Bangor

According to the pilot, the airplane took off with a flaps setting of 25 percent, per the operator’s procedures at the time. He stated that, immediately after raising the landing gear after takeoff, he heard an explosion and saw that all gauges for the left engine, a Pratt & Whitney Canada (P&WC) PT6A-34, pointed to zero, indicating a loss of power to the left engine. He also noted that the left propeller had completely stopped so he added full power to the right engine, left the flaps at 25 percent, and left the landing gear up. He further stated that, although he “stood on the right rudder,” he could not stop the airplane’s left turning descent. The pilot later noted that, after the left engine lost power, he “couldn’t hold V speeds” and “the stall warning horn was going off the whole time.” Post accident examination of the accident airplane’s left engine revealed that that it had failed and that the propeller had been feathered. Examination of the trim positions revealed that the rudder was at neutral trim and the aileron was at full left trim. Although these trim positions could have been altered when the wings separated from the fuselage during ground impact, the pilot’s comment that he “stood on the rudder” suggests that he either had not trimmed the airplane after the engine failure or had applied trim opposite the desired direction. The activation of the stall warning horn and the pilot’s statement that he “couldn’t hold V speeds” indicate that he also did not lower the nose sufficiently to maintain best single-engine rate of climb or best single-engine angle of climb airspeed. In addition, a performance calculation conducted during the National Transportation Safety Board’s investigation revealed that the airplane, with flaps set at 25 degrees, would have been able to climb at more than 400 feet per minute if the pilot had maintained best single-engine rate of climb airspeed and if the airplane had been properly trimmed. Post accident examination of the accident airplane’s left engine revealed fatigue fracturing of the first-stage sun gear.[1] According to the airplane’s maintenance records, during an October 1998 engine overhaul, the first-stage planet gear assembly was replaced due to “frosted and pitted gear teeth.” The planet gear assembly’s mating sun gear was also examined during overhaul but was found to be serviceable and was reinstalled with the new planet gear assembly, which was an accepted practice at the time. However, since then, the engine manufacturer determined that if either the sun gear or planet gear assembly needed to be replaced with a zero-time component, the corresponding mating gear/assembly must also be replaced with a zero-time component; otherwise, the different wear patterns on the gears could potentially cause “distress” to one or both of the components. Review of maintenance records showed that the engines were maintained, in part, under a Federal Aviation Administration (FAA)-approved “on-condition” maintenance program;[2] Business Air’s maintenance program was approved in May 1995. In April 2002, P&WC, the engine manufacturer, issued Service Bulletin (SB) 1403 Revision 7, which no longer mentioned on-condition maintenance programs and required, for the first time for other time between overhaul extension options, the replacement of a number of PT6A-34, -35, and -36 life-limited engine components, including the first-stage sun gear at 12,000 hours total time since new. The first-stage sun gear on the accident airplane failed at 22,064.8 hours. In November 2005 (when the Manchester accident occurred), Business Air was operating under an engine on-condition maintenance program that did not incorporate the up-to-date PT6A 34, -35, and -36 reliability standards for the life-limited parts listed in SB 1403R7 because the SB did not address previously approved on-condition maintenance programs. Three months later, in an e-mail message to Business Air, P&WC stated that it would continue to “endorse” Business Air’s engine on-condition maintenance program. Although SB 1403R7 improves PT6A-34, -35, and -36 engine reliability standards, allowing grandfathered on condition maintenance programs for these engines is less restrictive and does not offer the same level of reliability. The National Transportation Safety Board’s review of maintenance records further revealed numerous deficiencies in Business Air’s on-condition engine maintenance program that appear to have gone undetected by the Portland, Maine, Flight Standards District Office (FSDO), which is in charge of monitoring Business Air’s operations. For example, one infraction was that Business Air did not specify which parts were included in its on-condition maintenance program and which would have been removed by other means, such as hard-time scheduling.[3] Also, the operator used engine condition trend monitoring as part of determining engine health; however, review of records revealed missing data, inaccurate data input, a lack of regular trend analyses, and a failure to update trends or reestablish baselines when certain maintenance was performed. Another example showed that, although Business Air had an engine-oil analysis program in place, the time it took to send samples for testing and receive results was lengthy. According to maintenance records, the operator took an oil sample from the accident engine more than 2 weeks before the accident and sent it for testing. The oil sample, which revealed increased iron levels, would have provided valuable information about the engine’s health. However, the results, which indicated a decline in engine health, were not received until days after the accident. If the FAA had been properly monitoring Business Air’s maintenance program, it may have been aware of the operator’s inadequate maintenance practices that allowed, among other things, an engine with a sun gear well beyond what the manufacturer considered to be a reliable operating timeframe to continue operation. It also took more than 2 1/2 years after the accident for the FAA to finally present a consent order[4] to the operator, in which both parties not only acknowledged the operator’s ongoing maintenance inadequacies but also the required corrective actions. [1] A sun gear is the center gear around which an engine’s planet gear assembly revolves; together, the sun gear and planet gear assembly provide a means of reducing the engine’s rpm to the propeller’s rpm. [2] According to FAA Advisory Circular (AC) 120-17A, “Maintenance Control by Reliability Methods,” under on-condition maintenance programs, components are required to be periodically inspected or checked against some appropriate physical standard to determine whether they can continue in service. [3] According to FAA AC 120-17A, “Maintenance Control by Reliability Methods,” under hard time maintenance programs, components are required to be periodically overhauled or be removed from service. [4] A consent order is a voluntary agreement worked out between two or more parties to a dispute. It generally has the same effect as a court order and can be enforced by the court if anyone does not comply with the orders. [4] A consent order is a voluntary agreement worked out between two or more parties to a dispute. It generally has the same effect as a court order and can be enforced by the court if anyone does not comply with the orders.

En route to the company's home airport, the twin-engine airplane either experienced a loss of power to the right engine, or the pilot decided to shut the engine down. Although the home airport had night visual meteorological conditions, and there was no evidence of any malfunction with the remaining engine, the pilot opted to fly a night precision instrument approach to an airport 45 nautical miles closer, with a 1-mile visibility and a 100-foot ceiling. Unknown to the pilot, there was also fog at the airport. The pilot did not advise or seek assistance from air traffic control or the company. When the airplane broke out of the clouds, it was not stable. Approaching the runway, at full flaps and exceeding the 25 percent maximum for a go-around, the pilot added full power to the left engine. The high power setting, slow airspeed, and full flaps combination resulted in a minimum control speed (Vmc) roll. No determination could be made as to why the right engine was inoperative, and there were no mechanical or fuel-related anomalies found that would have precluded normal operation.

Approximately 3 minutes prior to the accident, the airplane was flying in a northeast direction, at 17,100 feet, and was instructed by air traffic controllers to contact Boston Center. He acknowledged the instruction, and no further transmissions were received from the pilot. Radar data indicated the airplane continued level at 17,100 feet on a northeasterly heading, and maintained a groundspeed of 255 knots, for approximately 2 minutes after the last transmission. The airplane then climbed 300 feet, and descended abruptly, losing 10,700 feet during the next 46 seconds, while maintaining an approximate ground speed of 255 knots. The airplane then initiated a climb from 6,700 feet to 7,600 feet, maintained an altitude of 7,600 feet for 4 seconds, and then entered a continuous descent until the last radar contact 17 seconds later, at an altitude of 2,400 feet. Several witnesses observed the airplane prior to it impacting the ground. All of the witness described the airplane in a "flat spin" with the engines running prior to impact. Examination of recorded weather data revealed several areas of light-to-moderate precipitation echoes in the vicinity of the accident site. The maximum echo tops were depicted ranging from 14,000 to 25,000 feet, with tops near 17,000 feet in the immediate vicinity of the accident site. Recorded radar images depicted the airplane traveling through an area of lower echoes for approximately 5-minutes immediately prior to the accident. AIRMET Zulu was current for icing conditions from the freezing level to 22,000 feet over the route of flight and the accident site. Four PIREPs were also issued indicating light-to-moderate rime to mixed icing in the clouds from the freezing level to 16,000 feet. Cloud tops were reported from 16,000 to 17,000 feet by two aircraft. Examination of the airplane and engines revealed no pre-impact mechanical anomalies. Additionally, examination of the cockpit overhead switch panel indicated propeller de-ice, engine intake heat, windshield anti-ice, and wing de-ice were all in the 'off' position. According to the pilot's toxicology test results, pseudoephedrine and diphenhydramine was detected in the pilot's urine. Diphenhydramine was not detected in the blood.

Following ATC clearance, engine start was at 1156 hrs and N90AG was cleared to taxi at 1201 hrs. All radio calls during the accident flight were made by the commander, seated in the right cockpit seat. During taxi, the crew completed their normal Before Takeoff Checks; these included confirmation that the control checks had been completed and that anti-ice might be required immediately after takeoff. Flap 20 had been selected for takeoff and the following speeds had been calculated and briefed by the pilots: V1 137 kt; VR 140 kt; V2 147 kt. By 1206 hrs, the aircraft was cleared to line up on Runway 15. At 1207 hrs, N90AG was cleared for takeoff with a surface wind of 140°/8 kt. The pilot in the left seat was handling the controls. Takeoff appeared normal up to lift-off. Rotation was started at about 146 kt with the elevator position being increased to 8°, in the aircraft nose up sense, resulting in an initial pitch rate of around 4°/second. Lift-off occurred 2 seconds later, at about 153 kt and with a pitch attitude of about 8° nose-up. Once airborne, the elevator position was reduced to 3° aircraft nose-up whilst the pitch rate increased to about 5°/second. Immediately after lift-off, the aircraft started to bank to the left. The rate of bank increased rapidly and 2 seconds after lift-off the bank angle had reached 50°. At that point, the aircraft heading had diverged about 10° to the left. Opposite aileron, followed closely by right rudder, was applied as the aircraft started banking; full right aileron and full right rudder had been applied within 1 second and were maintained until the end of the recording. As the bank angle continued to increase, progressively more aircraft nose-up elevator was applied. Stick-shaker operation initiated 3.5 seconds after lift-off and the recorders ceased 2 seconds later. The aircraft struck the ground, inverted, adjacent to the runway. The last recorded aircraft attitude was approximately 111° left bank and 13° nose-down pitch; the final recorded heading was about 114° (M). The aircraft was destroyed by impact forces and a post crash fire and all five occupants were killed, among them John Shumejda, President of the Massey-Ferguson Group and Ed Swingle, Vice President. The aircraft was leased by AGCO Massey-Ferguson.

According to the pilot, he was conducting a GPS approach during occasional low ceilings, reduced visibility and rain. At the minimum descent altitude, the ground was 'occasionally' visible through fog and rain. Near the missed approach point, the runway lights were visible, so he continued the descent. He lost visual contact with the runway, and began a missed approach, but collided with trees. The accident site was 2 miles prior to the runway, on rising terrain, 200 feet below the runway elevation. The missed approach point was over the approach end of the runway.

The twin-engine Aerostar departed on Runway 1. While on initial climb, after take-off, witnesses observed the airplane roll to the left until it became inverted, after which the nose dropped and the airplane impacted the ground in a near vertical nose down attitude. The fuselage was consumed with a post crash fire. On-site examination revealed the wing flaps and landing gear were retracted. No evidence of a mechanical failure or malfunction was found relating to the airplane, engines, or propellers. The investigation revealed that both propellers were rotating and absorbing power at the time of impact. The winds were reported from 360 degrees at 17 knots, with gusts to 25 knots.

The pilot was performing a night VOR/DME approach during which instrument meteorological conditions prevailed. The airplane was equipped with VOR, LORAN, and RNAV receivers. There were two step-downs fixes on the approach. At 13 DME the minimum altitude was 1,800 feet. At 10 DME the minimum altitude was 1,040 feet. The missed approach point was at 6 DME, and the VOR/DME transmitter was located 5.5 miles beyond the airport. Radar data revealed a descent profile based upon distances from the end of the runway, rather than DME from the VOR. The airplane reached an altitude of 1,000 feet when it was 13.52 miles from the VOR, and 7.58 miles from the approach end of the runway. It subsequently impacted rising terrain at an altitude of about 900 feet, about 11.5 miles from the VOR, and 5.5 miles from the approach end of the runway. Impact damage and a post-crash fire precluded a check of the radio set up at the time of the accident. According to FAR 135 a pilot-in-command was required to have 1,200 hours total time. The investigation documented the pilot's total time as about 1,057 hours.

The aircraft, a Piper PA-31-350 Navajo Chieftain (hereafter referred to as a Chieftain), took off at 1113 Atlantic daylight saving time on a charter flight from Port-Menier, Quebec, to Bangor, Maine, with one pilot and seven passengers on board. As the aircraft was approaching Charlo, New Brunswick, the pilot reported to Moncton Air Traffic Control Centre that his aircraft had a rough-running engine, and that he would be making an emergency landing at Charlo airport. While the pilot was apparently manoeuvring to land the aircraft, it crashed three miles west of the runway, in the community of Eel River Crossing. All eight occupants of the aircraft received fatal injuries.

The flight crew was advised prior to initiating the approach that visibility at the airport had decreased to 1/8 mile with light rain, fog and obscuration. Published landing visibility minimums for the approach was 1 mile. The 150 feet wide runway had been plowed 100 feet wide, and there were snowbanks up to 3 feet high on both sides. The airplane touched down on the unplowed portion of the runway onto a snowbank, collapsing the landing gear. The flightcrew stated that the approach lights and runway were in sight during the entire approach, and that the second pilot told the pic that he was too far left and needed to correct to the right as the airplane was about to touchdown. The tower controller stated that he lost sight of the airplane as it landed due to fog.

Diverted to Augusta after encountering deteriorating weather. Lost inverters, compass system during ILS, executed go-around. Second approach made visual to landing. Props would not enter fine pitch, braking not effective. Pilot steered airplane off runway down embankment. All three occupants escaped uninjured.