Illinois

The airplane was dispatched on an emergency medical services flight. While being vectored for an instrument approach, the pilot declared an emergency and reported that the airplane was out of fuel. He said the airplane lost engine power and that he was heading toward the destination airport. The airplane descended through clouds and impacted trees and terrain short of its destination. No preimpact anomalies were found during a postaccident examination. The postaccident examination revealed about 1.5 ounces of a liquid consistent with avgas within the airplane fuel system. Based on the three previous flight legs and refueling receipts, postaccident calculations indicated that the airplane was consuming fuel at a higher rate than referenced in the airplane flight manual. Based on this consumption rate, the airplane did not have enough fuel to reach the destination airport; however, a 20-knot tailwind was predicted, so it is likely that the pilot was relying on this to help the airplane reach the airport. Regardless, he would have been flying with less than the 45-minute fuel reserve that is required for an instrument flight rules flight. The pilot failed to recognize and compensate for the airplane’s high fuel consumption rate during the accident flight. It is likely that had the pilot monitored the gauges and the consumption rate for the flight he would have determined that he did not have adequate fuel to complete the flight. Toxicology tests showed the pilot had tetrahydrocannabinol and tetrahydrocannabinol carboxylic acid (marijuana) in his system; however, the level of impairment could not be determined based on the information available. However, marijuana use can impair the ability to concentrate and maintain vigilance and can distort the perception of time and distance. As a professional pilot, the use of marijuana prior to the flight raises questions about the pilot’s decision-making. The investigation also identified several issues that were not causal to the accident but nevertheless raised concerns about the company’s operational control of the flight. The operator had instituted a fuel log, but it was not regularly monitored. The recovered load manifest showed the pilot had been on duty for more than 15 hours, which exceeded the maximum of 14 hours for a regularly assigned duty period per 14 Code of Federal Regulations Part 135. The operator stated that it was aware of the pilot’s two driving while under the influence of alcohol convictions, but the operator did not request a background report on the pilot before he was hired. Further, the operator did not list the pilot-rated passenger as a member of the flight crew, yet he had flown previous positioning legs on the dispatched EMS mission as the pilot-in-command.

On July 24, 2011, about 0920 central daylight time, a Piper PA-46-350P, N46TW, owned and operated by a private pilot, sustained substantial damage when it impacted powerlines and terrain during takeoff from runway 27 at the Rantoul National Aviation Center Airport-Frank Elliott Field (TIP), near Rantoul, Illinois. A post impact ground fire occurred. The personal flight was operating under 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed at the time of the accident. An instrument flight rules (IFR) flight plan was on file. The pilot and two passengers sustained fatal injuries. The flight was originating from TIP at the time of the accident and was destined for Sarasota/Bradenton International Airport (SRQ), near Sarasota, Florida. A witness, who worked at the fixed base operator, stated that the pilot performed the preflight inspection of the airplane in a hangar. An estimated 80 pounds. of luggage was loaded behind the airplane's rear seat. The witness said that the pilot's wife told the pilot that she had to use the restroom. The pilot reportedly replied to her to "hurry because a storm front was coming." The witness said that the engine start was normal and that both passengers were sitting in the rear forward-facing seats when the airplane taxied out. A witness at the airport, who was a commercial pilot, reported that he observed the airplane takeoff from runway 27 and then it started to turn to the south. He indicated that the landing gear was up when the airplane was about 500 feet above the ground. The witness stated that a weather front was arriving at the airport and that the strong winds from the northwest appeared to "push the tail of the plane up and the nose down." The airplane descended and impacted powerlines and terrain where the airplane subsequently caught on fire. The witness indicated that the airplane's engine was producing power until impact.

The weekend before the accident, a fuel leak was identified. The fuel leak was subsequently repaired, and a final inspection the morning of the accident flight reportedly did not reveal any evidence of a continued fuel leak. Shortly after takeoff, the flight crew noticed a faint odor in the cockpit and a small amount of smoke near the radio room. The flight crew immediately initiated a turn with the intention of returning to the departure airport. About that time, they received a radio call from the pilot of the accompanying airplane advising that there was a fire visible on the left wing. The accident pilot subsequently executed an emergency landing to a corn field. Emergency crews were hampered by the muddy field conditions, and the fire ultimately consumed significant portions airframe. In-flight photographs showed the presence of fire on the aft lower portion of the left wing between the inboard and outboard engines. Located in the same area of the fire were fuel tanks feeding the left-side engines. After landing, heavy fire conditions were present on the left side of the airplane, and the fire spread to the fuselage. A postaccident examination noted that the C-channel installed as part of the No. 1 main fuel tank repair earlier in the week was partially separated. During the examination, the tank was filled with a small amount of water, which then leaked from the aft section of the repair area in the vicinity of the partially separated channel. Metallurgical examination of the repair area revealed a longitudinal fatigue crack along the weld seam. The fatigue nature of the crack was consistent with a progressive failure along the fuel tank seam that existed before the accident flight and was separate from the damage sustained in the emergency landing and postlanding fire. The repair earlier in the week attempted to seal the leak but did not address the existing crack itself. In fact, the length of the crack observed at the time of the repair was about one-half the length of the crack noted during the postaccident examination, suggesting that the crack progressed rapidly during the course of the accident flight. Because the repaired fuel tank was positioned within the open wing structure, a fuel leak of significant volume would have readily vaporized, producing a flammable fuel vapor/air mixture. Although the exact ignition source could not be determined due to the fire damage, it is likely that the fuel vapor and liquid fuel encountered hot surfaces from nearby engine components, which initiated the in-flight fire.

The flight encountered light rime icing during an instrument approach to the destination airport. The copilot was the pilot flying at the time of the accident. He reported that the airframe anti-icing system was turned off upon intercepting the instrument approach glide slope, which was shortly before the airplane descended below the cloud layer. He recalled observing light frost on the outboard wing and tip tank during the approach. The stick shaker activated on short final, and the airplane impacted left of the runway centerline before it ultimately departed the right side of the runway pavement and crossed a slight rise before coming to rest in the grass. The cockpit voice recorder transcript indicated that the pilots were operating in icing conditions without the wing anti- ice system activated for about 4 1/2 minutes prior to activation of the stick shaker. A postaccident examination of the airplane did not reveal any anomalies consistent with a preimpact failure of the flight control system or a loss of anti-ice system functionality. A performance study determined that the airplane’s airspeed during the final 30 seconds of the flight was about 114 knots and that the angle of attack ultimately met the stick shaker threshold. The expected stall speed for the airplane was about 93 knots. The airplane flight manual stated that anti-ice systems should be turned on prior to operation in icing conditions during normal operations. The manual warned that even small accumulations of ice on the wing leading edge can cause an aerodynamic stall prior to activation of the stick shaker and/or stick pusher.

The airplane was on an instrument flight in night instrument meteorological conditions approaching the destination airport. The pilot contacted the approach control facility by radio and was subsequently cleared for an instrument landing system (ILS) approach to the destination airport. During the approach, the air traffic approach controller advised the pilot twice that the airplane was to the right of the approach course. The controller suggested a left turn of 5 to 7 degrees to the pilot. Once the airplane was back on the inbound course, the approach controller instructed the pilot to contact a tower controller. The pilot never contacted the tower controller, but later reestablished contact with the approach controller, who provided radar vectors for a second attempt at the ILS approach. During the second approach, the controller again advised the pilot that the airplane was to the right of the approach course and provided the pilot a low altitude alert. The airplane then started a climb and a turn back toward the inbound course. The controller advised the pilot that the airplane would intercept the inbound course at the locator outer marker (LOM) for the approach and asked if the pilot would like to abort the approach and try again. The pilot declined and responded that he would continue the approach. No further transmissions were received from the pilot. The airplane impacted a building about 0.4 nautical miles from the LOM. The building and airplane were almost completely consumed by the postimpact fire. A postaccident examination revealed no evidence of mechanical malfunction or failure. The airplane's turning ground track and the challenging visibility conditions were conducive to the onset of pilot spatial disorientation.

The visibility at the time of the accident was 1/2 mile with fog and the vertical visibility was 100 feet. A witness stated that the pilot checked the weather, but that he appeared to be in a hurry and took off without performing a preflight inspection of the aircraft. After takeoff, air traffic control instructed the pilot to turn left to a heading of 270 degrees. The pilot reported to the controller that he was at 1,300 feet climbing to 3,000 feet and the controller cleared the pilot to climb to 4,000 feet; the pilot acknowledged the clearance. Witnesses on the ground noted that the airplane was loud; one witness located about 1.5 miles from the departure airport reported that the airplane flew overhead at treetop height. The airplane impacted trees and a residence about 2.3 miles north-northeast of the departure airport. The airplane's turning ground track and the challenging visibility conditions were conducive to the onset of pilot spatial disorientation. Post accident inspection failed to reveal any mechanical failure that would have resulted in the accident. The pilot purchased the airplane about three months prior to the accident; at that time he reported having 72.6 hours of instrument flight experience and 25 hours of multi-engine experience, with none in the accident airplane make and model. After purchasing the airplane, the pilot received 52 hours of flight instruction in the accident airplane in 7 days. Logbook records were not located to establish subsequent flight experience.

The flight was scheduled to pick up cargo at the destination airport and then deliver it to another location. During the descent and 14 minutes before the accident, the airplane encountered a layer of moderate rime ice. The captain, who was the pilot flying, and the first officer, who was the monitoring pilot, made multiple statements which were consistent with their awareness and presence of airframe icing. After obtaining visual flight rules conditions, the flight crew canceled the instrument flight rules clearance and continued with a right, circling approach to the runway. While turning into the base leg of the traffic pattern, and 45 seconds prior to the accident, the captain called for full flaps and the engine power levers were adjusted several times between 50 and 95 percent. In addition, the captain inquired about the autopilot and fuel balance. In response, the first officer stated that he did not think that the spoilerons were working. Shortly thereafter, the first officer gave the command to add full engine power and the airplane impacted terrain. There was no evidence of flight crew impairment or fatigue in the final 30 minutes of the flight. The cockpit voice recorder showed multiple instances during the flight in which the airplane was below 10,000 feet mean sea level that the crew was engaged in discussions that were not consistent with a sterile cockpit environment, for example a lengthy discussion about Class B airspeeds, which may have led to a relaxed and casual cockpit atmosphere. In addition, the flight crew appears to have conducted checklists in a generally informal manner. As the flight was conducted by a Part 135 operator, it would be expected that both pilots were versed with the importance of sterile cockpit rules and the importance of adhering to procedures, including demonstrating checklist discipline. For approximately the last 24 seconds of flight, both pilots were likely focusing their attention on activities to identify and understand the reason for the airplane's roll handling difficulties, as noted by the captain's comment related to the fuel balance. These events, culminating in the first officer's urgent command to add full power, suggested that neither pilot detected the airplane's decaying energy state before it reached a critical level for the conditions it encountered. Light bulb filament examination revealed that aileron augmentation system and stall warning lights illuminated in the cockpit. No mechanical anomalies were found to substantiate a failure in the aileron augmentation system. No additional mechanical or system anomalies were noted with the airplane. A performance study, limited by available data, could not confirm the airplane's movements relative to an aileron augmentation system or spoileron problem. The level of airframe icing and its possible effect on the airplane at the time of the accident could not be determined.

The crew was performing a local training flight at Decatur Airport, consisting of touch-and-go maneuvers. On final approach to runway 24, the instructor elected to simulate a failure of the right engine. Anticipating the touch-and-go procedure, the instructor deactivated the yaw damper system while the aircraft was about 10-20 feet above the runway. As the speed increased, the instructor called out 'speed' twice when the copilot reduced the power on the left engine. The aircraft rolled to the right, causing the right wingtip to struck the ground. The aircraft went out of control, veered off runway and came to rest, bursting into flames. Both pilots escaped with minor injuries while the aircraft was destroyed.

The airplane was destroyed and the occupants fatally injured when it impacted the ground during approach to landing. Examination of the airplane, its engines and propellers, revealed no anomalies that were determined to have existed prior to impact. The propellers were found to have been in their normal operating range and neither propeller was in a feathered position. The quill shafts of both engines showed evidence of damage due to the production of torque. A sound spectrum examination of audio transmissions showed signatures that both engines were operating during the last two radio transmissions from the airplane. Based on radar data, communications and meteorological information obtained during the investigation, the airplane was operating in visual meteorological conditions below an overcast layer of clouds. The radar data showed the airplane as it approached the airport and as it entered a left hand traffic pattern for runway 34. Radio communications confirmed that the airplane had been cleared for a left hand traffic pattern to runway 34. The radar data showed the airplane as it made a turn to the left while its speed decreased to about 82 knots calibrated airspeed as of the last received radar return. This radar return was about 0.1 nautical miles from the accident site and 0.8 nautical miles and 216 degrees from the approach end of runway 34. The airplane owner's manual listed stall speeds ranging from 81 to 94 knots calibrated airspeed for airplane configurations including gear and flaps up to gear down and flaps 15 degrees, and bank angles from 0 to 40 degrees. Flap position could not be determined because the flap chain had separated from the flap drive motor. The owner's manual also listed an approach speed of 103 knots.

The twin-engine airplane sustained substantial damage when it impacted the top of a single story industrial building and then impacted a landscape embankment and trees during an attempted single-engine go-around. The pilot reported that the left engine failed during initial climb. He feathered the left propeller and returned to the airport to execute an emergency landing. The pilot reported that he had "excessive speed" on final approach and "overshot the runway." When the airplane was at mid-field, the pilot elected to do a go-around. He did not raise the landing gear and the flaps remained about 15-degrees down. The airplane lost altitude and impacted the terrain about .5 miles from the airport. A witness reported seeing the airplane attempt to land on the runway twice during the same approach, but ballooned both times before executing the go-around. The Pilot's Operating Handbook (POH) "Rate-of-Climb One Engine Inoperative" chart indicated that about a 450-foot rate-of-climb was possible during the single-engine go-around if the airplane was in a clean configuration. The chart also indicated that a 350-foot penalty would be subtracted from the rate-of-climb if the landing gear were in the DOWN position, and additionally, a 200-foot penalty would be subtracted from the rate-of-climb if the flaps were in the 15-degree DOWN position. Inspection of the left engine revealed that the starter adapter shaft gear had failed. Inspection of the engine maintenance logbooks revealed that the Teledyne Continental Motors Service Bulletin CSB94-4, and subsequent revisions including the Mandatory Service Bulletin MSB94- 4F, issued on July 5, 2005, had not been complied with since the last engine overhaul on July 17, 1998. The service bulletin required a visual inspection of the starter adapter every 400 hours. The engine logbook indicated that the engine had accumulated about 1,270 hours since the last overhaul. The service bulletin contained a WARNING that stated, "Compliance with this bulletin is required to prevent possible failure of the starter adapter shaft gear and/or crankshaft gear which can result in metal contamination and/or engine failure."