Sunday, December 08, 2019

Loss of Engine Power (Partial): Convair C-131B Samaritan, N145GT; fatal accident occurred February 08, 2019 in the Atlantic Ocean

Left Wing Washed On Shore.

Left Wing Washed On Shore.

Left Wing Washed On Shore. 

Capt. Robert Hopkins

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


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




Location: Miami, United States

Accident Number: ERA19LA096
Date & Time: 02/08/2019, 1216 EST
Registration: N145GT
Aircraft: Convair C131
Aircraft Damage: Destroyed
Defining Event: Loss of engine power (partial)
Injuries: 1 Fatal, 1 Serious
Flight Conducted Under: Part 135: Air Taxi & Commuter - Non-scheduled 

On February 8, 2019, at 1216 eastern standard time, a General Dynamics Convair 340 (C-131B), N145GT, was destroyed during a ditching in the Atlantic Ocean about 32 miles east of Miami-Opa Locka Executive Airport (OPF), Miami, Florida. The captain was fatally injured, and the first officer was seriously injured. The airplane was registered to and operated by Conquest Air, Inc., as a Title 14 Code of Federal Regulations Part 135 cargo flight. Visual meteorological conditions prevailed, and an instrument flight rules (IFR) flight plan was filed. The flight departed Lynden Pindling International Airport (MYNN), Nassau, Bahamas, at 1113.


The accident occurred during a return trip to OPF. The first officer stated that, for the first flight of the day (from OPF to MYNN), the preflight inspection, engine start, taxi, and engine run-up were normal and that about 900 gallons of fuel was on board. The flight to MYNN was normal until the first officer, who was the pilot monitoring, attempted to adjust the left engine propeller control for the speed for cruise flight, yet there was no movement on the gauge, and the power was stuck at 2,400 rpm. The first officer tried to reset the propeller control circuit breaker but was unable to do so. The captain stabilized power on both engines, and the remainder of the flight to MYNN was uneventful. After the airplane landed, the captain asked the first officer to send a text message to maintenance control, but the message did not transmit. The captain told the first officer not to worry and indicated that, if they were unable to reset the propeller control on the ground during the engine run-up, then they would shut down the airplane and call maintenance.


The first officer stated that, before the accident flight began, the engines started normally, and both propellers were cycled. The captain and the first officer were able to reset the left propeller control, so the airplane departed for OPF. The first officer was the pilot flying, and he stated that the airplane was operating normally during the takeoff and initial climb; however, as the airplane climbed through 4,000 ft, the left engine propeller control stopped working, and the power was again stuck at 2,400 rpm. The captain tried to adjust the propeller control and inadvertently increased power to 2,700 rpm. The captain then took control of the airplane and stabilized the power on both engines. He leveled the airplane at 4,500 ft, canceled the IFR flight plan, and flew via visual flight rules direct to OPF. The first officer suggested that they return to MYNN, but the captain wanted to continue to OPF (OPF was located about 160 nautical miles west-northwest of MYNN). The first officer indicated that he did not want to disagree with the captain's decision given the captain's "extensive" experience.


The flight proceeded normally until the beginning of the descent (the first officer did not remember the altitude) to 1,500 ft, when the right engine began to surge and lose power. The first officer stated that the captain turned on both boost pumps and tried to stabilize the right engine with the mixture and throttle but that the engine began to backfire and shake "violently" with variations in the brake mean effective pressure (BMEP), fuel pressure, fuel flow indications, rpm, and manifold pressure. At that point, the flight crew performed the engine failure emergency checklist. As part of the checklist, the right engine was feathered, and the mixture was brought to the cutoff position. The first officer reported that, shortly afterward, the left engine also began to surge and shake "violently" with the same variations experienced after the right engine began to surge. At that point, the captain tried to control the left engine, and the first officer declared an emergency.


The first officer stated that, as the captain maneuvered the airplane to ditch, the airplane impacted the water "violently." During the impact, the first officer struck his head hard on the instrument panel. The first officer unbuckled his harness and saw the captain slumped over in his seat and unresponsive. He tried to lift the captain from his seat but was not able to do so. The first officer realized that he needed to get out of the airplane when the water inside the cockpit was chest high. The first officer stated that he kicked open the cockpit door and saw that the tail had separated from the empennage. He grabbed the life raft and exited from the tail of the airplane. He was rescued by a US Coast Guard helicopter.


The first officer stated that he did not know what caused the engines to lose power. According to the operator, "at the first sign of a mechanical malfunction the crew should have landed as soon as practicable."





PERSONNEL INFORMATION


The captain held an airline transport pilot certificate with ratings for airplane single- and multiengine land and instrument airplane. He held type ratings for the Boeing 727 and 737; the Convair 240, 340, and 440; and LR-JET. The operator reported that the captain had 23,000 hours total flight experience, of which 725 hours were in the accident airplane make and model. The captain also held a Federal Aviation Administration (FAA) first-class medical certificate dated January 22, 2019.


The first officer held a commercial pilot certificate with ratings for airplane single- and multiengine land and instrument airplane. He held type ratings in the Convair 240, 340, and 440 (second-in-command privileges only). The operator reported that the first officer had 650 hours total flight experience, of which 305 hours were in the accident airplane. The first officer also held an FAA first-class medical dated August 25, 2018.


AIRCRAFT INFORMATION


The airplane was equipped with two Pratt & Whitney R-2800CB3 radial engines and two Hamilton Sunstrand 43E60-377 propellers that were being maintained under an approved aircraft inspection program. The airplane's last inspection was on the day before the accident. At that time, the left engine had accrued 1,943 hours, the right engine had accrued about 417 hours, and the airframe had accrued about 12,701 hours.


WRECKAGE AND IMPACT INFORMATION


The left wing washed ashore. The rest of the airplane was not recovered from the ocean. Thus, the engines could not be examined and tested to determine the cause of the failures. 


Pilot Information


Certificate: Commercial

Age: 68, Male
Airplane Rating(s): Multi-engine Land; Single-engine Land
Seat Occupied: Left
Other Aircraft Rating(s): None
Restraint Used:
Instrument Rating(s): Airplane
Second Pilot Present: Yes
Instructor Rating(s): None
Toxicology Performed: No
Medical Certification: Class 1 None
Last FAA Medical Exam: 01/22/2019
Occupational Pilot: Yes
Last Flight Review or Equivalent: 08/09/2018
Flight Time:  23000 hours (Total, all aircraft), 725 hours (Total, this make and model), 21000 hours (Pilot In Command, all aircraft)

Co-Pilot Information


Certificate: Commercial

Age: 28, Male
Airplane Rating(s): Multi-engine Land; Single-engine Land
Seat Occupied: Right
Other Aircraft Rating(s): None
Restraint Used:
Instrument Rating(s): Airplane
Second Pilot Present: Yes
Instructor Rating(s): None
Toxicology Performed: No
Medical Certification: Class 1 Waiver Time Limited Special
Last FAA Medical Exam: 08/25/2018
Occupational Pilot: Yes
Last Flight Review or Equivalent: 06/16/2018
Flight Time: 650 hours (Total, all aircraft), 305 hours (Total, this make and model)



Aircraft and Owner/Operator Information


Aircraft Make: Convair

Registration: N145GT
Model/Series: C131 B
Aircraft Category: Airplane
Year of Manufacture: 1955
Amateur Built: No
Airworthiness Certificate: Transport
Serial Number: 256
Landing Gear Type: Retractable - Tricycle
Seats: 3
Date/Type of Last Inspection: 02/07/2019, AAIP
Certified Max Gross Wt.: 47000 lbs
Time Since Last Inspection:
Engines: 2 Reciprocating
Airframe Total Time: 12701.2 Hours at time of accident
Engine Manufacturer: P&W
ELT: Installed, not activated
Engine Model/Series: R2800CB3
Registered Owner: Conquest Air Inc
Rated Power: 2400 hp
Operator: Conquest Air Inc
Operating Certificate(s) Held: On-demand Air Taxi (135)
Operator Does Business As:   
Operator Designator Code: Q0UA

Meteorological Information and Flight Plan


Conditions at Accident Site: Visual Conditions

Condition of Light: Day
Observation Facility, Elevation: OPF, 6 ft msl
Distance from Accident Site: 32 Nautical Miles
Observation Time: 1253 EST
Direction from Accident Site: 90°
Lowest Cloud Condition:
Visibility:  10 Miles
Lowest Ceiling: Broken / 3600 ft agl
Visibility (RVR): 
Wind Speed/Gusts: 7 knots /
Turbulence Type Forecast/Actual: None / None
Wind Direction: 40°
Turbulence Severity Forecast/Actual: N/A / N/A
Altimeter Setting: 30.21 inches Hg
Temperature/Dew Point: 26°C / 17°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Nassau, AO (NAS)
Type of Flight Plan Filed: IFR
Destination: Miami, FL (OPF)
Type of Clearance: IFR; VFR Flight Following
Departure Time: 1113 EST
Type of Airspace: Unknown 

Wreckage and Impact Information


Crew Injuries: 1 Fatal, 1 Serious

Aircraft Damage: Destroyed
Passenger Injuries: N/A
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 1 Fatal, 1 Serious
Latitude, Longitude: 25.000000, -79.000000 (est)

Flight Control System Malfunction/Failure: Robinson R44 Raven II, N484AB; accident occurred January 08, 2019 near Garner Field Airport (KUVA), Uvalde, Texas



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

Additional Participating Entity: 

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

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/N484AB

Location: Uvalde, TX
Accident Number: CEN19LA065
Date & Time: 01/08/2019, 1000 CST
Registration: N484AB
Aircraft: Robinson R44
Aircraft Damage: Substantial
Defining Event: Flight control sys malf/fail
Injuries: 1 Minor, 1 None
Flight Conducted Under: Part 91: General Aviation - Instructional

On January 8, 2019, about 1000 central standard time, a Robinson R44 II helicopter, N484AB, experienced a hard landing during an autorotation shortly after takeoff from Garner Field Airport, Uvalde, Texas. The flight instructor sustained minor injuries, the student pilot was not injured, and the helicopter sustained substantial damage. The helicopter was registered to and operated by a private individual as a Title 14 Code of Federal Regulations Part 91 instructional flight. Visual meteorological conditions prevailed at the time of the accident, and a flight plan was not filed. The local flight was originating at the time of the accident.

According to the flight instructor, all pre-takeoff checks were normal with no anomalies noted. Once the helicopter was through effective translational lift and about 40 knots airspeed, the collective was raised to increase the available power to takeoff power setting. Shortly thereafter, a loud pop/bang was heard followed by an uncommanded right yaw and severe vibrations. Due to the low altitude and airspeed, the flight instructor immediately initiated an autorotation. Upon touchdown, the helicopter tilted forward with the main rotor blades about 6 inches from contacting the ground. The flight instructor applied aft cyclic to correct, and the main rotor blades contacted the tailboom.

Postaccident examination of the helicopter revealed the tailboom was partially separated, and the tail rotor driveshaft system was damaged. During the examination, the clutch assembly lubricant was drained and an unusual amount of metallic debris was noted in the strainer. The clutch assembly was removed and sent to Robinson Helicopter Company for further examination.

Examination and disassembly of the clutch assembly revealed galling of the sprags and the corresponding sprag contact surfaces on the shaft and hub.

According to the Robinson R44 maintenance manual, the clutch assemblies are to be inspected for metallic flakes every 500 hours. The most recent inspection on the clutch assembly was completed on April 18, 2018, about 245 hours prior to the accident.

Flight Instructor Information

Certificate: Flight Instructor; Commercial
Age: 30, Male
Airplane Rating(s): None
Seat Occupied:Left
Other Aircraft Rating(s): Helicopter
Restraint Used: 3-point
Instrument Rating(s): Helicopter
Second Pilot Present: Yes
Instructor Rating(s): Helicopter; Instrument Helicopter
Toxicology Performed: No
Medical Certification: Class 1 With Waivers/Limitations
Last FAA Medical Exam: 09/18/2018
Occupational Pilot: Yes
Last Flight Review or Equivalent: 08/15/2018
Flight Time:  2650 hours (Total, all aircraft), 1200 hours (Total, this make and model), 2600 hours (Pilot In Command, all aircraft), 250 hours (Last 90 days, all aircraft), 150 hours (Last 30 days, all aircraft), 5 hours (Last 24 hours, all aircraft)

Student Pilot Information

Certificate: Private
Age: 39, Male
Airplane Rating(s): Single-engine Land
Seat Occupied: Right
Other Aircraft Rating(s): None
Restraint Used: 3-point
Instrument Rating(s): None
Second Pilot Present:Yes
Instructor Rating(s): None
Toxicology Performed: No
Medical Certification: Class 2 Without Waivers/Limitations
Last FAA Medical Exam: 04/04/2018
Occupational Pilot: No
Last Flight Review or Equivalent:
Flight Time:   400 hours (Total, all aircraft), 20 hours (Total, this make and model), 320 hours (Pilot In Command, all aircraft), 25 hours (Last 90 days, all aircraft), 10 hours (Last 30 days, all aircraft), 1 hours (Last 24 hours, all aircraft)

Aircraft and Owner/Operator Information

Aircraft Make: Robinson
Registration: N484AB
Model/Series: R44 II
Aircraft Category: Helicopter
Year of Manufacture: 2006
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: 11390
Landing Gear Type: Skid;
Seats: 4
Date/Type of Last Inspection: 11/07/2018, Annual
Certified Max Gross Wt.: 2500 lbs
Time Since Last Inspection: 245 Hours
Engines: 1 Reciprocating
Airframe Total Time: 1680.9 Hours at time of accident
Engine Manufacturer: Lycoming
ELT: Not installed
Engine Model/Series: IO-540-AE1A5
Registered Owner: Bodie Nunn
Rated Power: 205 hp
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:
Distance from Accident Site:
Observation Time: 0930 CST
Direction from Accident Site: 
Lowest Cloud Condition: Clear
Visibility:  10 Miles
Lowest Ceiling: None
Visibility (RVR):
Wind Speed/Gusts: Calm /
Turbulence Type Forecast/Actual: None / None
Wind Direction:  
Turbulence Severity Forecast/Actual: N/A / N/A
Altimeter Setting: 29.95 inches Hg
Temperature/Dew Point: 25°C / 15°C
Precipitation and Obscuration: No Precipitation
Departure Point: Uvalde, TX (UVA)
Type of Flight Plan Filed: None
Destination: Uvalde, TX (UVA)
Type of Clearance: None
Departure Time: 1000 CST
Type of Airspace: Class G

Airport Information

Airport: Garner Field (UVA)
Runway Surface Type: N/A
Airport Elevation: 941 ft
Runway Surface Condition: Dry
Runway Used: N/A
IFR Approach: None
Runway Length/Width:
VFR Approach/Landing: Forced Landing 

Wreckage and Impact Information

Crew Injuries: 1 Minor, 1 None
Aircraft Damage: Substantial
Passenger Injuries: N/A
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 1 Minor, 1 None
Latitude, Longitude: 29.210278, -99.743056 (est)

System/Component Malfunction/Failure (Non-Power): Cessna T210M Turbo Centurion II, N1237M; accident occurred January 06, 2019 at Bishop International Airport (KFNT), Flint, Genesee County, Michigan

Front view of airplane on runway.
Federal Aviation Administration

Rear view of airplane on runway.
Federal Aviation Administration

Nose landing gear well with leaking hydraulic hose.
Federal Aviation Administration

Close view of degraded hydraulic hose.
Federal Aviation Administration

Hydraulic fluid dipstick.




Federal Aviation Administration

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

Federal Aviation Administration / Flight Standards District Office; Belleville, Michigan


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/N1237M


Location: Flint, MI
Accident Number: CEN19LA059
Date & Time: 01/06/2019, 1640 EST
Registration: N1237M
Aircraft: Cessna T210
Aircraft Damage: Substantial
Defining Event: Sys/Comp malf/fail (non-power)
Injuries: 4 None
Flight Conducted Under: Part 91: General Aviation - Personal

On January 6, 2019, about 1640 eastern standard time, a Cessna T210 airplane, N1237M, experienced an unsafe landing gear indication and landed with the gear partially extended at Bishop International Airport (FNT), Flint, Michigan. The private pilot and 3 passengers were not injured, and the airplane sustained substantial damage. The airplane was registered to Fly Happy LLC and operated by the pilot under the provisions of Title 14 Code of Federal Regulations Part 91 as a personal flight. Day visual meteorological conditions prevailed at the time of the accident and a flight plan was not filed. The flight originated from Clare Municipal Airport (48D), Clare, Michigan, about 1600, and was destined for FNT.

The pilot reported that after departure from 48D he raised the landing gear handle and the gear motor continued to operate longer than normal with an abnormal sound toward the end of the retract sequence. The right main gear did not fully retract and hung about 45° rearward; the left main gear was not visible from the pilot's vantage. The pilot troubleshot the issue for 20 to 25 minutes by completing the emergency procedure checklists, but the landing gear did not respond. At some point during the pilot's troubleshooting, the nose landing gear fully extended. The pilot continued the flight to FNT and declared an emergency with air traffic control (ATC). Before landing the pilot attempted to extend the landing gear but was only able to get the nose gear to extend. During a flyby ATC confirmed that both main landing gear were not extended.

During the emergency landing at FNT, the nose gear remained extended and the two main gear were partially retracted. The airplane spun about 180° and came to rest on the runway (figure 1).


Figure 1. Accident airplane on runway

The responding Federal Aviation Administration (FAA) inspector completed a postaccident examination of the airplane and provided oversight for a functional test of the landing gear system. The examination revealed the nose gear well partially covered in red hydraulic fluid, no hydraulic fluid observed on the corresponding dipstick, and a damaged nose gear door actuator hydraulic hose, part number (p/n) S2178-4-0095A (figure 2).

Figure 2. Damaged hydraulic hose

To facilitate a functional test of the hydraulic system, the airplane was raised on jack stands and about 16 ounces of hydraulic fluid was added to the hydraulic reservoir. The emergency gear extension handle was actuated in attempt to extend the main landing gear before preforming the full functional test. After 10 to 12 pumps, hydraulic fluid sprayed from the damaged hydraulic hose. There was no resistance felt from the emergency handle during actuation. The hydraulic system was unable to build pressure so the functional test was terminated. The damaged hose was replaced with a new hose and the functional test was resumed. With the new hose installed, the emergency handle was actuated and the main landing gear extended and locked without anomaly.

A review of the airplane's maintenance records revealed that the last annual inspection was completed on September 9, 2018, at 3,840.2 hours total airframe time. The airplane accumulated 32.8 hours since the annual inspection with no hydraulic hose or landing gear discrepancies noted. The nose gear door actuator hose was first replaced in October 1977, and then replaced again on April 4, 1996, at 2,059.2 hours total time. The airplane had accumulated 1,813.4 hours total time since the hydraulic hose was replaced.

The airplane manufacturer's inspection guidelines are to perform a functional test and inspect the landing gear system every 200 hours. The maintenance manual states, "Each 5 years, overhaul all retraction and brake system components. Check for wear and replace all rubber packings and backups and hydraulic hoses." This maintenance requirement applied to this airplane. Additional guidance associated with the inspection was Cessna service newsletter, SNL85-54, issued during November 1985, which changed the 5-year overhaul/replacement requirement to an "on condition" overhaul/replacement interval based on part numbers involved. The damaged hose, p/n S2178-4-0095A, was considered an "on condition" component and could be replaced based on its condition at the time of maintenance.

In 1992, the airplane manufacturer released Cessna service bulletin, SEB92-8, that called for the replacement of all S2178-4 hydraulic hoses with p/n S2888-4-0095. According to available maintenance documentation, the airplane was never equipped with the updated hydraulic hose. 

Pilot Information

Certificate: Private
Age: 54, Male
Airplane Rating(s): Single-engine Land
Seat Occupied: Left
Other Aircraft Rating(s): None
Restraint Used: 3-point
Instrument Rating(s): Airplane
Second Pilot Present: No
Instructor Rating(s): Airplane Single-engine; Instrument Airplane
Toxicology Performed: No
Medical Certification: Class 2 With Waivers/Limitations
Last FAA Medical Exam: 06/26/2018
Occupational Pilot: No
Last Flight Review or Equivalent: 09/30/2017
Flight Time:  1877 hours (Total, all aircraft), 309 hours (Total, this make and model), 1762 hours (Pilot In Command, all aircraft), 22 hours (Last 90 days, all aircraft), 7 hours (Last 30 days, all aircraft) 



Aircraft and Owner/Operator Information

Aircraft Make: Cessna
Registration: N1237M
Model/Series: T210 M
Aircraft Category: Airplane
Year of Manufacture: 1977
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: 21061927
Landing Gear Type: Retractable - Tricycle
Seats: 6
Date/Type of Last Inspection: 09/05/2018, Annual
Certified Max Gross Wt.: 4000 lbs
Time Since Last Inspection:
Engines: 1 Reciprocating
Airframe Total Time: 3873 Hours at time of accident
Engine Manufacturer: Continental Motors
ELT: C126 installed, not activated
Engine Model/Series: TSIO-520-R
Registered Owner: Fly Happy LLC
Rated Power: 310 hp
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: KFNT, 766 ft msl
Distance from Accident Site: 0 Nautical Miles
Observation Time:1653 EST 
Direction from Accident Site: 115°
Lowest Cloud Condition: Clear
Visibility:  10 Miles
Lowest Ceiling: None
Visibility (RVR):
Wind Speed/Gusts: 9 knots /
Turbulence Type Forecast/Actual: /
Wind Direction: 40°
Turbulence Severity Forecast/Actual: /
Altimeter Setting: 30.32 inches Hg
Temperature/Dew Point: 1°C / -6°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Clare, MI (48D)
Type of Flight Plan Filed: None
Destination: Flint, MI (FNT)
Type of Clearance: VFR; VFR Flight Following
Departure Time: 1600 EST
Type of Airspace: Class C

Airport Information

Airport: Bishop Intl (FNT)
Runway Surface Type: Asphalt
Airport Elevation: 782 ft
Runway Surface Condition: Dry
Runway Used: 09
IFR Approach: None
Runway Length/Width: 7201 ft / 150 ft
VFR Approach/Landing: Full Stop; Traffic Pattern 

Wreckage and Impact Information

Crew Injuries: 1 None
Aircraft Damage: Substantial
Passenger Injuries: 3 None
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 4 None
Latitude, Longitude: 42.969167, -83.755278 (est)

Aerodynamic Stall/Spin: Cessna 550 Citation II, N941JM; accident occurred November 30, 2018 at Hector International Airport (KFAR), Fargo, Cass County, North Dakota


View of the ice build-up on the airplane’s windshield.

View of the front of the airplane.

View of the accident site from the front of the airplane. 

View of passengers and first responders near the accident airplane.

View of emergency personnel and first responders at accident site.



View of the airplane and damage to the right wing.

View of the damage to the right wing.

View of the damage to the left wing.

View of the ice build-up on the AOA probe.

View of runway and the airplane in the grass infield.

View of the ice build-up on the leading edge of the right wing.
Federal Aviation Administration

View of ice build-up of left horizontal stabilizer. 
Federal Aviation Administration 

View of ice build-up of left horizontal and vertical stabilizer.
Federal Aviation Administration 

View of the airplane's center pedestal.
Federal Aviation Administration 

View of the airplane's cabin from the rear. 
Federal Aviation Administration 

View of seat positioned over the toilet.
Federal Aviation Administration 

View of the couch and cabinet.
Federal Aviation Administration 

View of couch, cabinet, seats from the front of the cabin. 
Federal Aviation Administration 

View of the couch and its seatbelts. 
Federal Aviation Administration 

View of couch seatbelt with broken steel cable. 
Federal Aviation Administration 


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

Additional Participating Entities:

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

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/N941JM


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

HISTORY OF FLIGHT

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

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

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

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

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

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

PERSONNEL INFORMATION

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

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

Single-pilot Exemption

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

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

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

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



AIRCRAFT INFORMATION

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

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

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

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

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

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

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

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

Flaps

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

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

The manual further states:

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

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

Ice Protection

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

METEOROLOGICAL INFORMATION

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

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

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

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

FLIGHT RECORDERS

Multiple Electronic Devices Examination

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

Cockpit Voice Recorder

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

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

Flight Data Recorder

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

WRECKAGE AND IMPACT INFORMATION

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

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

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

TESTS AND RESEARCH INFORMATION

NTSB Radar Performance Study

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

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

ADDITIONAL INFORMATION

Operational Control of the Flight

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

Pilot Information

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

Aircraft and Owner/Operator Information

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

Meteorological Information and Flight Plan

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

Airport Information

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

Wreckage and Impact Information

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