframe and powerplant mechanic with inspection authorization examined the airplane after the accident and reported seeing drops of fluid on the ground beneath the right brake. He removed the right brake, and noted only drops of fluid emerged from the separated brake line. Further inspection of the brake revealed fluid seeping around the piston assembly. He disassembled the brake and found an o-ring or packing, was misshaped. He repaired the brake and reinstalled it 2 days after the accident but did not bleed the brake or add any fluid. 

Aircraft and Owner/Operator Information

Aircraft Make: Cessna
Registration: N7081Q
Model/Series: 172 L
Aircraft Category: Airplane
Amateur Built: No
Operator: Carolina Aviation Of Aiken LLC
Operating Certificate(s) Held: None 

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: CRE, 31 ft msl
Observation Time: 1153 EST
Distance from Accident Site:
Temperature/Dew Point: 11°C / 3°C
Lowest Cloud Condition: Clear
Wind Speed/Gusts, Direction: 13 knots / 19 knots, 40°
Lowest Ceiling: None
Visibility:  10 Miles
Altimeter Setting: 30.36 inches Hg
Type of Flight Plan Filed: None
Departure Point: Aiken, SC (AIK)
Destination: North Myrtle Beach, SC (CRE)

Wreckage and Impact Information

Crew Injuries: 1 None
Aircraft Damage: Substantial
Passenger Injuries: N/A
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 1 None
Latitude, Longitude: 33.811667, -78.723889 (est)

Pilatus PC-12, registered to and operated by Rico Aviation LLC, N933DC: Fatal accident occurred April 29, 2017 near Rick Husband Amarillo International Airport (KAMA), Amarillo, Texas

Robin Shaw


Misty Nicholson


Scott Riola


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

Additional Participating Entities:

Federal Aviation Administration / Flight Standards District Office; Lubbock, Texas
Federal Aviation Administration; AVP-100; Washington, District of Columbia
Pratt & Whitney; West Virginia
Pilatus
Honeywell; Kansas
Hartzell Propellers; Piqua, Ohio
Rico Aviation; Amarillo, Texas

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

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


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

http://registry.faa.gov/N933DC

Joshua D. Lindberg
Investigator In Charge 
National Transportation Safety Board

Location: Amarillo, TX
Accident Number: CEN17FA168
Date & Time: 04/28/2017, 2348 CDT
Registration: N933DC
Aircraft: PILATUS AIRCRAFT LTD PC 12
Aircraft Damage: Destroyed
Defining Event: Loss of control in flight
Injuries: 3 Fatal
Flight Conducted Under: Part 135: Air Taxi & Commuter - Non-scheduled - Air Medical (Medical Emergency)

Analysis


The pilot and two medical crewmembers departed on an air ambulance flight in night instrument meteorological conditions to pick up a patient. After departure, the local air traffic controller observed the airplane's primary radar target with an incorrect transponder code in a right turn and climbing through 4,400 ft mean sea level (msl), which was 800 ft above ground level (agl). The controller instructed the pilot to reset the transponder to the correct code, and the airplane leveled off between 4,400 ft and 4,600 ft msl for about 30 seconds. The controller then confirmed that the airplane was being tracked on radar with the correct transponder code; the airplane resumed its climb at a rate of about 6,000 ft per minute (fpm) to 6,000 ft msl. The pilot changed frequencies as instructed, then contacted departure control and reported "with you at 6,000 [ft msl]" and the departure controller radar-identified the airplane. About 1 minute later, the departure controller advised the pilot that he was no longer receiving the airplane's transponder; the pilot did not respond, and there were no further recorded transmissions from the pilot. Radar data showed the airplane descending rapidly at a rate that reached 17,000 fpm. Surveillance video from a nearby truck stop recorded lights from the airplane descending at an angle of about 45° followed by an explosion.

The airplane impacted a pasture about 1.5 nautical miles south of the airport, and a postimpact fire ensued. All major components of the airplane were located within the debris field. Ground scars at the accident site and damage to the airplane indicated that the airplane was in a steep, nose-low and wings-level attitude at the time of impact. The airplane's steep descent and its impact attitude are consistent with a loss of control.

An airplane performance study based on radar data and simulations determined that, during the climb to 6,000 ft and about 37 seconds before impact, the airplane achieved a peak pitch angle of about 23°, after which the pitch angle decreased steadily to an estimated -42° at impact. As the pitch angle decreased, the roll angle increased steadily to the left, reaching an estimated -76° at impact. The performance study revealed that the airplane could fly the accident flight trajectory without experiencing an aerodynamic stall. The apparent pitch and roll angles, which represent the attitude a pilot would "feel" the airplane to be in based on his vestibular and kinesthetic perception of the components of the load factor vector in his own body coordinate system, were calculated. The apparent pitch angle ranged from 0° to 15° as the real pitch angle steadily decreased to -42°, and the apparent roll angle ranged from 0° to -4° as the real roll angle increased to -78°. This suggests that even when the airplane was in a steeply banked descent, conditions were present that could have produced a somatogravic illusion of level flight and resulted in spatial disorientation of the pilot.

Analysis of the performance study and the airplane's flight track revealed that the pilot executed several non-standard actions during the departure to include: excessive pitch and roll angles, rapid climb, unexpected level-offs, and non-standard ATC communications. In addition to the non-standard actions, the pilot's limited recent flight experience in night IFR conditions, and moderate turbulence would have been conducive to the onset of spatial disorientation. The pilot's failure to set the correct transponder code before departure, his non-standard departure maneuvering, and his apparent confusion regarding his altitude indicate a mental state not at peak acuity, further increasing the chances of spatial disorientation.

A postaccident examination of the flight control system did not reveal evidence of any preimpact anomalies that would have prevented normal operation. The engine exhibited rotational signatures indicative of engine operation during impact, and an examination did not reveal any preimpact anomalies that would have precluded normal engine operation. The damage to the propeller hub and blades indicated that the propeller was operating under high power in the normal range of operation at time of impact.

Review of recorded data recovered from airplane's attitude and heading reference unit did not reveal any faults with the airplane's attitude and heading reference system (AHRS) during the accident flight, and there were no maintenance logbook entries indicating any previous electronic attitude director indicator (EADI) or AHRS malfunctions. Therefore, it is unlikely that erroneous attitude information was displayed on the EADI that could have misled the pilot concerning the actual attitude of the airplane. A light bulb filament analysis of the airplane's central advisory display unit (CADU) revealed that the "autopilot disengage" caution indicator was likely illuminated at impact, and the "autopilot trim" warning indicator was likely not illuminated. A filament analysis of the autopilot mode controller revealed that the "autopilot," "yaw damper," and "altitude hold" indicators were likely not illuminated at impact. The status of the "trim" warning indicator on the autopilot mode controller could not be determined because the filaments of the indicator's bulbs were missing. However, since the CADU's "autopilot trim" warning indicator was likely not illuminated, the mode controller's "trim" warning indicator was also likely not illuminated at impact.

Exemplar airplane testing revealed that the "autopilot disengage" caution indicator would only illuminate if the autopilot had been engaged and then disconnected. It would not illuminate if the autopilot was off without being previously engaged nor would it illuminate if the pilot attempted and failed to engage the autopilot by pressing the "autopilot" pushbutton on the mode controller. Since the "autopilot disengage" caution indicator would remain illuminated for 30 seconds after the autopilot was disengaged and was likely illuminated at impact, it is likely that the autopilot had been engaged at some point during the flight and disengaged within 30 seconds of the impact; the pilot was reporting to ATC at 6,000 ft about 30 seconds before impact and then the rapid descent began.

The airplane was not equipped with a recording device that would have recorded the operational status of the autopilot, and the investigation could not determine the precise times at which autopilot engagement and disengagement occurred. However, these times can be estimated as follows:

The pilot likely engaged the autopilot after the airplane climbed through 1,000 ft agl about 46 seconds after takeoff, because this was the recommended minimum autopilot engagement altitude that he was taught.
According to the airplane performance study, the airplane's acceleration exceeded the autopilot's limit load factor of +1.6g about 9 seconds before impact. If it was engaged at this time, the autopilot would have automatically disengaged.

The roll angle data from the performance study were consistent with engagement of the autopilot between two points: 1) about 31 seconds before impact, during climb, when the bank angle, which had stabilized for a few seconds, started to increase again and 2) about 9 seconds before impact, during descent, at which time the autopilot would have automatically disengaged. Since the autopilot would have reduced the bank angle as soon as it was engaged and there is no evidence of the bank angle reducing significantly between these two points, it is likely that the autopilot was engaged closer to the latter point than the former. Engagement of the autopilot shortly before the latter point would have left little time for the autopilot to reduce the bank angle before it would have disengaged automatically due to exceedance of the normal load factor limit.

Therefore, it is likely that the pilot engaged the autopilot a few seconds before it automatically disconnected about 9 seconds before impact.

The operator reported that the airplane had experienced repeated, unexpected, inflight autopilot disconnects, and, two days before the accident, the chief pilot recorded a video of the autopilot disconnecting during a flight. Exemplar airplane testing and maintenance information revealed that, during the flight in which the video was recorded, the autopilot's pitch trim adapter likely experienced a momentary loss of power for undetermined reasons, which resulted in the sequence of events observed in the video. It is possible that the autopilot disconnected during the accident flight due to the pitch trim adapter experiencing a loss of power, which would have to have occurred between 30 and 9 seconds before impact.

A postaccident weather analysis revealed that the airplane was operating in an environment requiring instruments to navigate, but it could not be determined if the airplane was in cloud when the loss of control occurred. The sustained surface wind was from the north at 21 knots with gusts up to 28 knots, and moderate turbulence existed. The presence of the moderate turbulence could have contributed to the controllability of the airplane and the pilot's inability to recognize the airplane's attitude and the autopilot's operational status. 



Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The pilot's loss of airplane control due to spatial disorientation during the initial climb after takeoff in night instrument meteorological conditions and moderate turbulence. 

Findings

Aircraft
Heading/course - Not attained/maintained (Cause)
Pitch control - Not attained/maintained (Cause)
Lateral/bank control - Not attained/maintained (Cause)

Personnel issues
Aircraft control - Pilot (Cause)
Spatial disorientation - Pilot (Cause)

Environmental issues
Turbulence - Not specified
Dark - Not specified

Factual Information

History of Flight

Initial climb
Loss of control in flight (Defining event)
Loss of visual reference 

On April 28, 2017, about 2348 central daylight time, a Pilatus PC-12 airplane, N933DC, impacted terrain near Rick Husband Amarillo International Airport (AMA), Amarillo, Texas. The airline transport pilot and the two medical flight crewmembers were fatally injured. The airplane was destroyed. The airplane was registered to and operated by Rico Aviation LLC under the provisions of Title 14 Code of Federal Regulations (CFR) Part 135 as an air ambulance flight. Instrument meteorological conditions prevailed at the time of the accident, and the flight was operated on an instrument flight rules (IFR) flight plan. The flight was originating at the time of the accident and was en route to Clovis Municipal Airport (CVN), Clovis, New Mexico.

The AMA-based flight crew was first notified of an air ambulance mission by the Rico Aviation medical dispatcher at 2248. The mission was to transport a patient from Clovis, New Mexico, to Lubbock, Texas. The mission was delayed until receiving arrangements were made for the patient at the destination medical facility. During the delay, the pilot continued his flight preparation, including requesting and receiving his air traffic control (ATC) clearance.

A review of Federal Aviation Administration (FAA) ATC data revealed that, at 2332:15, the pilot contacted AMA ground control, said that he had received automatic terminal information service Oscar, and requested an IFR clearance to CVN. At 2332:40, the ground controller issued the pilot a clearance to CVN "as filed" with a climb to a final altitude of 8,000 ft mean sea level (msl); the assigned transponder code was 4261. The pilot correctly read back the clearance.

Final acceptance of the mission by the Rico Aviation medical dispatcher and the pilot came at 2334. The pilot contacted AMA ground control at 2341:54 and requested to taxi to the runway for departure. The ground controller instructed the pilot to taxi to runway 4. At 2343:50, the local controller cleared the flight for takeoff and instructed the pilot to turn right on course after departure. The pilot acknowledged the takeoff clearance and instructions.

After departing runway 4, the local controller observed a primary target with an associated transponder code of 4254, which was the code that had been assigned to the airplane on its previous flight. The local controller observed the 4254 target climb through 4,400 ft msl and instructed the pilot to reset the transponder to 4261. The pilot reset the transponder code to 4261. The local controller observed the beacon code change from 4254 to 4261, then advised the pilot "I've got you now," and instructed him to contact AMA departure control.

At 2346:54, the pilot contacted AMA departure control and reported "with you at 6,000 [ft msl]." The west radar departure controller radar-identified the airplane. At 2348:12, the departure controller advised the pilot that he was no longer receiving the airplane's transponder; the pilot did not respond. The departure controller made three more transmissions to the pilot without response. There were no further recorded transmissions to or from the airplane. The local controller reported to the departure controller that he had observed a fireball and reported a potential crash.

Figure 1 shows the plotted AMA radar data illustrating the accident flight path. The red targets are from transponder code 4254, and the blue targets are from transponder code 4261. The last eight recorded targets are labeled with their mode C reported altitudes.

Figure 1 – Plotted radar data illustrating the accident flight path

Surveillance video from a nearby truck stop, located about 400 yards southwest of the accident site, recorded lights from the airplane followed by an explosion. Still images were taken from the video and layered to produce figure 2, which depicts the airplane's final flight path. The images show the airplane descending about a 45°angle to ground impact.


Figure 2 – Accident airplane's final flight path 

Pilot Information

Certificate: Airline Transport; Commercial
Age: 57, Male
Airplane Rating(s): Multi-engine Land; Multi-engine Sea; Single-engine Land; Single-engine Sea
Seat Occupied: Left
Other Aircraft Rating(s): Gyroplane
Restraint Used: Unknown
Instrument Rating(s): Airplane
Second Pilot Present: No
Instructor Rating(s): Airplane Multi-engine; Airplane Single-engine; Gyroplane; Instrument Airplane
Toxicology Performed: Yes
Medical Certification: Class 2 With Waivers/Limitations
Last FAA Medical Exam: 01/19/2017
Occupational Pilot: Yes
Last Flight Review or Equivalent: 12/21/2016
Flight Time: 5866 hours (Total, all aircraft), 73 hours (Total, this make and model), 5759 hours (Pilot In Command, all aircraft), 28 hours (Last 90 days, all aircraft), 15 hours (Last 30 days, all aircraft), 0.3 hours (Last 24 hours, all aircraft) 

The pilot-in-command (PIC), age 57, had been employed at Rico Aviation since November 2016. While employed at Rico Aviation, he had flown with the company's director of operations (DO), the chief pilot, and the contracted flight instructor who trained Rico Aviation pilots in the PC-12, none of whom reported any concerns or issues with the pilot's flying skills. They also stated that there were no difficulties during the pilot's PC-12 training. For Pilatus PC-12 airplane-specific ground and flight training, Rico Aviation contracted with ACFT Services, LLC. Rico Aviation training records did not show the dates of the PC-12 ground training that ACFT Services provided to the pilot. Rico Aviation records indicated that the pilot's initial flight training in the PC-12 occurred between October 26 and 28, 2016, and was conducted by the ACFT Services instructor. ACFT Services issued the pilot a certificate of completion of training dated October 28, 2016. The training records showed satisfactory completion of maximum rate climbs, stalls in multiple configurations, and unusual attitude recovery. Also, high speed descents were discussed during this training. Further flight training was provided by the Rico Aviation DO on December 14, 2016, and by the Rico Aviation chief pilot on November 15, 2016, and December 15, 2016.



Autopilot Use, Procedures, and Training

According to the ACFT Services instructor who provided the PC-12 flight training to the pilot, pilots were taught to follow the manufacturer's limitation as to when to engage the autopilot after takeoff. The PC-12 airplane flight manual stated that the autopilot must not be engaged when the airplane is below 1,000 ft above ground level (agl). The standard procedure at Rico Aviation, confirmed by the Rico Aviation chief pilot, was to engage the autopilot at 1,000 ft agl after takeoff or when comfortably established in the climb.

The chief pilot had flown with the accident pilot on several occasions and had provided flight instruction to him in preparation for his Part 135 proficiency check, which was completed on December 21, 2016. He stated that the pilot used the autopilot normally and showed good knowledge of the autopilot but could fly fine without it.

The Rico Aviation training records indicated that the DO had flown with the pilot 7 days before the pilot's proficiency check. The DO stated that he had also flown with the pilot after the pilot's proficiency check as well as about a month before the accident on a repositioning flight. During these flights, he noticed no areas in which the pilot needed extra training. He thought the pilot would rather hand-fly the airplane than use the autopilot.

The DO, the chief pilot, and a medical crewmember all reported that they had not heard any negative comments from other Rico Aviation employees about the pilot's performance. The medical crewmember and the chief pilot each reported no known personal or medical issues that could have affected the pilot's performance.

The pilot's logbooks were not recovered during the investigation, and the pilot's recent flight experience was obtained from the Rico Aviation PC-12 airplane flight logs, which were kept at the company's Amarillo base.

The pilot had flown 28 hours in the preceding 90 days and 115 hours in the last year, 73 hours of which were in the PC-12. A review of the pilot's duty records from the operator indicated he had 4.2 hours of IFR flight time in the preceding 90 days, with 1.4 hours of this time at night. The pilot had accumulated a total of 2.6 hours of night IFR time, and 5.9 hours total IFR time since his last instrument proficiency check on December 21, 2016.



Pilot's Preaccident History

The pilot worked the night shift, from 1900 to 0800, on April 25th through April 28th and had logged 2 hours during those 3 shifts; he rotated between the Amarillo base and the Dalhart base during those dates. While on duty in Amarillo, he stayed at the Rico Aviation hangar at AMA. While on duty in Dalhart, he stayed at a crew house. When off-duty in Amarillo, he stayed at a local motel. The chief pilot stated that the pilot had checked out of the motel the morning of April 28, and he had no knowledge of the pilot's activities during the day. 

In correspondence with the pilot's wife, who resided in another state, she reported that the pilot did not have any problems adapting to the overnight duty schedule. She stated that he would sleep during the day and stay awake when on duty overnight. When preparing to start an overnight duty schedule, he would acclimate to that sleep/work schedule 1 or 2 days before. She was not aware of any sleep or health issues relating to his schedule. In the 3 days before the accident, she reported nothing unusual or out-of-the ordinary in any of her routine daily contacts with the pilot. 

Aircraft and Owner/Operator Information

Aircraft Make: PILATUS AIRCRAFT LTD
Registration: N933DC
Model/Series: PC 12
Aircraft Category: Airplane
Year of Manufacture: 1994
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: 105
Landing Gear Type: Retractable - Tricycle
Seats: 4
Date/Type of Last Inspection: 03/02/2017, Annual
Certified Max Gross Wt.:
Time Since Last Inspection:
Engines: 1 Turbo Prop
Airframe Total Time: 4407.5 Hours as of last inspection
Engine Manufacturer: P&W CANADA
ELT: Installed, not activated
Engine Model/Series: PT6A-67B
Registered Owner: RICO AVIATION LLC
Rated Power: 500 hp
Operator: RICO AVIATION LLC
Operating Certificate(s) Held: On-demand Air Taxi (135)

Airplane Background Information

The airplane was a nine-passenger, single-engine, turboprop airplane. It was configured as an air-ambulance with pilot and copilot seats, four seats in the cabin, and a patient bed. According to the last available flight logs, the airplane had accumulated 4,466.9 total hours and 3,769 total cycles.

Airplane Maintenance Information

According to the company's FAA-issued operations specifications, Rico Aviation was to maintain aircraft that were type-certificated with nine or fewer passenger seats in accordance with the manufacturer's maintenance documents and 14 CFR Parts 43, 91, and 135. All maintenance, preventive maintenance, and alterations to the aircraft, engines, propeller, and appliances were to be performed in accordance with current FAA regulations; manufacturer's service manuals, recommendations, and specifications; manufacturer's service bulletins and service letters; and airworthiness directives.

Chapters 4 and 5 in the Pilatus PC-12/45 Aircraft Maintenance Manual (AMM) contained the maintenance intervals for each airworthiness limitation item, 100-hour inspection, annual inspection, supplemental structural inspections, and progressive inspection requirements.

On March 2, 2017, a set of routine maintenance inspections and tasks was accomplished at an airplane total time of 4,407.5 hours and 3,658 total cycles. In addition to the routine maintenance inspections and tasks, 21 discrepancies (non-routine items) were corrected during this maintenance visit, including the following item:

Autopilot disconnecting on approaches – Removed Autopilot Computer P/N 065-0064-15, S/N 2175. Installed "Modified" Autopilot Computer P/N 065-0064-15, S/N X1898

There was one additional log entry for an autopilot discrepancy reported by a Rico Aviation pilot on April 26, 2017:

Autopilot disconnects on climb and cruise. Maintenance troubleshot the system and suspect Autopilot Trim Adapter to be causing issue. Removed Autopilot Trim Adapter P/N: 065-00164-0100, S/N: 1745. Installed Tested Autopilot Trim Adapter (KTA336-100) P/N 065-00164-0100, S/N: 1794. System ops check good. All work performed in accordance with the Pilatus PC-12 Maintenance Manual Ch. 22-10-07.

The maintenance records did not reveal any write ups or logbook items indicating any issues with the electronic attitude director indicator (EADI) or attitude and heading reference system (AHRS).

For a full list of the maintenance completed see the Maintenance Factual Report in the public docket associated with this report.

Autopilot System Description

The PC-12's primary flight control system for pitch, roll, and yaw is controlled by push-pull rods and/or cables. The secondary flight control system for roll and yaw consists of electrically-actuated trim tabs installed on the primary flight control surfaces; for pitch, the horizontal stabilizer is trimmed electrically. Trim positions for pitch, roll, and yaw are visually depicted on a triple trim indicator on the center console. The horizontal stabilizer, rudder, and aileron trim systems share a trim interrupt switch, which, if pressed due to a trim runaway of any of the respective systems, disconnects power from the pitch trim adapter and the aileron, rudder, and horizontal stabilizer trim actuators. The rocker-type switch is installed on the center pedestal and protected by a safety cover. The two-position switch is labeled "INTR" for the interrupt position and "NORM" for the normal position.

The airplane was equipped with a Honeywell (formerly Bendix/King) KFC-325 digital automatic flight control system (AFCS), which provided 3-axis (pitch, roll, and yaw) control. This system provided flight director guidance, autopilot functionality, and autopilot system monitoring. According to Honeywell, the system consists, in part, of a single KCP 220 autopilot computer, a mode controller, an altitude preselector, a pitch trim adapter, pitch, roll, and yaw servo-actuators, a control wheel steering (CWS) switch, a go-around switch, an autopilot disconnect switch, an EADI, and an electronic horizontal situation indicator. The autopilot computer processes flight environment and navigation data from a variety of sensors to compute pitch and roll steering commands. The pilot provides input to the AFCS through the KMC 321 mode controller, located on the forward instrument panel.

The AFCS requires the successful completion of a pilot-activated preflight test (PFT) as a prerequisite for autopilot mode engagement. A momentary depression of the self-test button on the mode controller will start a 5-second check of the functionality of the autopilot system, the auto trim system, including the KTA 336 trim adapter, and their system monitors.

Indications to the pilot of successful PFT completion is four flashes of the "TRIM" caption on the mode controller as the system is driven twice in each direction with the drive request being interrupted. This operation simulates a trim runaway and checks the ability of both monitors to detect it. After the test sequence, the aural warning tones are annunciated, and the autopilot annunciator on the mode controller flashes twelve times. If the PFT circuit detects a failure, the red "TRIM" caption on the mode controller stays on, and the red "A/P TRIM" warning on the Central Advisory and Warning System (CAWS) display unit illuminates.

After the successful completion of the PFT, the autopilot can be engaged by the pilot during flight by depressing the "AP" pushbutton on the mode controller. The autopilot will disengage when any of the following occur: 

On the mode controller, the "AP" pushbutton is pushed to turn off the autopilot.
On the control wheels, the "A/P DISC" pushbutton is pushed.
The trim trigger on either control wheel is depressed (manual trim engaged).
The trim interrupt switch is pushed.
The alternate stabilizer trim switch is set to "UP" or "DOWN."
A loss of power to the autopilot computer or the trim adapter occurs.
The monitors within the autopilot computer detect a failure.

The following autopilot monitor limit(s) are exceeded: 

Roll rates more than 10° per second (Except when the CWS switch is held depressed.)
Pitch rates more than 5° per second (Except when the CWS switch is held depressed.)
Accelerations outside of a +1.6g to +0.3g envelope (Disengagement will take place regardless of whether the CWS switch is activated.)

When the autopilot is disengaged, manually by the pilot or automatically when a problem is detected, the following captions and warnings are displayed:

On the mode controller, the "AP" caption flashes four times then turns off.
On the CAWS display unit, the amber "A/P DISENG" caution message will illuminate 3 seconds after the signal input to the CAWS changes from 28V (autopilot engaged) to 0V (autopilot disengaged) and the CWS button is not pressed. The caption will remain illuminated for about 26 to 27 seconds; it extinguishes at a maximum of 30 seconds from the initial time of the autopilot disconnect.
On the EADI, the red "AP" caption flashes five times then turns off.
The autopilot disconnect warning tone is annunciated in the loudspeakers and the headsets.
The CAWS gong warning tone is annunciated.

The autopilot system incorporates an automatic electric pitch trim system that provides pitch autotrim during autopilot operation via the stabilizer pitch trim actuator and automatic rudder trim relief during yaw damper and autopilot operation. No aileron autotrim function is available on the installed autopilot system. Annunciation of pitch and rudder autotrim occurs on the triple trim indicator by illumination of each respective pitch or rudder trim light and annunciation to the CAWS to make the autopilot trim advisory caption illuminate.

According to Honeywell, the maximum bank angle that the autopilot can command is 25°. Additionally, if the airplane is in a steady-state condition above 25° of bank, or above the pitch limit, the autopilot will engage. However, upon engagement, the autopilot will bring the airplane back to wings level maintaining the existing pitch attitude. If the airplane is in a condition that exceeds the following autopilot monitor limit(s), the autopilot will not engage:

Roll rates more than 10° per second (except when the CWS switch is held depressed)

Pitch rates more than 5° per second (except when the CWS switch is held depressed)

Accelerations outside of a +1.6g to +0.3g envelope

If a pilot were to override the autopilot while it was engaged and the CWS switch was not depressed, the autopilot would attempt to return the aircraft to the state before the override condition. However, if the autopilot monitors are tripped while attempting to return to the previous state, the autopilot will disengage.

The AHRS senses the magnetic heading of the aircraft and its pitch, roll, and yaw attitudes. The AHRS processes the data and sends it to other aircraft systems to use for display and control. An attitude and heading reference unit (AHRU) is one of the components of the AHRS. The AHRU has built-in test equipment that continuously monitors the AHRS. The memory of the AHRU keeps a history of the failures that occur. If a power failure occurs the memory of the AHRU keeps the last available satisfactory data.

The autopilot wiring terminal blocks found in the wreckage were a non-sealed type. 

Meteorological Information and Flight Plan

Conditions at Accident Site: Instrument Conditions
Condition of Light: Night
Observation Facility, Elevation: KAMA, 3604 ft msl
Distance from Accident Site: 2 Nautical Miles
Observation Time: 2353 UTC
Direction from Accident Site: 1°
Lowest Cloud Condition:
Visibility:  10 Miles
Lowest Ceiling: Broken / 700 ft agl
Visibility (RVR):
Wind Speed/Gusts: 21 knots / 28 knots
Turbulence Type Forecast/Actual: /
Wind Direction: 360°
Turbulence Severity Forecast/Actual: /
Altimeter Setting: 29.78 inches Hg
Temperature/Dew Point: 7°C / 7°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Amarillo, TX (AMA)
Type of Flight Plan Filed: IFR
Destination: CLOVIS, NM (CVN)
Type of Clearance: IFR
Departure Time: 2345 CDT
Type of Airspace: Class C 

Preflight Weather Briefing – ForeFlight

At 2303, the pilot retrieved a ForeFlight weather briefing for the accident flight and he filed an IFR flight plan. the ForeFlight briefing would have displayed in the ForeFlight app and been emailed to the pilot immediately after the flight plan was filed. The pilot also viewed multiple weather images before the flight, but the specific items viewed by the pilot are not logged by ForeFlight.

Archived Weather Data

At 2353, AMA reported wind from 360° at 21 knots with gusts to 28 knots, visibility of 10 statute miles or greater, ceiling broken at 700 ft agl, overcast cloud base at 1,200 ft agl, temperature of 7°C, dew point temperature of 7°C, and an altimeter setting of 29.78 inches of mercury. The remarks section of the 2353 observation included: station with a precipitation discriminator, peak wind of 32 knots from 360° occurred at 2326, lightning more than 10 miles away to the west, rain began at 2314 and ended at 2325, and ceiling variable between 500 ft agl and 900 ft agl.

Data from the AMA weather radar indicated light values of reflectivity around the accident location. A radial velocity image from around the time of the accident identified veering wind (wind that turns clockwise with increasing height) in the lowest 10,000 ft msl around the accident location. A wind profile for AMA around the accident time indicated that, near the accident location, the wind at 4,000 and 5,000 ft msl was from the north-northeast at 35 knots; the wind at 6,000 ft msl was from the northeast at 30 knots; the wind at 7,000 ft msl was from the east at 30 knots; the wind at 8,000 ft msl was from the southeast at 35 knots; and the wind at 9,000 ft msl was from the south-southeast at 45 knots.

The graphical turbulence guidance (GTG) depicted the probability of clear air turbulence at altitudes of 3,000, 5,000, 7,000, and 9,000 ft msl, applicable to times surrounding the accident. These images depicted mainly light-to-moderate turbulence over AMA. The GTG is not intended to predict turbulence associated with convection and thunderstorm clouds but may provide some guidance in areas of properly predicted thunderstorms when the convection is widespread.

A high-resolution rapid refresh model sounding for the accident location at 0000 on April 29, 2017, revealed that the near-surface wind was from the north-northeast about 20 knots. About 5,500 ft msl, the wind was from the northeast about 30 knots. Above this level, the wind veered with height and increased in magnitude to a south wind at 45 knots about 11,000 ft msl. A temperature inversion was noted between 6,200 ft and 7,800 ft msl, and the freezing level was near 13,000 ft msl. Calculations made by the rawinsonde observation program identified a layer of significant turbulence between about 5,500 and 12,600 ft msl. Relative humidity was greater than 90% between near the surface and about 10,000 ft msl and in a layer between about 16,000 and 18,000 ft msl.

The warning coordination meteorologist for the National Weather Service (NWS) Weather Forecast Office (WFO) in Amarillo, Texas, provided a 3D image (figure 3, which shows AMA at the center of the 3D box) that showed a wind shear zone between 2,500 and 3,500 ft msl as seen from the AMA weather radar about 2355. The red area indicates wind away from the radar, and the green area indicates wind toward the radar. The image shows a northerly wind near the surface and a 40 to 60 knot southerly wind above 4,000 ft msl. 

There were no publicly disseminated pilot reports for AMA for altitudes below 10,000 ft msl between 2100 on April 28, 2017, and 0300 on April 29, 2017.


Figure 3 – Wind profile, 3D view 

At 2036, a terminal aerodrome forecast was issued for AMA by the NWS WFO in Amarillo that forecasted for the accident time: wind from 020° at 17 knots with gusts to 25 knots, visibility greater than 6 miles, light rain showers, scattered clouds at 3,000 ft agl, and ceiling overcast at 5,000 ft agl.

At 2145, an AIRMET SIERRA was issued for IFR conditions and precipitation/mist below 10,000 ft msl for an area that included the accident location. At the accident time, there were no AIRMETs active for turbulence or low level wind shear potential below 10,000 ft msl that included the accident location. At 2145, an AIRMET TANGO was issued for moderate turbulence between 10,000 ft msl and FL180 for an area that included the accident location.

There were no convective or non-convective SIGMET advisories active at the accident time that included the accident location. A convective SIGMET was issued at 2255 for an area that was very close to the accident location.

According to the National Oceanic and Atmospheric Administration's Aviation Weather Center (AWC), "any Convective SIGMET implies severe or greater turbulence, severe icing, and low level wind shear." Further, according to discussion with AWC staff, convective SIGMETs are not geographically static for their valid period, rather they should move with any movement vector included in that convective SIGMET. NWS Instruction 10-811 and FAA Advisory Circular (AC) 00-45H both address the "movement" field (e.g., "MOV FROM 24045KT") in the text of a convective SIGMET. AC 00-45H provides the following translation for the portion of the convective SIGMET containing the movement field: "an intensifying area of severe thunderstorms moving from 240° at 45 knots (to the northeast)." According to the Domestic Operations Branch Chief at the AWC, "on occasion when the thunderstorm cells contained in the [convective SIGMET] are moving in vastly different direction than the [convective SIGMET], we add a comment at the bottom of the [convective SIGMET] something like 'CELL MOV FROM 22040KT.' Of course, we don't include all comment options in the NWS Directives, so most people don't know this."

Other Flight Crew Reports

Flight crewmembers of several different airplanes that arrived and departed AMA within about 1 hour of the accident time were contacted regarding turbulence and/or weather conditions encountered on the approach to/departure from AMA.

The first officer of an Embraer 170 airplane that landed at AMA about 40 minutes before the accident time reported no significant weather conditions.

The flight crew of an Embraer 145 airplane that landed at AMA about 25 minutes before the accident time reported that they encountered light chop to light turbulence. The crew did not remember giving or being asked for any PIREPs.

The flight crew of a Boeing 737 airplane that departed AMA about 1 hour after the accident time reported that they were concerned about the weather in the area. There was some drizzle as they taxied out. They were concerned about ice and storms in the area. They experienced moderate to heavy turbulence during the climb-out, and there were isolated storm cells to the east. They did not experience ice buildup on the airplane, but they deviated for weather as they departed to the east. The captain said, "it wasn't the worst turbulence he had been in, but it was close." The first officer said that the moderate- to-heavy turbulence from the time they departed until climbing through 10,000 ft msl was some of the worst turbulence he had experienced. The onboard weather radar was solid green, and they deviated around some yellow cells.

The Boeing 737 flight crew further reported that they did not know to expect significant turbulence during the departure. Since the AMA control tower was closed when they departed, they were communicating solely with the air route traffic control center controller, and they did not receive any weather information. Their flight was after midnight so there was very little air traffic in the area, and no one was communicating about the turbulence over AMA. They did not give a pilot report about the turbulence encountered near AMA. They stated that the severity of turbulence they encountered is the type they would want to be aware of in advance.

Flight data recorder (FDR) data from the Boeing 737 was provided by the operator. Plots of wind information recorded on the FDR as well as the wind profile derived from additional FDR data are included in the Meteorology Factual Report in the public docket associated with this report.

WRECKAGE AND IMPACT INFORMATION

The airplane impacted a pasture (figure 4) adjacent to several stationary train cars about 1.5 nautical miles south of AMA, and a postimpact fire ensued. The wreckage debris path was generally oriented along a northeast-southwest line, and the airplane impacted the ground facing southwest. All major structural components of the airplane were located within the debris field.


Figure 4 – Accident site viewed from the south 

Ground scars at the accident site and damage to the airplane were consistent with the airplane impacting in a steep, nose-low and wings-level attitude. The top soil was dark and relatively soft extending 3 to 4 ft deep, and the subsoil was a relatively hard clay. The impact crater was about 5 ft deep. A section of the left winglet, the left pitot tube, and the angle of attack sensor from the left wing were found embedded in the ground; the winglet is noticeable on the far right side of figure 4. The vertical stabilizer remained attached to the fuselage and sustained relatively minor damage compared to the rest of the airplane structure. The horizontal stabilizer separated near mid-span, and both sides were identified. The left side was severely crushed from the leading edge aft; a corresponding impact mark was observed in the ground near the center and in front of the impact crater.

Airframe Examination

The wreckage was documented at the accident site and then relocated to a secure hangar at AMA for a full layout and detailed examination. The airplane was heavily fragmented (figure 5).


Figure 5 – Wreckage organized in hangar 

A postaccident examination of the flight control system did not reveal evidence of any preimpact anomalies that would have prevented normal operation. The flap actuator jackscrews indicated that the flaps were fully retracted at the time of impact. The landing gear were retracted at the time of impact.

Engine Examination

The engine was found separated from the airplane and adjacent to the initial impact crater. The engine exhibited significant impact and compression deformation and was partially covered in soot from the postimpact fire. The propeller had separated from the engine, and a fractured section of the propeller hub flange remained attached to the propeller shaft. The engine was recovered to a secure hangar for examination and disassembly.

The engine exhibited rotational signatures indicative of engine operation during impact. The examination did not reveal any pre-impact anomalies that would have precluded normal engine operation.

Propeller Examination

All four propeller blades separated from the hub assembly and were found at the accident site; two blades were in the impact crater; one blade shank was just forward of the impact crater with its corresponding tip section about 100 yards forward and to the right of the debris path; and the fourth blade was about 50 yards to the right of the debris path. About 90% of the hub fragments were recovered.

The propeller blades (figure 6) exhibited damage consistent with engine operation during impact.


Figure 6 – Propeller 

There were no preimpact anomalies found that would have prevented or degraded normal propeller operation.

Autopilot Component Examinations

The autopilot components found in the wreckage were examined. Of the components recovered, the CAWS display unit, KMC 321 mode controller, KCP 220 autopilot computer, autopilot pitch/roll/yaw servos, autopilot pitch trim adapter, KMH 820 multi-hazard computer, altitude preselector, and AHRU were subjected to additional examinations and testing for evidence and data extraction.

A download of the AHRU data revealed that the elapsed time of the unit was 2,936.5 hours, and the last recorded fault, a "Roll Synchro Fail" fault, was recorded at elapsed time 2,923.4 hours.

The CAWS display unit and the KMC 321 mode controller could not be functionally tested due to impact-related damage; however, a light bulb filament examination was conducted on both units at the NTSB Materials Laboratory. The CAWS "A/P DISENG" amber annunciator contained two light bulbs, and the filaments from both bulbs were intact and stretched, consistent with illumination at the time of impact. Also, the CAWS "A/P TRIM" red annunciator contained two light bulbs, and the filaments from both bulbs were broken but not stretched. The KMC 321 mode controller autopilot (AP), yaw damper (YD) and altitude hold (ALT) light bulb filaments were broken but not stretched. The two lightbulbs for the red "TRIM" warning annunciator were found broken with their respective filaments missing. Broken but unstretched filaments are indicative of the light not being illuminated at impact.

For additional details on the examination of the autopilot components, see the System Factual Report in the public docket associated with this report.

MEDICAL AND PATHOLOGICAL INFORMATION

A review of FAA medical records indicated that the pilot reported no significant medical concerns to the FAA, and as of the most recent medical examination the medical examiner identified no significant conditions on physical examination.

South Plains Forensic Pathology, P.A., Lubbock, Texas, completed an autopsy on the pilot. The autopsy report concluded that the cause of death was multiple blunt impact injuries.

The FAA's Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, performed toxicological tests on specimens that were collected during the pilot's autopsy. Results were negative for all tests conducted.

TESTS AND RESEARCH

Aircraft Performance Study

An aircraft performance study for this accident used AMA airport surveillance radar data, measurements made at the accident site, historical AMA weather observations, wind data derived from the FDR of the Boeing 737 that departed about 1 hour after the accident, and ATC communications to estimate the position and orientation of the airplane during the accident flight. The entire study with all figures is available in the public docket associated with this report.

The simulation indicated that, after lifting off from AMA runway 4, the airplane accelerated to about 193 knots calibrated airspeed (KCAS) while climbing between 600 and 1,200 ft per minute (fpm) to an altitude of about 4,400 ft msl, or about 800 ft agl (figure 7). The airplane leveled about 4,300 to 4,400 ft msl for about 30 seconds; at 23:46:30, it resumed climbing, reaching 6,000 ft msl (2,400 ft agl) at 23:46:52. During this climb, the airplane decelerated from 193 KCAS to 122 KCAS. At 23:47:02, the airplane started an increasingly rapid descent from 6,000 ft msl to the ground (elevation 3,600 ft msl). Based on the simulation, the estimated rate of descent and airspeed at impact were about 17,000 fpm and 220 KCAS, respectively. The estimated time of impact was 23:47:19.

Figure 7 – Simulation of accident flight, altitude vs time graph

At 23:45:42, while climbing through 4,100 ft msl (500 ft agl), the airplane started a slow right roll (figure 8), reaching a roll angle of about 42° at 23:46:10. At 23:46:24, the roll angle had decreased to 36°, and the pitch angle started to increase steadily, which was consistent with the climb to 6,000 ft msl. At 23:46:32, when the roll angle was 30°, the airplane started rolling more quickly to the left, rolling through wings level at 23:46:40, then on a ground track of 267° true.

Figure 8 – Google Earth view of radar data and simulation trajectory

The simulation required full throttle from 23:45:24 through 6,000 ft msl, except for two brief power reductions, one between 23:45:48 and 23:45:56 when there was a pause in the increase in airspeed and another between 23:46:28 and 23:46:30 when the airplane leveled briefly at 4,400 ft msl.

The simulation control inputs were well within the airplane's control travel limits, and the computed column and wheel control forces required were generally (until the last 7 seconds of the flight) within the one-hand, short-term force limit prescribed in 14 CFR 23.143.

The simulation maximum normal load factor reached at impact was about 2.6g.

Throughout the simulation, the airplane was not at risk of an aerodynamic stall.

The airplane achieved a peak pitch angle of about 23° at 23:46:42 (figure 9), after which the pitch angle decreased steadily to an estimated -42° at impact. As the pitch angle decreased, the roll angle increased steadily to the left, reaching an estimated -76° at impact.

An estimate of the "apparent" pitch and roll angles, which represent the attitude a pilot would "feel" the airplane to be in based on his vestibular/kinesthetic perception of the components of the load factor vector in his own body coordinate system, was made based on the simulation load factors. The "apparent" pitch angle ranged between 0° and 15°, and the "apparent" roll angle ranged between 0° and -4° (figure 9).

Figure 9 – Simulation apparent pitch and roll angles

Autopilot Testing and Results

The Rico Aviation chief pilot indicated that "there was a continuing issue with the airplane's autopilot." The autopilot "would often disconnect unexpectedly, triggering a master warning tone. It would require the pilot to reset the system by pushing the autopilot test button, then re-engaging the autopilot." On April 26, 2017, the chief pilot captured the airplane's autopilot issue on video during a flight, and the video was reviewed during the investigation. 

The video began with a view of the instrument panel showing the amber "A/P DISENG" caution message illuminated on the CAWS display unit indicating that the autopilot had recently disengaged. The video continued with the pilot re-engaging the autopilot in navigation and altitude hold mode by depressing the AP, navigation, and altitude hold pushbuttons on the mode controller; the amber "A/P DISENG" message extinguished when the AP button was pressed. About 5 seconds after autopilot re-engagement, a red "TRIM" warning illuminated on the autopilot mode controller along with a master warning and a red "A/P TRIM" warning on the CAWS display unit; the autopilot remained engaged. The pilot then momentarily depressed the self-test button on the mode controller, which started the 5-second PFT. After the PFT was completed, the red trim warnings extinguished, and the amber "A/P DISENG" caution message on the CAWS display unit illuminated after 3 seconds. This was the end of the video. According to Pilatus, the action of re-engaging the autopilot after it has automatically disconnected is contrary to instructions in the AFM. The AFM in several instances prohibits continued autopilot operation following abnormal operation or malfunctioning.

Testing on an exemplar Pilatus PC-12/45 airplane found that the issue with the autopilot, as described by the chief pilot and as observed in the video, could occur only when the following three sequential events occurred: 

The autopilot disconnected automatically when electrical power was removed from the pitch trim adapter for less than 10 seconds, which resulted in the amber "A/P DISENG" caution message illuminating after 3 seconds and no trim warning messages being displayed.

The autopilot was re-engaged contrary to AFM procedures.

The autopilot commanded a pitch trim input.

The testing revealed that when these three events occurred, a red "TRIM" warning was displayed on the mode controller along with a continuous autopilot trim fail warning tone, the red master warning, and a red "A/P TRIM" warning on the CAWS display unit, and the autopilot remained engaged. The results of this test were consistent with the events that occurred in the video.

The testing also revealed that, if electrical power was removed from the pitch trim adapter for more than 30 seconds, the autopilot would immediately disconnect with the proper annunciations, but 13.5 seconds after the removal of power, the following three indications would illuminate at the same time:

The red master warning

The red "TRIM" caption on the mode controller

The red "A/P TRIM" annunciator on the CAWS display unit

The continuous autopilot trim fail warning tone was not annunciated. The results of this test were not consistent with the events recorded on the video because the red trim warnings in the video occurred more than 14 seconds after the autopilot had disconnected.

Testing revealed that the "A/P DISENG" caption would only illuminate if the autopilot had been engaged and then disconnected, either manually or automatically. It would not illuminate if the autopilot was off without being previously engaged nor would it illuminate if the pilot attempted and failed to engage the autopilot by pressing the AP pushbutton on the mode controller.

Airport Information

Airport: RICK HUSBAND AMARILLO INTL (AMA)
Runway Surface Type: 
Airport Elevation: 3606 ft
Runway Surface Condition: Unknown
Runway Used: 04
IFR Approach: None
Runway Length/Width: 13502 ft / 200 ft
VFR Approach/Landing: None 

Wreckage and Impact Information

Crew Injuries: 3 Fatal
Aircraft Damage: Destroyed
Passenger Injuries: N/A
Aircraft Fire: On-Ground
Ground Injuries: N/A
Aircraft Explosion: On-Ground
Total Injuries: 3 Fatal
Latitude, Longitude: 35.196389, -101.704722 (est) 

Organizational And Management Information


According to the company's FAA-issued operations specifications, Rico Aviation was authorized to conduct 14 CFR Part 135 on-demand operations carrying nine passengers or less. The company was based at AMA. In addition to the accident airplane, the company operated 2 Cessna Conquest CE-441 airplanes and 1 Cessna Citation CE-525A airplane. Rico Aviation had been operating for 20 years. The owner and president was the current DO. The Lubbock Flight Standards District Office provided oversight for Rico Aviation. Both the chief pilot and the DO had been designated by the FAA as company flight instructors. Rico Aviation operated air-ambulance flights typically consisting of one pilot, one to two medical crewmembers, and a patient.



NTSB Identification: CEN17FA168
Nonscheduled 14 CFR Part 135: Air Taxi & Commuter
Accident occurred Friday, April 28, 2017 in Amarillo, TX
Aircraft: PILATUS AIRCRAFT LTD PC 12, registration: N933DC
Injuries: 3 Fatal.

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

On April 28, 2017, about 2348 central daylight time, a Pilatus PC-12 airplane, N933DC, impacted terrain near Rick Husband Amarillo International Airport (AMA), Amarillo, Texas. The airline transport pilot and two flight crew were fatally injured. The airplane was destroyed. The airplane was registered to and operated by Rico Aviation LLC, under the provisions of 14 Code of Federal Regulations Part 135 as an air ambulance flight. Instrument meteorological conditions prevailed at the time of the accident and the flight was operated on an instrument flight rules (IFR) flight plan. The flight was originating at the time of the accident and was en route to Clovis Municipal Airport (CVN), Clovis, New Mexico. 

At 2248, the flight request was received from a medical center in Clovis to retrieve and transfer a patient to Lubbock, Texas. The flight was accepted by the Rico Aviation crew at 2334.

A review of preliminary Federal Aviation Administration (FAA) air traffic control information revealed that about 2332 the pilot received an IFR clearance and about 2344 he taxied to runway 4 at intersection A. About 2345 the airport tower controller cleared the airplane for takeoff on course, which was a right turn. About 2346 the same controller instructed the pilot to reset his transponder and then transferred communications to the departure controller. About 2347 the pilot reported at 6,000 ft msl and the departure controller radar identified the airplane. About 2348 the controller advised the pilot that he was no longer receiving the transponder, but the pilot did not respond. The controller made 3 more transmissions to the pilot without response. The airport tower controller observed a fireball and reported a crash.

Surveillance video from a nearby business recorded the accident airplane in a steep descent at a high rate of speed followed by an explosion.

The airplane impacted a pasture (figure 1) adjacent to several stationary train cars about 1 nautical mile south of AMA and a post impact fire ensued. The wreckage debris path was generally oriented southwest. All major structural components of the airplane were located within the wreckage.

The pilot, age 57, held an airline transport pilot certificate with a rating for airplane multi-engine land; a commercial pilot certificate with ratings for airplane single engine land, airplane single engine sea airplane multi-engine sea, rotorcraft-gyroplane; a flight engineer certificate for turbojet powered aircraft; a flight instructor certificate for airplane single engine and multi-engine, instrument airplane, and rotorcraft-gyroplane; an advanced and instrument ground instructor certificate; a powerplant mechanic certificate; and a repairman experimental aircraft builder certificate.

On the medical certificate application, dated January 19, 2017, the pilot reported that his total flight experience included 5,800 hours and 80 hours in last six months. This pilot was issued a second-class medical certificate with the limitation "must have available glasses for near vision."

According to FAA and maintenance records, the airplane was manufactured in 1994. Its most recent annual and 100-hour inspections were completed March 2, 2017, at 4,407.5 hours total time.

At 2353, the AMA automated weather observation recorded wind from 360° at 21 knots gusting to 28 knots, 10 statute miles visibility, broken clouds at 700 ft above ground level (agl), overcast cloud layer at 1,200 ft agl, temperature 45° F, dew point 45°F, altimeter setting 29.78 inches of mercury. Remarks: peak wind from 360° at 32 knots at 2346, lightning distant west, rain began at 2314 and ended at 2325, variable ceiling from 500 to 900 ft agl.

A preliminary review of the weather data revealed wind shear beginning about 6000 ft msl along with a temperature inversion at the same altitude.

The wreckage has been retained by the NTSB for further examination.