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
Site:
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
Circumstances:
The aircraft was destroyed when it broke up in-flight and impacted an open field near Harmon, North Dakota. The airline transport certificated pilot, flight nurse, and paramedic were fatally injured. The airplane was registered to and operated by Bismarck Air Medical under the provisions of Title 14 Code of Federal Regulations Part 135. Visual meteorological conditions prevailed at the time of the accident, and an instrument flight rules (IFR) flight plan had been filed for the air medical cross-country flight. The flight originated from Bismarck Municipal Airport (BIS), Bismarck, North Dakota, at 2230, and was en route to Sloulin Field International Airport (ISN), Williston, North Dakota. Preliminary information indicated the crew was en route to ISN to pick up a neonatal infant for transport back to BIS. Radar data indicated the airplane climbed on a direct course until reaching 14,000 feet above sea level. Ground speed was at 240 knots. The airplane then entered a steep right bank and radar contact was lost. No distress calls were received. Wreckage was scattered for about 1 mile long and 600 feet wide on snow-covered terrain. The cockpit area, cabin area, empennage, both engines and propellers, and both wings were identified and recovered. Flight control continuity was established.

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

Date & Time: Feb 22, 2018 at 1939 LT
Type of aircraft:
Operator:
Registration:
N771XW
Flight Phase:
Survivors:
No
Site:
Schedule:
Eagle Creek Airpark - Green Bay
MSN:
441-0065
YOM:
1978
Location:
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
3
Circumstances:
On February 22, 2018, at 1939 eastern standard time, A Cessna 441 Conquest II airplane, N771XW, impacted terrain following a loss of control in Rossville, Indiana. The airline transport rated pilot and two passengers were fatally injured, and the airplane was destroyed. The airplane was registered to and operated by Ponderosa Aviation LLC under the provisions of Title 14 Code of Federal Regulations Part 91 as a business flight. Night instrument meteorological conditions prevailed for the flight, which was operating on an instrument flight plan. The flight originated from the Eagle Creek Airpark (EYE), Indianapolis, Indiana, about 1920, with an intended destination of the Green Bay Austin Straubel International Airport (GRB), Green Bay, Wisconsin. Shortly after takeoff the pilot deviated from the assigned heading and altitude. When questioned by the Indianapolis departure controller, the pilot replied that the airplane was out of control. The pilot then turned the airplane to a heading 90° and explained to the controller that he had a trim problem and difficulty controlling the airplane, but that he had the airplane back to straight and level. The pilot was issued a turn to a heading of 310°, followed by a clearance to climb and maintain 13,000 ft. The pilot was then instructed to contact the Chicago Air Route Traffic Control Center (ZAU). The pilot checked in with ZAU57 sector stating that he was climbing from 10,600 ft to 13,000 ft. The pilot was cleared to climb to FL200 (20,000 ft) followed by a climb to FL230. The pilot was instructed to change frequencies to ZAU46 sector. The pilot then transmitted that he needed a minute to get control of the airplane and that he was having difficulty with the trim. Communication and radar contact was then lost. Several witnesses reported hearing the airplane flying overhead. They all described the airplane as being very loud and that the engine sound was steady up until they heard the impact. The airplane impacted the terrain in a plowed field (upper field) which was soft and muddy. A shallow disruption of the dirt was present which was about 250 ft in length. The impact mark was visible up to the crest of a slight incline where the main pieces of wreckage began. Trees bordered the east end of the field and just beyond the treeline was a tree-covered hill which descended about 50 ft at a slope of about 50°. The trees on the hillside were about 80 to 100 ft tall. At the bottom of the hill was an 8 - 10 ft wide creek. The east bank of the creek was treelined and beyond the trees were to more open fields (lower fields) which were divided by a row of small trees and brush. The wreckage was scattered in the upper field, down the hillside, and into the lower fields. The entire wreckage path was about ¼ mile in length. Recorded weather conditions present 17 miles west of the accident site were overcast at 1,500 ft with 10 miles visibility. The witnesses reported similar conditions in at the accident site.

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
Circumstances:
Shortly after takeoff from runway 25 at Renmark Airport, while in initial climb, the twin engine aircraft went out of control and crashed in a desert area located 4 km west of the airfield. The aircraft was destroyed and all three crew members were killed. They were performing a training mission (check flight) from Adelaide to Renmark and back.

Crash of a Cessna 441 Conquest II in Climax: 2 killed

Date & Time: Nov 9, 2015 at 1016 LT
Type of aircraft:
Operator:
Registration:
N164GP
Flight Phase:
Survivors:
No
Site:
Schedule:
Lakeland - Cairo
MSN:
441-0164
YOM:
1980
Location:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
1150
Captain / Total hours on type:
150.00
Copilot / Total flying hours:
9500
Aircraft flight hours:
18422
Circumstances:
The purpose of the flight was for the commercial pilot/owner to pick up passengers at the destination airport and return to the departure airport. The airplane was 33 miles from its destination in cruise flight at 3,300 ft mean sea level (msl) and above a solid cloud layer when the pilot declared to air traffic control (ATC) that he had the destination airport "in sight" and cancelled his instrument flight rules (IFR) clearance. During the 13 minutes after cancellation of the IFR clearance, the airplane's radar track made an erratic sequence of left, right, and 360° turns that moved the airplane away from the destination airport in a westerly direction. The altitudes varied between about 4,000 and 900 ft msl. Later, the pilot reestablished communication with ATC, reported he had lost visual contact with the airport, and requested an instrument approach to the destination airport. The controller then provided a sequence of heading and altitude assignments to vector the airplane onto the approach, but the pilot did not maintain these assignments, and the controller provided several corrections. The pilot expressed his inability to identify the initial approach fix (IAF) and asked the controller for the correct spelling. The radar target then climbed and subsequently entered a descending right turn at 2,500 ft msl and 180 knots ground speed near the IAF, before radar contact with the airplane was lost. Although a review of airplane maintenance records revealed that the airplane was overdue for several required inspections, examination of the wreckage revealed signatures consistent with both engines being at high power at impact, and no evidence of any preimpact mechanical anomalies were found that would have precluded normal operation. Examination of the airplane's panel-mounted GPS, which the pilot was using to navigate the flight, revealed that the navigation and obstruction databases were expired. During a weather briefing before the flight, the pilot was warned of low ceilings and visibility. The weather conditions reported near the destination airport about the time of the accident also included low ceilings and visibilities. The restricted visibility conditions and the high likelihood of inadvertent entry into instrument meteorological conditions were conducive to the development of spatial disorientation. The flight's erratic track, which included altitude and directional changes inconsistent with progress toward the airport, were likely the result of spatial disorientation. After reestablishing contact with ATC and being cleared to conduct an instrument approach to the destination, the airplane's flight track indicated that the pilot was not adequately prepared to execute the controller's instructions. The pilot's subsequent loss of control was likely the result of spatial disorientation due to his increased workload and operational distractions associated with his attempts to configure his navigation radios or reference charts. Postaccident toxicological testing of samples obtained from the pilot revealed the presence of ethanol; however, it could not be determined what percentage was ingested or produced postmortem. The testing also revealed the presence of amphetamine, an opioid painkiller, two sedating antihistamines, and marijuana. Although blood level quantification of these medications and drugs could not be made from the samples provided, their combined effects would have directly impacted the pilot's decision-making and ability to fly the airplane, even if each individual substance was only present in small amounts. Based in the reported weather conditions at the time the pilot reported the airport in sight and canceled his IFR clearance, he likely was not in a position to have seen the destination airport even though he may have been flying between cloud layers or may have momentarily observed the ground. His decision to cancel his IFR clearance so far from the destination, in an area characterized by widespread low ceilings and reduced visibility, increased the pilot's exposure to the hazards those conditions posed to the successful completion of his flight. The pilot showed other lapses in judgment associated with conducting this flight at the operational, aircraft, and the personal level. For example, 1) the pilot did not appear to recognize the significance of widespread low ceilings and visibility along his route of flight and at his destination (nor did he file an alternate airport even though conditions warranted); 2) the accident airplane was being operated beyond mandatory inspection intervals; and 3) toxicological testing showed the pilot had taken a combination of multiple medications and drugs that would have likely been impairing and contraindicated for the safe operation of an airplane. The pilot's decision-making was likely affected by the medications and drugs.
Probable cause:
The pilot's loss of airplane control due to spatial disorientation. Also causal to the accident was the pilot's impairment by the combined effects of multiple medications and drugs.
Final Report: