Crash of a Piper PA-46-310P Malibu in Hilltop Lakes: 4 killed

Date & Time: Sep 20, 2020 at 1050 LT
Operator:
Registration:
N236KM
Flight Type:
Survivors:
No
Schedule:
Horseshoe Bay – Natchitoches
MSN:
46-8508014
YOM:
1985
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
1107
Circumstances:
While in cruise flight at 19,000 ft mean sea level (msl), the pilot declared an emergency to air traffic control and stated that the airplane had lost engine power and that he needed to divert. The pilot elected to divert to an airport that was about 5 miles south of his position. Archived automatic dependent surveillance-broadcast data and commercially available flight track data showed that a descent was initiated from 19,000 ft and the airplane proceeded directly to, and circled around, the airport one time while descending. The last data point showed the airplane at 1,250 ft msl (about 750 ft above ground level) and about 1 mile north of the approach end of the runway. From the cruise altitude of 19,000ft until the last data point, about 12 minutes and 45 seconds had elapsed, which equated to an average descent rate of about 1,392ft per minute. Witnesses located about 1/4 mile south of the end of the runway on a miniature golf course noticed the propeller on the airplane was not turning. They stated that they saw the airplane in a “really hard” left bank; the nose of the airplane dropped, and it impacted the ground in a near vertical attitude. The airplane came to rest along a road about 200 ft south of the airport property. The airplane impacted the terrain in a nose low, near vertical attitude and sustained substantial damage to fuselage and both wings. It is likely that, based on the location of the runway, relative to the miniature golf course, the pilot initiated the left bank to avoid bystanders on the ground and inadvertently exceeded the wing’s critical angle of attack, which resulted in an aerodynamic stall. The airplane was equipped with an engine trend monitor (ETM), which captured various events concerning the accident flight, including engine start, operating limit exceedances, and power checks. The ETM captured a power check while the airplane was at 19,100 ft. About 3 minutes 32 seconds later, an engine off event was recorded. The ETM further captured a logon message, which was consistent with the power being cycled, at an altitude of 3,542 ft, 9 minutes, 52 seconds later. The ETM did not record any start attempts between the logged engine off event and when power was lost to the unit. A postaccident examination of the airframe, engine, and accessories did not reveal any mechanical malfunctions or anomalies that would have precluded normal operation. Although it cannot be determined whether a restart attempt would have been successful, the data were consistent with a restart not being attempted. Both the engine failure and power off landing checklists contained instructions for the pilot to establish the airspeed at 90 knots; however, when the winds aloft were applied to the reported groundspeeds, it was evident this did not occur. Furthermore, the power off landing checklist instructed the pilot to be about 1,500 ft above the airport on the downwind leg; however, data indicate that the airplane was about 5,000 ft above the airport on the downwind leg. The rapid descent from 5,000 ft on the downwind leg to about 750 ft above ground level on the final leg resulted in an unstabilized approach.
Probable cause:
The loss of engine power for reasons that could not be determined and the pilot’s failure to maintain control of the airplane which resulted in an aerodynamic stall and spin. Contributing to the accident was the pilot’s failure to establish and maintain a proper glidepath.
Final Report:

Crash of a Piper PA-46-350P Malibu Mirage in Jacksonville

Date & Time: Sep 16, 2020 at 1340 LT
Operator:
Registration:
N972DD
Flight Type:
Survivors:
Yes
Schedule:
Jacksonville - Jacksonville
MSN:
46-36637
YOM:
2014
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total hours on type:
1141.00
Copilot / Total flying hours:
534
Copilot / Total hours on type:
9
Aircraft flight hours:
629
Circumstances:
The instructor pilot reported that while practicing an engine-out landing in the traffic pattern, the pilot-rated student overshot the turn from base leg to final rolling out to the right of the runway centerline. The student pilot attempted to turn back toward the runway and then saw that the airplane’s airspeed was rapidly decreasing. The instructor reported that when he realized the severity of the situation it was too late to do anything. The student attempted to add power for a go-around but was unable to recover. The airplane stalled about 10 ft above the ground, impacted the ground right of the runway, and skidded onto the runway where it came to rest. Both wings and the forward fuselage were substantially damaged. Both pilots stated there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation.
Probable cause:
The student pilot’s failure to maintain control of the airplane during the landing approach and the exceedance of the airplane’s critical angle of attack at low altitude resulting in an aerodynamic stall. Contributing was the instructor pilot’s failure to adequately monitor the student pilot’s actions during the approach.
Final Report:

Crash of a Pilatus PC-12/47 in Mesquite

Date & Time: Apr 23, 2020 at 1600 LT
Type of aircraft:
Operator:
Registration:
N477SS
Flight Type:
Survivors:
Yes
Schedule:
Dallas – Muscle Shoals
MSN:
813
YOM:
2007
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
2283
Captain / Total hours on type:
1137.00
Aircraft flight hours:
7018
Circumstances:
Shortly after takeoff the pilot reported to the air traffic controller that he was losing engine power. The pilot then said he was going to divert to a nearby airport and accepted headings to the airport. The pilot then reported the loss of engine power had stabilized, so he wanted to return to his departure airfield. A few moments later the pilot reported that he was losing engine power again and he needed to go back to his diversion airport. The controller reported that another airport was at the pilot’s 11 o’clock position and about 3 miles. The pilot elected to divert to that airport. The airplane was at 4,500 ft and too close to the airport, so the pilot flew a 360° turn to set up for a left base. During the turn outbound, the engine lost all power, and the pilot was not able to reach the runway. The airplane impacted a field, short of the airport. The airplane’s wings separated in the accident and a small postcrash fire developed. A review of the airplane’s maintenance records revealed maintenance was performed on the day of the accident flight to correct reported difficulty moving the Power Control Lever (PCL) into reverse position. The control cables were inspected from the pilot’s control quadrant to the engine, engine controls, and propeller governor. A static rigging check of the PCL was performed with no anomalies noted. Severe binding was observed on the beta control cable (propeller reversing cable). The cable assembly was removed from the engine, cleaned, reinstalled, and rigged in accordance with manufacturer guidance. During a post-accident examination of the engine and propeller assembly, the beta control cable was found mis-rigged and the propeller blades were found in the feathered position. The beta valve plunger was extended beyond the chamfer face of the propeller governor, consistent with a position that would shut off oil flow from the governor oil pump to the constant speed unit (CSU). A wire could be inserted through both the forward and aft beta control cable clevis inspection holes that function as check points for proper thread engagement. The forward beta control cable clevis adjustment nut was rotated full aft. The swaging ball end on the forward end of the beta control cable was not properly secured between the clevis rod end and the push-pull control terminal and was free to rotate within the assembly. Before takeoff, the beta valve was in an operational position that allowed oil flow to the CSU, resulting in normal propeller control. Vibration due to engine operation and beta valve return spring force most likely caused the improperly secured swaging ball to rotate (i.e. “unthread”) forward on the beta control cable. The resulting lengthening of the reversing cable assembly allowed the beta valve to stroke forward and shut off oil flow to the propeller CSU. Without propeller servo oil flow to maintain propeller control, the propeller faded to the high pitch/feather position due to normal leakage in the transfer bearing. The reported loss of power is consistent with a loss of thrust due to the beta control cable being mis-rigged during the most recent maintenance work.
Probable cause:
The loss of engine power due to a mis-rigged beta control cable (propeller reversing cable), which resulted in a loss of thrust inflight.
Final Report:

Crash of a Beechcraft B200 Super King near Coleman: 3 killed

Date & Time: Feb 20, 2020 at 0600 LT
Operator:
Registration:
N860J
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Abilene – Harlingen
MSN:
BB-1067
YOM:
1982
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
5300
Circumstances:
The pilot and two passengers departed on an instrument flight rules cross-country flight in night instrument meteorological conditions (IMC). The pilot was instructed by air traffic control to climb to 12,000 ft, and then cleared to climb to FL230. The pilot reported to the controller that the airplane encountered freezing drizzle and light rime icing during the climb from 6,500 ft to 8,000 ft mean sea level (msl). As the airplane climbed through 11,600 ft msl, the pilot reported that they had an issue with faulty deicing equipment and needed to return to the airport. The controller instructed the pilot to descend and cleared the airplane back to the airport. When asked by the controller if there was an emergency, the pilot stated that they “blew a breaker,” and were unable to reset it. As the controller descended the airplane toward the airport, the pilot reported that they were having issues with faulty instruments. At this time, the airplane was at an altitude of about 4,700 ft. The controller instructed the pilot to maintain 5,000 ft, and the pilot responded that he was “pulling up.” There was no further communication with the pilot. Review of the airplane’s radar track showed the airplane’s departure from the airport and the subsequent turn and southeast track toward its destination. The track appeared as a straight line before a descending, right turn was observed. The turn radius decreased before the flight track ended. The airplane impacted terrain in a right-wing-low attitude. The wreckage was scattered and highly fragmented along a path that continued for about 570 ft. Examination of the wreckage noted various pieces of the flight control surfaces and cables in the wreckage path. Control continuity could not be established due the fragmentation of the wreckage; however, no preimpact anomalies were found. Examination of the left and right engines found rotational signatures and did not identify any pre-impact anomalies. A review of maintenance records noted two discrepancies with the propeller deice and surface deice circuit breakers, which were addressed by maintenance personnel. Impact damage and fragmentation prevented determination of which circuit breaker(s) the pilot was having issues with or an examination of any deicing systems on the airplane. The radio transmissions and transponder returns reflected in the radar data indicate that the airplane’s electrical system was operational before the accident. It is likely that the pilot’s communications with the controller and attempted troubleshooting of the circuit breakers introduced distractions from his primary task of monitoring the flight instruments while in IMC. Such interruptions would make him vulnerable to misleading vestibular cues that could adversely affect his ability to effectively interpret the instruments and maintain control of the airplane. The pilot’s report of “faulty instruments” during a decreasing radius turn and his initial distraction with the circuit breakers and radio communications is consistent with the effects of spatial disorientation.
Probable cause:
The pilot’s loss of airplane control due to spatial disorientation. Contributing to the accident was the pilot’s distraction with a “popped” circuit breaker and communications with air traffic control.
Final Report:

Crash of a Beechcraft B60 Duke in Big Spring

Date & Time: Jan 29, 2020 at 1710 LT
Type of aircraft:
Operator:
Registration:
N50JR
Flight Type:
Survivors:
Yes
Schedule:
Abilene – Midland
MSN:
P-303
YOM:
1974
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
25000
Captain / Total hours on type:
7.00
Circumstances:
The pilot was conducting a cross-country flight at a cruise altitude of 10,500 ft mean sea level when the left engine lost all power. He secured the engine and elected to continue to his destination. Shortly thereafter, the right engine lost all power. After selecting an airport for a forced landing, he overflew the runway and entered the pattern. The pilot stated that on short final, after extending the landing gear, "the plane quit flying and the airspeed went to nothing." The airplane landed 200 to 300 yards short of the runway threshold, resulting in substantial damage to the wings and fuselage. During a postaccident examination, only tablespoons of fuel were drained from the left tank. Due to the position of the airplane, the right tank could not be drained; however, when power was applied to the airplane, both fuel quantity gauges indicated empty fuel tanks. Neither fuel tank was breached during the accident, and there was no discoloration present on either of the wings or engine nacelles to indicate a fuel leak; therefore, the loss of engine power is consistent with fuel exhaustion.
Probable cause:
A total loss of engine power in both engines due to fuel exhaustion, which resulted in a landing short of the runway.
Final Report:

Crash of a Cessna 208B Grand Caravan in Victoria: 1 killed

Date & Time: Dec 9, 2019 at 2017 LT
Type of aircraft:
Operator:
Registration:
N4602B
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Victoria – Houston
MSN:
208B-0140
YOM:
1988
Flight number:
MRA679
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
12680
Captain / Total hours on type:
1310.00
Aircraft flight hours:
17284
Circumstances:
The airline transport pilot departed on a night cargo flight into conditions that included an overcast cloud ceiling and “hazy” visibility, as reported by another pilot. About one minute after takeoff, the pilot made a series of course changes and large altitude and airspeed deviations. Following several queries from the air traffic controller concerning the airplane’s erratic flight path, the pilot responded that he had “some instrument problems.” The pilot attempted to return to land at the departure airport, but the airplane impacted terrain after entering a near-vertical dive. The airplane was one of two in the operator’s fleet equipped with an inverter system that electrically powered the pilot’s (left side) flight instruments. Examination of the annunciator panel lighting filaments revealed that the inverter system was not powered when the airplane impacted the ground. Without electrical power from an inverter, the pilot’s side attitude indicator and horizontal situation indicator (HSI) would have been inoperative and warning flags would have been displayed over the respective instruments. The pilot had a history of poor procedural knowledge and weak flying skills. It is possible that he either failed to turn on an inverter during ground operations and did not respond to the accompanying warning flags, or he did not switch to the other inverter in the event that an inverter failed inflight. Due to impact damage, the operational status of the two inverters installed in the airplane could not be confirmed. However, the vacuum-powered flight instruments on the copilot’s (right side) were operational, and the pilot could have referenced these instruments to maintain orientation. Based on the available information, the pilot likely lost control of the airplane after experiencing spatial disorientation. The night marginal visual flight rules conditions and instrumentation problems would have been conducive to the development of spatial disorientation, and the airplane’s extensive fragmentation indicative of a high-energy impact was consistent with the known effects of spatial disorientation. Ethanol identified during toxicology testing may have come from postmortem production and based on the low levels recorded, was unlikely to have contributed to this accident. Morphine identified in the pilot’s liver could not be used to extrapolate to antemortem blood levels; therefore, whether or to what extent the pilot’s use of morphine contributed to the accident could not be determined.
Probable cause:
The pilot’s loss of control due to spatial disorientation. Contributing to the accident were the inoperative attitude indicator and horizontal situation indicator on the pilot’s side of the cockpit, and the pilot’s failure to reference the flight instruments that were operative.
Final Report:

Crash of a Socata TBM-850 in Breckenridge

Date & Time: Oct 14, 2019 at 1245 LT
Type of aircraft:
Operator:
Registration:
N850NK
Flight Type:
Survivors:
Yes
Schedule:
San Angelo - Breckenridge
MSN:
432
YOM:
2007
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
8195
Captain / Total hours on type:
6.00
Aircraft flight hours:
2878
Circumstances:
The pilot reported that, during the approach and while the airplane was about 500 ft above ground level and 81 knots, he "felt the descent rate increase significantly." The pilot increased engine power, but "the high rate of descent continued," and he then increased the engine power further. A slow left roll developed, and he applied full right aileron and full right rudder to arrest the left roll. He also reduced the engine power, and the left roll stopped. The pilot regained control of the airplane, but the airplane's heading was 45° left of the runway heading, and the airplane impacted trees and then terrain. The airplane caught fire, and the pilot and passenger exited through the emergency exit. The airplane sustained substantial damage to the windscreens and fuselage. The pilot reported that there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation.
Probable cause:
The pilot's failure to maintain bank control and adequate altitude during the approach, which resulted in his failure to maintain the runway heading and a subsequent collision with trees and terrain.
Final Report:

Crash of a Beechcraft 350i Super King Air in Addison: 10 killed

Date & Time: Jun 30, 2019 at 0911 LT
Operator:
Registration:
N534FF
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Addison – Saint Petersburg
MSN:
FL-1091
YOM:
2017
Location:
Crew on board:
2
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
10
Captain / Total flying hours:
16450
Captain / Total hours on type:
1100.00
Copilot / Total flying hours:
2357
Copilot / Total hours on type:
189
Aircraft flight hours:
691
Circumstances:
The pilot, co-pilot, and eight passengers departed on a cross-country flight in the twin-engine airplane. One witness located on the ramp at the airport reported that the airplane sounded underpowered immediately after takeoff “like it was at a reduced power setting.” Another witness stated that the airplane sounded like it did not have sufficient power to takeoff. A third witness described the rotation as “steep,” and other witnesses reported thinking that the airplane was performing aerobatics. Digital video from multiple cameras both on and off the airport showed the airplane roll to its left before reaching a maximum altitude of 100 ft above ground level; it then descended and impacted an airport hangar in an inverted attitude about 17 seconds after takeoff and an explosion immediately followed. After breaching a closed roll-up garage door, the airplane came to rest on its right side outside of the hangar and was immediately involved in a postimpact fire. Sound spectrum analysis of data from the airplane’s cockpit voice recorder (CVR) estimated that the propeller speeds were at takeoff power (1,714 to 1,728 rpm) at liftoff. About 7 seconds later, the propeller speeds diverged, with the left propeller speed decreasing to about 1,688 rpm and the right propeller speed decreasing to 1,707 rpm. Based on the airplane’s estimated calibrated airspeed of about 110 knots and the propeller rpm when the speeds diverged, the estimated thrust in the left engine decreased to near 0 while the right engine continued operating at slightly less than maximum takeoff power. Analysis of available data estimated that, 2 seconds after the propeller speed deviation, the airplane’s sideslip angle was nearly 20°. During the first 5 seconds after the propeller speed deviation, the airplane’s roll rate was about 5° per second to the left; its roll rate then rapidly increased to more than 60° per second before the airplane rolled inverted. Witness marks on the left engine and propeller, the reduction in propeller speed, and the airplane’s roll to the left suggest that the airplane most likely experienced a loss of thrust in the left engine shortly after takeoff. The airplane manufacturer’s engine-out procedure during takeoff instructed that the landing gear should be retracted once a positive rate of climb is established, and the propeller of the inoperative engine should be feathered. Right rudder should also be applied to balance the yawing moment imparted by a thrust reduction in the left engine. Examination of the wreckage found both main landing gear in a position consistent with being extended and the left propeller was unfeathered. The condition of the wreckage precluded determining whether the autofeather system was armed or activated during the accident flight. Thus, the pilot failed to properly configure the airplane once the left engine thrust was reduced. Calculations based on the airplane’s sideslip angle shortly after the propeller speed deviation determined that the thrust asymmetry alone was insufficient to produce the sideslip angle. Based on an evaluation of thrust estimates provided by the propeller manufacturer and performance data provided by the airplane manufacturer, it is likely that the pilot applied left rudder, the opposite input needed to maintain lateral control, before applying right rudder seconds later. However, by then, the airplane’s roll rate was increasing too rapidly, and its altitude was too low to recover. The data support that it would have been possible to maintain directional and lateral control of the airplane after the thrust reduction in the left engine if the pilot had commanded right rudder initially rather than left rudder. The pilot’s confused reaction to the airplane’s performance shortly after takeoff supports the possibility that he was startled by the stall warning that followed the propeller speed divergence, which may have prompted his initial, improper rudder input. In addition, the NTSB’s investigation estimated that rotation occurred before the airplane had attained Vr (rotation speed), which decreased the margin to the minimum controllable airspeed and likely lessened the amount of time available for the pilot to properly react to the reduction in thrust and maintain airplane control. Although the airplane was slightly over its maximum takeoff weight at departure, its rate of climb was near what would be expected at maximum weight in the weather conditions on the day of the accident (even with the extended landing gear adding drag); therefore, the weight exceedance likely was not a factor in the accident. Engine and propeller examinations and functional evaluations of the engine and propeller controls found no condition that would have prevented normal operation; evidence of operation in both engines at impact was found. Absent evidence of an engine malfunction, the investigation considered whether the left engine’s thrust reduction was caused by other means, such as uncommanded throttle movement due to an insufficient friction setting of the airplane’s power lever friction locks. Given the lack of callouts for checklists on the CVR and the pilot’s consistently reported history of not using checklists, it is possible that he did not check or adjust the setting of the power lever friction locks before the accident flight, which led to uncommanded movement of the throttle. Although the co-pilot reportedly had flown with the pilot many times previously and was familiar with the B-300, he was not type rated in the airplane and was not allowed by the pilot to operate the flight controls when passengers were on board. Therefore, the co-pilot may not have checked or adjusted the friction setting before the flight’s departure. Although the investigation considered inadequate friction setting the most likely cause of the thrust reduction in the left engine, other circumstances, such as a malfunction within the throttle control system, could also result in loss of engine thrust. However, heavy fire and impact damage to the throttle control system components, including the power quadrant and cockpit control lever friction components, precluded determining the position of the throttle levers at the time of the loss of thrust or the friction setting during the accident flight. Thus, the reason for the reduction in thrust could not be determined definitively. In addition to a lack of callouts for checklists on the CVR, the pilots did not discuss any emergency procedures. As a result, they did not have a shared understanding of how to respond to the emergency of losing thrust in an engine during takeoff. Although the co-pilot verbally identified the loss of the left engine in response to the pilot’s confused reaction to the airplane’s performance shortly after takeoff, it is likely the co-pilot did not initiate any corrective flight control inputs, possibly due to the pilot’s established practice of being the sole operator of flight controls when passengers were on board. The investigation considered whether fatigue from inadequately treated obstructive sleep apnea contributed to the pilot’s response to the emergency; however, the extent of any fatigue could not be determined from the available evidence. In addition, no evidence indicates that the pilot’s medical conditions or their treatment were factors in the accident. In summary, the available evidence indicates that the pilot improperly responded to the loss of thrust in the left engine by initially commanding a left rudder input and did not retract the landing gear or feather the left propeller, which was not consistent with the airplane manufacturer’s engine out procedure during takeoff. It would have been possible to maintain directional and lateral control of the airplane after the thrust reduction in the left engine if right rudder had been commanded initially rather than left rudder. It is possible that the pilot’s reported habit of not using checklists resulted in his not checking or adjusting the power lever friction locks as specified in the airplane manufacturer’s checklists. However, fire and impact damage precluded determining the position of the power levers or friction setting during the flight.
Probable cause:
The pilot’s failure to maintain airplane control following a reduction of thrust in the left engine during takeoff. The reason for the reduction in thrust could not be determined. Contributing to the accident was the pilot’s failure to conduct the airplane manufacturer’s emergency procedure following a loss of power in one engine and to follow the manufacturer’s checklists during all phases of operation.
Final Report:

Crash of a Boeing 767-375ER off Anahuac: 3 killed

Date & Time: Feb 23, 2019 at 1239 LT
Type of aircraft:
Operator:
Registration:
N1217A
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Miami - Houston
MSN:
25685/430
YOM:
1992
Flight number:
5Y3591
Location:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
11172
Captain / Total hours on type:
1252.00
Copilot / Total flying hours:
5073
Copilot / Total hours on type:
520
Aircraft flight hours:
91063
Aircraft flight cycles:
23316
Circumstances:
On February 23, 2019, at 1239 central standard time, Atlas Air Inc. (Atlas) flight 3591, a Boeing 767-375BCF, N1217A, was destroyed after it rapidly descended from an altitude of about 6,000 ft mean sea level (msl) and crashed into a shallow, muddy marsh area of Trinity Bay, Texas, about 41 miles east-southeast of George Bush Intercontinental/Houston Airport (IAH), Houston, Texas. The captain, first officer (FO), and a nonrevenue pilot riding in the jumpseat died. Atlas operated the airplane as a Title 14 Code of Federal Regulations Part 121 domestic cargo flight for Amazon.com Services LLC, and an instrument flight rules flight plan was filed. The flight departed from Miami International Airport (MIA), Miami, Florida, about 1033 (1133 eastern standard time) and was destined for IAH. The accident flight’s departure from MIA, en route cruise, and initial descent toward IAH were uneventful. As the flight descended toward the airport, the flight crew extended the speedbrakes, lowered the slats, and began setting up the flight management computer for the approach. The FO was the pilot flying, the captain was the pilot monitoring, and the autopilot and autothrottle were engaged and remained engaged for the remainder of the flight. Analysis of the available weather information determined that, about 1238:25, the airplane was beginning to penetrate the leading edge of a cold front, within which associated windshear and instrument meteorological conditions (as the flight continued) were likely. Flight data recorder data indicated that, during the time, aircraft load factors consistent with the airplane encountering light turbulence were recorded and, at 1238:31, the airplane’s go-around mode was activated. At the time, the accident flight was about 40 miles from IAH and descending through about 6,300 ft msl toward the target altitude of 3,000 ft msl. This location and phase of flight were inconsistent with any scenario in which a pilot would intentionally select go-around mode, and neither pilot made a go-around callout to indicate intentional activation. Within seconds of go-around mode activation, manual elevator control inputs overrode the autopilot and eventually forced the airplane into a steep dive from which the crew did not recover. Only 32 seconds elapsed between the go-around mode activation and the airplane’s ground impact.
Probable cause:
The NTSB determines that the probable cause of this accident was the inappropriate response by the first officer as the pilot flying to an inadvertent activation of the go-around mode, which led to his spatial disorientation and nose-down control inputs that placed the airplane in a steep descent from which the crew did not recover. Contributing to the accident was the captain’s failure to adequately monitor the airplane’s flightpath and assume positive control of the airplane to effectively intervene. Also contributing were systemic deficiencies in the aviation industry’s selection and performance measurement practices, which failed to address the first officer’s aptitude-related deficiencies and maladaptive stress response. Also contributing to the accident was the Federal Aviation Administration’s failure to implement the pilot records database in a sufficiently robust and timely manner.
Final Report:

Crash of a Cessna 421C Golden Eagle III near Canadian: 2 killed

Date & Time: Feb 15, 2019 at 1000 LT
Registration:
N421NS
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Amarillo – Canadian
MSN:
421C-0874
YOM:
1980
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
5000
Aircraft flight hours:
6227
Circumstances:
The pilot was conducting a personal cross-country flight with one passenger in his twin-engine airplane. There was no record that the pilot received a weather briefing before the accident flight. While en route to the destination, the pilot was in contact with air traffic control and received visual flight rules flightfollowing services. About 18 miles from the destination airport, the radar service was terminated, as is typical in this geographic region due to insufficient radio and radar coverage below 7,000 ft. The airplane was heading northeast at 4,900 ft mean sea level (msl) (about 2,200 ft above ground level [agl]). About 4 minutes later, radar coverage resumed, and the airplane was 6 miles west of the airport at 4,100 ft msl (1,400 ft agl) and climbing to the north. The airplane climbed through 6,000 ft msl (3,300 ft agl), then began a shallow left turn and climbed to 6,600 ft msl (3,800 ft agl), then began to descend while continuing the shallow left turn ; the last radar data point showed the airplane was about 20 nm northwest of the airport, 5,100 ft msl (2,350 ft agl) on a southwest heading. The final recorded data was about 13 miles northwest of the accident site. A witness near the destination airport heard the pilot on the radio. He reported that the pilot asked about the cloud height and the witness responded that the clouds were 800 to 1,000 ft agl. In his final radio call, the pilot told the witness, "Ok, see you in a little bit." The witness did not see the airplane in the air. The airplane impacted terrain in a slightly nose-low and wings-level attitude with no evidence of forward movement, and a postimpact fire destroyed a majority of the wreckage. The damage to the airplane was consistent with a relatively flat spin to the left at the time of impact. A postaccident examination did not reveal any preimpact mechanical malfunctions or anomalies that would have precluded normal operation. A detailed examination of the cockpit instruments and other portions of the wreckage was not possible due to the fire damage. A cold front had advanced from the northeast and instrument meteorological conditions prevailed across the region surrounding the accident site and the destination airport; the cloud ceilings were 400 ft to 900 ft above ground level. The airplane likely experienced wind shear below 3,000 ft, and there was likely icing in the clouds. While moderate icing conditions were forecast for the accident site, about the time of the accident, investigators were unable to determine the amount and severity of icing the flight may have experienced. The weather conditions had deteriorated over the previous 1 to 2 hours. The conditions at the destination airport had been clear about 2 hours before accident, and visual flight rules conditions about 1 hour before accident, when the pilot departed. Based on the available evidence it is likely that the pilot was unable to maintain control of the airplane, which resulted in an aerodynamic stall and spin into terrain.
Probable cause:
The pilot's failure to maintain control of the airplane while in instrument meteorological conditions with icing conditions present, which resulted in an aerodynamic stall and spin into terrain.
Final Report: