Preliminary Reports
Checkride Spoiled by Gear-up Landing
Cessna 510, Feb. 20, 2020, Daytona Beach, Florida – A practical test for a single-pilot type rating ended abruptly after the applicant neglected to extend the landing gear during a zero-flaps landing. Neither he nor the designated pilot examiner was injured.
The applicant had completed “a series of maneuvers, emergencies, and landings” before the examiner directed him to land with the flaps retracted. The applicant reported having performed the zero-flaps landing checklist and believed he’d extended the gear, but after touching down with a “thump” he attributed to a blown tire, he saw that the gear handle was still up. The gear warning horn was disabled with the flaps retracted. Once the airplane was lifted off the runway, the gear extended and locked normally.
One Fatality in Cheyenne Crash
Piper PA-31T1 Cheyenne I, April 20, 2020, Billings, Montana – The twin-engine turboprop was destroyed when it went down immediately after takeoff, killing the solo pilot. Radar data showed that it remained on the extended centerline of Runway 28L, reaching a maximum altitude of 100 feet at 81 knots groundspeed before slowing to 70 knots and disappearing from coverage. A witness described it as having “a slow descent trajectory and a slight nose-up attitude.” Ground scars at the accident site a mile and a half west of the airport suggested a wings-level, nose-up impact. The pilot had requested traffic pattern work, switching to Runway 28R after an initial takeoff from 28L.
American Missionary Pilot Killed in Indonesia
Quest Kodiak 100, May 11, 2020, Mamit, Papua, Indonesia – An American pilot flying for the Mission Aviation Fellowship died when her bush plane went down in Lake Sentani while attempting to deliver a shipment of rapid coronavirus test kits and school supplies to Mamit, a remote village in the Papua highlands. Joyce Lin, 40, had reported an emergency two minutes after takeoff. Divers located the wreckage in the lake and recovered her body.
Lin, who earned a computer science degree from the Massachusetts Institute of Technology, had previously worked as a flight instructor in Maryland. She joined MAF in 2017, serving as both a pilot and an information technology specialist.
Final Reports
Landing Overrun Followed Below-minimums Approach
Beechcraft A100, Feb. 26, 2018, Havre-St. Pierre, Quebec, Canada – The captain’s decision to descend below the approach procedure’s minimum descent altitude (MDA) in heavy snow showers that reduced visibility to one-third of that required for the approach led the charter flight to touch down just 700 feet from the end of the 4,498-foot runway. One crew member and three of the six passengers suffered minor injuries after the King Air continued some 220 feet past the end of the runway into a snowbank, collapsing the landing gear. Ground visibility was reported as one-quarter mile in heavy snow, with a vertical visibility of 400 feet.
The Strait Air flight, the third of seven legs scheduled for that day, had departed from Sept-Îles half an hour earlier after a 46-minute delay to clear snow that had accumulated on the airplane during its ground stop. The captain was the pilot flying, with the first officer monitoring. The flight reached its maximum altitude of 11,000 feet before descending to begin the localizer/DME approach to Runway 08 at Havre-St. Pierre. Snow-removal operations were in progress, but the central 80 feet of the 100-foot-wide runway was reported to be clear, with 30-inch snowdrifts to either side. The crew extended gear and flaps inside the intermediate approach fix and the airplane tracked the final approach course on the optimal three-degree descent path to the final approach fix (FAF).
The first officer was unable to see the runway environment at the FAF or after reaching the MDA, but the captain claimed to have the runway in sight and continued the descent, flying manually. The crew momentarily lost all visual references before spotting a section of pavement about four feet wide and 20 feet long ahead and slightly to their right, with which the captain aligned the airplane. The airplane flew another 20 seconds after crossing the threshold before landing approximately 3,800 feet down the runway.
Canadian aviation regulations, unlike those of the U.S. or most other ICAO members, do not establish firm weather minimums for instrument approaches. Rather, “visibilities published on approach charts are for informational purposes only” and based on a general limiting visibility for all airport operations. “Numerous exceptions and conditions” come into play in determining when approaches are allowed, though commercial operators are generally authorized to attempt them in three-quarters the visibility specified on the approach plate. The final report of the Transportation Safety Board acknowledges that this arrangement is inherently confusing and that the captain of the accident flight “incorrectly believed that he was allowed to conduct the approach.” In response, the TSB issued Recommendation A20-01, advocating that “The Department of Transport review and simplify operating minima for approaches and landings at Canadian aerodromes.”
Takeoff Crash Traced to Inadequate Anti-torque Inputs
Eurocopter EC130, Jan. 19, 2019, Mansfield, Victoria, Australia – The loss of control that subsequently destroyed the aircraft was instigated by the pilot’s failure to apply sufficient right pedal during an unusually rapid liftoff, allowing uncompensated torque to spin the helicopter until he attempted a precautionary landing. The left skid caught on a low mound next to the landing site, rolling the ship onto its left side and shattering the main rotor blades on contact with the ground. The pilot shut off the fuel and electrical systems and helped evacuate the two passengers, who were unhurt. The pilot himself suffered minor injuries.
In a final report published on May 29, the Australian Transportation Safety Bureau noted that the entire accident sequence took place in the span of about five seconds. Post-accident examination found no evidence of mechanical failure; the helicopter was operating well below its maximum gross weight and had performed properly on the flight from Moorabbin Airport less than four hours earlier. Skies were clear and winds were relatively light at about 10 knots.
The pilot reported that he had climbed straight out rather than pausing while light on the skids and then lifting into a controlled hover. The helicopter yawed left and began to spin rapidly, first around the tail rotor and then around the axis of the main rotor mast. He attempted to counter primarily with cyclic, which proved ineffective, before lowering collective to try to land. The ATSB noted that while 227 of his 315 total hours had been logged in the EC130, his initial training took place in the lower-powered Hughes 300, which has a conventional tail rotor and a counterclockwise main rotor. The EC130 has a clockwise main rotor system and a Fenestron (shrouded tail rotor) that requires proportionately greater pedal input to offset comparable torque. In addition, he had flown only 13.5 hours since a flight review 14 months earlier and not at all in the preceding 46 days.
Autopilot Disconnect, Deficient Skills Cited in Red River Downing
Piper PA46-350P JetProp Conversion, Feb. 28, 2019, Shreveport, Louisiana – The turbine-conversion Piper Malibu that crashed into the Red River shortly after takeoff, killing its pilot and the only passenger, had experienced a series of intermittent autopilot failures that had never been diagnosed or corrected. Nevertheless, its owner, described by both a friend and a former instructor as a “weak” instrument pilot, chose to take off into a 600-foot overcast. Examination of the aircraft after its recovery showed that the autopilot system recorded a manual electric trim fault that would have triggered the autopilot to disconnect, followed by roll and yaw faults that probably reflected the unusual attitudes entered in the last moments of the accident sequence.
In its finding of probable cause published on May 19, the NTSB also noted that the airplane was loaded 550 pounds above its maximum ramp weight, though its center of gravity was within limits. The excess weight was not cited as a cause or contributing factor.
The Malibu took off from the Shreveport Downtown Airport’s Runway 32 at 10:37 a.m. on an IFR flight plan to Vernon, Texas. As it entered the cloud deck at an altitude of 600 feet, the pilot was instructed to turn left to a heading of 270 degrees and climb to 12,000 feet. The initial left turn continued past the assigned heading and into a tightening spiral; the pilot responded “Stand by” after being assigned a revised heading of 140 degrees. Thirty-five seconds later, the pilot transmitted “We’re in trouble up here” as the airplane underwent a series of increasingly divergent airspeed, altitude, groundspeed, and vertical speed excursions. The last radar hit showed a groundspeed of 31 knots at an altitude of 575 feet. Attitude data downloaded from its avionics suite showed the airplane descending from its maximum altitude of 1,987 feet to 822 feet, then rebounding to 1,980 feet at vertical speeds ranging from -6,001 to 5,834 fpm. The final data point, recorded at 10:40, showed it descending through 1,217 feet at a rate of -6,818 fpm.
The airplane had been converted to turbine power in February 2016. The instructor who provided the owner’s transition training recalled his having flown well using the autopilot, but described his hand-flying instrument skills as “weak” and said that he’d recommended the owner get frequent recurrent training. The mechanic who did the airplane's last annual inspection said that the owner had reported intermittent autopilot problems including failures to track the selected heading or course, but a November 2018 appointment to troubleshoot this had not been kept. The mechanic, who was himself a pilot, had flown with the owner and considered his instrument skills “deficient.” The pilot’s girlfriend remembered several instances in the months leading up to the accident in which the autopilot had not engaged after takeoff. During those events, the pilot had focused on bringing the autopilot back online, allowing the airplane to enter an unusual attitude on at least one occasion.