Preliminary Reports
Hypoxia Suspected in Loss of Fire Spotter
Twin Commander 695A, Nov. 4, 2023, Cloncurry, Queensland, Australia
Earlier anomalies in flight track and pilot communications suggest hypoxia as a possible cause of the crash that claimed the lives of the pilot and two fire spotters. The IFR flight to perform aerial photography of fire zones north of Mount Isa climbed to FL280 after departure from Toowoomba. Twenty minutes later the pilot requested descent to FL150; after six minutes, the pilot requested and was cleared to climb back to FL280.
The pilot acknowledged a frequency change at 12:45:51 but failed to respond to 15 separate transmissions over almost an hour. He did check in on the correct frequency at 13:41 but didn’t respond to subsequent transmissions.
A Royal Australian Air Force flight eventually reached the Twin Commander on another frequency, after which contact with ATC was re--established. Four readbacks of the clearance to operate in the vicinity of Mount Gordon suggested confusion on the part of the pilot, whose “rate and volume of speech had substantially lowered from earlier communications and was worsening.” A requested frequency change at 14:19 went unanswered, as did eight subsequent attempts to reach the pilot.
By 14:25, the airplane’s groundspeed had dropped form 225 to 104 knots as heading and altitude remained steady. It then departed controlled flight, entering a left spin at a descent rate that reached 13,500 fpm.
Oil Pressure Warnings Preceded Emergency Highway Landing
Bombardier Challenger 604, Feb. 9, 2024, Naples, Florida
Oil pressure warnings preceded the failure of both engines and the fatal crash of the business jet that landed on a highway near Naples Municipal Airport in Florida. The two pilots of the Part 135 flight operated by Ace Aviation Services (doing business as Hop-A-Jet), were killed in the accident. The flight attendant and two passengers escaped with minor injuries.
Flight data recorder information revealed that the first of three master warnings was recorded less than a minute before both engines flamed out: first, “L Engine Oil Pressure,” then, “R Engine Oil Pressure,” and then, “Engine.” The system alerted pilots with the illumination of a “Master Warning” light, a corresponding red message on the crew alerting system, and a triple chime voice advisory, “Engine oil.”
Twenty seconds later, at about 1,000 feet msl and 122 knots on a shallow intercept angle for the final approach course, the crew announced, “…lost both engines…emergency…making an emergency landing.” The tower controller acknowledged the call and cleared the airplane to land. Seven seconds later, with the aircraft at 900 feet and 115 knots, the crew replied, “We are cleared to land but we are not going to make the runway… ah…we have lost both engines.”
Dashcam video submitted to the NTSB that captured the final second of the flightshowed the airplane descending in a shallow left turn and then the wings leveling before it touched down aligned with traffic traveling in the southbound lanes of Interstate 75. The left main landing gear touched down first in the center of the three lanes followed by the right main landing gear in the right lane.
The airplane continued through the breakdown lane and into a grass-shoulder area before running into a concrete sound barrier, coming to rest about 1,000 feet past the initial touchdown point, upright in the grass area, opposite the direction of vehicle travel. Both engine throttle levers were found near the IDLE stop position
After the Challenger came to rest, the cabin attendant said she found the cabin and emergency exits blocked by fire. She then coordinated a successful egress through the baggage compartment door in the tail section of the aircraft.
The airplane, N823KD, was returning to Naples from Ohio State University Airport in Columbus, Ohio, where it had flown earlier in the day. It received 2,345 pounds (350 gallons) of fuel before departing.
The 2004 model aircraft’s most recent continuous airworthiness inspection was completed on January 5 at 9,763 total hours of operation. NTSB said a visual examination of the main fuel control and main fuel pump revealed no anomalies and the oil filter appeared in good condition with no particles seen within the pleats. The main fuel inlet port exhibited a small, yellow--colored debris particle.
Six Killed in Helicopter Charter
Airbus EC130B4, Halloran Springs, California, Feb. 9, 2024
A charter flight from Palm Springs, California to Boulder City, Nevada crashed in a remote California desert, killing all six on board. The VFR flight departed at 20:45 and tracked Interstate Highways 10, 215, and 15, descending to 3,500 feet msl—150 feet agl—near Barstow, California. The last ADS-B track points showed gradually decreasing altitude and increasing groundspeed. The wreckage was found at an elevation of 3,360 feet. Witnesses who reported a “fireball” described weather conditions as mixed rain and snow.
Final Reports
LTE Cited in Fatal Police Crash
MD Helicopters MD500N, Feb. 19, 2022, Newport Beach, California
While focused on conditions on the ground, the pilot allowed the helicopter’s airspeed to decay during a low-speed, low-altitude right orbit. Corrective inputs failed to arrest an uncommanded right yaw and the aircraft spun into the harbor, coming to rest on the seabed. The pilot escaped with minor injuries but the tactical flight officer (TFO) drowned while trying to extricate himself from the cabin. Both had received underwater egress training.
The accident occurred about 30 minutes into a routine night patrol by the Huntington Beach Police Department. As they departed Newport Beach, a radio transmission advised of a fight just south of their location. The pilot began orbiting the scene at 500-600 feet while the TFO scanned the ground with the infrared camera. The pilot tightened the orbit and slowed the helicopter as ground officers arrived.
He responded to a sudden, aggressive right yaw with full left pedal and forward cyclic, but without effect. The turn tightened into a spinning descent; control inputs appeared partially effective, but without a visible horizon the pilot was unable to gauge his altitude. He chose not to enter autorotation because the area was heavily populated.
The helicopter hit the water hard on the TFO’s side of the cabin, shattering the canopy, and settled on its right side. To escape, the TFO had to make his way through the submerged cabin. His body was found partway out of the left door’s window, and his autopsy suggested he’d survived the impact without serious injury.
Though the pilot recalled only slowing the craft to 50 knots airspeed, flight track data indicated that it had essentially entered a hover, drifting sideways for the last 30 seconds before the sudden yaw.
The NTSB noted that “tight-radius, uncoordinated turns in a high-power and low--airspeed regime” increase susceptibility to loss of tail rotor effectiveness and suggested that the pilot’s attention to the scene on the ground may have compromised his awareness of flight conditions. Fatigue was also cited as a possible factor, as the pilot’s day had begun at 04:00 in order to catch commercial flights home from a trip out of state.
Programming Confusion Precipitated Fatal Stall
Pilatus PC-12/47E, Feb. 13, 2022, Beaufort, North Carolina
The 67-year-old commercial pilot’s decision to take off after failing to enter a flight plan into the airplane’s integrated flight management system left him struggling to program the system throughout the 28-minute flight, distracting him from monitoring its attitude as it pitched up, slowed, and eventually stalled. All eight on board were killed when the single--engine turboprop crashed into the ocean some three miles offshore as the pilot attempted to navigate to the initial approach fix for the GPS approach to Runway 26 of Michael J. Smith Field (KMRH) in Beaufort, N.C.
The voice channel of the lightweight data recorder captured the pilot trying to teach a student pilot in the right front seat how to enter a flight plan, eventually saying, “We’ll get it later.” Power was advanced for takeoff at 13:34 and the Pilatus climbed on autopilot to the selected altitude of 3,500 feet, entering a 2,100-foot overcast layer without an IFR clearance. Several minutes passed before the pilot contacted air traffic control requesting both VFR flight following and an IFR clearance to KMRH. Four minutes after the controller warned that Restricted Area R-5306A was active and the pilot promised to remain clear to its east, the Pilatus penetrated the restricted airspace. Multiple calls from the controller went unanswered as the pilot and passenger continued trying to program the flight management system, so the controller told the military aircraft operating there to remain above 4,000 feet.
The CVR recorded the pilot’s frustration with programming the avionics throughout the flight. After being cleared to cross the CIGOR initial approach fix at or above 1,900 feet, the airplane descended to 1,700. Engine torque was reduced and airspeed decayed as the pitch attitude gradually increased, reaching 10 degrees nose-high at 109 knots at 13:59.
Fourteen seconds later the stall alert and stick shaker activated, the autopilot disconnected, and engine power increased to nearly full. The pilot continued to discuss the avionics as airspeed diminished to 93 and then 83 knots and pitch increased to 31.7 degrees nose-up and the stick pusher activated. The controller radioed the Pilatus without response as it climbed to 4,700 feet at 14:01. The recording ended less than a minute later and showed that the aircraft rolled right beyond 90 degrees and pitched 50 degrees nose-down in its final descent.