Crash of a Cessna 414A Chancellor off Sydney: 2 killed

Date & Time: Aug 5, 2010 at 2337 LT
Type of aircraft:
Operator:
Registration:
C-GENG
Survivors:
No
Schedule:
Butonville - Sydney
MSN:
414A-0288
YOM:
1979
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Aircraft flight hours:
9677
Circumstances:
The privately owned Cessna 414A departed Toronto/Buttonville Municipal Airport, Ontario, en route to Sydney, Nova Scotia. The flight was operating under an instrument flight rules flight plan with the pilot-in-command and the aircraft owner on board. Nearing Sydney, the aircraft was cleared to conduct an instrument approach. At the final approach waypoint the pilot was advised to discontinue the approach due to conflicting traffic. While manoeuvring for a second approach, the aircraft departed from controlled flight, entered a rapid descent and impacted the water at 2335 Atlantic Daylight Time. The aircraft wreckage was located using a side-scan sonar 11 days later, in 170 feet of water. The aircraft had been destroyed and both occupants were fatally injured. No signal was detected from the emergency locator transmitter.
Probable cause:
Findings as to Causes and Contributing Factors:
1. It is likely that the PIC and the owner were both suffering some degree of spatial disorientation during the final portion of the flight. This resulted in a loss of control of the aircraft and the crew was unable to recover prior to contacting the surface of the water.
2. The PIC did not accept assistance in the form of radar vectors, which contributed to the workload during the approach.
3. Self-imposed pressure likely influenced the crew’s decision to depart Buttonville despite the flight conditions, lengthy day, and lack of experience with the aircraft and the destination airport.
Other Findings:
1. It could not be conclusively determined who was flying the aircraft at the time of the occurrence.
2. The lack of onboard recording devices prevented the investigation from determining the reasons why the aircraft departed controlled flight.
3. The practice of placing aircraft technical records on board aircraft may impede an investigation if the records are lost due to an accident.
Final Report:

Crash of a Cessna 414 Chancellor off San Andrés

Date & Time: Jul 26, 2008 at 1052 LT
Type of aircraft:
Registration:
XB-JBD
Flight Type:
Survivors:
Yes
Schedule:
San Salvador – San Andrés – Barranquilla
MSN:
414-0253
YOM:
1971
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
1196
Aircraft flight hours:
4480
Circumstances:
The twin engine aircraft departed San Salvador-Ilopango Airport on a private flight to Barranquilla with an intermediate stop in San Andrés Island, carrying one passenger and one pilot. On final approach to San Andrés-Gustavo Rojas Pinilla Airport runway 06, the left engine failed. The pilot increased power on the right engine but the aircraft continued to lose height. The pilot ditched the aircraft near the coast. Both occupants evacuated safely and were quickly rescued while the aircraft was damaged beyond repair.
Probable cause:
Failure of the left engine on final due to fuel exhaustion. It remained a total of 3 gallons of fuel in the left fuel tank and 23 gallons in the right main tank.
Final Report:

Crash of a Cessna 414 Chancellor in Benton: 2 killed

Date & Time: Feb 16, 2008 at 1845 LT
Type of aircraft:
Operator:
Registration:
N41LP
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Benton - Wichita
MSN:
414-0491
YOM:
1980
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
565
Captain / Total hours on type:
52.00
Aircraft flight hours:
6656
Circumstances:
According to witnesses, the airplane departed runway 35 and was observed flying in and out of the clouds. Several of the witnesses observed the airplane initiate a turn to the west. One witnesses commented that it was dark but he could still see the silhouette of the airplane. He observed the airplane descend below the trees. All of the witnesses reported flames and "fireballs." On scene evidence was consistent with the airplane impacting trees in a left turn. The airplane was destroyed. An examination of the airplane, flight controls, engines, and remaining systems revealed no anomalies. Weather observations and radar data depicted low clouds, and restricted visibility due to rain and mist, in the vicinity of the airport. Toxicological examination revealed cetirizine, an antihistamine, consistent with use within the previous 12 hours. Most studies have not found any significant impairment from the medication, though it is reported to cause substantial sedation in some individuals.
Probable cause:
The pilot's failure to maintain clearance from the trees. Contributing to the accident was the pilot's flight into known adverse weather conditions and the low clouds and visibility.
Final Report:

Crash of a Cessna 414 Chancellor in Rocksprings: 2 killed

Date & Time: Feb 9, 2007 at 1715 LT
Type of aircraft:
Operator:
Registration:
N69845
Survivors:
No
Schedule:
Houston – Rocksprings
MSN:
414-0637
YOM:
1975
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
2212
Aircraft flight hours:
5466
Circumstances:
The 2,212-hour instrument rated commercial pilot collided with terrain while circling to land after completing an instrument approach to an uncontrolled non-towered airport. The airport had two instrument approaches to Runway 14; a VOR and a RNAV(GPS). The published minimums for a circling approach to Runway 32 are a 500 foot ceiling and one mile visibility (VOR14) and a 700 foot ceiling and one mile visibility for RNAV(GPS) to Runway 14. The weather at the airport at the time of the accident was reported as 300 overcast, visibility of 3/4 of a mile in mist, with winds from 020 degrees at 10 knots gusting to 14 knots. Two witnesses reported that the airplane circled over the airport and then descended straight to the ground. Radar data revealed that after the airplane made the instrument approach to Runway 14, at approximately 2,800 feet mean sea level (msl), the airplane initiated a circling turn to the left and a slight descent. The last radar hit showed the airplane at 2,600 feet at a groundspeed of 186 knots. A post impact fire consumed some of the airframe. The pilot's logbooks were not located during the course of the investigation and his instrument experience and currency could not be determined. The pilot was reported to be very familiar with the airport and the 2 instrument approaches. A detailed examination of the wreckage of the airplane failed to reveal any anomalies with the airframe, structure, or systems. Flight control continuity was established at the accident site. The engines were examined, and no mechanical anomalies were found. The propellers were shipped to the manufacturer's facility for examination and teardown. Both propellers were rotating at the time of ground impact. Neither of the two propellers was found in the feathered position. Blade damage was consistent with both propellers operating under power at the time of impact. No mechanical defects were noted with either propeller.
Probable cause:
The pilot's failure to maintain clearance with terrain. Contributing factors were the below approach/landing minimums weather and the drizzle/mist weather conditions.
Final Report:

Crash of a Cessna 414 Chancellor in Johnstown: 2 killed

Date & Time: Dec 26, 2006 at 1555 LT
Type of aircraft:
Operator:
Registration:
N400CS
Flight Type:
Survivors:
No
Schedule:
Morgantown - Teterboro
MSN:
414-0613
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
3547
Aircraft flight hours:
5904
Circumstances:
The airplane encountered in-flight icing, and the pilot diverted to an airport to attempt to knock the ice off at a lower altitude. During the instrument approach, the pilot advised the tower controller of the ice, and that it depended on whether or not the ice came off the airplane if she would land. As the airplane broke out of the clouds, it appeared to tower personnel to be executing a missed approach; however, it suddenly "dove" for the runway. The tower supervisor noticed that the landing gear were not down, and at 75 to 100 feet above the runway, advised the pilot to go around. The airplane continued to descend, and by the time it impacted the runway, the landing gear were only partially extended, and the propellers and airframe impacted the pavement. The pilot then attempted to abort the landing. The damaged airplane became airborne, climbed to the right, stalled, and nosed straight down into the ground.
Probable cause:
The pilot's improper decision to abort the landing with a damaged airplane. Contributing to the accident were the damage from the airplane's impact with the runway, the pilot's failure to lower the landing gear prior to the landing attempt, and the in-flight icing conditions.
Final Report:

Crash of a Cessna 414A Chancellor in Lawrenceville: 3 killed

Date & Time: Dec 25, 2006 at 2030 LT
Type of aircraft:
Operator:
Registration:
N62950
Flight Type:
Survivors:
No
Schedule:
Pahokee - Lawrenceville
MSN:
414-0086
YOM:
1970
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
631
Captain / Total hours on type:
406.00
Aircraft flight hours:
4313
Circumstances:
According to Atlanta Air Route Traffic Control Center (ARTCC) personnel, the pilot was given the current weather information before attempting his first instrument approach into Gwinnett County Airport-Briscoe Field (LZU), Lawrenceville, Georgia, which included: winds calm, visibility 1/2-mile in fog, and ceiling 100 feet. The pilot acknowledged the current weather information and elected to continue for the instrument landing system (ILS) runway-25 approach. During the first landing attempt, the pilot reported that he was going to execute a missed approach, but that he saw the airport below and wanted to attempt another approach. The ARTCC controller provided the pilot with radar vectors back to the ILS runway-25 approach and again updated the pilot with current weather conditions. During the second approach the tower controller advised the pilot that he was left of the runway-25 centerline. Shortly after the pilot acknowledged that he was left of the centerline, the tower controller saw a bright "orange glow" off of the left side of the approach end of runway 25. Although the weather conditions were below approach minimums for the runway 25-approach, the pilot elected to attempt the landing. A flight inspection of the ILS was completed on December 26, 2006, and the results of the inspection revealed that the ILS runway-25 approach system was satisfactory. Examination of the airframe, flight control system components, engines and system components revealed no evidence of preimpact mechanical malfunction.
Probable cause:
The pilot's failure to follow the instrument approach procedure. Contributing to the accident was the pilot's descent below the prescribed decision height altitude.
Final Report:

Crash of a Cessna 414A Chancellor in Kahului: 3 killed

Date & Time: Mar 8, 2006 at 1913 LT
Type of aircraft:
Operator:
Registration:
N5601C
Flight Type:
Survivors:
No
Schedule:
Honolulu - Kahului
MSN:
414A-0113
YOM:
1978
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
3141
Aircraft flight hours:
8734
Circumstances:
The twin-engine medical transport airplane was on a positioning flight when the pilot reported a loss of power affecting one engine before impacting terrain 0.6 miles west of the approach end of the runway. The airplane was at 2,600 feet and in a shallow descent approximately 8 miles northwest of the airport when the pilot checked in with the tower and requested landing. Three and a half minutes later, the pilot reported that he had lost an engine and was in a righthand turn. Radar data indicated that the airplane was 2 miles southwest of the airport at 1,200 feet msl. The radar track continued to depict the airplane in a descent and in a right-hand turn, approximately 1.9 miles west of the approach end of the runway. The altitude fluctuated between 400 and 600 feet, the track turned right again, and stabilized on an approximate 100- degree magnetic heading, which put the airplane on a left base for the runway. The track entered a third right-hand turn at 500 feet. The pilot's last transmission indicated that one engine was not producing power. The last radar return was 6 seconds later at 200 feet, in the direct vicinity of where the wreckage was located. Using the radar track data, the average ground speed calculations showed a steady decrease from 134 knots at the time of the pilot's initial report of a problem, to 76 knots immediately before the airplane impacted terrain. The documented minimum controllable airspeed (VMC) for this airplane is 68 knots. The zero bank angle stall speed varied from 78 knots at a cruise configuration to 70 knots with the gear and flaps down. A sound spectrum study using recorded air traffic control communications concluded that one engine was operating at 2,630 rpm, and one engine was operating at 1,320 rpm. Propeller damage was consistent with the right engine operating at much higher power than the left engine at the time of impact, and both propellers were at or near the low pitch stops (not feathered). Examination and teardown of both engines did not reveal any evidence of mechanical malfunction. Investigators found that the landing gear was down and the flaps were fully deployed at impact. In this configuration, performance calculations showed that level flight was not possible with one engine inoperative, and that once the airspeed had decreased below minimum controllable airspeed (VMC), the airplane could stall, roll in the direction of the inoperative engine, and enter an uncontrolled descent. The pilot had been trained and had demonstrated a satisfactory ability to operate the airplane in slow flight and single engine landings. However, flight at minimum controllable airspeed with one engine inoperative was not practiced during training. The operator's training manual stated that during single engine training an objective was to ensure the pilot reduced drag; however, there was no procedure to accomplish this objective, and the ground training syllabus did not specifically address engine out airplane configuration performance as a dedicated topic of instruction. The operator's emergency procedures checklist and manufacturer's information manual clearly addressed the performance penalties of configuring the airplane with an inoperative engine, propeller unfeathered, the landing gear down, and/or the flaps deployed. The engine failure during flight procedure checklist and the engine inoperative go-around checklist, if followed, configure the airplane for level single engine flight by feathering the propeller, raising the flaps, and retracting the landing gear.
Probable cause:
The failure of the pilot to execute the published emergency procedures pertaining to configuring the airplane for single engine flight, which would have allowed him to maintain minimum controllable airspeed (VMC) and level flight. The pilot's failure to maintain minimum controllable airspeed (VMC) led to a stall and subsequent VMC roll at a low altitude. Contributing to the accident was the operator's inadequate pilot training in the single engine flight regime, and the loss of power from the left engine for undetermined reasons.
Final Report:

Crash of a Cessna 414 Chancellor in Petersburg

Date & Time: Dec 2, 2004 at 1310 LT
Type of aircraft:
Registration:
N2EQ
Flight Type:
Survivors:
Yes
Schedule:
Petersburg - Petersburg
MSN:
414-0373
YOM:
1972
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3000
Captain / Total hours on type:
130.00
Copilot / Total flying hours:
5600
Circumstances:
The purpose of the flight was to "check out" the airplane before delivering it to its new owner, and to provide the copilot with an indoctrination ride in the Cessna 414. During the approach, the pilot provided guidance and corrections to the copilot. The copilot flew the airplane to within 200 feet of the ground when the nose of the airplane yawed abruptly to the right. The pilot took control of the airplane, and pushed the engine and propeller controls to the full forward position. He placed the fuel pump switches to the "high" position, retracted the flaps, and attempted to retract the landing gear. With full left rudder and full left aileron applied, he could neither maintain directional control nor stop a roll to the right. The airplane struck the ground and continued into the parking area where it struck an airplane and a waste-oil tank. Examination of the airplane following the accident revealed that the landing gear was down and locked, and the propeller on the right engine was not feathered. The emergency procedure for an engine inoperative go-around required landing gear retraction and a feathered propeller on the inoperative engine. The pilot's handbook further stated, "Climb or continued level flight is improbable with the landing gear extended and the propeller windmilling." After the accident, both pilots stated that they didn't notice a power loss on the right engine until the copilot surrendered the flight controls. The right engine was removed and placed in a test cell. The engine started immediately on the first attempt and ran continuously without interruption.
Probable cause:
The partial loss of engine power for undetermined reasons, and the pilot's failure to maintain adequate airspeed (Vmc).
Final Report:

Crash of a Cessna 414 Chancellor in Linz

Date & Time: Feb 13, 2004 at 0615 LT
Type of aircraft:
Operator:
Registration:
OE-FRW
Flight Phase:
Survivors:
Yes
Schedule:
Linz - Stuttgart
MSN:
414-0825
YOM:
1975
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
2527
Captain / Total hours on type:
830.00
Copilot / Total flying hours:
522
Copilot / Total hours on type:
250
Aircraft flight hours:
4463
Circumstances:
The twin engine aircraft departed Linz-Hörsching Airport on a taxi flight to Stuttgart with five passengers and two pilots on board. During the takeoff roll on runway 27, at a speed of 105 knots, the crew started the rotation. Immediately after liftoff, the aircraft adopted a high nose attitude with an excessive angle of attack. It rolled to the left, causing the left gear door and the left propeller to struck the runway surface, followed shortly later by the right propeller. After the speed dropped, the aircraft stalled and crash landed on the runway. It slid for few dozen metres and came to rest 2,752 metres past the runway threshold. All seven occupants were evacuated, one passenger suffered serious injuries. The aircraft was damaged beyond repair.
Probable cause:
The loss of control immediately after liftoff was the consequence of an aircraft contaminated with ice, resulting in an excessive weight, a loss of lift and a consequent stall. The following factors were identified:
- Poor flight preparation,
- The crew failed to follow the SOP procedures prior to takeoff,
- The aircraft has not been deiced prior to takeoff, increasing the total weight of the aircraft by 231 kilos, 8% above the MTOW,
- This situation caused the CofG to be out of the permissible limits,
- Poor judgment on part of the crew when the undercarriage were lowered.