Georgia

On 2 May 2018, at approximately 1127 hours local time (L), the Mishap Aircraft (MA), a WC-130H, tail number 65-0968, assigned to the Puerto Rico Air National Guard, 156th Airlift Wing (156 AW), located at Muñiz Air National Guard Base, Puerto Rico, crashed approximately 1.5 miles northeast of Savannah/Hilton Head International Airport (KSAV), Georgia. All nine members aboard the MA—Mishap Pilot 1 (MP1), Mishap Pilot 2, Mishap Navigator, Mishap Flight Engineer, and Mishap Loadmaster (collectively the “Mishap Crew (MC)”), and four mission essential personnel, Mishap Airman 1, 2, 3, and 4—perished during the accident. The MC’s mission was to fly the MA to the 309th Aerospace Maintenance and Regeneration Group at Davis-Monthan Air Force Base, Arizona (commonly referred to as the “Boneyard”), for removal from service. The MA had been at KSAV for almost a month, since 9 April 2018, to undergo prescheduled fuel cell maintenance and unscheduled work on engine number one by 156 AW maintenance personnel using the facilities of the 165th Airlift Wing. During takeoff roll, engine one revolutions per minute (RPM) fluctuated and did not provide normal RPM when MP1 advanced the throttle lever into the flight range for takeoff. Approximately eight seconds prior to aircraft rotation, engine one RPM and torque significantly decayed, which substantially lowered thrust. The fluctuation on roll and significant performance decay went unrecognized by the MC until rotation, when MP1 commented on aircraft control challenges and the MA veered left and nearly departed the runway into the grass before it achieved flight. The MA departed KSAV at approximately 1125L. As the MC retracted the landing gear, they identified the engine one RPM and torque malfunction and MP1 called for engine shutdown. However, the MC failed to complete the Takeoff Continued After Engine Failure procedure, the Engine Shutdown procedure, and the After Takeoff checklist as directed by the Flight Manual, and the MA’s flaps remained at 50 percent. Additionally, MP1 banked left into the inoperative engine, continued to climb, and varied left and right rudder inputs. At an altitude of approximately 900 feet mean sea level and 131 knots indicated air speed, MP1 input over nine degrees of left rudder, the MA skidded left, the left wing stalled, and the MA departed controlled flight and impacted the terrain on Georgia State Highway 21.

The private pilot departed on an instrument flight rules flight plan in his twin-engine turbojet airplane. The flight was uneventful until the air traffic controller amended the flight plan, which required the pilot to manually enter the new routing information into the GPS. A few minutes later, the pilot told the controller that he was having problems with the GPS and asked for a direct route to his destination. The controller authorized the direct route and instructed the pilot to descend from 22,000 ft to 6,000 ft, during which time the sound of the autopilot disconnect was heard on the cockpit voice recorder (CVR). During the descent, the pilot told the controller that the airplane had a steering problem and was in the clouds. The pilot was instructed to descend the airplane to 4,100 ft, which was the minimum vectoring altitude. The airplane continued to descend, entered visual meteorological conditions, and then descended below the assigned altitude. The controller queried the pilot about the airplane's low altitude and instructed the pilot to maintain 4,100 ft. The pilot responded that he was unsure if he would be able to climb the airplane back to that altitude due to steering issues. The controller issued a low altitude warning and again advised the pilot to climb back to 4,100 ft. The pilot responded that the autopilot was working again and that he was able to climb the airplane to the assigned altitude. The controller then instructed the pilot to change to another radio frequency, but the pilot responded that he was still having a problem with the GPS. The pilot asked the controller to give him direct routing to the airport. A few minutes later, the pilot told the controller that he was barely able to keep the airplane straight and its wings level. The controller asked the pilot if he had the airport in sight, which he did not. The pilot then declared an emergency and expressed concerns related to identifying the landing runway. Afterward, radio contact between the controller and the pilot was lost. Shortly before the airplane impacted the ground, a witness saw the airplane make a complete 360° roll to the left, enter a steep 90° bank to the left, roll inverted, and enter a vertical nose-down dive. Another witness saw the airplane spiral to the ground. The airplane impacted the front lawn of a private residence, and a postcrash fire ensued.The pilot held a type rating for the airplane, but the pilot's personal logbooks were not available for review. As a result, his overall currency and total flight experience in the accident airplane could not be determined. The airplane was originally certified for operations with a pilot and copilot. To obtain an exemption to operate the airplane as a single pilot, a pilot must successfully complete an approved single-pilot exemption training course annually. The accident airplane was modified, and the previous owner was issued a single-pilot conformity certificate by the company that performed the modifications. However, there was no record indicating that the accident pilot received training under this exemption. Several facilities that have single-pilot exemption training for the accident airplane series also had no record of the pilot receiving training for single-pilot operations in the accident airplane. Therefore, unlikely that the pilot was properly certificated to act as a single-pilot. The GPS was installed in the airplane about 3.5 years before the accident. A friend of the pilot trained him on how to use the GPS. The friend said that the pilot generally was confused about how the unit operated and struggled with pulling up pages and correlating data. The friend of the pilot had flown with him several times and indicated that, if an air traffic controller amended a preprogrammed flight plan while en route, the pilot would be confused with the procedure for amending the flight plan. The friend also said the pilot depended heavily on the autopilot, which was integrated with the GPS, and that he would activate the autopilot immediately after takeoff and deactivate it on short final approach to a runway. The pilot would not trim the airplane before turning on the autopilot because he assumed that the autopilot would automatically trim the airplane, which led to the autopilot working against the mis-trimmed airplane. The friend added that the pilot was "constantly complaining" that the airplane was "uncontrollable." A postaccident examination of the airplane and the autopilot system revealed no evidence of any preimpact deficiencies that would have precluded normal operation. This information suggests that pilot historically had difficulty flying the airplane without the aid of the autopilot. When coupled with his performance flying the airplane during the accident flight without the aid of the autopilot, it further suggests that the pilot was consistently unable to manually fly the airplane. Additionally, given the pilot's previous experience with the GPS installed on the airplane, it is likely that during the accident flight the pilot became confused about how to operate the GPS and ultimately was unable to properly control of the airplane without the autopilot engaged. Based on witness information, it is likely that during the final moments of the flight the pilot lost control of the airplane and it entered an aerodynamic stall. The pilot was then unable to regain control of the airplane as it spun 4,000 ft to the ground.

The 69-year-old commercial pilot was making a personal cross-country flight in the newly purchased airplane. When the airplane was on final approach to the destination airport in night visual meteorological conditions, airport surveillance video showed it pitch up and roll to the right. The airplane then descended in a nose-down attitude to impact in a ravine on the right side of the runway. During the descent over the ravine the right wing came in contact with a powerline that briefly cut power to the airport. Postaccident examination of the airframe, engines, and their components revealed no evidence of mechanical anomalies or malfunctions that would have precluded normal operation. The pilot's toxicology findings identified five different impairing medications: clonazepam, temazepam, hydrocodone, nortriptyline, and diphenhydramine. Although the results were from cavity blood and may not accurately reflect antemortem levels, the hydrocodone, temazepam, and diphenhydramine levels were high enough to likely have had some psychoactive effects. While the exact effects of these drugs in combination are not known, it is likely that the pilot was impaired to some degree by his use of this combination of medications, which likely contributed to his failure to maintain control of the airplane.

The airline transport pilot delayed his scheduled departure for the night cargo flight due to thunderstorms along the route. Before departing, the pilot explained to the flight follower assigned to the flight that if he could not get though the thunderstorms along the planned route, he would divert to the alternate airport. While en route, the pilot was advised by the air traffic controller in contact with the flight of a "ragged line of moderate, heavy, and extreme" precipitation along his planned route. The controller also stated that he did not see any breaks in the weather. The controller cleared the pilot to descend at his discretion from 7,000 ft mean sea level (msl) to 3,000 ft msl, and subsequently, the controller suggested a diversion to the northeast for about 70 nautical miles that would avoid the most severe weather. The pilot responded that he had enough fuel for such a diversion but concluded that he would "see what the radar is painting" after descending to 3,000 ft msl. About 1 minute 30 seconds later, as the airplane was descending through 7,000 ft msl, the controller stated, "I just lost you on radar, I don't show a transponder, it might have to do with the weather." About 40 seconds later, the pilot advised the controller that he intended to deviate to the right of course, and the controller told the pilot that he could turn left and right as needed. Shortly thereafter, the pilot stated that he was going to turn around and proceed to his alternate airport. The controller cleared the pilot direct to his alternate and instructed him to maintain 3,000 ft msl. The pilot acknowledged the instruction, and the controller then stated, "do you want to climb back up? I can offer you any altitude." The pilot responded that he would try to climb back to 3,000 ft msl. The controller then recommended a heading of 180° to "get you clear of the weather quicker," and the pilot responded, "alright 180." There were no further communications from the pilot. Shortly thereafter, radar data showed the airplane enter a right turn that continued through about 540°. During the turn its airspeed varied between 198 and 130 knots, while its estimated bank angles were between 40 and 50°. Examination of the wreckage indicated that airplane experienced an in-flight breakup at relatively low altitude, consistent with radar data that showed the airplane's last recorded altitudes to be around 3,500 ft msl. The symmetrical nature of the breakup, damage to the outboard wings, and damage to the upper fuselage were all signatures indicative that the left and right wings failed in positive overload almost simultaneously. All of the fracture surfaces examined had a dull, grainy appearance consistent with overstress separation. There was no evidence of pre-existing cracking noted at any of the separation points, nor was there evidence of any mechanical anomalies that would have prevented normal operation. Review of base reflectivity weather radar data showed that, while the pilot was maneuvering to divert to the alternate airport, the airplane was operating in an area of light precipitation that rapidly intensified to heavy precipitation, as shown by radar scans completed shortly after the accident. During this time, the flight was likely operating in clouds along the leading edge of the convective line, where the pilot most likely would have encountered updrafts and severe or greater turbulence. The low visibility conditions that existed during the flight, which was conducted at night and in instrument meteorological conditions, coupled with the turbulence the flight likely encountered, were conducive to the development of spatial disorientation. Additionally, the airplane's maneuvering during the final moments of the flight was consistent with a loss of control due to spatial disorientation. The pilot's continued flight into known convective weather conditions and his delayed decision to divert the flight directly contributed to the accident. Although the operator had a system safety-based program, the responsibility for the safe outcome of the flight was left solely to the pilot. Written company policy required completion of a flight risk assessment tool (FRAT) before each flight by the assigned flight follower; however, a FRAT was not completed for the accident flight. The flight followers responsible for completing the FRATs were not trained to complete them for night cargo flights, and the operator's management was not aware that the FRATs were not being completed for night cargo flights. Further, if a FRAT had been completed for the accident flight, the resultant score would have allowed the flight to commence into known hazardous weather conditions without any further review. If greater oversight had been provided by the operator, it is possible that the flight may have been cancelled or re-routed due to the severity of the convective weather conditions present along the planned route of flight.

The pilot reported that the purpose of the flight was to reposition the airplane to another airport for refuel. During preflight, he reported that the airplane's two fuel gauges read "low," but the supplemental electronic fuel totalizer displayed 55 total gallons. He further reported that it is not feasible to visual check the fuel quantity, because the fueling ports are located near the wingtips and the fuel quantity cannot be measured with any "external measuring device." According to the pilot, his planned flight was 20 minutes and the fuel quantity, as indicated by the fuel totalizer, was sufficient. The pilot reported that about 12 nautical miles from the destination airport, both engines began to "surge" and subsequently lost power. During the forced landing, the pilot deviated to land in grass between a highway, the airplane touched down hard, and the landing gear collapsed. The fuselage and both wings sustained substantial damage. The pilot reported no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation. The pilot reported in the National Transportation Safety Board Pilot/ Operator Aircraft Accident Report that there was a "disparity" between the actual fuel quantity and the fuel quantity set in the electronic fuel totalizer. He further reported that a few days before the accident, he set the total fuel totalizer quantity to full after refueling, but in hindsight, he did not believe the fuel tanks were actually full because the wings may not have been level during the fueling. The "Preflight" chapter within the operating manual for the fuel totalizer in part states: "Digiflo-L is a fuel flow measuring system and NOT a quantity-sensing device. A visual inspection and positive determination of the usable fuel in the fuel tanks is a necessity. Therefore, it is imperative that the determined available usable fuel be manually entered into the system."

The pilots of the business jet were conducting a cross-country positioning flight. According to the pilot flying (PF), the flight was uneventful until the landing. While completing the descent checklist and while passing through 18,000 ft mean sea level (msl), the pilot monitoring (PM), received the automated weather report from the destination airport and briefed the PF that the wind was variable at 6 knots, gusting to 17 knots. The PF then programmed the flight management system for a visual approach to runway 7 and briefed the reference speed (Vref) as 107 knots and the go-around speed as 129 knots based on an airplane weight. The PF further reported that he knew the runway was over 4,400 ft long (the runway was 4,495 ft long) and he thought that the airplane needed about 2,900 ft of runway to safely land. During the left descending turn to the base leg of the traffic pattern, the PF overshot the final approach and had to turn back toward the runway centerline as the airplane was being “pushed by the winds.” About 500 ft above ground level (agl), both pilots acknowledged that the approach was “stabilized” while the airspeed was fluctuating between 112 and 115 knots. About 200 ft agl, both pilots noticed that the airplane was beginning to descend and that the airspeed was starting to decrease. The PF added power to maintain the descent rate and airspeed. The PF stated that, after adding power and during the last 200 ft of the approach, the wind was “gusty,” that a left crosswind existed, that the ground speed seemed “very fast,” and that excessive power was required to maintain airspeed. When the airplane was between about 75 and 100 ft agl, the PF asked the PM for the wind information, and the PM responded that the wind was variable at 6 knots, gusting to 17 knots. Both pilots noted that the ground speed was “very fast” but decided to continue the approach. Neither pilot reported seeing the windsock located off the right side of the runway. Review of weather data recorded by the airport’s automated weather observation system revealed that about 3 minutes before the landing, the wind was from 240° at 16 knots, gusting to 26 knots, which would have resulted in a 3- to 5-knot crosswind and 16- to 26-knot tailwind. Assuming these conditions, the airplane’s landing distance would have been about 4,175 ft per the unfactored landing distance performance chart. Tire skid marks were found beginning about 1,000 feet from the approach end of runway 7. The PF stated that the airplane touched down “abruptly at Vref+5 and he applied the brakes while the PM applied the speed brakes. Neither pilot felt the airplane decelerating, so the PF applied harder pressure to the brakes with no effect and subsequently applied full braking pressure. When it was evident that the airplane was going to depart the end of the runway, the PM applied the emergency brakes, at which point he felt some deceleration; however, the airplane overran the end of the runway and travelled through grass and mud for about 370 feet before stopping. Examination of the airplane revealed that the nose landing gear (NLG) had collapsed, which resulted in the forward fuselage striking the ground and the airframe sustaining substantial damage. Although the pilots reported that they never felt the braking nor antiskid systems working and that they believed that they should have been able to stop the airplane before it departed the runway, postaccident testing of the brake and antiskid systems revealed no evidence of preaccident mechanical malfunctions or failures that would have precluded normal operation, and they functioned as designed. Given the tire skid marks observed on the runway following the accident, as well as the postaccident component examination and testing results, the brakes and antiskid system likely operated nominally during the landing. Based on the available evidence, the pilots failed to recognize performance cues and use available sources of wind information that would have indicated that they were landing in significant tailwind conditions and conduct a go-around. Landing under these conditions significantly increased the amount of runway needed to stop the airplane and resulted in the subsequent runway overrun and the collapse of the NLG.

The aircraft collided with a ditch during a precautionary landing after takeoff from Savannah/Hilton Head International Airport (SAV), Savannah, Georgia. The pilot and copilot sustained minor injuries, and the airplane was substantially damaged. The airplane was registered to Upper Deck Holdings, Inc. and was being operated by PlaneSense, Inc,. as a Title 14 Code of Federal Regulations Part 91 positioning flight. Visual meteorological conditions prevailed, and an instrument flight rules flight plan was filed for the flight to Blue Grass Airport (LEX), Lexington, Kentucky. The pilot in the left seat was the pilot monitoring and the copilot in the right seat was the pilot flying. The crew had the full length of the runway 1 available (7,002 ft) for takeoff. The pilots reported that the acceleration and takeoff was normal and after establishing a positive rate of climb, the crew received an auditory annunciation and a red crew alerting system (CAS) torque warning. The engine torque indicated 5.3 pounds per square inch (psi); the nominal torque value for the conditions that day was reported by the crew to be 43.3 psi. With about 2,700 ft of runway remaining while at an altitude of 200 ft msl, the copilot elected to land immediately; the copilot pushed the nose down and executed a 90° left descending turn and subsequently landed in the grass. Although he applied "hard" braking in an attempt to stop, the airplane impacted a drainage ditch, resulting in substantial impact damage and a postimpact fire. The pilot reported that, after takeoff, he observed a low torque CAS message and the copilot told him to "declare an emergency and run the checklist." The pilot confirmed that the landing gear were extended and the copilot turned the airplane to the left toward open ground between the runways and the terminal. About 60 seconds elapsed from the start of the takeoff roll until the accident. The airport was equipped with security cameras that captured the airplane from its initial climb through the landing and collision. One camera, pointed toward the west-southwest, recorded the airplane's left descending turn and its landing in the grass, followed by impact and smoke. A second camera, mounted on the control tower, pointed toward the southeast and showed the airplane during the initial climb before it leveled off and entered a descending left turn; it also showed the airplane land and roll through the grass before colliding with the ditch.

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.

The private pilot was conducting a personal cross-country flight. The pilot reported that, during cruise flight at 6,000 ft mean sea level, he observed a crew alerting system oil pressure message, followed by a total loss of engine power. An air traffic controller provided vectors to a local airport; however, the pilot reported that the airplane would not reach the runway. He did not attempt to restart the engine. He feathered the propeller and placed the power lever to "idle" and the condition lever to "cut off." The pilot subsequently attempted a forced landing to a sports field with the gear and flaps retracted. The airplane collided with trees and the ground and then came to rest upright. Examination of the engine revealed that it displayed contact signatures to its internal components and evidence of ingested unburned organic debris, consistent with the engine likely being unpowered and the engine gas generator and power sections wind-milling at the time of impact. No evidence of any preimpact mechanical anomalies or malfunctions to any of the engine components was found that would have precluded normal operation. Recorded GPS flight track and systems data showed that the loss of engine power was preceded by about 5 minutes of flight on a constant heading and altitude with an excessive lateral g force of about 0.17 g and a bank angle between about 8 and 10 degrees, consistent with a side-slip flight condition. The airplane then entered a right turn with the autopilot engaged, and it lost power at the end of the turn. The data indicated that, even though the autopilot was engaged, the lateral g forces increased as the airplane leveled off and accelerated, indicating that the automatic rudder trim feature of the yaw damper system was not engaged. Given that the yaw damper system operated normally after the flight, it is likely that the pilot inadvertently and unknowingly disengaged the yaw damper during flight with the autopilot engaged. During a postaccident interview, the pilot stated that he was not aware of a side-slip condition before the loss of engine power. Although the fuel tank system was designed to prevent unporting of the fuel lines during momentary periods of uncoordinated flight, it was not intended to do so for extended periods of uncoordinated flight. Therefore, the fuel tank feed line likely unported during the prolonged uncoordinated flight, which resulted in the subsequent loss of engine power. If the pilot had recognized the side-slip condition, he could have returned to coordinated flight and prevented the engine power loss. Also, once the airplane returned to coordinated flight, an engine restart would have been possible.

The pilot was departing the private, fly-in community airport on a personal flight. He was familiar with the airport/fly-in community and was instrumental in its development. Fog was present at the time, and, according to witnesses, it was "rolling up the valley," which was a frequent event at the airport. The witnesses observed the airplane lift off the runway, drift to the left, and disappear into the fog with the landing gear extended. They heard the engine running normally, with no change in sound, until the crash. They heard two distinct "booms" about 4 to 6 seconds apart. They ran down to the departure end of the runway to look for a crash site and could not see the wreckage or any smoke or fire due to the fog. The wreckage was located on elevated terrain in a heavily wooded area, about 1,500 feet north of the departure end of the runway. The elevation at the crash site was about 250 feet higher than the elevation at the departure end of runway. A swath through the treetops leading to the main wreckage was indicative of a near-level flight path at impact. An examination of the airframe and engine did not reveal any evidence of a preexisting mechanical malfunction or failure. A review of the weather by a NTSB meteorologist revealed that the departure airport was at the edge of an area of low-topped clouds. Airport remarks included "Mountainous terrain all quadrants."