Monday, January 30, 2023

Collision with Terrain (non-CFIT): Cessna 172M Skyhawk, N9049H; accident occurred September 11, 2022 in Fort Collins, Larimer County, Colorado




LARIMER COUNTY, Colorado — The pilot of a small plane that crashed in northern Colorado in September last year has been criminally charged.

The Larimer County Sheriff's Office (LCSO) said 35-year-old Ahmed El-Kaddah was flying a Cessna 172M Skyhawk near Horsetooth Reservoir around 7 p.m. September 11, 2022. Witnesses told investigators the plane was being flown recklessly and buzzed several boats before turning west toward the mountains and crashing near Horsetooth Mountain.

El-Kaddah and his passenger survived the crash with only minor injuries, the Sheriff's Office said.

The pilot told authorities the plane had a mechanical issue, but an investigation by the National Transportation Safety Board (NTSB) and Federal Aviation Administration (FAA) determined the crash wasn't due to any "mechanical malfunctions or anomalies."

The NTSB report said statements made by El-Kaddah were inconsistent with recovered flight data.

The Sheriff's Office contacted the FBI following the crash, but the FBI said El-Kaddah's actions did not meet the criteria for filing federal charges, the Sheriff's Office said.

The case was then presented to the 8th Judicial District Attorney's Office, which filed the following charges against El-Kaddah:

Five counts of menacing - class 1 misdemeanor

Six counts of reckless endangerment - class 2 misdemeanor

“The fact that someone would show such reckless disregard for the lives of others is concerning, but it’s even more disturbing on a date that holds so much pain and significance for our country,” said Larimer County Sheriff John Feyen. “The lack of legal accountability is frustrating to say the least, but in this and every case, we’ll continue to support victims and hold suspects accountable within the confines of the law.”

In a news release, LCSO said the 2021 Colorado Misdemeanor Reform legislation "narrowed the definition of felony menacing; as a result, threatening immediate serious injury with a vehicle or aircraft is classified as a misdemeanor under current law."

LCSO said El-Kaddah left the United States shortly after the crash and has not returned. A warrant has been issued for his arrest upon his return to the United States.

Anyone with information on El-Kaddah's location is asked to call Investigator Tyler Thomas at 970-498-5167.
























Aviation Accident Final Report - National Transportation Safety Board

Investigator In Charge (IIC): Williams, David

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

Additional Participating Entity:
Nelson Wolfmeier; Federal Aviation Administration / Flight Standards District Office; Denver, Colorado

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

Thunderbird Aviation LLC

Journeys Aviation 


Location: Fort Collins, Colorado 
Accident Number: CEN22LA414
Date and Time: September 11, 2022, 18:59 Local 
Registration: N9049H
Aircraft: Cessna 172M 
Aircraft Damage: Substantial
Defining Event: Collision with terr/obj (non-CFIT)
Injuries: 2 Minor
Flight Conducted Under: Part 91: General aviation - Personal

Analysis

A pilot and flight instructor were conducting a personal flight over a reservoir when they descended and flew at a low altitude over two boats on the water. After passing the second boat, they turned west into a cove and impacted rising terrain about 1 mile west of the shoreline, which resulted in substantial damage to the fuselage and both wings.

Following the accident, the flight instructor made differing and conflicting statements to the National Transportation Safety Board (NTSB). The first statement was that there was an engine malfunction and to avoid landing on the water or impacting boats on the surface, he elected to make a climbing right turn to the west, away from the lake, and the airplane subsequently impacted rising terrain. In a written statement provided by the flight instructor, he stated that the power had been reduced to “see more of the scenery.” Shortly thereafter, the pilot flying told him that he could not climb due to a jammed elevator. The flight instructor stated that he could only control the airplane through the use of trim and power manipulation. To avoid congested areas, they maneuvered to the reservoir and attempted to free the jammed elevator by “wiggling the flight control in and out,” which resulted in the airplane pitching down. He stated that after adding power and retrimming the airplane, he elected to fly west into the
valley to look for a landing area.

A review of flight track data revealed that the airplane did not descend as described in the written statement, but instead flew east to west over the reservoir and descended during a 270° turn over the reservoir that was initiated about mid-channel. The airplane traversed about 1.6 miles south along the reservoir before it turned west and climbed. The last recorded altitude was about 6,075 ft msl near the accident location.

Photographs provided by a witness show the airplane low over the water as it approached one of only three visible boats. At first, the airplane appeared headed toward the shore, but made a left turn toward the first boat. After making a very low pass over the boat, the airplane made a steep climb, followed by a steep right turn, and then flew at a low altitude over the second boat. After passing the second boat, the airplane appeared to depart toward a valley.

Postaccident examinations by the Federal Aviation Administration and the NTSB revealed no mechanical malfunctions or anomalies that would have precluded normal operation of the engine or flight controls.

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The pilot’s failure to maintain clearance from rising terrain while intentionally maneuvering the airplane at low altitudes, which resulted in substantial damage to the fuselage and both wings.

Findings

Personnel issues Decision making/judgment - Pilot
Environmental issues Mountainous/hilly terrain - Contributed to outcome

Factual Information

History of Flight

Maneuvering Collision with terr/obj (non-CFIT) (Defining event)

On September 11, 2022, about 1859 mountain daylight time, a Cessna 172 airplane, N9049H, sustained substantial damage when it was involved in an accident near Fort Collins, Colorado. The pilot and flight instructor sustained minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight.

During an initial telephone interview with the National Transportation Safety Board on September 12, the flight instructor stated that during the flight over Horsetooth Reservoir, an engine power issue had occurred. He stated that in an effort to avoid landing on the water or impacting boats on the surface, he elected to make a climbing right turn to the west, away from the lake, and the airplane impacted rising terrain.

In a written statement provided by the flight instructor on September 15, he reported that he and his brother (who was also a certificated pilot) were flying the airplane east of the Horsetooth Reservoir, between Fort Collins and the reservoir, and his brother reduced power to “observe more of the scenery.” Shortly after reducing the power, his brother told him that he could not climb due to a jammed elevator. The flight instructor stated that he took control of the airplane and confirmed that the elevator was jammed, and he used power and trim to climb. In an effort to avoid congested areas, they maneuvered to the reservoir and attempted to free the jammed elevator by “wiggling the flight control in and out,” which resulted in the airplane pitching down. He stated that after adding power and retrimming the airplane, he elected to fly west into the valley to look for a landing area. Unable to outclimb the rising terrain, the airplane impacted a tree and the rising terrain, which resulted in substantial damage to the fuselage and both wings.

Flight track data for this report was obtained from L3/Harris OpsVue, a commercially available web base product that aggregates and geo-references Federal Aviation Administration (FAA) data sources including data from FAA ASDE-X and ASSC systems, FAA terminal and en route radars, the FAA certified ADS-B Network and flight plan data from the En Route Automation Modernization (ERAM) system. The accident airplane was squawking a non-discreet beacon code of 1200 and positive identification could not be made. However, the flight track data obtained was consistent with the reported departure time and airport, and the flight track ended near the recorded accident location (figure 1). A review of the data revealed that the airplane was about 6,550 ft above mean sea level (msl) when it crossed the east bank of the reservoir headed west. After it crossed about mid-channel, the airplane turned right, about 270° while descending to an altitude below 5,500 ft msl (floor of coverage). Due to being below the floor of coverage, flight track and altitudes ceased to record. When the airplane was reacquired, the position was about 1 mile south at an altitude of about 5,375 ft msl. The airplane traversed about 1.6 miles south along the reservoir before it turned west and climbed.

The last recorded altitude was about 6,075 ft msl near the accident location.

Photographs provided by a witness show the airplane low over the water as it approached one of only three visible boats. At first, the airplane appeared headed toward the shore, but made a left turn toward the first boat (figures 2 and 3). After making a very low pass over the boat (figure 4), the airplane made a steep climb, followed by a steep right turn (figure 5), and then low over the second boat (figure 6). After passing the second boat, the airplane appeared to depart toward a valley.

An FAA air safety inspector completed an on-scene examination of the airplane. During the examination, flight control continuity was established from the control yokes to the elevator control surface with no binding or mechanical anomalies noted. A visual examination of the other flight controls revealed no anomalies that would have precluded normal operation. 

During a postaccident examination conducted by the NTSB, flight control continuity was established from the control yokes, through recovery cuts to all flight control surfaces with no binding or mechanical anomalies notes. The engine was examined, and no mechanical malfunctions or anomalies were found that would have precluded normal operation.

Flight instructor Information

Certificate: Airline transport; Flight instructor 
Age: 34,
Airplane Rating(s): Single-engine land; Multi-engine land
Seat Occupied: Right
Other Aircraft Rating(s): Unmanned (sUAS) 
Restraint Used: 3-point
Instrument Rating(s): Airplane
Second Pilot Present: Yes
Instructor Rating(s): Airplane multi-engine; Airplane single-engine; Instrument airplane
Toxicology Performed:
Medical Certification: Class 1 Without waivers/limitations 
Last FAA Medical Exam: January 3, 2022
Occupational Pilot: Yes 
Last Flight Review or Equivalent: June 11, 2022
Flight Time: 3580 hours (Total, all aircraft), 337 hours (Total, this make and model), 2571 hours (Pilot In Command, all aircraft), 72 hours (Last 90 days, all aircraft), 22 hours (Last 30 days, all aircraft), 1.5 hours (Last 24 hours, all aircraft)

Pilot Information

Certificate: Commercial 
Age: 38
Airplane Rating(s): Single-engine land; Multi-engine land
Seat Occupied: Left
Other Aircraft Rating(s): None 
Restraint Used: 3-point
Instrument Rating(s): Airplane 
Second Pilot Present: Yes
Instructor Rating(s): None
Toxicology Performed:
Medical Certification: None 
Last FAA Medical Exam:
Occupational Pilot: Yes 
Last Flight Review or Equivalent:
Flight Time: 7000 hours (Total, all aircraft)

Aircraft and Owner/Operator Information

Aircraft Make: Cessna 
Registration: N9049H
Model/Series: 172M 
Aircraft Category: Airplane
Year of Manufacture: 1975
Amateur Built:
Airworthiness Certificate: Normal 
Serial Number: 17265918
Landing Gear Type: Tricycle 
Seats: 4
Date/Type of Last Inspection: Certified 
Max Gross Wt.:
Time Since Last Inspection: 
Engines: 1 Reciprocating
Airframe Total Time: 
Engine Manufacturer: Lycoming
ELT: Engine Model/Series: O320
Registered Owner: 
Rated Power: 180
Operator:
Operating Certificate(s) Held: None

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual (VMC) 
Condition of Light: Day
Observation Facility, Elevation: KFNL, 5015 ft msl 
Distance from Accident Site: 9 Nautical Miles
Observation Time: 18:56 Local 
Direction from Accident Site: 128°
Lowest Cloud Condition: Clear
Visibility 10 miles
Lowest Ceiling: None
Visibility (RVR):
Wind Speed/Gusts: 5 knots / 
Turbulence Type Forecast/Actual:  /
Wind Direction: 180°
Turbulence Severity Forecast/Actual:  /
Altimeter Setting: 30.22 inches Hg
Temperature/Dew Point: 21°C / 5°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Boulder, CO (KBDU) 
Type of Flight Plan Filed: None
Destination: Fort Collins, CO
Type of Clearance: None
Departure Time: 
Type of Airspace: Class G

Wreckage and Impact Information

Crew Injuries: 2 Minor 
Aircraft Damage: Substantial
Passenger Injuries: 
Aircraft Fire: None
Ground Injuries: 
Aircraft Explosion: None
Total Injuries: 2 Minor
Latitude, Longitude: 40.546516,-105.17836 





Aircraft crashed under unknown circumstances. 

Date: 12-SEP-22
Time: 01:00:00Z
Regis#: N9049H
Aircraft Make: CESSNA
Aircraft Model: 172
Event Type: ACCIDENT
Highest Injury: MINOR
Flight Crew: 1 Minor Injuries
Pax: 1 Minor Injuries 
Aircraft Missing: No
Damage: SUBSTANTIAL
Activity: PERSONAL
Flight Phase: UNKNOWN (UNK)
Operation: 91
City: FORT COLLINS
State: COLORADO

Saturday, January 28, 2023

Pilatus PC-12/47E, N79NX: Fatal accident occurred February 13, 2022 in Beaufort, Carteret County, North Carolina

Ernest Durwood Rawls



RALEIGH, North Carolina — The families of five passengers killed in a 2022 plane crash off the North Carolina coast have settled wrongful death lawsuits against the companies that owned the plane and employed the pilot and the pilot’s estate for $15 million, family representatives announced Friday.

All eight people aboard the  Pilatus PC-12/47E died when it descended into the Atlantic Ocean off the Outer Banks. Four teenagers and two adults on the plane were returning from a hunting trip. The two others were the pilot and his adult son, who was a student pilot, the suit said.

Attorneys for the families filed dismissals in Carteret County on Thursday, reflecting that the companies that employed the pilot and owned the plane have paid $15 million, according to a news release.

The settling defendants are EDP Management Group and Green Assets, both of Wilmington, and the Estate of Ernest “Teen” Durwood Rawls, the pilot. The settlement was reached on behalf of the families of deceased passengers Noah Lee Styron, 16; Michael Daily Shepherd, 15; Jacob Nolan Taylor, 17; Jonathan Kole McInnis, 16; and Stephanie Fulcher, 42, the mother of McInnis. The four teenagers on board were all students at East Carteret High School.

Hunter Parks, 45, one of those killed in the crash, was the founder and chairman of Green Assets, according to the company’s website. His family is not involved in the suits.

“The families filed these lawsuits to get answers and hold accountable the companies and individuals whose negligence led to this tragedy,” Andrew C. Robb, a Kansas City-based aviation attorney who represented the families, said in a statement. “The families are grateful that this phase of their lawsuits has come to a close, and they will now continue the difficult process of trying to re-build their lives.”

There was no immediate response to Associated Press emails seeking comment from attorneys representing EDP Management Group and Green Assets. The settlement does not affect claims against Dillon’s Aviation of Greenville, which had performed maintenance on the plane, Robb said by telephone.

The plane took off February 13 in the early afternoon from Hyde County Airport, which is on the mainland near the Pamlico Sound. The plane’s destination was southwest across the sound to Beaufort, which is along the southern edge of the Outer Banks in Carteret County.

The suit filed in May alleged Rawls failed to maintain control over the plane and improperly flew into weather conditions with limited visibility that required the use of instrumentation. The suit also asserted that Rawls failed to maintain adequate communication with air traffic control and failed to avoid restricted military airspace, “leading to an erratic and irregular flight path.”

The suit alleged Rawls improperly relied on a co-pilot with “inadequate training and experience” to fly around the restricted airspace and in those weather conditions. Rawls’ son, Jeffrey Rawls, reportedly had 20 hours of flight experience, the suit stated. The suit also claimed Rawls failed to conduct a proper weight and balance evaluation before taking off.

The National Transportation Safety Board said in a preliminary accident report that the pilot had made no distress calls and no declarations of an emergency. The airplane had reached 4,700 feet (1,430 meters) and was climbing quickly, the NTSB’s report stated. There was no response to calls from an air traffic controller, and radar contact was lost.

A final report from the NTSB has not been issued.


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.

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

Additional Participating Entities:
Alexandra Grady; Federal Aviation Administration / Flight Standards District Office; Greensboro, North Carolina
Hartzell Propellers; Piqua, Ohio
Transportation Safety Board of Canada; Gatineau,  Quebec, Canada
Pratt & Whitney Canada; Saint-Hubert,  Quebec, Canada
Swiss Transportation Safety Investigation Board; Payerne, Switzerland
Pilatus Aircraft Ltd; Stans, Switzerland

EDP Management Group LLC


Location: Beaufort, North Carolina
Accident Number: ERA22LA120
Date and Time: February 13, 2022, 14:02 Local
Registration: N79NX
Aircraft: PILATUS AIRCRAFT LTD PC-12/47E 
Injuries: 8 Fatal
Flight Conducted Under: Part 91: General aviation - Personal

On February 13, 2022, about 1402 eastern standard time, a Pilatus PC-12, N79NX, was destroyed when it was involved in an accident near Beaufort, North Carolina. The commercial pilot, student pilot, and 6 passengers were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight.

The airplane departed Pitt-Greenville Airport (PGV), Greenville, North Carolina, about 1235, and landed at Hyde County Airport (7W6), Engelhard, North Carolina, at 1255. Then, the airplane departed runway 29 from 7W6, about 1335.

After departure, the pilot contacted air traffic control, reported they were going to level off at 3,500 ft mean sea level (msl), and requested visual flight rules (VFR) flight following as well as an instrument flight rules (IFR) clearance into Michael J. Smith Field Airport (MRH), Beaufort, North Carolina. At 1338, the controller advised the pilot that nearby restricted airspace was active, and the pilot confirmed that they would remain clear of the airspace and fly to the east. At 1341, the controller called the pilot and indicated that they were about to enter the restricted airspace. After multiple calls with no response from the pilot, the controller instructed the military aircraft in the restricted airspace to remain above 4,000 ft msl. At 1349, the pilot called the controller and requested the RNAV approach to runway 26 but was denied the request because of the active restricted airspace. Furthermore, the controller queried the pilot as to why he did not respond to the earlier radio calls, and the pilot responded that he “was trying to get out” and was unable to receive the radio transmissions. The controller offered an approach to runway 8 or runway 3, and the pilot chose runway 8.

At 1352, the controller reported that the restricted airspace was not active anymore and asked if the pilot wanted the RNAV approach to runway 26 instead. The pilot responded that he would appreciate that, and the controller cleared the pilot direct to CIGOR, the initial approach fix for the RNAV 26 approach. At 1355, the controller called the airplane and asked to verify if they were direct to CIGOR because the airplane was still on a southwesterly heading. The pilot responded “roger” and the controller said the airplane could proceed direct to CIGOR, to cross the waypoint at or above 1,900 ft msl and was cleared for the runway 26 RNAV approach. The pilot read back the instructions correctly and then at 1358, the controller contacted the airplane and issued a heading to CIGOR, but then indicated the airplane was “correcting now.” At 1358:46, the controller called the pilot and issued the local altimeter setting because the airplane was at 1,700 ft msl and was supposed to maintain 1,900 ft msl. The pilot read back the altimeter setting correctly, and that was the last transmission from the airplane.

At 1401, the controller called the airplane and asked what altitude it was at because the airplane was at 4,700 ft msl and climbing quickly. There was no response. Radar contact was lost with the airplane at 1402 and an ALNOT was issued at 1429. Throughout the communication with air traffic control, there were no distress calls or a declaration of emergency from the airplane.

The airplane impacted the Atlantic Ocean and was located by the US Coast Guard 3 miles offshore in about 60 ft of water. Dive crews recovered an ELT and a Light Data Recorder (LDR). The LDR was sent to the NTSB Recorders Laboratory for data download.

According to Federal Aviation Administration (FAA) airman records, the pilot seated in the left seat held a commercial pilot certificate with ratings for airplane multiengine land, airplane single-engine land, and instrument airplane. In addition, he held a ground instructor certificate and held a mechanic certificate for airframe and powerplant. His most recent second-class medical certificate was issued June 28, 2021. At that time, he reported 3,000 hours of flight experience.

According to FAA airman records, the passenger seated in the right seat held a student pilot certificate. His most recent third-class medical certificate was issued on July 6, 2021, and at that time he reported 20 hours of flight experience.

An examination of the wreckage is pending recovery.


Aircraft and Owner/Operator Information

Aircraft Make: PILATUS AIRCRAFT LTD
Registration: N79NX
Model/Series: PC-12/47E 
Aircraft Category: Airplane
Amateur Built:
Operator:
Operating Certificate(s) Held: None
Operator Designator Code:

Meteorological Information and Flight Plan

Conditions at Accident Site: IMC
Condition of Light: Day
Observation Facility, Elevation: MRH,8 ft msl
Observation Time: 13:58 Local
Distance from Accident Site: 19 Nautical Miles
Temperature/Dew Point: 7°C /6°C
Lowest Cloud Condition: 
Wind Speed/Gusts, Direction: 13 knots / 18 knots, 20°
Lowest Ceiling: Overcast / 900 ft AGL
Visibility: 10 miles
Altimeter Setting: 29.93 inches Hg
Type of Flight Plan Filed: None
Departure Point: Engelhard, NC (7W6)
Destination: Beaufort, NC (MRH)

Wreckage and Impact Information

Crew Injuries: 2 Fatal
Aircraft Damage: Destroyed
Passenger Injuries: 6 Fatal
Aircraft Fire: Unknown
Ground Injuries: N/A
Aircraft Explosion: Unknown
Total Injuries: 8 Fatal 
Latitude, Longitude: 34.81355,-76.2871

Those who may have information that might be relevant to the National Transportation Safety Board (NTSB) investigation may contact them by email witness@ntsb.gov, and any friends and family who want to contact investigators about the accident should email assistance@ntsb.gov. You can also call the NTSB Response Operations Center at 844-373-9922 or 202-314-6290. 
Jeffrey Worthington Rawls and Ernest (Teen) Durwood Rawls 


Ernest "Teen" Durwood Rawls 

Jonathan "Kole" McInnis

Jacob "Jake" Nolan Taylor

Michael Daily Shepherd

Noah Lee Styron

Stephanie Anne Fulcher

Douglas Hunter Parks

Ernest Durwood Rawls



Pilot Ernest "Teen" Rawls and passenger Jake Taylor

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

Wayne Estopinal, Sandy Johnson and Andrew Davis
~


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

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

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

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

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

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

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

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

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

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

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

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

Tamarack defends its winglets 

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

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

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

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

Remembering the victims 

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

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

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

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

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


















Andrew Dale Davis 


Aviation Accident Final Report - National Transportation Safety Board

Investigator In Charge (IIC): Aguilera, Jason

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

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

Investigation Docket - National Transportation Safety Board:



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

Analysis

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Probable Cause and Findings

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

Findings

Aircraft Control surface (fitting on wing) - Malfunction

Factual Information

History of Flight

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

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

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

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

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

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

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

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

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

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

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

Pilot Information

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

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

Aircraft and Owner/Operator Information

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

Autopilot

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

EGPWS

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

Aircraft Recording System

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

Active Technology Load Alleviation System

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

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

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

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

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

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

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

Maintenance

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

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

Meteorological Information and Flight Plan

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

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

Wreckage and Impact Information

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

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

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

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

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

ATLAS Components

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

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

Left TACS and TCU

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

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

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

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

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

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

Right TACS and TCU

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

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

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

Additional Information

Citation CJ2+ Operating Manual Unusual Attitude Recoveries

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

ATLAS Emergency Procedures

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

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

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

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

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

Service Bulletins and Airworthiness Directives Related to ATLA

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

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

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

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

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

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

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

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

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

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

Additional Fleet Events

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

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

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

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

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

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

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

Flight recorders

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

Medical and Pathological Information

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

Tests and Research

Airplane Performance

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

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