PRELIMINARY REPORTS
Grand Caravan, PA-18 Collide in VMC Over Alaska
Cessna 208B, near Russian Mission, Alaska, Aug. 31, 2016—The ATP-rated pilot and two passengers on board the Caravan perished when their aircraft collided with a Piper PA-18-150 Super Cub in day VMC 6.5 miles northwest of Russian Mission Airport (PARS). The scheduled Part 135 commuter flight was operating under VFR, as was the PA-18, operating a guided hunting expedition under Part 91. The pilot and passenger on board the Super Cub also died in the crash, and both aircraft sustained significant damage.
The Caravan departed PARS at 9:58 a.m. for Marshall Don Hunter Senior Airport (PADM), Marshall, Alaska. The Piper had departed Bethel Airport (PABE) 50 minutes before, destined for a remote hunting camp 20 miles northwest of Russian Mission. Respective company flight-following procedures were in effect for both aircraft, and the Cessna was equipped with ADS-B as part of its G1000 avionics package.
In a telephone conversation following the accident, a representative with the Caravan operator stated that the company’s operational control center (OCC) initiated overdue airplane procedures after the aircraft failed to arrive at Marshall at its scheduled time of 10:17 a.m. The OCC also contacted pilots of two company airplanes operating near Russian Mission and provided them with the accident aircraft’s last recorded lat-long coordinates. Those pilots visually confirmed the accident wreckage in an area of rolling terrain, with heavy vegetation 10 feet tall.
The owner of the hunting/fishing expedition company operating the Piper told investigators that, after delivering a customer to his hunting camp at 10:30 a.m., he flew over the intended destination of the accident aircraft and could see neither it nor its occupants. He then radioed company headquarters for the status of the accident flight, and after receiving the last latitude and longitude coordinates from its DeLorme flight following system, flew over the accident site and saw the wreckage.
The NTSB noted that the FAA has implemented full ADS-B coverage in Alaska under a joint industry/governmental program formerly known as Capstone. The Cessna’s ADS-B system was installed as part of that program, intended to provide the airplane’s position over terrain and warn pilots of the presence of other ADS-B-equipped aircraft in the area. The aircraft’s operator stated that the equipment on board the Cessna was ADS-B out, capable only of transmitting. The PA-18 was equipped with a Garmin GPSMap 296. Investigators have asked the FAA to provide radar and track data for both aircraft.
FACTUAL
Misrigged Aileron Cited in JetProp Takeoff Crash
Piper PA-46-350P, Spokane, Wash., May 7, 2015—In an updated factual report, the NTSB noted that the right aileron of a Piper Mirage JetProp that crashed during an emergency landing attempt had been misrigged to deflect in the same direction as the aircraft’s left aileron. The pilot-in-command (PIC), a company maintenance technician for Rocket Engineering and the pilot-rated passenger, a company sales representative, perished when the aircraft crashed in the Spokane River near Felts Field Airport (SFF) in day VMC.
The aircraft was on a post-maintenance test flight following an annual inspection conducted by the company. Multiple witnesses saw the aircraft in a 10-degree climbing right turn immediately after takeoff, followed by a more aggressive right turn as the aircraft passed through 1,000 agl on a southbound heading. Audio feeds recorded sounds of labored breathing over the advisory frequency, and the pilot replied “that's negative"” when asked by the tower controller if everything was OK.
Over the next 45 seconds, the aircraft completed almost two spiraling turns, with tower personnel observing the aircraft in a 90-degree right bank. The bank angle reduced as the aircraft descended through 700 feet agl, and the aircraft appeared to recover. Approximately 2.5 minutes later, the pilot reported, “We are trying to get under control here, be back with you.”
The aircraft continued to climb on an easterly course away from the airport, reaching 5,600 feet msl (4,000 feet agl) over the town of Newman Lake. The pilot told controllers that “things seem to be stabilizing,” adding he would perform further controllability tests before turning back to the airport.
Tower controllers granted the pilot’s request for a straight-in landing for Runway 22R at SFF. As the aircraft approached the airport, the pilot told controllers, “We have a control emergency there, a hard right aileron.”
Tower personnel noted the aircraft remained closely aligned with the extended centerline in a 20-degree, right-wing-low attitude throughout the final approach. As the aircraft flew over the runway, the controller noted the engine sound changed as if the aircraft were attempting a go-around. The aircraft then rolled sharply to the right and crashed in the river just north of SFF.
Post-accident examination of the wreckage revealed that the right-hand aileron drive cable followed the balance cable path through the wings past the pressure vessel seals, rather than the drive cable routing, and that the right-hand aileron balance cable had been connected to the left wing balance cable inboard of the cabin pressure vessel seal.
The 22-year A&P technician who performed and signed off on the annual inspection told investigators he had replaced PA-46 aileron cables “about five times” throughout his career. He worked exclusively on the accident aircraft and had fielded several calls from the aircraft’s owner for updates. He reported replacing the cables in compliance with maintenance manual procedures, removing and replacing each cable individually to prevent inadvertent mis-rigging, and confirming smooth and full-deflection aileron operation from both inside and outside the aircraft. He also stated that he asked another mechanic to check his work, specifically to verify correct aileron operation; the second mechanic told investigators that he assisted with reattaching the ailerons and verified secure installation of safety wire, but asserted that he was not asked to confirm correct aileron operation and that he did not do so.
The aircraft was manufactured in 1996 and modified in 2007 by Rocket Engineering under the JetProp supplemental type certificate ST00541SE, which included the installation of a 560-shp Pratt & Whitney Canada PT6A-35 turboprop. The airplane’s owner brought the aircraft to the company on April 16 this year for its annual inspection.
During the inspection period, the pilot also requested several avionics upgrades to be performed at another maintenance facility at SFF. Those upgrades required removal of the aft headliner, along with the middle and rear right seats to accommodate new electrical cable runs.
Premier I Suffers Wing Strike on Landing
Hawker Beechcraft 390, Wheeling, Ill., Dec. 10, 2015—The twin-engine business jet suffered a wing strike during a go-around on its first landing attempt at Chicago Executive Airport (PWK) in day VMC, followed by a hard second landing. The pilot-in command (PIC), copilot and five passengers were not injured. The PIC had recently purchased the aircraft and received his type rating and the copilot was on the familiarization flight to “ensure the safe operation of the airplane,” according to the NTSB.
The aircraft departed Monmouth Executive Airport (BLM), Farmingdale, N.J., at 3:45 p.m. CST on an IFR flight plan. Cockpit voice recordings indicate the copilot was handling the radios and directing the flight, with the PIC monitoring the autopilot.
As the aircraft descended out of FL200 to 4,000 feet the copilot contacted the FBO at PWK to ensure a vehicle was available to take him to Chicago O’Hare International Airport (ORD) as he was concerned he would miss his flight. On their initial contact with Chicago Approach, the crew said they had ATIS information Oscar. Approach replied that ATIS Yankee was current.
As the crew listened to the updated ATIS, the two pilots talked over a portion of the recording warning that a “low-level wind shear advisory was in effect for landing runways,” and the copilot subsequently failed to inform the PIC of the reported wind shear.
Approach directed the crew to fly a heading of 270 degrees with vectors to the GPS final approach course to Runway 16. As the copilot conversed with the PIC, both pilots missed a pirep stating an airplane that had just landed at PWK reported wind from 250 degrees true at 25 knots, gusting to 50 knots. Approach repeated the pirep while clearing the flight to the initial approach fix (IAF) while reporting the wind as 250 at 25 knots, gusting 34 knots, and altimeter setting 29.44.
The PIC subsequently asked the copilot if he wanted to fly the approach in view of the direct right crosswind, with the copilot replying “whatever you want.” The crew further discussed the copilot’s situation with his connecting flight as Approach transmitted to other aircraft an updated altimeter setting at PWK.
As they neared the IAF, the copilot told the PIC that he thought the PIC should fly the approach, with the copilot monitoring “to make sure that nothing gets bent.” The PIC agreed and took control of the aircraft. The crew confirmed with PWK Tower that they had the wind-shear warning from the pirep, with the copilot then remarking to the PIC that the flight crew providing the pirep consisted of “a bunch of Sissy-Marys.”
About one minute later, Tower informed a departing Cessna that several aircraft had reported 50-knot gusts, adding, “Unless you’re a seasoned pilot, I wouldn’t recommend flying that.” The CVR of the accident aircraft recorded the sound of laughter from the PIC.
Recordings show that the copilot grabbed the flight controls and aborted the landing just as the aircraft touched down, without announcing his intent. Both pilots confirmed they were manipulating the flight controls, and that they were fighting each other’s inputs. The PIC replied “no” when the copilot asked repeatedly if they had suffered a wing strike on the go-around.
After canceling their IFR clearance, the copilot accepted a visual approach to Runway 30, with a left quartering crosswind of 270 degrees at 16 kts gusting to 34 knots. The aircraft subsequently landed hard on the runway, the right main gear tire deflated, and the aircraft departed the right side of the runway and hit a concrete barrier.
Pilot Exits DHS Helicopter Before Rollover
Eurocopter EC120B, near Ajo, Ariz., June 13, 2016—The pilot exited the skid-equipped helicopter, operating for the U.S. Department of Homeland Security (DHS), shortly after landing on a volcanic rock hilltop. Soon after, the pilot heard “an audible change in the sound of the main rotor” and watched as the ground under the helicopter’s right skid gave way. The helicopter then rolled to the right, sustaining substantial damage to the tail boom. The pilot reported no apparent preflight mechanical failures before the accident, and no one was injured.
In its updated factual report, the NTSB cited a portion of the FAA-H-8083-21A Helicopter Flying Handbook (2012) stating: “Many helicopter operators have been lured into a ‘quick turnaround’ ground operation to avoid delays at airport terminals and to minimize stop/start cycles of the engine. As part of this quick turn-around, the pilot might leave the cockpit with the engine and rotors turning. Such an operation can be extremely hazardous if a gust of wind disturbs the rotor disk, or the collective flight control moves causing lift to be generated by the rotor system. Either occurrence may cause the helicopter to roll or pitch, resulting in a rotor blade striking the tail boom or the ground. Good operating procedures dictate that, generally, pilots remain at the flight controls whenever the engine is running and the rotors are turning.”
Bald Eagle Strike on Turbine Otter
De Havilland Canada DHC-3T, near Homer, Alaska, June 19, 2016—The Otter, converted to turboprop power, had departed Homer-Beluga Lake Seaplane Base (5BL) on a VFR company training flight in day VMC. Ten miles northeast of 5BL while cruising at 2,500 feet msl, the pilots saw what they believed to be a bald eagle off their left wing immediately before hearing and feeling an impact. The aircraft continued to fly straight-and-level with no apparent control issues, and the crew notified the Homer Flight Service Station of their intent to return to 5BL.
As they made their first approach to land, the crew experienced uncontrollable roll to the left below 75 mph. The pilots then declared an emergency and requested emergency services. On the second approach, the crew held airspeed above 75 mph until immediately before touchdown, and the aircraft landed successfully with no further control issues.
Inspection revealed substantial damage to the leading edge of the left wing, outboard of the landing light, over a length of about three feet. The leading edge, upper wing skin and lower wing skin were also fractured at the impact point, with the fracture in the upper wing skin extending aft by two to three feet and a resulting hole approximately one-foot square. Drag created by the damage disrupted airflow over the wing at low airspeeds, degrading performance on landing. Testing by the Smithsonian Institution Feather Identification Laboratory positively identified the remains as those of a bald eagle.
FINAL
Dynamic Rollover Cited in Bell 206B Takeoff Accident
Bell 206B, Linden, N.J., Feb. 6, 2016—A pilot’s failure to maintain control during takeoff resulted in dynamic rollover during a training flight; the flight instructor’s inadequate remedial action was a contributing factor, according to the NTSB.
During takeoff from a parking dolly in day VMC, the JetRanger suddenly rolled to the left as it became “light on the skids.” The flight instructor providing transition training to the pilot told investigators he had been looking left during the accident sequence to verify the area was clear of obstructions, and had “never felt anything that quick.” Security video showed the helicopter initially began to roll to the right during takeoff, followed immediately by the roll to the left.
The helicopter bounced as it struck the ground on its left side, and came to rest on its right side. The fuselage, main rotor blades, tail rotor blades and tail boom were substantially damaged during the accident.
The private pilot receiving instruction purchased the helicopter in July 2015 and reported 625 total flight hours with five hours in type. The CFI reported 25,000 total flight hours, with 2,760 hours in the Bell 206 and 1,020 hours as instructor in type. A 3,000-hour maintenance inspection had been performed recently, as well as a separate inspection by a mechanic requested by the owner-pilot. Both pilots stated the preflight inspection revealed no anomalies.