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Business Aircraft Accident Reports: September 2023
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Preliminary and final accident reports, September 2023
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Preliminary and final business aircraft accident reports, September 2023
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Preliminary Reports

Citation Approach Accident Claims Six

Cessna 550, July 8, 2023, Murrieta, California

All occupants of the 1979-model Cessna Citation 550 were killed when the airplane crashed at about 4:15 a.m. during a second attempted instrument approach to French Valley Airport. 

A marine layer had enveloped the airport in dense fog, but after executing a missed approach, the pilot requested clearance for a second attempt rather than diverting to an alternate airport. The airplane struck the ground about 500 feet short of the runway, creating a 200-foot-long debris field, and was almost entirely consumed by fire.

The flight had departed Las Vegas’s Harry Reid International Airport about one hour earlier. French Valley airport has a single runway and is served by a single GPS approach procedure.  Depending on aircraft equipment, the minimum descent altitude for straight-in approaches ranges from 250 to 521 feet agl.

Three Walk Away After Emergency Autorotation

Hughes 369D, July 9, 2023, Waldorf, Maryland

All three occupants escaped with only minor injuries after a sudden malfunction ended their powerline inspection flight. The Hughes 369D sustained substantial damage, including a rotor strike that severed the tail boom, in a forced landing next to a pond in a residential neighborhood.

After two hours of uneventful flight, the observer in the rear seat heard what he described as “an abnormal noise.” The pilot and the other observer agreed the noise was “suspicious” but did not initially conclude it was “abnormal.” However, after the pilot noticed “a vibration in the collective,” they chose to abort the remainder of the inspection and return to their base at Maryland Airport in Indian Head (2W5).

Company GPS track data showed the flight heading southwest at a steady altitude of 900 feet and 100 knots groundspeed for about eight minutes before suddenly entering a steep, descending left turn. The track ended at the accident site.

Crew members reported a “loud bang or pop noise and a hard left yaw,” prompting the pilot to enter an emergency autorotation. Home security footage showed the tail rotor striking the surface of the pond as the pilot flared for landing, causing the main rotor to hit the tail boom. The helicopter’s skids flattened the fence surrounding the pond and the ship came to rest upright with engine running. The pilot shut it down and the crew evacuated without assistance.

Six Perish in Mount Everest Sightseeing Crash

Airbus Helicopters AS350 B3E, July 11, 2023, Mount Everest, Nepal

An air tour to Mount Everest crashed just north of Kathmandu during its return flight, killing the Nepali pilot and all five passengers, who were reported to be Mexican citizens. Air traffic control lost contact with the flight as the AS350 B3E descended through 12,000 feet. Weather at the time of departure was described as good, but the accident occurred during Nepal’s monsoon season, and press reports quoted one official at the Kathmandu airport as saying that the pilot had changed course to avoid low weather.

Thirteen Casualties at Polish Airfield

Cessna 208B, July 17, 2023, Chrcynno, Poland

Five people including the Cessna Caravan’s pilot were killed and eight others injured, two of them critically, when the jump plane crashed into a hangar during what was  reported to have been stormy weather. All the victims except the pilot had gone into the hangar to take shelter from the storms. 

Unconfirmed accounts indicate that the pilot flying was a flight instructor who lost control during a touch-and-go; two other pilots undergoing training were also on board, but survived.

It was not initially clear whether the surviving pilots were among the injured. Multiple sources cited this as Poland’s worst skydiving-related accident since 2014, when the crash of a Piper Navajo near Topolow killed eleven.

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Final Reports

Meridian Lost in Apparently Botched Missed Approach

Piper PA-46-500TP, Dec. 10, 2021, Steamboat Springs, Colorado

Archived ADS-B track data indicated that the solo pilot began the left turn of the missed approach procedure just after passing the last stepdown waypoint but did not initiate the charted climb. Shortly afterwards, the Piper Meridian single-engine turboprop crashed into a mountainside at an elevation of 8,172 feet, killing the pilot. The accident occurred in night conditions at 18:09 local time. Weather reported at the airport, at elevation 6,882 feet msl, included a 1,200-foot overcast layer with only 1 mile visibility, suggesting the pilot was also in actual instrument conditions throughout the attempted approach. The reported visibility was below approach minimums for all aircraft categories.

The flight departed from Cody, Wyoming, about 17:05 on an IFR flight plan to Steamboat Springs. There is no record of the pilot having obtained a specific weather briefing, but a general route briefing ForeFlight provided when he filed his flight plan included a Metar report of 7 miles visibility below a broken ceiling at 4,500 feet agl. The en route portion of the flight was uneventful, and at 17:57 the pilot was cleared for the RNAV (GPS)-E approach to Runway 32.

The procedure requires a series of stepdowns, with minimum altitudes of 9,700 feet at the final approach fix and 8,740 feet at the WAKOR waypoint 2.2 nm from the runway threshold. Descent to the minimum descent altitude of 8,140 feet (1,258 feet agl) is authorized after passing WAKOR, and the Runway 32 threshold is the missed approach point. The missed approach procedure begins with a climbing left turn to 11,300 feet en route to a hold at the initial approach fix.

The ADS-B track showed that the airplane crossed the final approach fix at about 9,100 feet and WAKOR at 8,200 feet. Just after passing WAKOR, still two miles outside the missed approach point, it began a 180-degree left turn while descending to 7,850 feet, then started to climb. The last ADS-B return was recorded 3.5 miles north of the crash site at an altitude of 8,125 feet. 

The 43-year-old private pilot held an instrument rating and had received the required endorsements to operate a pressurized high-performance airplane. His logbook showed 581 hours of total flight experience that included 45.5 hours in actual instrument conditions and 45.3 hours of simulated instrument time. His night-flying time was not totalled and could not be determined from the two pages of his logbook excerpted in the investigation docket, but the last five entries were all logged as night time.

RCAF Training Crash Traced to Defective Seat Pins

AgustaWestland CH149 Cormorant, March 10, 2022, Gander, Newfoundland, Canada

Locking pins that were shorter than required by specification allowed the pilot’s seat to slip some 12 cm (4.7 inches) from its highest to lowest position during a hover exercise, causing an unrecoverable loss of control. All six crew members were injured, two seriously, and the CH149 Cormorant destroyed when the helicopter spun into the ground at the intersection of Runways 21 and 31 at Gander International Airport.

The accident occurred at the end of a training flight from the Royal Canadian Air Force (RCAF) 9 Wing Air Force Base focused on overland search and rescue operations. During a right pedal turn while hovering over the runway intersection, the pilot’s seat slipped, causing the collective to dip momentarily. 

The pilot, thinking the helicopter had banked right, “overcorrected to the left” and applied full left pedal, causing “an accelerated counterclockwise left yaw” that rotated the helicopter about 400 degrees with an increasing right roll before “the right outboard wheel, the right horizontal stabilizer, and the main rotor blades impacted the runway near simultaneusly.”

The pilot reported having done a “wiggle check” before the flight, rocking the seat back and forth to make sure it was secure. The investigation also found that the seat’s dual lever control assembly was “likely” out of adjustment, increasing the likelihood of the pins not locking securely. The RCAF report did not address how non-conforming locking pins came to be installed in the aircraft.

Runaway Conquest Collides with Hangar

Cessna 441, Dec. 13, 2022, Liberal, Kansas

The solo pilot’s decision to leave the cockpit with the engines running ended with the unoccupied Cessna Conquest taxiing into a hangar, resulting in “substantial damage to the fuselage” concentrated in the nose area. The aircraft was operated under a Part 135 charter certificate; the pilot was preparing to depart on a Part 91 positioning flight. He told investigators that he’d performed his preflight inspection about two hours earlier and did not do another walk-around before boarding.

After starting the engines, he found that the airplane would not move forward. He “thought he set the brakes,” set both engines to idle, and climbed out of the cockpit. 

The nose gear was chocked; when he pulled the chocks, the Conquest immediately began rolling forward. He narrowly avoided being struck by the left propeller and “jumped ahead of the airplane,” ran around the left side of the fuselage, and unsuccessfully attempted to re-enter the cockpit. He then watched it taxi across the ramp into a hangar.

The 73-year-old commercial pilot had 21,500 hours of career experience, including 150 hours in the preceding 90 days. He was not only rated in single- and multi-engine airplanes and helicopters, but held instructor ratings for single- and multi-engine airplanes and instrument instructor ratings in both airplanes and helicopters.

During a telephone interview, he told the NTSB investigator that “I have no idea what I was thinking when I decided to leave the engines running. I lost sight of the big picture when I chose to get out of the airplane with them running. I was not in a rush and was not being pressured by time. I should have done an additional walk around.”

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