Story ID: 004
Accidents: June 2020
By: David Jack Kenny
Caption: Preliminary and final reports
Word Count: 1629
Preliminary Reports
Caravan Freighter Crashes After Second Missed Approach

Cessna 208B, March 17, 2020, LaCrosse, Kansas – A Cessna Caravan on a Part 135 cargo flight was destroyed and its pilot killed while attempting to divert to Great Bend, Kansas after missing two approaches to the Hays (Kansas) Regional Airport in very low weather. The flight departed from Wichita at 7:51 a.m.; at 8:25, Hays reported 1 mile visibility under a 200-foot overcast and a temperature of 3 deg C. Radar and ADS-B coverage were lost at 8:31 as the airplane descended through 4,000 feet msl (about 2,000 feet agl) while being vectored for the ILS approach to Runway 34 and were reacquired at 8:43 when the pilot requested a second attempt at the ILS. An observation recorded at 8:41 showed that visibility had dropped to one-quarter mile in fog.

Contact was lost again between 8:53 and 8:59, at which time the pilot requested diversion to Great Bend. The Caravan climbed to 7,000 feet and turned south toward Great Bend, but entered a descending left turn and disappeared from coverage at 9:18. The wreckage was located about half an hour later. The aroma of jet fuel was observed at the site.

Pilot Survives Destruction of PC-12

Pilatus PC-12/47, April 23, 2020, Mesquite, Texas – The pilot was extracted with injuries after a forced landing that tore both wings off the airplane and ignited a post-crash fire. The single-engine turboprop, operated under a Part 135 certificate by Boutique Air, had departed from the Dallas-Fort Worth International Airport (DFW) on an IFR flight plan to Muscle Shoals, Alabama when the pilot reported that it was losing engine power and requested a diversion to Rockwall, Texas. After air traffic control issued vectors, the pilot said that power output had stabilized and requested a return to DFW, but shortly thereafter lost power again. The controller advised that the Mesquite airport was three miles ahead at 11 o’clock and the pilot attempted a 360-degree turn to set up for a left base entry to the traffic pattern, but the airplane came up short and went down in a muddy field.
Final Reports
Conquest Crashed Simulating Engine Failure After Takeoff

Cessna 441 Conquest II, May 30, 2017, Renmark, South Australia – Drawing on GPS data transmitted via the OzRunways application, Australia’s Transportation Safety Bureau concluded that the fatal crash of a Rossair Conquest II occurred after the crew simulated an engine failure during initial climb. Three highly experienced pilots were killed when the turboprop twin crashed “in an inverted near-vertical attitude” 60 seconds after taking off from Runway 25 at Renmark Airport. A comparison of airspeed and altitude readings with the flight’s previous departure from Adelaide led investigators to conclude that thrust on one engine had been reduced at about 400 feet above ground level. The Conquest’s Pilot’s Operating Handbook recommends conducting this maneuver at altitudes of 5,000 feet or above to provide ample room for recovery from any resulting loss of control.

The flight was an unusual dual evaluation, with a CASA flying operations inspector (FOI) observing the Rossair chief pilot’s conduct of a new line pilot’s operator proficiency check. Had it been completed successfully, the chief pilot would have obtained check pilot authorization for the Cessna 441. The FOI was in the left seat in the second row and thus unable to reach the flight controls. All three pilots held air transport pilot certificates and each had more than 5,000 hours of fixed-wing flight experience. The pilot being evaluated had flown for Rossair between May 2010 and August 2014, while the FOI had previously served as the company’s chief pilot.

The flight departed from Adelaide at 3:24 p.m. local time, climbed to 17,000 feet, and subsequently flew holding patterns and a practice RNAV-Z approach to Runway 07 at Renmark, circling to land on Runway 25. At 4:14, the Renmark common traffic advisory frequency recorded a transmission advising that the Conquest would be taking off from Runway 25 for airwork in the traffic pattern. A witness at the airport described its takeoff roll as normal, but the OzRunways GPS download showed that its heading began to veer to the right of the extended centerline as it climbed to 400 feet, just after reaching its maximum recorded airspeed of 132 knots. Ten seconds later it leveled off at 600 feet while its airspeed decayed below best single-engine rate of climb and continued to decline. The last data transmission was made about 60 seconds after liftoff at an airspeed of 107 knots and an altitude of 500 feet. Examination of the engines and propellers suggested that “both engines [were] operating at comparable low power settings prior to impact.” The landing gear and flaps were up.   

The ATSB investigation revealed that until a practice flight the week before the accident, the new hire had not tried to manage an engine failure in a Conquest in two and a half years, and the chief pilot hadn’t simulated one in nearly one year. An observer present on that flight described it as “messy” with the returning pilot being “rusty...well behind the airplane.” He also noted deficiencies in the chief pilot’s conduct of that training. The investigation also disclosed that the seat occupied by the FOI, who had more than 5,100 hours of Cessna 441 experience, was not equipped with headset jacks, hindering the FOI’s ability to respond quickly to an in-flight emergency.

Inadequate Planning Downs EMS Helicopter

Eurocopter AS350, Sept. 29, 2018, Ruidoso, New Mexico – The pilot of an EMS helicopter that descended into a mountainside on approach to a ski resort acknowledged never having calculated the in- or out-of-ground-effect hover ceilings or the density altitude at the accident site, which was subsequently determined to be above 12,000 feet. He also admitted being unaware that the resort had defined an approach, landing, and takeoff procedure. The helicopter sustained damage to its fuselage and vertical stabilizer after touching down hard, bouncing, and sliding down an embankment, but the pilot and two medical crew members were not injured.

En route to pick up a patient, the pilot made an eastbound reconnaissance and decided to go around upon seeing two cables in front of and below the helicopter’s flight path. After adding power to clear the cables, he lowered collective to address decreasing main rotor rpm, then made a 180-degree left turn back to the landing site. At about 20 feet above the ground, he raised collective and main rotor rpm again decayed, increasing the helicopter’s descent rate. As it neared touchdown, one of the medical crew members spotted a steel barrier cable below the helicopter, which the pilot made a 90-degree left turn to avoid. The helicopter turned 180 degrees while bouncing over the cable and eventually came to rest upright.

The 16,818-hour commercial pilot had more than 3,500 hours in make and model, but told investigators that this was only his second flight in a high-altitude mountainous environment; most of his previous experience had been acquired near sea level. Winds at the nearest reporting point, 14 nm away, were out of the southwest at 9 knots.

Loss of King Air Attributed to Lack of “Recent” Partial-Panel Training

Beech 200, Jan. 30, 2019, Whati, Northwest Territories, Canada –The crew’s decision to take off with the right attitude indicator inoperative proved fatal after the left-side instrument failed in flight. The two pilots were the only occupants of the Air Tindi King Air, which entered an uncontrolled descent during initial transition from cruise flight to the RNAV approach to Runway 28 of the Whati Airport. The Transportation Safety Board of Canada identified a lack of recent practice in partial-panel instrument technique as the final link in the accident chain. Neither company procedures nor Transport Canada regulations required recurrent partial-panel training, and the investigators found no record of either pilot having practiced it since obtaining their commercial ratings several years earlier. The accident aircraft was also the only one of Air Tindi’s five King Air 200s not equipped with an additional standby attitude indicator (AI), and its minimum equipment list did not authorize dispatch with the right AI inoperative.

The accident flight was the first leg of a scheduled six-segment route from Yellowknife to Whati, Wekweèti, and Ekati, and then back. Forecast weather conditions included ceilings of 600 to 1,200 feet, one to five miles visibility in light snow decreasing to half a mile in heavier snow showers, and moderate mixed icing between 2,000 and 12,000 feet msl. Crew communications captured by the cockpit voice recorder showed that the first officer initially noted the lack of response of his AI, a conventional vacuum-driven instrument, at 8:42 a.m. while running the after-start checklist. The captain assured him twice that it would begin to work, but during the initial portion of the takeoff roll, the first officer confirmed that it was still inoperative despite adequate indicated vacuum pressure. During the next 11 minutes they made several attempts to troubleshoot the instrument without success.

At 9:11, with the airplane descending through 10,800 feet, the electrically driven left AI flagged and the autopilot disconnected. The captain began to hand-fly using partial-panel references and attempted to climb, but the King Air did so only briefly before beginning to descend and turning about 60 degrees right. Thirty-eight seconds later it entered a gradual left turn that tightened into a steep descending spiral. Its terrain awareness and warning system issued five alerts in the last 10 seconds before the airplane struck trees in a shallow, nose-low attitude, leaving a 900-foot debris path. The calculated descent rate peaked at more than 35,600 fpm, but all major components were found at the accident site, ruling out an in-flight break-up. The remotely mounted vertical reference gyroscope driving the left AI showed signs of rotation at impact but was too extensively damaged for the reason the indicator flagged to be determined.