Crash of a Piper PA-46-350P Malibu Mirage near Aventon: 4 killed

Date & Time: Jun 7, 2019 at 1345 LT
Registration:
N709CH
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Naples - Easton
MSN:
46-36431
YOM:
2007
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
4
Circumstances:
While cruising at an altitude of 27,000 feet from Naples (Florida), to Easton (Maryland) in marginal weather conditions, the single engine airplane suffered a structural failure when both wings separated. Out of control, the airplane entered a dive and crashed inverted in a wooded area located near Aventon. The airplane was totally destroyed and all four occupants and two dogs were killed.

Crash of a Socata TBM-900 off Port Antonio: 2 killed

Date & Time: Sep 5, 2014 at 1410 LT
Type of aircraft:
Operator:
Registration:
N900KN
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Rochester - Naples
MSN:
1003
YOM:
2014
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
7100
Captain / Total hours on type:
4190.00
Copilot / Total flying hours:
410
Aircraft flight hours:
97
Circumstances:
The commercial pilot and his wife departed New York in their turboprop airplane on a crosscountry flight to Florida. About 1 hour 40 minutes into the flight and while cruising at flight level (FL) 280, the pilot notified air traffic control (ATC) of an abnormal indication in the airplane and requested a descent to FL180. The responding controller instructed the pilot to descend to FL250 and turn left 30°, and the pilot acknowledged and complied with the instruction; he then again requested a lower altitude. Although the pilot declined emergency handling and did not specify the nature of the problem, the controller independently determined that the flight had encountered a pressurization issue and immediately coordinated with another ATC facility to clear nearby traffic. The controller then issued instructions to the pilot to descend to FL200 and change course; however, the pilot did not comply with the assignments despite acknowledging the instructions multiple times. The pilot's failure to comply with the controller's instructions, his long microphone pauses after concluding a statement over the radio, and his confusion were consistent with cognitive impairment due to hypoxia. Further, the pilot's transmissions to ATC indicated impairment within 2 minutes 30 seconds of reporting the abnormal indication, which is consistent with the Federal Aviation Administration's published time of useful consciousness/effective performance time ranges for the onset of hypoxia. Military airplanes were dispatched about 30 minutes after the pilot's final transmission to ATC to intercept and examine the airplane. The pilots of the military airplanes reported that the airplane appeared to be flying normally at FL250, that both occupants appeared to be asleep or unconscious, and that neither occupant was wearing an oxygen mask. Photographs taken from one of the military airplanes revealed that the airplane's emergency exit door was recessed into the fuselage frame, consistent with a depressurized cabin. The military airplanes escorted the airplane as it continued on a constant course and altitude until it approached Cuban airspace, at which point they discontinued their escort. Radar data indicated that the airplane continued on the same flight track until about 5 hours 48 minutes after takeoff, when it descended to impact in the Caribbean Sea north of Jamaica. The flight's duration was consistent with a departure with full fuel and normal cruise endurance. Some of the wreckage, including fuselage and engine components, was recovered from the ocean floor about 4 months after the accident. Data recovered from nonvolatile memory in the airplane's global air system controller (GASC) indicated that several fault codes associated with the cabin pressurization system were registered during the flight. These faults indicated that the overheat thermal switch (OTSW), which was associated with overheat protection, had activated, which resulted in a shutdown of the engine bleed air supply to the cabin pressurization system. Without a bleed air supply to maintain selected cabin pressure, the cabin altitude would have increased to the altitude of the outside environment over a period of about 4 minutes. The faults recorded by the GASC's nonvolatile memory and associated system alerts/warnings would have been displayed to the pilot, both as discrete system anomaly messages on the crew alerting system (CAS) and as master warning and/or master caution annunciations. A witness report indicated that the pilot was known to routinely monitor cabin altitude while flying in the airplane and in his previous pressurized airplanes. Based on his instrument scanning practices and the airplane's aural warning system, he likely would have observed any CAS message at or near its onset. Thus, the CAS messages and the associated alerts were likely the precipitating event for the pilot's call to ATC requesting a lower altitude. The pilot was likely not familiar with the physiological effects of hypoxia because he had not recently been in an altitude chamber for training, but he should have been familiar with the airplane's pressurization system emergency and oxygen mask donning procedures because he had recently attended a transition course for the accident airplane make and model that covered these procedures. However, the pressurization system training segment of the 5-day transition course comprised only about 90 minutes of about 36 total hours of training, and it is unknown if the pilot would have retained enough information to recognize the significance of the CAS messages as they appeared during the accident flight, much less recall the corresponding emergency procedures from memory. Coupled with the pilot's reported diligence in using checklists, this suggests that he would have attempted a physical review of the emergency procedures outlined in the Pilot's Operating Handbook (POH). A review of the 656-page POH for the airplane found that only one of the four emergency checklist procedures that corresponded to pressurization system-related CAS messages included a step to don an oxygen mask, and it was only a suggestion, not a mandatory step. The combined lack of emergency guidance to immediately don an oxygen mask and the rapid increase in the cabin altitude significantly increased the risk of hypoxia, a condition resistant to self-diagnosis, especially for a person who has not recently experienced its effects in a controlled environment such as an altitude chamber. Additionally, once the pilot reported the problem indication to ATC, he requested a descent to FL180 instead of 10,000 ft as prescribed by the POH. In a second transmission, he accepted FL250 and declined priority handling. These two separate errors were either early signs of cognitive dysfunction due to hypoxia or indications that the pilot did not interpret the CAS messages as a matter related to the pressurization system. Although the cabin bleed-down rate was 4 minutes, the pilot showed evidence of deteriorating cognitive abilities about 2 minutes 30 seconds after he initially reported the problem to ATC. Ultimately, the pilot had less than 4 minutes to detect the pressurization system failure CAS messages, report the problem to ATC, locate the proper procedures in a voluminous POH, and complete each procedure, all while suffering from an insidious and mentally impairing condition that decreased his cognitive performance over time. Following the accident, the airplane manufacturer revised the emergency procedures for newly manufactured airplanes to require flight crews to don their oxygen masks as the first checklist item in each of the relevant emergency checklists. Further, the manufacturer has stated that it plans to issue the same revisions for previous models in 2017. The airplane manufacturer previously documented numerous OTSW replacements that occurred between 2008 and after the date of the accident. Many of these units were removed after the GASC systems in their respective airplanes generated fault codes that showed an overheat of the bleed air system. Each of the OTSWs that were tested at the manufacturer's facility showed results that were consistent with normal operating units. Additionally, the OTSW from the accident airplane passed several of the manufacturer's functional tests despite the presence of internal corrosion from sea water. Further investigation determined that the pressurization system design forced the GASC to unnecessarily discontinue the flow of bleed air into the cabin if the bleed air temperature exceeded an initial threshold and did not subsequently fall below a secondary threshold within 30 seconds. According to the airplane manufacturer, the purpose of this design was to protect the structural integrity of the airplane, the system, and the passengers in case of overheat detection. As a result of this accident and the ensuing investigation, the manufacturer made changes to the programming of the GASC and to the airplane's wiring that are designed to reduce the potential for the GASC to shut off the flow of bleed air into the cabin and to maximize the bleed availability. Contrary to its normal position for flight, the cockpit oxygen switch was found in the "off" position, which prevents oxygen from flowing to the oxygen masks. A witness's description of the pilot's before starting engine procedure during a previous flight showed that he may not have precisely complied with the published procedure for turning on the oxygen switch and testing the oxygen masks. However, as the pilot reportedly was diligent in completing preflight inspections and checklists, the investigation could not determine why the cockpit oxygen switch was turned off. Further, because the oxygen masks were not observed on either occupant, the position of the oxygen switch would not have made a difference in this accident.
Probable cause:
The design of the cabin pressurization system, which made it prone to unnecessary shutdown, combined with a checklist design that prioritized troubleshooting over ensuring that the pilot was sufficiently protected from hypoxia. This resulted in a loss of cabin pressure that rendered the pilot and passenger unconscious during cruise flight and eventually led to an in-flight loss of power due to fuel exhaustion over the open ocean.
Final Report:

Crash of a Pilatus PC-12 in State College: 6 killed

Date & Time: Mar 27, 2005 at 1348 LT
Type of aircraft:
Operator:
Registration:
N770G
Flight Type:
Survivors:
No
Schedule:
Naples-State College
MSN:
0299
YOM:
1999
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
6
Captain / Total flying hours:
1645
Captain / Total hours on type:
173.00
Aircraft flight hours:
1523
Circumstances:
On final approach in bad weather conditions, the aircraft hit the ground in a nosedown attitude and crashed in an open field located 25 yards from the Centre County Correctional Facility, near Bellefonte. All occupants were killed. The aircraft was making an ILS approach at the time of the accident. Unstabilised approach and aerodynamic stall due to low speed.

Crash of a Learjet 35 in Adwa: 2 killed

Date & Time: Aug 29, 1999 at 1630 LT
Type of aircraft:
Operator:
Registration:
N350JF
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Naples-Louxor-Djibouti City-Johannesburg
MSN:
35-219
YOM:
1979
Location:
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
10000
Copilot / Total flying hours:
10000
Aircraft flight hours:
5434
Aircraft flight cycles:
3657

Crash of a McDonnell Douglas MD-82 in Catania

Date & Time: Jan 28, 1999 at 2115 LT
Type of aircraft:
Operator:
Registration:
I-DAVN
Survivors:
Yes
Schedule:
Naples-Catane
MSN:
49435
YOM:
1988
Location:
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
78
Pax fatalities:
Other fatalities:
Total fatalities:
0

Crash of a Cessna 550 Citation II in Naples: 2 killed

Date & Time: Dec 31, 1995 at 1225 LT
Type of aircraft:
Operator:
Registration:
N91MJ
Flight Type:
Survivors:
No
Schedule:
Saint Louis-Marco Island
MSN:
550-0101
YOM:
1979
Location:
Crew on board:
2
Crew fatalities:
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
13026
Captain / Total hours on type:
2500.00
Aircraft flight hours:
6025

Crash of a Cessna 550 Citation II in Bahamas

Date & Time: Apr 26, 1995 at 1430 LT
Type of aircraft:
Registration:
N7RC
Flight Type:
Survivors:
Yes
Schedule:
Naples-Walker's Cay
MSN:
550-0019
YOM:
1978
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0

Crash of a Cessna 421 Golden Eagle in Flamingo: 3 killed

Date & Time: Nov 9, 1990 at 1447 LT
Type of aircraft:
Registration:
N21ST
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Key West-Naples
MSN:
421-0963
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
10100
Captain / Total hours on type:
50.00
Aircraft flight hours:
2741

Crash of a Piper PA-61 Aerostar (Ted Smith 601P) in Jacksonville

Date & Time: Nov 4, 1986 at 2024 LT
Registration:
N8002J
Flight Type:
Survivors:
Yes
Schedule:
Charleston – Naples
MSN:
61-0499-198
YOM:
1978
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
4180
Captain / Total hours on type:
2400.00
Aircraft flight hours:
2435
Circumstances:
While in cruise flight, the pilot noted that the left engine began losing power and oil pressure. He stated that he then shut down the engine and feathered the propeller. He declared an emergency and descended to land. While on final approach, he lowered the landing gear and selected full flaps to slow the aircraft. He stated the airspeed decayed and the aircraft began to roll and yaw to the left. Subsequently, it contacted the ground in a left wing low attitude, then partially cartwheeled before coming to rest. A post accident examination of the left engine revealed that a turbocharger oil seal had deteriorated & failed, allowing oil to escape through the turbocharger exhaust. There was evidence of the beginning of progressive failure of the turbocharger. Also, there were indications that the left propeller was not fully feathered and that it was windmilling at impact. The pilot believed that he may have moved the left prop control out of the feather position by mistake. Both occupants were slightly injured.
Probable cause:
Occurrence #1: loss of engine power (partial) - mech failure/malf
Phase of operation: cruise - normal
Findings
1. (f) lubricating system, oil seal - deteriorated
2. (f) lubricating system, oil seal - failure, partial
3. (f) fluid, oil - leak
4. (f) fluid, oil - starvation
5. (f) exhaust system, turbocharger - failure, partial
6. Propeller feathering - initiated
----------
Occurrence #2: loss of control - in flight
Phase of operation: approach - vfr pattern - final approach
Findings
7. Precautionary landing - initiated
8. (c) planned approach - improper - pilot in command
9. (c) propeller feathering - inadvertent deactivation - pilot in command
10. Gear extension - performed
11. (f) lowering of flaps - excessive - pilot in command
12. (c) airspeed (vmc) - not maintained - pilot in command
----------
Occurrence #3: in flight collision with terrain/water
Phase of operation: approach

Crash of a Cessna 402C in Naples: 1 killed

Date & Time: Sep 7, 1984 at 2110 LT
Type of aircraft:
Operator:
Registration:
N89PB
Flight Phase:
Survivors:
Yes
Schedule:
Naples - Tampa
MSN:
402C-0650
YOM:
1982
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
2639
Captain / Total hours on type:
412.00
Aircraft flight hours:
1495
Circumstances:
Shortly after takeoff, both engines lost power and a wheels up landing was made in an open field. The aircraft was destroyed by impact and fire. An investigation revealed that the aircraft had been refuel with Jet-A fuel rather than 100 low lead avgas. The lineman had inadvertently used the Jet-A fuel truck which was identical to the Avgas truck except for a decal, appx 4' by 16', which identified the type of fuel. The lineman stated that his training consisted of approximately 30 minutes of reading the company maintenance manual on how to refuel the different company aircraft, then was given on-the-job training for a brief time. When he went to refuel N89PB prior to the accident flight, he went to the parking space where the Avgas truck was normally parked, but on that occasion, the Jet-A fuel truck was there.
Probable cause:
Occurrence #1: loss of engine power (total) - nonmechanical
Phase of operation: climb - to cruise
Findings
1. (c) fluid, fuel grade - improper
2. (c) maintenance, service of aircraft/equipment - improper - ground personnel
3. (f) habit interference - ground personnel
4. (f) inadequate surveillance, inadequate procedure - company/operator mgmt
----------
Occurrence #2: forced landing
Phase of operation: landing - flare/touchdown
----------
Occurrence #3: in flight collision with terrain/water
Phase of operation: landing - flare/touchdown
Findings
5. Terrain condition - rough/uneven
6. Wheels up landing - performed - pilot in command
Final Report: