Wednesday, June 12, 2019

Powerplant System/Component Malfunction/Failure: Cessna 425 Conquest I, N622MM; fatal accident occurred June 10, 2019 near Butler Memorial Airport (KBUM), Bates County, Missouri





Aviation Accident Final Report - National Transportation Safety Board

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

Additional Participating Entities:
Federal Aviation Administration / Flight Standards District Office; Kansas City, Missouri
Cessna; Wichita, Kansas
Pratt & Whitney; Montreal, FN

Investigation Docket - National Transportation Safety Board:

Location: Butler, Missouri 
Accident Number: CEN19FA161
Date and  Time: June 10, 2019, 10:20 Local
Registration: N622MM
Aircraft: Cessna 425 
Aircraft Damage: Destroyed
Defining Event: Powerplant sys/comp malf/fail 
Injuries: 1 Fatal
Flight Conducted Under: Part 91: General aviation - Personal

Analysis

During a cross-country flight, the pilot initiated a descent to his intended destination. During the descent, the pilot informed air traffic control (ATC) that he could not retard power on the right engine. Later in the descent, the pilot decided to shut down the right engine. The pilot communicated his desire to land at the nearest airport to ATC, and ATC provided the pilot with the clearance to divert. Radar data showed the airplane in a steady descent toward the airport.

When the airplane was at an altitude of about 2,500 ft mean sea level, the pilot contacted ATC and stated that he was trying to get the airplane under control; radar data showed the airplane in a 360° right turn at the time. The pilot contacted ATC again and stated that he was going to land on a highway. No further transmissions were received from the pilot. After the right turn, the airplane continued in a descent through 1,300 ft mean sea level, at which point radar contact was lost. A witness saw the airplane and stated that the airplane was low and slow but appeared to be in stable flight with both propellers spinning. She did not see any smoke coming from the airplane. She saw the airplane flying northeast to southwest when it suddenly descended nose first into the ground. The airplane impacted a gravel road adjacent to a 100-fttall grain silo about 1 mile from the highway and about 3.3 miles from the airport.

Examination of the airframe flight controls, throttle quadrant rigging, and engines revealed no mechanical anomalies. The left and right engine fuel control units (FCU) were disassembled and showed no pre-existing mechanical anomalies that could have prevented normal operation. Some contaminants were found in the Py air sections of both FCUs. According to the manufacturer, if an FCU’s Py bleed was partially restricted with debris, modulation of power could be altered. However, each FCU’s Py bleed had no restrictions or blockages. Examination of the fuel pumps, propeller governors, and overspeed governors of both engines revealed no mechanical anomalies that could have prevented normal operation.

According to the Cessna 425 single-engine performance chart, the airplane could have maintained level flight with one engine inoperative if the landing gear and flaps were retracted and the inoperative engine’s propeller was feathered. At the time of impact, the airplane’s landing gear was extended, the flaps were at 10° down, and the right engine propeller condition lever was about 0.25 inch from minimum and not in the feather detent position.

The reason for the pilot’s reported problem with retarding the right engine’s throttle could not be determined. It is unknown why the pilot made a right turn into the inoperative engine toward the end of the descent, and the reason for the pilot’s loss of control could not be determined.

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 during a descent to a diversion airport with only the left engine operating. Contributing to the accident was a malfunction of the right engine throttle, the cause of which could not be determined.

Findings
Aircraft Power lever - Malfunction
Aircraft (general) - Unknown/Not determined
Personnel issues (general) - Pilot
Not determined (general) - Unknown/Not determined

Factual Information

History of Flight

Enroute-descent Powerplant sys/comp malf/fail (Defining event)
Emergency descent Controlled flight into terr/obj (CFIT)

On June 10, 2019, about 1020 central daylight time, a Cessna 425 airplane, N622MM, was destroyed when it was involved in an accident near Butler, Missouri. The private pilot sustained fatal injuries. The cross-country flight was conducted under the provisions of Title 14 Code of Federal Regulations Part 91.

The flight originated about 0554 eastern daylight time from Vero Beach Municipal Airport, Vero Beach, Florida, and its planned destination was New Century Airport (IXD), Olathe, Kansas. After an uneventful 970-mile flight, the pilot initiated a descent to IXD and was in direct communication with air traffic control (ATC).

About 1004 central daylight time (all times from this point forward are central daylight time), the pilot told the radar controller that he had a “major problem” and could not retard the right engine throttle. Shortly afterward, the controller instructed the pilot to change frequencies to another radar controller. At 1008:32, the controller told the pilot that he was observing the airplane climbing and descending and acknowledged that the pilot was having engine trouble. The pilot advised the controller that he was going to have to shut down the right engine while it was at full power. The controller then asked the pilot if the airplane could make IXD. The pilot responded that he could make the airport but that he might have to shut down the engine on final approach.

At 1011:54, the pilot reported that he was operating the airplane with one engine. At 1013:40, the pilot requested the nearest airport, and the controller advised the pilot that the Butler Airport (BUM) was the nearest airport and was about 8 miles away. At 1015:32, the pilot stated that he would have to land on runway 18 at BUM; 36 seconds later, the pilot reported that he had the airport in sight.

At 1017:45, the pilot advised the controller that he was trying to get the airplane under control. The controller then confirmed that the pilot had BUM in sight and cleared the airplane for a visual approach.

Between 1018:53 and 1019:08, the pilot advised the controller that the airplane was “gonna go down” on the highway. No further transmissions were received from the pilot. Radar data showed that the airplane made a 360° right turn when the airplane was at an altitude of about 2,500 ft mean sea level, as shown in figures 1 and 2. The last radar data point was recorded when the airplane was at 1,300 ft mean sea level. 

A witness who was traveling in her car on the highway reported that she saw the airplane. She stated that the airplane was low and slow but appeared to be in stable flight with both propellers spinning. She did not see any smoke coming from the airplane. She saw the airplane flying northeast to southwest before it suddenly descended nose first into the ground. The airplane impacted a gravel road adjacent to a 100-ft-tall grain silo, about 1-mile from the highway and about 3.3 miles from BUM.

Pilot Information

Certificate: Private
Age: 80,Male
Airplane Rating(s): Single-engine land; Multi-engine land
Seat Occupied: Left
Other Aircraft Rating(s): None 
Restraint Used: 4-point
Instrument Rating(s): Airplane 
Second Pilot Present: No
Instructor Rating(s): None 
Toxicology Performed: Yes
Medical Certification: Class 3 With waivers/limitations
Last FAA Medical Exam: March 14, 2019
Occupational Pilot: No 
Last Flight Review or Equivalent: April 15, 2019
Flight Time: 3457 hours (Total, all aircraft), 1891 hours (Total, this make and model), 24 hours (Last 90 days, all aircraft), 5 hours (Last 24 hours, all aircraft)

According to pilot records, he had completed recurrent ground and flight training in the Cessna 425 on April 4, 2019.

Aircraft and Owner/Operator Information

Aircraft Make: Cessna 
Registration: N622MM
Model/Series: 425 No Series 
Aircraft Category: Airplane
Year of Manufacture: 1984
Amateur Built:
Airworthiness Certificate: Normal 
Serial Number: 425-0187
Landing Gear Type: Retractable - Tricycle
Seats: 7
Date/Type of Last Inspection: June 3, 2019 Annual 
Certified Max Gross Wt.:
Time Since Last Inspection: 
Engines: Turbo prop
Airframe Total Time: 6092 Hrs as of last inspection 
Engine Manufacturer: Pratt & Whitney
ELT: Installed, not activated 
Engine Model/Series: PT6A-112
Registered Owner: 
Rated Power: 500 Horsepower
Operator: On file
Operating Certificate(s) Held: None

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual (VMC)
Condition of Light: Day
Observation Facility, Elevation: BUM 
Distance from Accident Site:
Observation Time: 10:15 Local
Direction from Accident Site:
Lowest Cloud Condition: Clear
Visibility 10 miles
Lowest Ceiling: None
Visibility (RVR):
Wind Speed/Gusts: 4 knots / 
Turbulence Type Forecast/Actual: None / None
Wind Direction: 90° 
Turbulence Severity Forecast/Actual: N/A / N/A
Altimeter Setting: 30 inches Hg 
Temperature/Dew Point: 26°C / 20°C
Precipitation and Obscuration:
Departure Point: Vero Beach, FL (VRB)
Type of Flight Plan Filed: IFR
Destination: Olathe, KS (IXD)
Type of Clearance: IFR
Departure Time: 05:54 Local
Type of Airspace: Class E

Airport Information

Airport: Butler Memorial Airport BUM 
Runway Surface Type:
Airport Elevation: 893 ft msl 
Runway Surface Condition: Dry
Runway Used:
IFR Approach: None
Runway Length/Width:
VFR Approach/Landing: None

Wreckage and Impact Information

Crew Injuries: 1 Fatal
Aircraft Damage: Destroyed
Passenger Injuries:
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 1 Fatal
Latitude, Longitude: 38.350276,-94.340278

The airplane initially impacted a gravel road with the right wing tip in a nose-down, right-wing-low attitude. The right engine/nacelle impacted the ground between the gravel road and a 100-ft-tall grain silo. The left wing struck a steel staircase on the
exterior of the silo. The left and right main landing gear also contacted the silo. Rubber tire transfer marks were observed about 20 and 30 ft up the silo steel structure. A small fragment of airplane aluminum was found attached to the silo about 30 ft up. One of the left propeller blades contacted the silo about 15 ft up and left a black, white, and red paint smear on the silo surface. The nose of the airplane struck an air cycle machine at the base of the silo before as the airplane impacted the ground. The airplane then cartwheeled onto the left engine and came to rest inverted about 30 ft from the initial impact point, as shown in figure 3.

The left, right, and nose landing gear were found extended. The flaps were positioned about 10° nose down. Flight control continuity was established from the cockpit to all flight control surfaces. The fuel selector handles in the cockpit were found in cross-feed positions, with the left selector in the right main position and the right selector in the left main position.

The right engine power control lever was found at the full forward position. The right engine propeller condition lever was found about 0.25 inch from minimum. The right engine fuel lever was found in the fuel cutoff position (off). The left engine power control lever was found at the full forward position. The left engine propeller condition lever was found about 0.50 inch back from maximum. The left engine fuel lever was found in the run position (on). The control linkages were impact damaged, and an examination of the available control linkages found no anomalies with the rigging.

The left and right engines were examined during teardowns. No mechanical anomalies were found that could have prevented normal operation.

The left and right engine fuel control units (FCU) were disassembled, and no pre-existing mechanical anomalies were found that could have prevented normal operation. Some contaminants were found in the Py air sections of both FCUs. According to the manufacturer, if
an FCU’s Py bleed was partially restricted with debris, modulation of power could be altered.

Examination of each FCU’s Py bleed found no restrictions or blockages. 

Examinations of the fuel pumps, propeller governors, and overspeed governors of both engines revealed no mechanical anomalies that could have prevented normal operation.

Additional Information

According to the Cessna 425 single-engine performance chart, the airplane could have maintained level flight with one engine inoperative if the landing gear and flaps were retracted and the inoperative engine’s propeller was feathered. The right engine propeller condition lever was not found in the feather detent position.

Medical and Pathological Information

According to the autopsy report from the Office of the Jackson County Medical Examiner, Kansas City, Missouri, the pilot’s cause of death was multiple blunt force trauma.

Toxicology testing performed by the Federal Aviation Administration Forensic Sciences Laboratory detected dextromethorphan (an over-the-counter cough medicine commonly marketed as Robitussin), its metabolite dextrorphan, rosuvastatin (a medication to control high cholesterol), and metoprolol (a medication to control high blood pressure) in the pilot’s blood and urine. Ramipril (a medication to control high blood pressure) and the over-thecounter pain and inflammation medications acetaminophen, salicylate (aspirin), and ibuprofen were detected only in the pilot’s urine. All of these medications are considered non-impairing.  No ethanol was detected in the pilot’s blood.


Location: Butler, MO
Accident Number: CEN19FA161
Date & Time: 06/10/2019, 1030 CDT
Registration: N622MM
Aircraft: Cessna 425
Injuries:1 Fatal 
Flight Conducted Under: Part 91: General Aviation - Personal 

On June 10, 2019, about 1030 central daylight time, a Cessna 425 multi-engine airplane, N622MM, registered to Santa Fe Investments Inc., of Wilmington, Delaware, and operated by the pilot, was destroyed during a forced landing after experiencing engine problems, near Butler, Missouri. The private pilot sustained fatal injuries. The cross country flight was being conducted under the provisions of 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed and an instrument flight rules (IFR) flight plan was filed. The flight originated at 0554 from the Vero Beach Municipal Airport (VRB), Vero Beach, Florida, and its planned destination was the New Century Air Center Airport (IXD), Olathe, Kansas.

According to preliminary information provided by Air Traffic Control (ATC), the pilot was beginning to descend to set up his approach to IXD. Passing through about 17,000 feet msl, the pilot told the ATC controller that he was having problems retarding the power on the right engine. Passing through about 13,200 feet msl, the pilot told the controller that he was going to lower the landing gear and continue to proceed direct to IXD, and stated that he would have to shut down the right engine when he was in range of the airport. Passing through about 12,900 feet msl, The pilot told the controller that the right engine was still stuck at full power, and that he was going to have to shut the right engine down. Passing through about 7,800 feet msl, the pilot requested to change his destination to the nearest airport. The controller advised the pilot that the nearest airport was Butler Memorial Airport (BUM), about 8 miles away, and gave the pilot a vector to BUM.

Passing through about 6,200 feet msl, the controller asked the pilot to change frequencies and the pilot acknowledged but did not have the airport in sight. The controller issued another vector toward BUM. Passing through about 5,400 feet msl, the pilot told the controller that he still did not have the airport in sight, and a few seconds later told the controller that he had the airport in sight. Passing through about 4,000 feet msl, the controller advised the pilot of a possible tailwind if landing on runway 18 at BUM, and the pilot responded that he would go-around and set up for runway 36. Passing through about 2,900 feet msl, the controller asked the pilot if he had the airport in sight, and the pilot responded to standby and said, "I am trying to get this thing under control." Passing through about 1,800 feet msl, the pilot told the controller that, "she's going down," and stated that he was going to try to land on highway 69. The last radar information showed the airplane about 1,700 feet msl.

A witness near the accident site saw the airplane at low altitude, nosing down toward a field. Evidence at the accident site showed that the airplane impacted a 75-foot tall grain silo and fell to the ground. The grain silo was located about one mile from a highway, and about 4 miles from BUM. Local residents responded to the accident site and reported the accident.

The wreckage was moved to a secure facility and detailed examinations of the airframe fuel system and engines were conducted. Examinations of the engine accessories are ongoing. 

Aircraft and Owner/Operator Information

Aircraft Make: Cessna
Registration: N622MM
Model/Series: 425 No Series
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: BUM
Observation Time: 1015 CDT
Distance from Accident Site:
Temperature/Dew Point: 26°C / 20°C
Lowest Cloud Condition: Clear
Wind Speed/Gusts, Direction: 4 knots / , 90°
Lowest Ceiling: None
Visibility: 10 Miles
Altimeter Setting: 30 inches Hg
Type of Flight Plan Filed: IFR
Departure Point: Vero Beach, FL (VRB)
Destination: Olathe, KS (IXD) 

Wreckage and Impact Information

Crew Injuries: 1 Fatal
Aircraft Damage: Destroyed
Passenger Injuries: N/A
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 1 Fatal
Latitude, Longitude: 38.350278, -94.340278


 John N. McConnell Jr.


VERO BEACH, Florida  —  Authorities with the Bates County Coroner's Office say the pilot killed when his Cessna 425 Conquest I plane crashed into a western Missouri grain bin Monday has been identified as 80-year-old John N. McConnell Jr.

Neighbor Tom Kappus, of Vero Beach, said McConnell had homes in both Vero Beach and Kansas City.

Kappus said he was devastated when he learned his friend had died.

"It's such a sad day to think that John is not here," Kappus said. "He's one of those people you always expect to see."

Producing Artistic Director/CEO for Riverside Theatre Allen Cornell said he met McConnell through his wife, who became a board member when the couple moved to the Vero Beach.

"It's just hard for all of us here at the theatre to believe this happened because he was one of our mainstay supporters," Cornell said. "He was instrumental in so many things that we did here."

According to the Federal Aviation Administration, McConnell departed from the Vero Beach Airport and was headed to the Butler Memorial Airport when the plane crashed.

McConnell was the only person on board.

The National Transportation Safety Board is leading the investigation.

Story and video ➤ https://www.wpbf.com






KANSAS CITY, Missouri — One man died in a plane crash Monday morning in Bates County, Missouri.

The Missouri State Highway Patrol said that the crash happened off of Interstate 49 between Adrian and Passaic. The Bates County Sheriff's Office called the area part of rural Butler.

MSHP confirmed the pilot was the only person on board the small plane and was killed in the accident.

The Bates County Coroner's Office on Tuesday identified the pilot as 80-year-old John N. McConnell, of Kansas City, Missouri and Vero Beach, Florida.

The Cessna 425 Conquest I plane was headed for the Butler Memorial Airport from Vero Beach.

The Bates County Sheriff's Office said that the plane crashed into a grain bin.

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

14 comments:

  1. 80 year old pilot (flying alone) + fuel required miscalculation + complacency = very unfortunate ending to himself and a fine aircraft. I had noticed that this aircraft in previous flights had to divert more then once to another airport most likely due to running low on fuel. My prayers are with the family. Come on guys, it's nice to be able to fly as we get older, but for goodness sakes take a long a safety pilot!

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  2. I have flown with many older pilots, as an instructor, and it is difficult to tell them that they are not up to "par", where they need to be better than "par".

    The issue is that even though I stop flying with them to keep my signature out of their logbooks does not stop them from flying without a flight review, medical or another qualified person, or in a legal airplane.

    The airlines live by a rule for a reason ....

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  3. And does being 30 or 40 make you any better or smarter? I'll bet a study of "fuel starvation" accidents is more skewed to the under 50s than the over 50s.

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  4. Not smarter, but more cognizant of your situation as a flight progresses

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  5. fuel starvation? perhaps. I'm not that familiar with the C425, but 4+30 must be getting close. However, the crash occurred around 1030 on what was apparently a CAVU day. You mean to tell me, he could not have picked a more suitable place to dead stick it, but the side of a grain elevator, when all about him were wide open fields??

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  6. "Not smarter, but more cognizant of your situation as a flight progresses"

    Plenty of 30 and 40 year olds in the stats to argue that age doesn't matter on lack of situational awareness

    RIP

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  7. Remember it's a twin. So fuel starvation means that one engine conks out. So suddenly he's got 400+ horsepower on one side and zero on the other. Flightaware depicts a tight 360-degree turn to the right at the very end. My theory would be that the right engine ran out of fuel and this initiated the tight turn to the right.

    It's not helpful that this occurred at the 4 1/2 hour mark. A pilot of any age is fatigued at the 4 1/2 hour mark. I'm not 80 years old and I would be startled plenty.

    Also unhelpful is that this plane is so fast and sleek. Power-to-weight of the 425 is almost on par with WWII warbirds. It's a very potent airplane. Once it got loose it might be be difficult to get it back.

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  8. I would venture to guess fatigue and fuel mismanagement.

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  9. According to flightaware, he was going to IXD and then diverted to Butler; meaning his intended destination was further than Butler. Guessing he diverted here due to a fuel limitation, and then experienced fuel exhaustion.


    Regardless of the cause, RIP to the pilot and condolences to his family.

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  10. You have NO idea about this wonderful pilot. He was very conscientious and calculating. Keep your thoughts to yourself. No one planned so well as he did. You may just find yourself in the same situation one day!

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  11. He was an amazing pilot. Extremely prepared and conscientious. Never took a chance with weather and planned perfectly. If you don't know him, keep your thoughts to yourself... because you have NO idea of the brilliant man who lost his life. God bless his family in this tragic time.

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  12. Interesting discussion on Beechtalk.com.

    Not likely fuel exhaustion.

    Some evidence that it's a strange over speed condition on engine.

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  13. The grain silo looks to be in perfect order, not a dent that I can see nor is the silo knocked off kilter. Where exactly did the plane strike the silo?

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