Story ID: 004AccidentsAINMar17
Accidents: March 2017
By: Amy Laboda
Caption: Preliminary and final reports
Word Count: 1989
Preliminary Reports Emergency Landing after Low-fuel Indication Ends Short of Runway
Cessna 208B Grand Caravan, Dec. 27, 2016, Fort McMurray Airport, Alberta, Canada—The pilot and his three passengers were uninjured after he landed 1,400 feet short of the runway in a Cessna 208B Grand Caravan near Fort McMurray Airport, Alberta, Canada. The aircraft sustained substantial damage.

On a VFR flight from Camrose to Fort McMurray, the pilot noted that his “reservoir fuel low” warning light illuminated. He completed the emergency checklist and told ATC that the aircraft had an engine issue; however, he did not declare an emergency. The pilot joined the base leg for Runway 25 at Fort McMurray and was beginning a turn to final when the engine lost power. The pilot elected to land on a service road east of the airport, but settled in a field off airport property, southwest of the runway threshold.
S-92A Loses Tail-rotor Authority on Landing at North Sea Wellhead
Sikorsky S-92A, Dec. 28, 2016, West Franklin wellhead platform, North Sea, UK — A Sikorsky S-92A transporting passengers from Aberdeen, Scotland, to the Elgin-Franklin Offshore Field in the North Sea experienced a loss of tail-rotor effectiveness on approach and set down hard at the West Franklin wellhead platform. No one was injured in the incident; however, the helicopter sustained left outer main-wheel rim distortion, a seized tail-rotor pitch change shaft (TRPCS) bearing and a servo piston fracture. There was minor damage to the platform helideck.

Disassembly of the tail rotor revealed signs of severe overheating, with extreme wear on all thrust races and barrel-shaped bearing rollers. The roller bearings seized to the inner member. The outer race roller had excessive axial play (0.5 in), such that the tail-rotor driveshaft imparted a torsional load to the tail-rotor servo, causing the primary piston rod to fracture inside the servo. This caused the secondary piston sleeve to separate axially from the primary piston, resulting in total loss of tail-rotor control.

The components were shipped to Sikorsky for analysis. Initial findings indicate rapid (less than 4.5 hours) bearing failure, according to the operator’s health and usage monitoring system (Hums).

The operator instituted a review of all Hums data, fleet-wide borescope inspections and a requirement that Hums be serviceable before flight. It also reduced the time between Hums analysis to five hours.

Sikorsky issued an All Operators Letter (AOL), CCS-92-AOL-16-0019 three days after the incident, describing the event and emphasizing the use of the HumsS Tail Gearbox Bearing Energy Tool. It then issued an Alert Service Bulletin (ASB) mandating a one-time inspection of the TRPCS and bearing assembly before the next flight from a maintenance facility. Analysis of the malfunction continues by the UK Air Accidents Investigation Branch and Sikorsky.
Hawker 800XP Nose Gear Collapses on Roll-out
Hawker 800XP, Jan. 2, 2017, Scottsdale, Ariz.—A Hawker 800XP operated by Pinnacle Air Charter as a personal Part 91 flight was substantially damaged when the nose landing gear collapsed during the landing roll at Scottsdale Airport (KSDL), Scottsdale, Ariz. There were no injuries. The flight, conducted by two ATP-certified pilots, originated in Tucson, Ariz, flying to KSDL in VMC on an IFR flight plan.

On the approach to KSDL, the pilot reported to ATC that the nose landing gear light was red, indicating that the nosewheel was not down and locked. The pilot left the traffic pattern and referred to the emergency checklist. The pilots used the hand pump to lower the landing gear manually, but the red light still indicated that the nose gear was not down and locked. The pilot asked the tower for a landing-gear check and the tower replied that it appeared that the nose gear was down and straight. The pilot executed a normal landing, and as the airplane passed through 35-40 knots, the nose gear collapsed. The airplane came to rest 50 yards farther down the runway.
MU-2 Runs Off Snowy Runway on Landing
Mitsubishi MU-2, Jan. 7, 2017, Niles, Mich.— A Mitsubishi MU-2 flown by a private pilot on a personal IFR flight was damaged when it ran off the left side of a snow-covered runway after completing the Rnav 33 approach at Jerry Tyler Memorial Airport (3TR) in Niles, Mich. The pilot pulled back the power levers into beta range on touchdown and the airplane made an unexpected left turn off the runway, coming to rest in a snow-covered field, sustaining substantial damage.

The automated weather observation station at South Bend (Indiana) International Airport (KSBN), nine miles south of the accident site, recorded wind from 250 degrees at 14 knots.

The airport snow-plow operator said he checked the runway conditions on the morning of the accident and noted a light dusting to a half inch of snow, but the pavement was still visible. When he returned after the accident he saw two or more inches of snow on the runway. The pilot said he found no Notams relating to snow on the runway.
Citation 525 Collides with Trees after Runway Excursion
Cessna Citation 525S, Jan. 16, 2017, Howell, Mich.— A private pilot flying a Citation 525S on a Part 91 instrument flight in VFR conditions from Batavia, N.Y., was seriously injured when the aircraft hit a fence and trees after overrunning Runway 13 at Livingston County Airport (KOZW) in Howell, Mich. The Citation was substantially damaged.

King Air C90 Carrying Brazilian Supreme Court Justice Crashes

Beechcraft King Air C90, Jan. 19, 2017, Paraty, Brazil—Brazilian Supreme Court Justice Teori Zavascki, along with a pilot and two other passengers, was killed when the twin turboprop crashed in heavy rain off the coast near Paraty Airport, Brazil. The cockpit voice recorder was recovered from the wreckage the day after the crash and is being analyzed.
King Air 300 Crashes on Takeoff from Tucson
Beechcraft King Air 300, Jan. 23, 2017, Tucson, Ariz.—A King Air 300 operating under Part 91 on a personal flight was destroyed and its pilot and a passenger were killed when it hit the ramp on takeoff from Tucson International Airport (KTUS).

A witness saw the airplane take off from Runway 11L and pitch up in the initial climb. Some 100to 150 feet above the runway, the airplane suddenly yawed to the left. The left wing dropped and the airplane rolled left, the nose dropped and the airplane struck the ground inverted. Another witness described the airplane yawing from left to right while climbing. The airplane then rolled left and went inverted. After impact, the airplane slid 650 feet across the ramp and collided with a concrete wall, engulfed in flames.

Final Reports

PC-12 Display Malfunctioned in IFR 

Pilatus PC-12/47E, June 18, 2016, Paraburdoo, Western Australia—A Pilatus PC-12 47E experienced severe display and data anomalies after a night takeoff on an IFR flight plan in western Australia. As the aircraft climbed through 250 feet agl at 110 knots the pilots noticed the radio altimeter (radalt) wind down to zero. The radalt low altitude awareness display rose to meet the altitude readout. The synthetic vision image on both pilots’ Honeywell Primus Apex Smart View primary flight displays (PFDs) then showed the runway move rapidly left and off the screen, and the ground representation on the PFD appeared to rise rapidly to meet the zero-pitch reference line. The pilot flying reacted by pulling back on the control column, and the flight path indicator moved up to about 15degrees, according to the flight data. No warnings or cautions illuminated, the stick shaker stall warning did not activate and the crew did not receive any oral alerts from the terrain awareness and warning system (Taws).

The pilot flying reported that the synthetic vision image created the impression that the aircraft was sinking rapidly toward the ground, and they responded instinctively by pulling back on the control column. There was no vestibular sensation that the aircraft was descending, nor had there been any indication of a strong wind that might have caused the aircraft to drift off the runway centerline. The resulting sensory confusion caused the pilot flying to experience motion sickness. The combination of the runway and the radalt speed tape moving up created a strong illusion that the aircraft was going to hit the ground. The pilot flying reported that they realized something was wrong, but initially could not process it. The image of the ground rising up and the runway disappearing rapidly sideways took the focus of the pilot flying away from anything else, he told Australian Transport Safety Bureau (ATSB) investigators.

The check pilot looked outside (there was no standby instrument on the right side of the cockpit), and was able to discern the horizon in the moonlight. He cautioned the pilot flying that the aircraft had a nose-high attitude, which prompted the pilot flying to switch focus to the electronic standby instrumentation system (ESIS) and closely monitor the attitude and the airspeed tape there.

The pilot flying lowered the nose to regain an eight-degree pitch attitude and the flight data showed that the airspeed increased from 101 knots back to the target airspeed of 110 knots. As the aircraft climbed through 850 feet, the synthetic vision display corrected itself and all indications returned to normal, where they remained for the duration of the flight.

After the incident, an engineering assessment by the ATSB determined that both antennas associated with the radalt system had failed after more than 9,000 service hours. The antennas did not have a life limit, but were required to be replaced "on condition."

The aircraft operator has advised the ATSB that it has replaced the radalt antennas across its fleet and amended the minimum equipment list to include synthetic vision.  Pilots were alerted to the potential hazard of a synthetic vision failure and the event has been discussed by the training and check department, which is also reviewing the possibilities for incorporating into check flights scenarios related to ambiguous/incorrect information from the primary flight display.  

Honeywell issued a Pilot Advisory Letter (PAL-APEX-01) to all pilots, chief pilots and flight operations describing the event and advising pilots that the use of synthetic vision is for situational awareness. The company is also exploring ways to make the system more robust.  

Cessna 441 Hit wire on Landing

Cessna 441 Conquest II, Sept. 5, 2016, Coorabie ALA, South Australia—A charter pilot flying a turboprop Cessna 441 from Adelaide, Australia, to the Coorabie aircraft landing area (ALA) for the first time hit a powerline on final approach to a sloping runway, resulting in minor damage to the aircraft. There were nine passengers on board.

The pilot was following a company aircraft that landed successfully at the airport. He received an advisory 30 miles from the airport to land on the down-sloping Runway 32. On short final the pilot reported that the aircraft decelerated suddenly. At the same time, there was a slight shudder of the right engine and a change in the sound of the propeller pitch. The pilot immediately increased the power to both engines and leveled the aircraft. He checked the engine instruments and the annunciator panel and saw no abnormal indications.

The pilot aborted the approach anyway, flew the circuit and landed successfully. After aircraft shutdown the pilot noticed damage to the right propeller blades and suspected he had hit the powerline crossing the approach end of Runway 32.

The Australian Transport Safety Bureau determined that better orientation might have kept this pilot from succumbing to the visual illusions generated by the down-sloping runway and undulating terrain, which made him set up the final approach at a flat one-degree glideslope instead of a standard three-degree glideslope. Australian regulations do not require marking of powerlines such as the one crossing the final approach path to Runway 32 at Coorabie ALA; however, the powerline operator has since marked that cable with standard orange ball markers.