Leesburg-Executive

The pilot was conducting a GPS circling instrument approach in instrument meteorological conditions to an airport with which he was familiar. During the final minute of the flight, the airplane descended to and leveled off near the minimum descent altitude (MDA) of about 600 ft mean sea level (msl). During this time, the airplane’s groundspeed slowed from about 90 knots to a low of 65 knots. In the few seconds after reaching 65 knots groundspeed, the flight track abruptly turned left off course and the airplane rapidly descended. The final radar point was recorded at 200 ft msl less than 1/10 mile from the accident site. Two home surveillance cameras captured the final few seconds of the flight. The first showed the airplane in a shallow left bank that rapidly increased until the airplane descended in a steep left bank out of camera view below a line of trees. The second video captured the final 4 seconds of the flight; the airplane entered the camera view already in a steep left bank near treetop level, and continued to roll to the left, descending out of view. Both videos showed the airplane flying below an overcast cloud ceiling, and engine noise was audible until the sound of impact. Postaccident examination of the airplane revealed no evidence of preimpact mechanical malfunctions that would have precluded normal operation. The propeller signatures, witness impact marks, audio recordings, and witness statements were all consistent with the engines producing power at the time of impact. The pilot likely encountered restricted visibility of about 2 statute miles with mist and ceilings about 700 ft msl. When the airplane deviated from the final approach course and descended below the MDA, the destination airport remained 3.5 statute miles to the northeast. Although the airplane was observed to be flying below the overcast cloud layer, given the restricted visibility, it is likely that the pilot was unable to visually identify the airport or runway environment at any point during the approach. According to airplane flight manual supplements, the stall speed likely varied from 76 to 67 knots indicated airspeed. The exact weight and balance and configuration of the airplane could not be determined. Based upon surveillance video, witness accounts, and automatic dependent surveillance-broadcast data, it is likely that, as the pilot leveled off the airplane near the MDA, the airspeed decayed below the aerodynamic stall speed, and the airplane entered an aerodynamic stall and spin from which the pilot was unable to recover. Based on a readout of the pilot’s cardiac monitoring device and autopsy findings, while the pilot had a remote history of arrhythmia, sudden incapacitation was not a factor in this accident. Autopsy findings suggested that the pilot’s traumatic injuries were not immediately fatal; soot material in both the upper and lower airways provided evidence that the pilot inhaled smoke. This autopsy evidence supports that the pilot’s elevated carboxyhemoglobin level was from smoke inhalation during the postcrash fire. In addition, there were no distress calls received from the pilot and there was no evidence found that would indicate there was an in-flight fire. Thus, carbon monoxide exposure, as determined by the carboxyhemoglobin level, was not a contributing factor to the accident.

Four minutes after taking off on an instrument flight rules flight, during an assigned climb to 4,000 feet, the pilot advised the departure air traffic controller that the airplane was having "instrument problems" and that he wanted to "stay VFR" (visual flight rules), which the controller acknowledged. As directed, the pilot subsequently contacted the next sector departure controller, who instructed him to climb to 8,000 feet. The pilot stated that he would climb the airplane after clearing a cloud and reiterated that the airplane was having "instrument problems." The controller told the pilot to advise when he could climb the airplane. About 30 seconds later, the pilot told the controller that he was climbing the airplane to 8,000 feet, and, shortly thereafter, the controller cleared the airplane to 11,000 feet, which the pilot acknowledged. Per instruction, the pilot later contacted a center controller, who advised him of moderate-to-heavy precipitation along his (northbound) route for the next 10 miles and told him that he could deviate either left or right and, when able, proceed direct to an intersection near his destination. The pilot acknowledged the direct-to-intersection instruction, and the controller told the pilot to climb the airplane to 13,000 feet, which the pilot acknowledged. The pilot did not advise the center controller about the instrument problems. The airplane subsequently began turning east, eventually completing about an 80-degree turn toward heavier precipitation, and the controller told the pilot to climb to 15,000 feet, but the pilot did not respond. After two more queries, the pilot stated that he was trying to maintain "VFR" and that "I have an instrument failure here." The controller then stated that he was showing the airplane turning east, which "looks like a very bad idea." He subsequently advised the pilot to turn to the west but received no further transmissions from the airplane. Radar indicated that, while the airplane was turning east, it climbed to 9,500 feet but that, during the next 24 seconds, it descended to 7,500 feet and, within the following 5 seconds, it descended to just above ground level (the ground-based radar altitude readout was 0 feet). The pilot recovered the airplane and climbed it northeast-bound to 1,500 feet during the next 20 seconds. It then likely stalled and descended northwest-bound into shallow waters of a wildlife refuge. Weather radar returns indicated that the airplane's first descent occurred in an area of moderate-to-heavy rain but that the second descent occurred in light rain. The ceiling at the nearest recording airport, located about 20 nautical miles from the accident site, was 1,500 feet, indicating that the pilot likely climbed the airplane back into instrument meteorological conditions (IMC)before finally losing control. The investigation could not determine the extent to which the pilot had planned the flight. Although a flight plan was on file, the pilot did not receive a formal weather briefing but could have self-briefed via alternative means. The investigation also could not determine when the pilot first lost situational awareness, although the excessive turn to the east toward heavier precipitation raises the possibility that the turn likely wasn't intentional and that the pilot had already lost situational awareness. Earlier in the flight, when the pilot reported an instrument problem, the two departure controllers coordinated between their sectors in accordance with air traffic control procedures, allowing him to remain low and out of IMC. Although the second controller told the pilot to advise when he was able to climb, the pilot commenced a climb without further comment. The controller was likely under the impression that the instrument problem had been corrected; therefore, he communicated no information about a potential instrument problem to the center controller. The center controller then complied with the level of service required by advising the pilot of the weather conditions ahead and by approving deviations. The extent and nature of the deviation was up to the pilot with controller assistance upon pilot request. The pilot did not request further weather information or assistance with deviations and only told the center controller that the airplane was having an instrument problem after the controller pointed out that the airplane was heading into worsening weather. Due to impact forces, only minimal autopsy results could be determined. Federal Aviation Administration medical records indicated that the 16,560-hour former military pilot did not have any significant health issues, and the pilot's wife was unaware of any preexisting significant medical conditions. The wreckage was extremely fractured, which precluded thorough examination. However, evidence indicated that all flight control surfaces were accounted for at the accident scene and that the engines were under power at the time of impact. The airplane was equipped with redundant pilot and copilot flight instruments, redundant instrument air sources, onboard weather radar, and a storm scope. The pilot did not advise any of the air traffic controllers about the extent or type of instrument problem, and the investigation could not determine which instrument(s) might have failed or how redundant systems could have been failed at the same time. Although the pilot stated on several occasions that the airplane was having instrument problems, he opted to continue flight into IMC. By doing so, he eventually lost situational awareness and then control of airplane but regained both when he acquired visual ground contact. Then, for unknown reasons, he climbed the airplane back into IMC where he again lost situational awareness and airplane control but was then unable to regain them before the airplane impacted the water.

The pilot obtained three weather briefings before departure. At that time, the current weather along the route of flight showed significant convective activity and a moving squall line, and the forecast predicted significant thunderstorm activity along the planned route of flight. The pilot was concerned about the weather and mentioned that he would be looking for "holes" in the weather to maneuver around via the use of his on-board weather radar. He decided to fly a route further south to avoid the severe weather. Radar data indicates that, after departure, the pilot flew a southerly course that was west of the severe weather before he asked air traffic control for a 150-degree heading that would direct him toward a "hole" in the weather. A controller, who said he also saw a "hole" in the weather, told the pilot to fly a 120-degree heading and proceed direct to a fix along his route of flight. The airplane flew into a line of very heavy to intense thunderstorms during cruise flight at 25,000 feet before the airplane began to lose altitude and reverse course. The airplane then entered a rapid descent, broke up in flight, and subsequently impacted terrain. Review of recorded precipitation data showed that there was substantial information available to the controller about moderate to extreme weather along the aircraft’s route of flight. While the controller stated that he saw a hole or clear area ahead of the aircraft, this is contradicted by both the recorded data and the statement of a second controller working the D-position at the time of the accident. The first controller did not advise the pilot of the severe weather that was along this new course heading and the pilot entered severe weather and began to lose altitude. The controller queried the pilot about his altitude loss and the pilot mentioned that they had gotten into some "pretty good turbulence." This was the last communication from the pilot before the airplane disappeared from radar. Review of recorded precipitation data showed that there was substantial information available to the controller about moderate to extreme
weather along the aircraft’s route of flight. The controller did not provide advisories to the pilot regarding the adverse weather's immediate safety hazard to the accident flight as required by Federal Aviation Administration Order 7110.65. Examination of the recovered sections of flight control surfaces revealed that all of the fractures examined exhibited signs consistent with overstress failure. There was no evidence of preexisting cracking on any of the fracture surfaces examined and no preaccident anomalies were noted with the engines.

The private pilot, who sat in the left seat, was executing the LOC RWY 17 instrument approach in actual instrument meteorological conditions, when the airplane decelerated, lost altitude, and began a left turn about 2 miles from the airport. Subsequently, the airplane collided with terrain and came to rest on residential property. The radar data also indicated that the airplane was never stabilized on the approach. A witness, a private pilot, said the airplane "appeared" out of the fog about 300-400 feet above the ground. It was in a left bank, with the nose pointed down, and was traveling fast. The airplane then "simultaneously and suddenly level[ed] out," pitched up, and the engine power increased. The witness thought that the pilot realized he was low and was trying to "get out of there." The airplane descended in a nose-high attitude, about 65 degrees, toward the trees. Radar data indicates that the airplane slowed to 80 knots about 3 miles from the airplane, and then to 68 knots 18 seconds later as the airplane began to turn to the left. Examination of the airplane and engine revealed no mechanical deficiencies. Weather reported at the airport 25 minutes before the accident included wind from 140 degrees at 5 knots, visibility 1 statute mile, and ceiling 500 foot overcast. Weather 5 minutes before the accident included wind from 140 degrees at 5 knots, visibility 1 statute miles, and ceiling 300 foot overcast.

During arrival at night, the flight was being controlled by a developmental controller (DC), who was being supervised by an instructor (IC). The pilot (plt) was instructed to descend & cross the STILL Intersection (Int) at 3,000 ft. STILL Int was aligned with the localizer (loc) approach (apch) course, 10.1 mi from the apch end of runway 17 (rwy 17); the final apch fix (FAF) was 3.9 mi from the rwy. About 5 mi before reaching STILL Int, while on course & level at 3,000 ft, the plt was cleared for a Loc Rwy 17 Apch. Radar data showed the aircraft (acft) continued to STILL Int, then it turned onto the loc course toward the FAF. Shortly after departing STILL Int, while inbound on the loc course, the acft began a descent. Before the acft reached the FAF, the DC issued a frequency change to go to UNICOM. During this transmission, the IC noticed a low altitude alert on the radar display, then issued a verbal low altitude alert, saying, 'check altitude, you should be at 1,500 ft (should have said '1,800 ft' as that was the minimum crossing altitude at the FAF), altitude's indicating 1,200, low altitude alert.' There was no response from the plt. This occurred about 2 mi before the FAF. Minimum descent altitude (MDA) for the apch was 720 ft. The acft struck tree tops at 750 ft, about 1/2 mi before the FAF. The IC's remark 'you should be at 1,500 ft' was based on an expired apch plate with a lower FAF minimum crossing altitude; the current minimum crossing altitude at the FAF was 1,800 ft. Apch control management had not made the current plate available to the controllers. Investigation could not determine whether a current apch plate would have prompted an earlier warning by the controllers.

While cruising at FL240, the pilot observed the engine oil pressure gradually decrease from the normal to the caution range and a drop in manifold pressure. He requested and received vectors for a precautionary landing at an airport short of his destination. During the descent, the oil pressure continued to drop to zero and engine power was lost. He was able to locate the airport underneath the overcast, but loss of engine power prevented him from reaching the runway. The airplane impacted trees 1,200 feet from the airport. The 6 engine cylinder assemblies were changed 7 hours prior to the accident. Examination of the engine and turbochargers did not reveal the source of the oil loss.

The aircraft crashed into a lake during a forced landing after the engines quit. The pilot-in-command had gone for a local flight with a pilot/passenger. After a few minutes of flight he announced that they did not have any fuel. The aircraft was on an approach to return when both engines began to cut out. The aircraft did not make the runway and impacted in the lake. The occupants were able to evacuate and were picked up by fishermen. The aircraft came to rest on the bottom of the lake. The aircraft had just completed a cross-country with the same pilot-in-command and no refueling was accomplished.