Alabama

The pilot received a preflight briefing from the Gainesville Automated Flight Service Station before departing on the instrument flight. The briefer advised the pilot of the potential for occasional moderate turbulence between 24,000 and 37,000 feet and on the current Convective SIGMET for embedded thunderstorms over southern Mississippi. The flight was in cruise flight at 24, 000 feet when the airplane encountered moderate to severe turbulence and heavy rain. The airplane descended from 24,000 feet to 3,100 feet in a descending right turn in 2 minutes and 10 seconds before radar contact was lost. The airplane was located 8 hours 26 minutes after the accident along a crash debris line that extended between 1.31 miles and 1.53 miles northwest of Arlington, Alabama. Airframe components recovered from the accident site were submitted to the NTSB Materials laboratory for examination. The examinations revealed all failures were consistent with overstress fracturing and there was no evidence of pre-existing conditions or fatigue damage. Examination of the airframe revealed that the airframe design limits were exceeded. The Pilot's Operating Handbook states the maximum structural cruising speed is 173 knots indicated airspeed or 170 knots calibrated airspeed. The co-pilot airspeed indicator at the crash site indicated 180 knots calibrated airspeed. The design maneuvering speed is 135 knots indicated airspeed or 133 knots calibrated airspeed.

The flight was climbing from 5,000 to 10,000 feet and the pilot obtained a maximum altitude of 6,300 feet. The airplane then began to lose altitude and deviate off course. The pilot declared a mayday and reported the airplane was in a spin. Several witnesses near the accident site reported hearing airplane engine noises and seeing the airplane descend from the clouds in a nose-down spiral to the ground. Two AIRMETs were valid at the time of the accident and included the accident location: "AIRMET TANGO update 3 for turbulence ... . Occasional moderate turbulence below a flight level of 18,000 feet due to wind shear ... ." "AIRMET ZULU update 2 for ice and freezing level ... . Occasional moderate rime and/or mixed icing in clouds and precipitation below 8,000 feet." Two pilots who departed in separate Beech 200 airplanes about the time of the accident airplane stated they encountered "moderate rime" icing between 5,000 and 6,000 feet, and one pilot reported instrument meteorological conditions and light turbulence between 1,800 to 6,000 feet. Examination of the airplane revealed no evidence of airframe or engine malfunction. The de-ice ejector flow control valves for the left wing, right wing, and empennage pneumatic boots were removed for examination, and all valves functioned when power was supplied.

A review of communications between Mobile Downtown Control Tower, and the pilot revealed that while on approach the pilot reported having a problem. The Ground Controller reported that he had the airplane in sight and cleared the flight to land on runway 18. The pilot stated that he had a "run away engine", and elected to shut down the engine and continued the approach. The Controller then cleared the pilot again to runway 18. The pilot then stated that he did not think that he was going to "make it." The airplane collided with a utility pole and the ground and burst into flames short of the runway. The post-accident examination of the engine found that the fuel control unit arm to the fuel control unit interconnect rod end connection was separated from the rod end swivel ball assembly. The swivel ball assembly was found improperly attached to the inboard side of the arm, with the bolt head facing inboard, instead of outboard, and the washer and nut attached to the arm's outboard side instead of the inboard side. The rod separation would resulted in a loss of power lever control. The published emergency procedures for "Power Lever Control Lose," states; If minimum power obtained is excessive: 1) reduce airspeed by setting airplane in nose-up attitude at IAS < 178 KIAS. 2) "inert Sep" switch--On. 3) if ITT >800 C "Inert Sep"--Off. 4) Landing Gear Control--Down. 5) Flaps--Takeoff. 6) Establish a long final or an ILS approach respecting IAS < 178 KIAS. 7) When runway is assured: Condition Lever to --Cut Off. 8) Propeller Governor Lever to-- Feather. 9) Flaps --Landing as required (at IAS <122 KIAS). 10) Land Normally without reverse. 11) Braking as required. The pilot stated to Mobile Downtown Control Tower, Ground Control that he had a "run away engine" and that he "had to shut down the engine". As a result of the pilot not following the published emergency procedures, the airplane was unable to reach the runway during the emergency.

The airplane was destroyed by impact forces. There was no evidence of fire. Wreckage examinations and all recovered wreckage from the impact area revealed no evidence of an inflight collisionor breakup, or of external contact by a foreign object. An examination of the engine and the propeller indicated that the engine was producing power at impact. The recovered components showed no evidence of preexisting powerplant, system, or structural failures. Wreckage examinations showed crushing and bending consistent with a moderate angle of descent and a moderate right-wing-down attitude at impact. The amount of wreckage recovered indicates that all parts of the airplane were at the crash site. The wreckage was scattered over an area of about 600 feet. An examination of radar and airplane performance data indicated that the accident airplane initiated a descent from 3,000 feet immediately after the accident pilot was given a second traffic advisory by air traffic control. The pilot reported that the traffic was above him. At the time the pilot stated that he needed to deviate, data indicate that the accident airplane was in or entering an uncontrolled descent. Radar data indicated that, after departure from the airport, the closest identified airplane to the accident airplane was a DC-10, which was at an altitude of about 4,000 feet. The horizontal distance between the two airplanes was about 1.1 nautical miles, and the vertical distance between the airplanes was about 1,600 feet. The accident airplane was never in a location at which wake turbulence from the DC-10 would have intersected the Cessna's flightpath (behind and below the DC-10's flightpath). Given the relative positions of the accident airplane and the DC-10, wake turbulence was determined to not be a factor in this accident. Although the DC-10 was left of the position given to the pilot by Mobile Terminal Radar Approach Control, air traffic controllers do not have strict angular limits when providing traffic guidance. The Safety Board's airplane performance simulation showed that, beginning about 15 seconds before the time of the pilot's last transmission ("I needed to deviate, I needed to deviate"), his view of the DC-10 moved diagonally across the windscreen from his left to straight in front of the Cessna while tripling in size. The airplane performance simulation also indicated that the airplane experienced high bank and pitch angles shortly after the pilot stated, "I needed to deviate" (about 13 seconds after the transmission, the simulation showed the airplane rolling through 90° and continuing to roll to a peak of about 150° 3 seconds later) and that the airplane appeared to have nearly recovered from these extreme attitudes at impact. Performance data indicated that the airplane would had to have been structurally/aerodynamically intact to reach the point of ground impact from the point of inflight upset. There was no evidence of any other aircraft near the accident airplane or the DC-10 at the time of the accident. Soon after the accident, U.S. Coast Guard aircraft arrived at the accident scene. The meaning of the pilot's statement that he needed to deviate could not be determined. A review of air traffic control radar and transcripts revealed no evidence of pilot impairment or incapacitation before the onset of the descent and loss of control. A sound spectrum study conducted by the Safety Board found no evidence of loud noises during the pilot's last three radio transmissions but found that background noise increased, indicating that the cockpit area was still intact and that the airspeed was increasing. The study further determined that the overspeed warning had activated, which was consistent with the performance study and extreme fragmentation of the wreckage. Radar transponder data from the accident airplane were lost below 2,400 feet. The signal loss was likely caused by unusual attitudes, which can mask transponder antenna transmissions. A garbled transponder return recorded near the DC-10 was likely caused by the accident airplane's transponder returns masking the DC-10's returns (since the accident airplane was projected to be in line between the DC-10 and the ground radar) or by other environmental phenomena. Red transfer or scuff marks were observed on many pieces of the airplane wreckage, and these marks were concentrated on the lower airframe skin forward of the main landing gear and the nose landing gear area. The Safety Board and four laboratories compared the red-marked airplane pieces to samples of red-colored items found in the wreckage. These examinations determined that most of the red marks were caused by parts of the airplane, cargo, and items encountered during the wreckage recovery. The marks exhibited random directions of motion, and none of the marks exhibited evidence of an in-flight collision with another aircraft. A small piece of black, anodized aluminum found embedded in the left wing was subsequently identified as a fragment from a cockpit lighting dimmer. The accident occurred at night, with the moon obscured by low clouds. Instrument meteorological conditions prevailed, although visual conditions were reported between cloud layers. The terminal aerodrome forecast reported a possible cloud layer at 3,000 feet. Weather data and observations by the DC-10 pilot indicated that, after flying about 100 to 500 feet above the cloud layer and soon after sighting the DC-10, the accident airplane would have entered clouds. A number of conditions were present on the night of the accident that would have been conducive to spatial disorientation. For example, no visible horizon references existed between the cloud layers in which the pilot was flying because of the night conditions. In addition, to initiate a visual search and visually acquire the DC-10, varying degrees of eye and head movements would have accompanied the pilot's shifting of attention outside the cockpit. Once the DC-10 was visually acquired by the pilot, it would have existed as a light source moving against an otherwise featureless background, and its relative motion across and rising in the Cessna's windscreen could have been disorienting, especially if the pilot had fixated on it for any length of time. Maneuvering the airplane during this search would likely have compounded the pilot's resultant disorientation.

The flight departed from Little Rock, Arkansas, about 2356 cst, and approximately 49 minutes after takeoff, the FAA approved un-augmented Automated Weather Observing System (AWOS-3) installed at the destination airport began reporting the visibility as 1/4 statute mile; the visibility continued to be reported as that value for several hours after the accident. Title 14 CFR Part 135.225 indicates no pilot may begin an instrument approach procedure to an airport with an approved weather reporting facility unless the latest weather report issued by that weather reporting facility indicates that weather conditions are at or above the authorized IFR landing minimums for that airport. The listed minimums for the ILS approach to runway 05 was in part 3/4 mile visibility. A METAR taken at the destination airport approximately 2 minutes after the accident indicated overcast clouds existed at 100 feet, the temperature and dew point were 4 and 2 degrees Celsius, respectively, and the altimeter setting was 30.16 inHg. No precipitation was present across Arkansas, Mississippi, or Alabama, and no radar echoes were noted along the accident airplane's route of flight. The freezing level near the departure and destination airports at the nominal time of 0600 (4 hours 17 minutes after the accident) was 12000 and 14,500 feet mean sea level, respectively. A witness at the airport reported the fog was the thickest he had seen since working at the airport for the previous year. The flight was cleared for an ILS approach to runway 05, and the pilot was advised frequency change was approved. The witness waiting at the airport reported hearing a sound he associated with a shotgun report. Radar data indicated that between 0138:47, and 0142:11, the airplane was flying on a northeasterly heading and descended from 2,400 feet msl, to 900 feet msl. At 0142:11, the airplane was located .43 nautical mile from the approach end of runway 05. The next recorded radar target 24 seconds later indicated 1,000 feet msl, and was .20 nautical mile from the approach end of runway 05. The touchdown zone elevation for runway 05 is 700 feet msl. The airplane crashed in a wooded area located approximately 342 degrees and .37 nautical mile from the approach end of runway 05; the wreckage was located approximately 4 hours after the accident. Examination of trees revealed evidence the airplane was banked to the left approximately 24 degrees, and the descent angle from the trees to the ground was calculated to be approximately 22 degrees. All components necessary to sustain flight were either attached to the airplane or in close proximity to the main wreckage. There was no evidence of post crash fire and a strong odor of fuel was noted at the scene upon NTSB arrival. A 8-inch diameter pine tree located near the initial ground impact sight exhibited black paint transfer and a smooth cut surface that measured approximately 46 inches in length. The bottom portion of the cut was located 4 feet above ground level. The flap actuator was found nearly retracted; examination of the components of the flap system revealed no evidence of preimpact failure or malfunction. Examination of the flight control system for roll, pitch, and yaw revealed no evidence of preimpact failure or malfunction. Examination of the engine and engine components with TSB of Canada oversight revealed no evidence of preimpact failure of the engine or engine components. Examination of the propeller with FAA oversight revealed no evidence of preimpact failure or malfunction. Examination of the components of the autopilot system, selected avionics and flight instruments from the airplane with FAA oversight revealed no evidence of preimpact failure or malfunction. The pilot's attitude indicator had been replaced on October 14, 2001, and according to FAA personnel, the mechanic and facility that performed the installation did not have the necessary equipment to perform the operational checks required to return the airplane to service. The FAA flight checked the ILS approach to runway 05 two times after the accident and reported no discrepancies.

The pilot and passengers were on a instrument flight returning home. When they were within range of the destination airport, the controller cleared the flight for an instrument approach. Moment later the pilot canceled his instrument flight plan and told the controller that he was below the weather. Low clouds, reduced visibility and fog existed at the destination airport at the time of the accident. The airplane collided with a river bank as the pilot maneuvered for the visual approach. The post-crash examination of the airplane failed to disclose a mechanical problem.

According to witnesses, the airplane collided with two deer shortly after touchdown. Following the collision, the airplane continued down the runway with the tires smoking, veered off the right side of the runway near the end, crossed a taxiway, impacted into a ditch and burst into flames. After the accident, the captain and first officer both reported that the thrust reversers failed to operate after they were deployed during the landing. Examination of the landing gear found all three gear collapsed. The right and left main tires had areas of rubber that were worn completely through. The flaps were found extended, and both thrust reversers were found in the stowed position. Examination of the cockpit found the throttles in the idle position, and the thrust reverser levers in the stowed position. Aircraft performance calculations indicate that the airplane traveled 1,500 feet down the runway after touchdown, in 4.2 seconds, before striking the deer. The calculations also indicate that the airplane landed with a ground speed of 124 knots. At 124 knots and maximum braking applied, the airplane should have come to a complete stop in about 850 feet. However, investigation of the accident site and surrounding area revealed heavy black skid marks beginning at the first taxiway turnoff about 1,500 feet down the 5,010 foot runway. The skid marks continued for about 2,500 feet, departed the right side of the runway and proceeded an additional 500 feet over grass and dirt. The investigation revealed that deer fur was found lodged in the squat switch on the left main landing gear, likely rendering the squat switch inoperative after the impact with the deer, and prior to the airplane’s loss of control on the runway. Since a valid signal from the squat switch is required for thrust reverser deployment, the loss of this signal forced the thrust reversers to stow. At this point, the electronic engine control (EEC) likely switched to the forward thrust schedule and engine power increased to near takeoff power, which led to the airplane to continue down the runway, and off of it. Following the accident, the manufacturer issued an Airplane Flight Manual revision that Page 2 of 8 ATL01FA021 changed the name of the “Inadvertent Stow of Thrust Reverser During Landing Rollout” abnormal procedure to “Inadvertent Stow of Thrust Reverser After a Crew-Commanded Deployment” and moved it into the emergency procedures section.
[This Brief of Accident was modified on April 5, 2010, based on information obtained during NTSB Case No. DCA08MA098.]

During the takeoff roll and initial climb both engines were producing normal power. As the airplane climbed through 150 feet, the left engine lost power. The pilot reported that he feathered the left propeller. He further stated that following the securing of the left engine, the right engine began to 'power down.' The pilot reported that he was unable to maintain a climb attitude and was forced to land on the airport in a grassy area. The subsequent examination of the cockpit disclosed that the left engine throttle was in the full forward position, and the right throttle lever was in the mid-range position. Both propeller levers were found full forward. The left engine mixture lever was in the full forward position, and the right mixture lever full aft, or lean, position. The functional check of both engines was conducted. Initially the left engine would not start, but after troubleshooting the fuel system, the left fuel boost pump was determined to have been defective. The 'loss of engine power after liftoff' checklist requires that the pilot identify the inoperative engine and to feather the propeller for the inoperative engine.

The airplane descended to 2,600 feet to the NDB, and initiated the approach upon crossing the NDB. As the airplane descended below 1,500 feet MSL, Huntsville lost radar contact. The next communication with the airplane was when the pilot radioed that he was initiating the missed approach. The published missed approach procedure is, 'Climbing lift turn to 2,700 direct CPP NDB and hold.' The airplane made a series of turns within the next one minute and 24 seconds. Additionally, the airplane's altitude varied but it never climbed above the altitude of 1,700 feet. The airplane wreckage was located approximately 3.5 miles north of the airport on a 345 degree heading on the opposite side of the outbound course to the NDB. Witnesses in the immediate area stated that they could hear the airplane flying low over their homes but could not see it due to the foggy conditions. A review of pilot records did not show the pilot having any fixed wing airplane experience.

The C-21A, a USAF designation of the Learjet 35A was assigned to the 332nd Airlift Flight at Randolph AFB, Texas. The aircraft would depart Randolph AFB as flight Kiowa 71 to Wright-Patterson AFB, Andrews AFB and then back to Randolph. The aircraft was landed at Andrews AFB at 10:57. The crew requested a full load of fuel and told Serv-Air maintenance technicians that they had been unable to transfer fuel from the wing tanks to the fuselage tank. A Serv-Air maintenance technician removed the fuel-control panel from the aircraft and replaced the fuselage-tank transfer/fill switch. The maintenance technician told the crew that replacement of the fuselage-tank switch had not corrected the problem and that he was going to try to correct the problem by replacing the fuel-control relay panel. This was a time consuming job. The crew decided to continue back to Randolph without the repairs. The fuselage fuel tank was full and they had not had trouble earlier in the day getting fuel out of the fuselage tank. The aircraft departed from Andrews AFB at 16:38. The aircraft was in cruise flight at FL390 at 17:53 when the crew began to transfer fuel from the fuselage tank to the wing tanks. The crew did not know that the right standby fuel pump was operating and was preventing fuel from being transferred from the fuselage tank to the right wing. Bearings in the right standby pump were in a deteriorated condition and the pump had required higher-than-normal electrical current for rotation. The higher-than-normal electrical current had caused progressive damage to two contacts in the fuel control relay panel and eventually had caused the contacts to bond together. This caused the pump to run continuously throughout the flight and to prevent fuel transfer from the fuselage tank to the right wing. The aircrew noticed that the left wing-tip tank had become 800 pounds [363 kilograms] heavier than the right wing-tip tank during the transfer, and they attempted to analyse the malfunction and correct the imbalance. A fuel-imbalance during-fuel-transfer malfunction however was not included in the Air Force training syllabus, nor was the procedure contained in the C-21A checklist. At 17:56, the copilot told the Atlanta Air Route Traffic Control Center (Atlanta Center) controller, "Sir, we need to revise our flight plan. We’re having a problem getting some fuel out of one of our wings. Can we get vectors to Maxwell Air Force Base? And we’re going to need to dump fuel for about five minutes." The crew at 18:00 began to dump fuel from the left wing-tip tank. However, they still had an imbalance in the wing tanks themselves of about 200 pounds (91 kilograms). At 18:03 the flight was cleared to descend from FL350. The crew then observed that fuel quantity was decreasing rapidly in the right wing tank, that the left wing tank was full and that the left wing-tip tank had begun to fill with fuel. At 18:07, the copilot told the Atlanta Center controller, "Sir, we’d like to declare an emergency at this time for a fuel problem and, ah, get to Maxwell quick as we can." They were cleared direct to Maxwell AFB and cleared to descend to 17,000 feet, and later to 11,000 feet. At 18:15, the copilot told Atlanta Center, "We need to change the airfield, to get to the closest piece of pavement we can land on." The controller said, "Kiowa 71, we got an airport at 12 o’clock and 12 miles. It’s Alexander City." The crew accepted this and began their emergency descent into Alexander City airport. At 18:16 the copilot took over control since the captain did not have the airfield in sight and the copilot did. The aircraft was northeast of the airport at 8,800 feet and was descending at 5,600 feet per minute with the wing-lift spoilers extended when the copilot told Atlanta Center that they were on a left base for the runway. The crew attempted to fly a visual traffic pattern to runway 18 but were in a poor position to complete the approach and landing. They subsequently elected to enter a left downwind leg for runway 36. As airspeed was reduced, aileron authority diminished and, because of the fuel imbalance, the aircraft became difficult to control. The copilot, flying from the right seat, did not have a good view of the runway and asked the aircraft commander for help in positioning the aircraft on downwind and in beginning the turn toward the runway. The captain wanted to get the gear down but the copilot had difficult controlling the plane already: "Don’t put anything down," the copilot said. "Nothing down, nothing down." The aircraft was at 2,030 feet when the gear-warning horn sounded. The captain said, "Gear down. Gear down." The copilot said, "No. Stand by. Stand by." "Gear down," the captain said. "Gear down, man." "No, not yet, not yet," the copilot said. The copilot then asked the aircraft commander to "push the power up a little bit for me." Power was increased and the gear was extended. The aircraft was at about 1,500 feet and was one mile southwest of the runway at 18:19 when the copilot began a left turn. Approximately halfway through the final turn and one mile due south of runway 36, the aircraft abruptly rolled out, flew through the extended runway centerline and continued in an east, northeasterly direction approximately 800 feet above the ground. The copilot had rolled out of the turn to regain lateral control of the aircraft. At this time the right engine was operating at a reduced thrust setting in an attempt to counteract the effects of the fuel imbalance. The captain, to center the ball in the slip indicator, applied pressure on the left rudder, against pressure that was being applied on the right rudder by the copilot. The captain said, "Step on the rudder. Step on the rudder." The copilot said, "Paul, no. Paul, don’t." The application of left rudder caused the aircraft to roll left rapidly. It rolled inverted entered the trees and struck the ground.