North Carolina

After a flight from Dallas-Addison, the crew made two stops at Palm Coast, Florida, and Goldsboro, North Carolina, before returning to his base at Washington-Warren Field. After landing on runway 23, the airplane suffered a runway excursion and came to a halt, bursting into flames. Both crew members evacuated safely while the airplane was partially destroyed by fire.

On final approach to Raleigh-Durham Airport, while on a positioning flight from Wilmington-New Hanover Airport, the single engine airplane went out of control and crashed nearby the runway. Both occupants were quickly rescued and the airplane was damaged beyond repair. It was reported that the pilot was attempting a go around procedure when the accident occurred.

The pilot departed Lake Norman Airpark Runway 32 at 1152LT on a local flight. After takeoff, he continued to the northwest for about 10 minutes then initiated a turn to the left and a descent back to the airfield. On short final, the single engine airplane crashed nearby a wooded area located near Adrian Lane, about 1,200 metres short of runway 14. The airplane was destroyed and the pilot, sole on board, was killed.

Before departing on the flight, the pilot of the turbo-propeller-equipped, single-engine airplane and student pilot-rated passenger seated in the right front seat of the airplane attempted to enter a flight plan into the airplane’s integrated flight management system. They ultimately did not complete this task prior to takeoff with the pilot remarking, “we’ll get to it later.” The pilot subsequently departed and climbed into instrument meteorological conditions (IMC) without an instrument flight rules (IFR) flight plan. After entering IMC, he contacted air traffic control and asked for visual flight rules (VFR) flight following services and an IFR clearance to the destination airport. From shortly after when the airplane leveled after takeoff through the final seconds of the flight, the pilot attempted to program, delete, reprogram, and activate a flight plan into the airplane’s flight management system as evidenced by his comments recorded on the airplane’s cockpit voice recorder (CVR). After departing, the pilot also attempted to navigate around restricted airspace that the airplane had flown into. The CVR audio showed that during the final 10 minutes of the flight, the pilot was unsure of the spelling of the fix he should have been navigating to in order to begin the instrument approach at the destination airport, and more generally expressed frustration and confusion while attempting to program the integrated flight management system. As the pilot continued to fixate on programming the airplane’s flight management system and change the altimeter setting, the airplane’s pitch attitude increased to 10° nose up, while the airspeed had decayed to 109 knots. As a result of his inattention to this airspeed decay, the stall warning system activated and the autopilot disconnected. During this time the airplane began climbing and turning to the right and then to the left before entering a steep descending right turn that continued until the airplane impacted the ocean. For the final 2 and 1/2 minutes of the flight, the pilot was provided with stall warnings, stick shaker activations, autopilot disconnect warnings, and terrain avoidance warning system alerts. The airplane impacted the ocean about 3 miles from the coast. Examination of the recovered sections of the airplane did not reveal evidence of any mechanical failures or malfunctions of the airframe or engine that would have precluded normal operation. The instrument meteorological conditions present in the area at the time of the accident were conducive to the development of spatial disorientation. The airplane’s erratic flight track in the final 2 minutes of flight, culminating in the final rapidly descending right turn, were consistent with the known effects of spatial disorientation. It is likely that the pilot’s inadequate preflight planning, and his subsequent distraction while he unsuccessfully attempted to program the airplane’s flight management system during the flight resulted in his failure to adequately monitor the airplane’s speed. This led to the activation of the airplane’s stall protection and warning systems as the airplane approached and entered an aerodynamic stall. The resulting sudden deactivation of the autopilot, combined with his inattention to the airplane’s flight attitude and speed, likely surprised the pilot. Ultimately, the pilot failed to regain control of the airplane following the aerodynamic stall, likely due to spatial disorientation. The pilot had a history of mantle cell lymphoma that was in remission and his maintenance treatment with a rituximab infusion was over 60 days prior to the accident. The pilot also had a history of back pain and had received steroid injections and nonsteroidal anti-inflammatory drugs. By self-report, he had taken oxycodone for pain management; it is unknown how frequently he used this medication or if he had used the medication on the day of the accident. While oxycodone can result in fatigue and dizziness, and may interfere with reaction time, given the information from the CVR, it could not be determined if the pilot had these side effects. A few weeks prior to the accident, the pilot reported having COVID-19 and receiving a 5-day treatment course of hydroxychloroquine and ivermectin. While there are some impairing side effects associated with the use of those medications, enough time had elapsed that no adverse effects would be expected. There is an increased risk of a sudden incapacitating cardiovascular event such as a dysrhythmia, stroke, or pulmonary embolism in people who have recovered from their COVID-19 infection. The risk is slight for those not hospitalized for the infection. The pilot did not have an underlying cardiovascular disease that would pose an increased risk for a sudden incapacitating event and the CVR did not provide evidence of a sudden incapacitating event occurring. Thus, it could not be determined if the pilot’s medical conditions of mantle cell lymphoma, back pain, and recent history of COVID-19 and the medications used to treat these conditions, including rituximab, oxycodone, hydroxychloroquine, and ivermectin, were contributing factors to this accident.

According to the pilot, during the takeoff roll from the 5,000-ft-long runway, after reaching an airspeed of 90 knots, the airplane’s acceleration slowed. The airplane reached a maximum airspeed of about 92 knots, which was below the planned rotation speed of 100 knots. The pilot elected to abort the takeoff with about 1,500 ft of remaining runway. He reduced the power to idle and initiated maximum braking. The pilot stated that he did not sense the airplane slowing down but observed tire marks on the runway postaccident that were consistent with braking. The airplane continued off the end of the runway and collided with a fence before coming to a stop. All of the occupants exited the airplane safely, and a post-crash fire ensued. Examination of the runway revealed tire skid marks that began 1,200 ft from the runway end and continued into the grass leading to the airplane. An examination of the airplane revealed that the entire cockpit and cabin areas were destroyed by fire. The engines did not display evidence of a catastrophic failure but were otherwise unable to be examined in more detail due to the degree of fire damage. The parking brake control was found in the off position. All hydraulic brake lines were destroyed by fire, and the main landing gear sustained fire and impact damage. Although the tire marks on the runway indicated that some braking action took place, the extensive fire damage precluded a detailed examination of the braking system, and there was insufficient evidence to determine the reason for the runway excursion.

The pilot departed on the cross-country flight with the airplane about 730 lbs over its maximum gross weight. While in cruise altitude at 27,000 ft mean sea level (msl), the pilot reported to air traffic control that he observed weather on his radar along his route and ahead of his position. The areas of weather included thunderstorms with cloud tops up to 43,000 ft msl. The controller acknowledged the weather; however, she did not provide specifics to the pilot, including the size and strength of the area of precipitation or cloud tops information, nor did she solicit or disseminate any pilot reports related to the conditions, as required. The airplane entered an area of heavy to extreme precipitation, likely a thunderstorm updraft, while in instrument meteorological conditions. Tracking information indicated that the airplane climbed about 300 ft, then entered a right, descending spiral and broke up in flight at high altitude. The recovered wreckage was found scattered along a path about 2.6 miles in length. Both wings separated, and most of the empennage was not located. The airplane was likely about 148 lbs over the maximum allowable gross weight at the time of the accident. Examination of the wreckage revealed no evidence of a pre accident malfunction or failure that would have prevented normal operation. The pilot, who owned the airplane, did not possess an instrument rating. The pilot-rated passenger in the right seat was instrument-rated but did not meet resency of experience requirements to act as pilot-in-command. Toxicology testing detected a small amount of ethanol in the pilot’s liver but not in muscle. After absorption, ethanol is uniformly distributed throughout all tissues and body fluids; therefore, the finding in one tissue but not another is most consistent with post-mortem production. Hazardous weather avoidance is ultimately the pilot’s responsibility, and, in this case, the airplane was sufficiently equipped to provide a qualified pilot with the information necessary to navigate hazardous weather; however, the controller’s failure to provide the pilot with adequate and timely weather information as required by Federal Aviation Administration Order JO 7110.65X contributed to the pilot’s inability to safely navigate the hazardous weather along his route of flight, resulting in the penetration of a thunderstorm and the resulting loss of airplane control and inflight breakup.

The airline transport pilot was conducting a cross-country aerial observation flight in the multiengine airplane. The pilot reported that the airplane was on the final leg of the traffic pattern when he reduced the power levers for landing and noticed that the right engine sounded like the propeller was moving toward the beta position. The pilot increased the engine power, and the sound stopped. As the airplane got closer to the runway, he decreased the engine power, and the sound returned. In addition, the airplane began to yaw right. The pilot applied left aileron and rudder inputs to remain above the runway centerline without success. While over the runway, the pilot reduced the engine power to idle, and the airplane continued to yaw right. The pilot applied full power in an attempt to perform a go-around; however, the airplane yawed about 30 degrees off the runway centerline, touched down in the grass, and impacted trees before coming to rest. The right wing, right engine, and right propeller assembly were impact-separated. The right engine propeller came to rest about 50 ft forward of the main wreckage, and it was found in the feathered position. A review of maintenance records revealed that the right propeller had been overhauled and reinstalled on the airplane 2 days before the accident and had operated 9 hours since that time. Subsequent testing of the right propeller governor revealed that it functioned without anomaly; however, the speed settings were improperly configured. Further, the testing revealed that the beta valve travel from the neutral position was out of tolerance. Although this could have let oil pressure port to one side of the spool or the other and, thus, changed the propeller blade angle, it could not be determined whether this occurred during the accident landing. Impact damage precluded examination of the right propeller governor control linkage; therefore, it could not be determined if it was inadequately installed or rigged, which could have resulted in the propeller moving into the beta position. The investigation could not determine why the right propeller moved toward the beta position as engine power was reduced, as reported the pilot.

According to the pilot, she was flying an instrument landing system approach when she noted that the glide slope was out of service. She transitioned to a localizer-only approach and continued. Night, instrument meteorological conditions prevailed with a 400-foot ceiling. She noticed that the airplane was "high and fast" on final approach, so she used speed brakes and flaps to slow the airplane and descend to the minimum descent altitude. As the airplane descended below the ceiling, she observed runway lights and attempted to land on the runway. The airplane landed long, departed the runway at the departure end, and struck an embankment before coming to rest. An inspector from the Federal Aviation Administration examined the airplane and confirmed substantial damage to the fuselage, wings, and empennage. The pilot reported no pre-impact mechanical malfunctions or failures with the airplane that would have precluded normal operation.

The pilot departed in night instrument flight rules (IFR) conditions on a medical specimen transport flight. During the climb, an air traffic controller told the pilot that the transponder code he had selected (2501) was incorrect and instructed him to reset the transponder to a different code (2531). Shortly thereafter, the airplane reached a maximum altitude of about 3,300 ft and then entered a descending right turn. The airplane’s enhanced ground proximity warning system recorded a descent rate of 11,245 ft per minute, which triggered two “sink rate, pull up” warnings. The airplane subsequently climbed from an altitude of about 1,400 ft to about 2,000 ft before it entered another turning descent and impacted the ground about 5 miles northeast of the departure airport. The airplane was fragmented and strewn along a debris path that measured about 800-ft long and 300-ft wide. Postaccident examination of the airplane did not reveal any preimpact mechanical malfunctions that would have precluded the pilot from controlling the airplane. The engine did not display any evidence of preimpact anomalies that would have precluded normal operation. An open resistor was found in the flight computer that controlled the autopilot. It could not be determined if the open resistor condition existed during the flight or occurred during the impact. If the resistor was in an open condition at the time of autopilot engagement, the autopilot would appear to engage with a mode annunciation indicating engagement, but the pitch and roll servos would not engage. The before taxiing checklist included checks of the autopilot system to verify autopilot function before takeoff. It could not be determined if the pilot performed the autopilot check before the accident flight or if the autopilot was engaged at the time of the accident. The circumstances of the accident are consistent with the known effects of spatial disorientation. Dark night IFR conditions prevailed, and the track of the airplane suggests a loss of attitude awareness. Although the pilot was experienced in night instrument conditions, it is possible that an attempt to reset the transponder served as an operational distraction that contributed to a breakdown in his instrument scan. Similarly, if the autopilot’s resistor was in an open condition and the autopilot had been engaged, the pilot’s failure to detect an autopilot malfunction in a timely manner could have contributed to spatial disorientation and the resultant loss of control.

The pilot was not familiar with the mountain airport. The airplane was high during the first visual approach to the runway. The pilot performed a go-around and the airplane was again high for the second approach. During the second approach, the approach angle steepened, and the airplane pitched nose-down toward the runway. The nosegear touched down about halfway down the runway followed by main gear touchdown. The airplane then bounced and the sound of engine noise increased as the airplane banked right and the right wing contacted the ground. The airplane subsequently flipped over and off the right side of the runway, and a postcrash fire ensued. Examination of the airframe and engines did not reveal any preimpact mechanical malfunctions. The examination also revealed that the right engine thrust reverser was deployed during the impact sequence, and the left engine thrust reverser was stowed. Although manufacturer data revealed single-engine reversing has been demonstrated during normal landings and is easily controllable, the airplane had already porpoised and bounced during the landing. The pilot’s subsequent activation of only the right engine’s thrust reverser would have created an asymmetrical thrust and most likely exacerbated an already uncontrolled touchdown. Had the touchdown been controlled, the airplane could have stopped on the remaining runway or the pilot could have performed a go-around uneventfully.