PRELIMINARY REPORTS
UPS Caravan Lands Off Airport after Engine Failure
Cessna 208B Caravan, July 3, 2017, near Marfa, Texas—A Cessna 208B Super Cargomaster operated under Part 135 by Martinaire Cargo was substantially damaged and its pilot, the sole occupant, sustained minor injuries in a forced landing near Alpine-Casparis Municipal Airport (E38) near Marfa, Texas.
The flight departed E38 on an IFR flight plan en route to Maverick County Memorial International Airport (5T9), Eagle Pass, Texas, just after 6 p.m. in day VMC. While climbing through 500 feet agl the pilot heard a loud bang, followed by a squealing noise, as the engine lost power. The pilot told investigators he released backpressure on the controls and rapidly pulled the propeller control to the feather position. During the forced landing, the right and left wings were damaged when they hit utility poles. The airplane came to rest in a field near Highway 118. Firefighters responded.
U.S.-registered TBM 700 Spins Out of IFR into Japanese Mountains
Daher TBM 700, Aug. 14, 2017, Yao Airport, Japan—A U.S.-registered Daher TBM 700 flown by an experienced Japanese owner-pilot crashed in mountainous terrain in the Nara prefecture near Yao Airport. Some eyewitnesses reported that the airplane spun out of the clouds. Fire consumed the wreckage and the 68-year-old pilot and his wife, the only passenger, were killed.
The airplane departed Yao Airport just before noon in IMC. Just 15 minutes into the flight the pilot told Kansai Approach he wanted to turn back to Yao. Radar contact was lost three minutes later. The Japan Transport Safety Board reached the accident site the next day and commented that the wreckage distribution indicated the turboprop single might have disintegrated in flight.
The airplane had been imported to Japan from the U.S. in early June this year, and a Japanese maintenance company conducted a maintenance check that took several weeks. No maintenance issues were uncovered; however, three days before the accident the aircraft suffered unspecified radio trouble during a flight from Yao to Kobe Airport (UKB/RJBE) and was forced to return to Yao.
Strange Noise on Takeoff Morphs into Big Bang on Landing
Thrush S2R-800, Aug. 16, 2017, Stephan Lake Lodge, Alaska—A turbine-powered Thrush (formerly Rockwell International) S2R-800 on a cargo flight from Willow, Alaska, lost control and departed the runway while landing at Stephan Lake Lodge Airport, Alaska, 46 miles northeast of Talkeetna. The commercial pilot was uninjured. The left wing and the empennage of the airplane sustained substantial damage.
The airplane was registered to and operated by Glenn Air of Palmer, Alaska, and was operating under Part 91 in VMC. The pilot reported that the purpose of the flight was to transport bulk fuel to Stephan Lake Lodge Airport. While taking off from Willow Airport, the pilot reported he heard a “whack" noise from the rear of the airplane, which he attributed to a rock striking a flap. After an uneventful flight, the pilot landed into the wind on Runway 18 at Stephan Lake Lodge Airport.
Upon touchdown on the dirt and gravel runway, the tail of the airplane came down, and the pilot reported he heard a “loud bang." He reported the tailwheel assembly “went clear" to the ground and he had no rudder authority. The pilot managed to hold a straight path on the runway for about 600 feet, but with loss of airspeed the airplane veered to the right and off the runway at about 25 mph, coming to rest after hitting the ditch that runs parallel to the runway. The pilot found that a bolt in the front tail spring attachment assembly had failed.
Aeromedical flight found intact in a ditch, but all on board lost
Airbus Helicopters BK117-C2, Sept. 8, 2017, Hertford, North Carolina—A commercial pilot, two flight nurses and one patient were killed when the BK117-C2 descended into a ditch and caught fire after losing power near a wind farm in Hertford, North Carolina. The pilot had accrued 1,027 hours in the same make and model as the accident helicopter, and had been employed with Air Methods for nine years.
The day VMC Part 135 flight left Sentara Albemarle Regional Medical Center Heliport (NC98) at 11:08 a.m. destined for the Duke University North Heliport (NC92) and heading northwest at 1,000 feet agl. Eight minutes after takeoff, the helicopter began a turn toward the south. A minute later the transmitted data ended at an altitude of about 1,200 feet msl and a groundspeed of 75 knots, while the helicopter was on a southeasterly track.
Witnesses reported seeing “heavy" or "dark,” even “bluish,” smoke trailing behind the helicopter while it was in flight. One witness reported that the helicopter was "hovering" and "not travelling forward" while it was a "couple of hundred feet" above the wind turbine farm. Another witness reported hearing a "popping noise" before seeing the helicopter turn left, then right. It then descended quickly and appeared “in control" with the main and tail rotors turning before he lost sight of it.
The helicopter hit the ground in a shallow turf drainage pathway 30 feet wide and 2,000 feet long between two fields of tall grass on a wind turbine farm. The fuselage came to rest in a seven-foot-wide ditch in the center of the pathway, and was oriented on a heading of 261 degrees magnetic. There were no ground scars leading toward or away from the main wreckage.
Examination of the wreckage revealed that all major components of the helicopter were present at the accident site. The cabin had collapsed downward and was partially consumed by a post-crash fire. The tailboom remained largely intact. Flight control continuity was established from the cockpit area to the rotor systems and engines. All main and tail rotor blades remained attached to the rotor hubs. The number-four (red) main rotor blade was found rotated 180 degrees in the hub with its pitch links fractured and partially melted. None of the main or tail-rotor blades exhibited leading-edge damage, chord-wise scratches or other evidence of rotation. The outboard four feet of the number-one (yellow) blade came to rest in the eight-foot-tall grass adjacent to the drainage path. The grass on either side of the blade was undisturbed. The tailrotor shaft remained attached to the transmission. The transmission could not be rotated by hand.
No foreign object debris damage was found on the axial compressor blades of either engine. No damage was seen on the visible portions of the turbine blades at the rear of either engine. The gas generator of the number-one engine moved freely when rotated by hand. The number-two engine gas generator would not rotate. The number-one engine fuel shutoff valve was found in the open position. The number-two engine fuel shutoff valve was damaged and in the field its position could not be determined. The number-two engine rear turbine shaft bearing showed discoloration consistent with overheating and lack of lubrication. The bearing roller pins were worn down to the surface of the bearing race. The end of the turbine shaft aft of the nut exhibited rotational non-uniform damage.
FAA records show that a 30-hour engine inspection was completed on August 15 this year. At that time the helicopter and both engines had accrued 2,673 hours. Several more inspections were completed during scheduled maintenance on September 1. At that time the helicopter had accrued 2,710 hours. According to the operator, a mechanic performed a daily airworthiness check on the aircraft.
The helicopter was equipped with an onboard audio and video recording system that was damaged by heat; however, the memory device remained intact. The unit was sent to the NTSB vehicle recorder laboratory for examination.
FINAL REPORT
Turbine Otter Accident Revealed Lack of Safety Culture
De Havilland Canada DHC-3T, June 25, 2015, Ketchikan, Alaska—The NTSB blamed the lack of a safety “culture,” manifest by extreme pressure put on pilots that encouraged them to fly in hazardous weather, as one of the causes for the loss of a turbine Otter, its pilot and eight passengers on a Misty Fjords excursion package from Holland America cruise lines. The Board also cited the operator, Promech, for lack of a formal safety program and inadequate operational control for releasing flights for departure.
The flight, operating under Part 135, was carrying cruise-ship passengers on a VMC trip over remote inland fjords, coastal waterways and mountainous, tree-covered terrain in the Misty Fjords National Monument Wilderness. The weather was marginal VFR, in changeable conditions.
This operator’s pilots could choose between two standard tour routes between Rudyerd Bay and Ketchikan: the “short route” (52 nm) takes about 25 minutes and is primarily over land; the “long route” (63 nm) takes about 30 minutes and is primarily over seawater channels. Although the long route is less scenic, it was generally preferred in poor weather. Route choice was at the pilot’s discretion.
The accident pilot chose the short route for expediency and climbed to an altitude that would have provided safe terrain clearance had he followed the typical short route. Instead, he deviated and turned west early, placing the airplane on a collision course with a 1,900-foot mountain. In the final two seconds of the flight the airplane pitched up rapidly before striking terrain at about 1,600 feet. Investigators concluded that the timing of this aggressive pitch-up maneuver strongly suggests that the pilot continued the flight into near-zero visibility conditions and, as soon as he realized that the flight was on a collision course with the terrain, he pulled back aggressively on the elevator control in an ineffective attempt to avoid the terrain.
The airplane was equipped with Class B Taws that would have provided terrain avoidance alerts; however, it is likely it was inhibited, a common practice among tour operators in the area, who routinely fly at altitudes that generate frequent “nuisance” alerts. The airplane was not equipped, and was not required to be equipped, with any crash-resistant flight recording system. However, data retrieved from other devices, such as the Chelton system and passengers' personal electronic devices, as well as ADS-B recorded data, provided information about the flight.
"Promech and at least one other operator that was willing to take more weather-related risks were both able to fly more revenue passengers than two other more conservative operators who cancelled flights that day," the NTSB said in a statement on the findings.
NTSB chair at the time Robert Sumwalt said in the NTSB statement, "Pilot decisions are informed, for better or worse, by their company's culture. This company allowed competitive pressure to overwhelm the common-sense needs of passenger safety in its operations. That's the climate in which the accident pilot worked."
The NTSB held the final report hearing in Alaska, and made a dozen recommendations regarding the safety of operations of tour aircraft in the state, including the establishment of a more conservative set of weather minimums tailored to the air-tour operations conducted in Ketchikan and applicable to all area air-tour operators to help balance competing goals of production and safety and remove the incentive individual operators have had in the past to adopt the lowest possible weather minimums to stay competitive.
PRELIMINARY REPORTS
UPS Caravan Lands Off Airport after Engine Failure
Cessna 208B Caravan, July 3, 2017, near Marfa, Texas—A Cessna 208B Super Cargomaster operated under Part 135 by Martinaire Cargo was substantially damaged and its pilot, the sole occupant, sustained minor injuries in a forced landing near Alpine-Casparis Municipal Airport (E38) near Marfa, Texas.
The flight departed E38 on an IFR flight plan en route to Maverick County Memorial International Airport (5T9), Eagle Pass, Texas, just after 6 p.m. in day VMC. While climbing through 500 feet agl the pilot heard a loud bang, followed by a squealing noise, as the engine lost power. The pilot told investigators he released backpressure on the controls and rapidly pulled the propeller control to the feather position. During the forced landing, the right and left wings were damaged when they hit utility poles. The airplane came to rest in a field near Highway 118. Firefighters responded.
U.S.-registered TBM 700 Spins Out of IFR into Japanese Mountains
Daher TBM 700, Aug. 14, 2017, Yao Airport, Japan—A U.S.-registered Daher TBM 700 flown by an experienced Japanese owner-pilot crashed in mountainous terrain in the Nara prefecture near Yao Airport. Some eyewitnesses reported that the airplane spun out of the clouds. Fire consumed the wreckage and the 68-year-old pilot and his wife, the only passenger, were killed.
The airplane departed Yao Airport just before noon in IMC. Just 15 minutes into the flight the pilot told Kansai Approach he wanted to turn back to Yao. Radar contact was lost three minutes later. The Japan Transport Safety Board reached the accident site the next day and commented that the wreckage distribution indicated the turboprop single might have disintegrated in flight.
The airplane had been imported to Japan from the U.S. in early June this year, and a Japanese maintenance company conducted a maintenance check that took several weeks. No maintenance issues were uncovered; however, three days before the accident the aircraft suffered unspecified radio trouble during a flight from Yao to Kobe Airport (UKB/RJBE) and was forced to return to Yao.
Strange Noise on Takeoff Morphs into Big Bang on Landing
Thrush S2R-800, Aug. 16, 2017, Stephan Lake Lodge, Alaska—A turbine-powered Thrush (formerly Rockwell International) S2R-800 on a cargo flight from Willow, Alaska, lost control and departed the runway while landing at Stephan Lake Lodge Airport, Alaska, 46 miles northeast of Talkeetna. The commercial pilot was uninjured. The left wing and the empennage of the airplane sustained substantial damage.
The airplane was registered to and operated by Glenn Air of Palmer, Alaska, and was operating under Part 91 in VMC. The pilot reported that the purpose of the flight was to transport bulk fuel to Stephan Lake Lodge Airport. While taking off from Willow Airport, the pilot reported he heard a “whack" noise from the rear of the airplane, which he attributed to a rock striking a flap. After an uneventful flight, the pilot landed into the wind on Runway 18 at Stephan Lake Lodge Airport.
Upon touchdown on the dirt and gravel runway, the tail of the airplane came down, and the pilot reported he heard a “loud bang." He reported the tailwheel assembly “went clear" to the ground and he had no rudder authority. The pilot managed to hold a straight path on the runway for about 600 feet, but with loss of airspeed the airplane veered to the right and off the runway at about 25 mph, coming to rest after hitting the ditch that runs parallel to the runway. The pilot found that a bolt in the front tail spring attachment assembly had failed.
Aeromedical flight found intact in a ditch, but all on board lost
Airbus Helicopters BK117-C2, Sept. 8, 2017, Hertford, North Carolina—A commercial pilot, two flight nurses and one patient were killed when the BK117-C2 descended into a ditch and caught fire after losing power near a wind farm in Hertford, North Carolina. The pilot had accrued 1,027 hours in the same make and model as the accident helicopter, and had been employed with Air Methods for nine years.
The day VMC Part 135 flight left Sentara Albemarle Regional Medical Center Heliport (NC98) at 11:08 a.m. destined for the Duke University North Heliport (NC92) and heading northwest at 1,000 feet agl. Eight minutes after takeoff, the helicopter began a turn toward the south. A minute later the transmitted data ended at an altitude of about 1,200 feet msl and a groundspeed of 75 knots, while the helicopter was on a southeasterly track.
Witnesses reported seeing “heavy" or "dark,” even “bluish,” smoke trailing behind the helicopter while it was in flight. One witness reported that the helicopter was "hovering" and "not travelling forward" while it was a "couple of hundred feet" above the wind turbine farm. Another witness reported hearing a "popping noise" before seeing the helicopter turn left, then right. It then descended quickly and appeared “in control" with the main and tail rotors turning before he lost sight of it.
The helicopter hit the ground in a shallow turf drainage pathway 30 feet wide and 2,000 feet long between two fields of tall grass on a wind turbine farm. The fuselage came to rest in a seven-foot-wide ditch in the center of the pathway, and was oriented on a heading of 261 degrees magnetic. There were no ground scars leading toward or away from the main wreckage.
Examination of the wreckage revealed that all major components of the helicopter were present at the accident site. The cabin had collapsed downward and was partially consumed by a post-crash fire. The tailboom remained largely intact. Flight control continuity was established from the cockpit area to the rotor systems and engines. All main and tail rotor blades remained attached to the rotor hubs. The number-four (red) main rotor blade was found rotated 180 degrees in the hub with its pitch links fractured and partially melted. None of the main or tail-rotor blades exhibited leading-edge damage, chord-wise scratches or other evidence of rotation. The outboard four feet of the number-one (yellow) blade came to rest in the eight-foot-tall grass adjacent to the drainage path. The grass on either side of the blade was undisturbed. The tailrotor shaft remained attached to the transmission. The transmission could not be rotated by hand.
No foreign object debris damage was found on the axial compressor blades of either engine. No damage was seen on the visible portions of the turbine blades at the rear of either engine. The gas generator of the number-one engine moved freely when rotated by hand. The number-two engine gas generator would not rotate. The number-one engine fuel shutoff valve was found in the open position. The number-two engine fuel shutoff valve was damaged and in the field its position could not be determined. The number-two engine rear turbine shaft bearing showed discoloration consistent with overheating and lack of lubrication. The bearing roller pins were worn down to the surface of the bearing race. The end of the turbine shaft aft of the nut exhibited rotational non-uniform damage.
FAA records show that a 30-hour engine inspection was completed on August 15 this year. At that time the helicopter and both engines had accrued 2,673 hours. Several more inspections were completed during scheduled maintenance on September 1. At that time the helicopter had accrued 2,710 hours. According to the operator, a mechanic performed a daily airworthiness check on the aircraft.
The helicopter was equipped with an onboard audio and video recording system that was damaged by heat; however, the memory device remained intact. The unit was sent to the NTSB vehicle recorder laboratory for examination.
FINAL REPORT
Turbine Otter Accident Revealed Lack of Safety Culture
De Havilland Canada DHC-3T, June 25, 2015, Ketchikan, Alaska—The NTSB blamed the lack of a safety “culture,” manifest by extreme pressure put on pilots that encouraged them to fly in hazardous weather, as one of the causes for the loss of a turbine Otter, its pilot and eight passengers on a Misty Fjords excursion package from Holland America cruise lines. The Board also cited the operator, Promech, for lack of a formal safety program and inadequate operational control for releasing flights for departure.
The flight, operating under Part 135, was carrying cruise-ship passengers on a VMC trip over remote inland fjords, coastal waterways and mountainous, tree-covered terrain in the Misty Fjords National Monument Wilderness. The weather was marginal VFR, in changeable conditions.
This operator’s pilots could choose between two standard tour routes between Rudyerd Bay and Ketchikan: the “short route” (52 nm) takes about 25 minutes and is primarily over land; the “long route” (63 nm) takes about 30 minutes and is primarily over seawater channels. Although the long route is less scenic, it was generally preferred in poor weather. Route choice was at the pilot’s discretion.
The accident pilot chose the short route for expediency and climbed to an altitude that would have provided safe terrain clearance had he followed the typical short route. Instead, he deviated and turned west early, placing the airplane on a collision course with a 1,900-foot mountain. In the final two seconds of the flight the airplane pitched up rapidly before striking terrain at about 1,600 feet. Investigators concluded that the timing of this aggressive pitch-up maneuver strongly suggests that the pilot continued the flight into near-zero visibility conditions and, as soon as he realized that the flight was on a collision course with the terrain, he pulled back aggressively on the elevator control in an ineffective attempt to avoid the terrain.
The airplane was equipped with Class B Taws that would have provided terrain avoidance alerts; however, it is likely it was inhibited, a common practice among tour operators in the area, who routinely fly at altitudes that generate frequent “nuisance” alerts. The airplane was not equipped, and was not required to be equipped, with any crash-resistant flight recording system. However, data retrieved from other devices, such as the Chelton system and passengers' personal electronic devices, as well as ADS-B recorded data, provided information about the flight.
"Promech and at least one other operator that was willing to take more weather-related risks were both able to fly more revenue passengers than two other more conservative operators who cancelled flights that day," the NTSB said in a statement on the findings.
NTSB chair at the time Robert Sumwalt said in the NTSB statement, "Pilot decisions are informed, for better or worse, by their company's culture. This company allowed competitive pressure to overwhelm the common-sense needs of passenger safety in its operations. That's the climate in which the accident pilot worked."
The NTSB held the final report hearing in Alaska, and made a dozen recommendations regarding the safety of operations of tour aircraft in the state, including the establishment of a more conservative set of weather minimums tailored to the air-tour operations conducted in Ketchikan and applicable to all area air-tour operators to help balance competing goals of production and safety and remove the incentive individual operators have had in the past to adopt the lowest possible weather minimums to stay competitive.