Crash of a Cessna 441 Conquest II near Winchester: 2 killed

Date & Time: Feb 7, 2021 at 1647 LT
Type of aircraft:
Operator:
Registration:
N44776
Flight Type:
Survivors:
No
Site:
Schedule:
Thomasville – Winchester
MSN:
441-0121
YOM:
1980
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
The pilot was conducting a cross-country flight and was beginning an instrument flight rules approach from the south. Weather conditions at the destination airport included a ceiling between 800 and 1,000 ft and light rime icing conditions in clouds; the pilot was aware of these conditions. Elevated, wooded terrain existed along the final approach course. Radar and automatic dependent surveillance-broadcast data revealed that the airplane crossed the intermediate approach fix at the correct altitude; however, the pilot descended the airplane below the final approach fix altitude about 4 miles before the fix. The airplane continued in a gradual descent until radar contact was lost. No distress calls were received from the airplane before the accident. The airplane crashed on a north-northwesterly heading about 5 miles south of the runway threshold. The elevation at the accident site was about 1,880 ft, which was about 900 ft higher than the airport elevation. Postaccident examination of the airframe, engines, and propellers revealed no evidence of a pre-existing mechanical failure or anomaly that would have precluded normal operation. Because of the weather conditions at the time of the final approach, the pilot likely attempted to fly the airplane under the weather to visually acquire the runway. The terrain along the final approach course would have been obscured in low clouds at the time, resulting in controlled flight into terrain.
Probable cause:
The pilot’s failure to follow the published instrument approach procedure by prematurely descending the airplane below the final approach fix altitude to fly under the low ceiling conditions, which resulted in controlled flight into terrain.
Final Report:

Crash of a Cessna 441 Conquest II in Harmon: 3 killed

Date & Time: Nov 18, 2018 at 2240 LT
Type of aircraft:
Operator:
Registration:
N441CX
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Bismarck - Williston
MSN:
441-0305
YOM:
1982
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
4685
Captain / Total hours on type:
70.00
Circumstances:
The pilot and two medical crewmembers were repositioning the airplane to pick up a patient for aeromedical transport. Dark night instrument meteorological conditions prevailed for the flight. Radar data showed the airplane climb to 14,000 ft mean sea level after departure and proceed direct toward the destination airport before beginning a right descending turn. The airplane subsequently broke up inflight and impacted terrain. No distress calls were received from the pilot before the accident. Although weather conditions were conducive for inflight icing, no evidence of structural icing was identified at the scene. The debris field was 2,500 ft long and the disbursement of the wreckage confirmed that both wings, the horizontal stabilizer, both elevators, and both engines separated from the airplane before impacting the ground. Examination of the wreckage revealed that the initiating failure was the failure of the wing where it passed through the center of the airplane. The three wing spars exhibited S-bending deformation, indicative of positive overload producing compressive buckling and fracture. Further, impact signatures as black paint transfers and gouged aluminum, were consistent with the left outboard wing separating when it was struck by the right engine after the wing spars failed. There was no evidence of any pre-exiting conditions that would have degraded the strength of the airplane structure at the fracture locations. Flight control continuity was confirmed. An examination of the engines, propellers, and available systems showed no mechanical malfunctions or failure that could have contributed to the accident. The descending right turn was inconsistent with the intended flight track and ATC-provided clearance. However, there was insufficient information to determine how it was initiated and when the pilot became aware of the airplane's state in the dark night IMC conditions. Yet, the
absence of a distress call or communication with ATC about the airplane's deviation suggests that the pilot was not initially aware of the change in state. The structural failure signatures on the airplane were indicative of the wings failing in positive overload, which was consistent with the pilot initiating a pullup maneuver that exceeded the airplane spars' structural integrity during an attempted recovery from the spiral dive.
Probable cause:
The pilot's failure to maintain control of the airplane in dark night conditions that resulted in an in-flight positive overload failure of the wings and the subsequent in-flight breakup of the airplane.
Final Report:

Crash of a Cessna 441 Conquest II in Rossville: 3 killed

Date & Time: Feb 22, 2018 at 1939 LT
Type of aircraft:
Operator:
Registration:
N771XW
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Eagle Creek Airpark - Green Bay
MSN:
441-0065
YOM:
1978
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
2248
Captain / Total hours on type:
454.00
Aircraft flight hours:
6907
Circumstances:
The airline transport pilot and two passengers departed in the twin-engine, pressurized airplane on a business flight in night instrument meteorological conditions. Shortly after takeoff, the airplane began to deviate from its assigned altitude and course. The controller queried the pilot, who responded that the airplane was "… a little out of control." After regaining control of the airplane, the pilot reported that he had experienced a "trim issue." The airplane continued on course and, about 13 minutes later, the pilot again reported a trim malfunction and said that he was having difficulty controlling the airplane. The flight's heading and altitude began to deviate from the course for the last 8 minutes of radar data and became more erratic for the last 2 minutes of radar data; radar and radio communication were subsequently lost at an altitude of about 18,300 ft in the vicinity of the accident site. Several witnesses reported hearing the airplane flying overhead. They all described the airplane as being very loud and that the engine sound was continuous up until they heard the impact. The airplane impacted a field in a relatively level attitude at high speed. The wreckage was significantly fragmented and the wreckage path extended about 1/4 mile over several fields. Examination of the available airframe and engine components revealed no anomalies that would have precluded normal operation of the airplane. The accident airplane was equipped with elevator, rudder, and aileron trim systems; however, not all components of the trim system and avionics were located or in a condition allowing examination. Although the airplane was equipped with an electric elevator trim and autopilot that could both be turned off in an emergency, the investigation could not determine which trim system the pilot was reportedly experiencing difficulties with. It is likely that the pilot was unable to maintain control of the airplane as he attempted to address the trim issues that he reported to air traffic control.
Probable cause:
An in-flight loss of control for reasons that could not be determined based on the available evidence.
Final Report:

Crash of a Cessna 441 Conquest II in Renmark: 3 killed

Date & Time: May 30, 2017 at 1630 LT
Type of aircraft:
Operator:
Registration:
VH-XMJ
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Renmark - Adelaide
MSN:
441-0113
YOM:
1980
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
14751
Captain / Total hours on type:
987.00
Copilot / Total flying hours:
5000
Copilot / Total hours on type:
1000
Aircraft flight hours:
13845
Circumstances:
On 30 May 2017, a Cessna 441 Conquest II (Cessna 441), registered VH-XMJ (XMJ) and operated by AE Charter, trading as Rossair, departed Adelaide Airport, South Australia for a return flight via Renmark Airport, South Australia. On board the aircraft were:
• an inductee pilot undergoing a proficiency check, flying from the front left control seat
• the chief pilot conducting the proficiency check, and under assessment for the company training and checking role for Cessna 441 aircraft, seated in the front right control seat
• a Civil Aviation Safety Authority flying operations inspector (FOI), observing and assessing the flight from the first passenger seat directly behind the left hand pilot seat.
Each pilot was qualified to operate the aircraft. There were two purposes for the flight. The primary purpose was for the FOI to observe the chief pilot conducting an operational proficiency check (OPC), for the purposes of issuing him with a check pilot approval on the company’s Cessna 441 aircraft. The second purpose was for the inductee pilot, who had worked for Rossair previously, to complete an OPC as part of his return to line operations for the company. The three pilots reportedly started their pre-flight briefing at around 1300 Central Standard Time. There were two parts of the briefing – the FOI’s briefing to the chief pilot, and the chief pilot’s briefing to the inductee pilot. As the FOI was not occupying a control seat, he was monitoring and assessing the performance of the chief pilot in the conduct of the OPC. There were two distinct exercises listed for the flight (see the section titled Check flight sequences). Flight exercise 1 detailed that the inductee pilot was to conduct an instrument departure from Adelaide Airport, holding pattern and single engine RNAV2 approach, go around and landing at Renmark Airport. Flight exercise 2 included a normal take-off from Renmark Airport, simulated engine failure after take-off, and a two engine instrument approach on return to Adelaide. The aircraft departed from Adelaide at 1524, climbed to an altitude about 17,000 ft above mean sea level, and was cleared by air traffic control (ATC) to track to waypoint RENWB, which was the commencement of the Renmark runway 073 RNAV-Z GNSS approach. The pilot of XMJ was then cleared to descend, and notified ATC that they intended to carry out airwork in the Renmark area. The pilot further advised that they would call ATC again on the completion of the airwork, or at the latest by 1615. No further transmissions from XMJ were recorded on the area frequency and the aircraft left surveillance coverage as it descended towards waypoint RENWB. The common traffic advisory frequency used for air-to-air communications in the vicinity of Renmark Airport recorded several further transmissions from XMJ as the crew conducted practice holding patterns, and a practice runway 07 RNAV GNSS approach. Voice analysis confirmed that the inductee pilot made the radio transmissions, as expected for the check flight. At the completion of the approach, the aircraft circled for the opposite runway and landed on runway 25, before backtracking and lining up for departure. That sequence varied from the planned exercise in that no single-engine go-around was conducted prior to landing at Renmark. At 1614, the common traffic advisory frequency recorded a transmission from the pilot of XMJ stating that they would shortly depart Renmark using runway 25 to conduct further airwork in the circuit area of the runway. A witness at the airport reported that, prior to the take-off roll, the aircraft was briefly held stationary in the lined-up position with the engines operating at significant power. The take-off roll was described as normal however, and the witness looked away before the aircraft became airborne. The aircraft maintained the runway heading until reaching a height of between 300-400 ft above the ground (see the section titled Recorded flight data). At that point the aircraft began veering to the right of the extended runway centreline (Figures 1 and 15). The aircraft continued to climb to about 600 ft above the ground (700 ft altitude), and held this height for about 30 seconds, followed by a descent to about 500 ft (Figures 2 and 13). The information ceased 5 seconds later, which was about 60 seconds after take-off. A distress beacon broadcast was received by the Joint Rescue Coordination Centre and passed on to ATC at 1625. Following an air and ground search the aircraft was located by a ground party at 1856 about 4 km west of Renmark Airport. All on board were fatally injured and the aircraft was destroyed.
Probable cause:
Findings:
From the evidence available, the following findings are made with respect to the collision with terrain involving Cessna 441, registered VH-XMJ, that occurred 4 km west of Renmark Airport,
South Australia on 30 May 2017. These findings should not be read as apportioning blame or liability to any particular organisation or individual.
Contributing factors:
• Following a planned simulated engine failure after take-off, the aircraft did not achieve the expected single engine climb performance, or target airspeed, over the final 30 seconds of the flight.
• The exercise was not discontinued when the aircraft’s single engine performance and airspeed were not attained. That was probably because the degraded aircraft performance, or the
associated risk, were not recognised by the pilots occupying the control seats.
• It is likely that the method of simulating the engine failure and pilot control inputs, together or in isolation, led to reduced single engine aircraft performance and asymmetric loss of control.
• Not following the recommended procedure for simulating an engine failure in the Cessna 441 pilot’s operating handbook meant that there was insufficient height to recover following the loss of control.
Other factors that increased risk:
• The Rossair training and checking manual procedure for a simulated engine failure in a turboprop aircraft was inappropriate and, if followed, increased the risk of asymmetric control loss.
• The flying operations inspector was not in a control seat and did not share a communication systems with the crew. Consequently, he had reduced ability to actively monitor the flight and
communicate any identified performance degradation.
• The inductee pilot had limited recent experience in the Cessna 441, and the chief pilot had an extended time period between being training and being tested as a check pilot on this aircraft. While both pilots performed the same exercise during a practice flight the week before, it is probable that these two factors led to a degradation in the skills required to safely perform and monitor the simulated engine failure exercise.
• The chief pilot and other key operational managers within Rossair were experiencing high levels of workload and pressure during the months leading up to the accident.
• In the 5 years leading up to the accident, the Civil Aviation Safety Authority had conducted numerous regulatory service tasks for the air transport operator and had regular communication with the operator’s chief pilots and other personnel. However, it had not conducted a systemic or detailed audit during that period, and its focus on a largely informal and often undocumented approach to oversight increased the risk that organisational or systemic issues associated with the operator would not be effectively identified and addressed.
Other findings:
• A lack of recorded data from this aircraft reduced the available evidence about handling aspects and cockpit communications. This limited the extent to which potential factors contributing to the accident could be analysed.
Final Report: