Piper PA-61 Aerostar (Ted Smith 601)

While on a cross-country flight, according to radar data and weather information, the pilot descended below terrain clearance altitude and entered IMC conditions. The aircraft impacted a mountain peak approximately 100 feet below the summit. No flight plan had been filed and the pilot was not instrument rated.

During the takeoff roll on runway 25 at Randers Airport, the right engine lost power then failed. The pilot continued the takeoff procedure and completed the rotation. Just after liftoff, while in initial climb, smoke spread from the right engine into the cockpit. The pilot attempted an emergency landing when the aircraft crash landed, collided with trees and came to rest about 500 metres past the runway end. The pilot escaped uninjured and the aircraft was damaged beyond repair.

While operating in IMC, the pilot was vectored to the final approach course for an ILS approach. Weather at the airport was ceiling 200 feet and visibility 3/4 mile in mist. The pilot was cleared for the approach, which he acknowledged. No other transmissions were received from the accident airplane. Radar data showed the airplane intercept the final approach course, then track inbound. The airplane crossed the outer marker 420 feet below the glide slope. The last radar return showed the airplane at 440 feet agl, 3.9 miles from the runway. The airplane impacted the ground at a shallow angle about 1 mile north of the airport on the opposite side of the missed approach procedure. The elevation of the accident site was approximately 40 feet lower than the airport. The pilot had about 350 hours of total flight
experience. No pre-impact failures were identified with the airframe, engines, flight controls, or flight instruments.

During takeoff, the twin-engine airplane was observed to roll left, pitch nose down, and impact terrain shortly after the pilot reported to ATC that he had a problem. Witnesses reported that the left engine was producing black smoke during the takeoff roll. One witness stated that the airplane had slowed to approximately 60-70 mph prior to rolling to the left. A mechanic, who worked on the airplane prior to the accident, stated that the pilot reported being unable to maintain manifold pressure (MP) with the left engine. The mechanic found that the left engine's rubber interconnect boot, which routes induction air between the turbocharger controller elbow and the fuel servo, was 'gaping open.' The mechanic reseated the boot and tightened the clamp. The pilot flew the airplane and reported no problems. During a second flight, the pilot reported that the left engine was again unable to maintain MP. Prior to the accident flight, the pilot informed the mechanic that the 'hose had slid off again' and that it had been reinstalled and he 'felt sure it was o.k.' A witness stated that he saw the pilot working on the left engine the morning of the accident. At the accident site, the left engine's interconnect boot was found disconnected. The clamp securing the boot was not located. No other preimpact anomalies were found with the engines, propellers, turbochargers, or fuel servos.

The pilot departed on runway 06 with zero degrees of flaps. A witness said that she noticed that the airplane appeared to wobble and shudder, and immediately went into a steep right bank turn right after takeoff. The airplane then went into the clouds which were 200 to 400 feet agl. Radar data indicated that the airplane made several 90 degree turns prior to impacting the mountainous terrain 2.55 nm from the departure end of the runway. The pilot normally used 20 degrees of flaps for takeoff. A test pilot said that the airplane handles significantly different during takeoff if zero degrees of flaps are used verses 20 degrees of flaps. The upper cabin's entry door was found, with the locking handle and locking pins, in the closed position. No preimpact engine or airframe anomalies, which might have affected the airplane's performance, were identified.

The airplane took off from Port Huron, Michigan, on April 1, 1999, at 1130 est. The airplane was scheduled to arrive in Freemont, Ohio. An employee of the pilot's company said that the pilot was going to meet a customer there. At 1230 est, the customer called the company inquiring about the pilot. The employee said that the pilot 'would have taken the shortest route, over [Lake] St. Clair, Ontario [Province], and [Lake] Erie,' to get to Freemont, Ohio. An ALNOT was issued at 1803 est. Search and rescue operations were conducted by the U. S. Coast Guard, Civil Air Patrol, and the Canadian Search and Rescue Center. The search was suspended on April 10, 1999, at 2125 est. The passenger's body was discovered on May 1, 1999, in the Lake St. Clair shipping channel, approximately 6.9 miles east of St. Clair Shores, Michigan. On July 2, 1999, the pilot's body was found in Lake St. Clair. Parts of the airplane identified from the make and model of aircraft were recovered with the bodies.

Shortly after the airplane took off, a witness about 1 mile from the airport observed the airplane about 150 feet above the ground in a left turn, before it disappeared into the clouds. A witness across from where the airplane crashed stated he was in his shed when he heard the sound of an airplane overhead. When the sound faded and returned, like the airplane had circled above the shed, he stepped outside and looked for the airplane. He saw the airplane exit the clouds in a near vertical position and impact the ground. He described the engine noise as loud and smooth. The airplane impacted in a field about 3/4 miles from the departure airport and was consumed by a post crash fire. Streaks of oil were observed on the leading edge of the right horizontal stabilizer extending to its upper and lower surfaces. Disassembly of both engines did not reveal any pre-impact mechanical malfunctions. A weather observation taken after the accident reported included a visibility of 2 miles with light drizzle and mist, and the ceiling was 400 foot overcast. Witnesses described the weather at the accident site as '...pretty foggy,' and worse than the conditions reported at the airport.

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.

About three hours and twenty minutes after departing Bellingham, Washington, for Midland, Texas, the pilot contacted Klamath Falls (Oregon) Tower and told the controller of his intention to land. About 10 minutes later, while about 30 miles north of Klamath Falls, the pilot reported he was low on fuel and was not able to find the city. The tower responded with instructions that would take the pilot south to the airport. But because the pilot seemed not to be following the instructions, but was instead continuing to the west, he was switched to Seattle Center. Center provided the pilot with a southeasterly heading direct to Klamath Falls, but less than a minute later radar and radio contact with the aircraft was lost. Other pilots overheard the pilot transmit that he had lost power in one engine, and later state that he had lost power in both. Soon thereafter the aircraft was seen to descend to about 200 to 300 feet above the surface of Lake of the Woods. The aircraft then began to slow and its nose began to rise. As it was slowing, one of the engines surged back to a high power setting, and the aircraft almost immediately rolled quickly to the side and dove nearly straight down into the lake. During the post-accident inspection of the airframe, the throttle for the right engine was found retarded to idle, but the throttle for the left engine was found in the full-forward (maximum power) position. A review of the Aerostar owner's manual revealed that the Engine Failure/Restart checklist called for the throttle for a failed engine (both engines in this case) to be retarded to the 'Cracked 1/2 inch open' position. Toxicological results indicate the presence in the pilot's blood of chlordiazepoxide and three of its active metabolites, norchlordiazepoxide, nordiazepam, and oxazepam. Chlordiazepoxide (Librium) is a tranquilizer often used to treat anxiety and tension. At sufficient levels it can have significant adverse effects on judgement, alertness, and performance. It is known to cause drowsiness, mental dullness, and euphoria. The results also indicate the presence of diphenhydramine in the pilot's blood. Diphenhydramine is a sedating antihistamine, and in sufficient quantities is known to produce drowsiness, impaired coordination, blurred vision, and reduced mental alertness.

The airplane departed the airport and crashed shortly thereafter. Before departure, the airplane was fueled with 120 gallons of 100LL aviation fuel. According to the refueler, the airplane had full fuel tanks. The refueler also indicated the pilot had stated he wanted to be airborne prior to the arrival of bad weather. After the accident, the engines and propellers were disassembled and examined. No engine or propeller discrepancies were noted, except (post impact) heat damage.