Story ID: 004
Accidents: March 2021
By: David Jack Kenny
Caption: Preliminary and final accident reports, March 2021
Word Count: 1564
Preliminary Reports
Pilot of Crashed Citation Lacked Type Rating

Cessna 560 Citation V, Jan. 9, 2021, 14 miles southeast of Pine Grove, Oregon – The pilot of the Cessna Citation that crashed into the Mutton Mountains on the Warm Springs Indian Reservation did not hold a type rating for the accident airplane, though he was rated for the Learjet and the Grumman G-111 Albatross. Historical flight data and statements from acquaintances suggest that the accident took place on his first solo flight in the Citation. He was killed after the airplane spiraled down in a one-mile radius right turn from FL310 to the accident site at an elevation of 3,600 feet, a descent that took some eight minutes. The owner of a training facility in Arizona told investigators that while the private pilot had taken a Cessna 560 transition course in late 2020, he “had not performed to a level sufficient to be issued a type rating or single-pilot exemption.”

The accident occurred 30 minutes into an IFR flight from Troutdale, Oregon, to Boise, Idaho. Prior to takeoff, the pilot initially failed to read back his taxi clearance; after the handoff to Portland Approach, the pilot acknowledged clearance to climb to 15,000 feet but missed multiple calls from both Portland Approach and Troutdale Tower assigning a heading change. He then missed the next radio call and turned 15 degrees too far left when cleared to his next waypoint, putting him on a direct track towards Mt. Hood at an altitude of 12,000 feet. Given a revised heading, the airplane “eventually” rolled out on the correct track.

After a handoff, Seattle Center issued a low-altitude warning and a clearance to climb to FL230. The pilot initially read the next frequency back incorrectly. After making contact, he was cleared to FL370. Climbing through FL270, the airplane began drifting right. The pilot did not respond when advised that he was now 30 degrees right of course. The Citation continued to climb until it reached FL310, when it began its eight-minute right spiral downward. Weather did not initially appear to have been a factor, as skies were clear below a 10,000-foot overcast layer with light winds and good visibility.

Five Killed in South African Air Ambulance Accident

Bell 430, Jan. 21, 2021, Bergville, KwaZulu-Natal, South Africa – Two doctors, a transplant nurse, and a flight paramedic were killed when their helicopter crashed en route to pick up a critically ill patient for transport from Hillcrest to Johannesburg’s Netcare Millpark Hospital. The pilot was also killed when the ship went down in an open field, igniting grass fires that the local fire department extinguished. Unconfirmed reports that the helicopter exploded in midair were contradicted by others suggesting the fire ignited on impact. News photographs from the scene show the helicopter’s tail boom separated from its fuselage, but do not make clear whether that occurred before or after collision with the ground.
Final Reports
Otter Breakup Caused by Fatigue Fracture

de Havilland DHC-3 Otter, Oct. 26, 2019, Little Grand Rapids, Manitoba, Canada – A fatigue fracture in the right lift strut’s outboard upper lug plate led to an overload fracture of the inner lug plate, causing the strut to detach from the right wing and the wing to separate from the airframe. The pilot and two passengers were killed when the float-equipped airplane broke apart on approach to a water landing on Family Lake near the town of Little Grand Rapids. Metallurgic analysis found that the fracture originated on the inboard side of the lug’s bolt bore hole and propagated outwards. Both its location and the typical lack of visual evidence of fatigue cracking would have made this difficult or impossible to detect during the standard visual inspections mandated by the current holder of the airplane’s type certificate, Viking Air Ltd. The TSB’s report noted that “Non-destructive testing methods, such as the use of eddy current, or dye penetrant inspection, could detect these cracks,” but were not mandated by the inspection procedures in effect at the time.

The 1957-model airplane had accumulated 16,474 flight hours. Its last 100-hour inspection had been completed 77 hours prior to the accident. The right-wing strut assembly had been replaced in 1998 with a new unit manufactured in 1954 but never previously installed. It had a service life of 20,000 hours, of which 8,747 hours remained.

In response to the accident, Transport Canada issued Airworthiness Directive CF-2020-20, making compliance with the intensified inspection procedures of Viking Air’s Alert Service Bulletin V3/0011 mandatory for all DHC-3 lift strut assemblies with more than 2,500 hours time in service.

Air Force Crew Shut Down Wrong Engine

Bombardier Global Express (USAF E-11A), Jan. 27, 2020, Bagram, Afghanistan – A U.S. Air Force Accident Investigation Board concluded that the crew of the E-11A that crashed in Bagram Province mistakenly shut down the airplane’s right engine in response to the failure of the left engine. The twin-engine jet, a military variant of the Bombardier Global Express, was operating as a Battlefield Airborne Communications Node, relaying voice communications, images, and data between other air and ground forces. The flight also served as the copilot’s third Mission Qualification Training sortie.  

During a climb from FL420 to FL430 while in a prescribed orbit just west of Kabul, a blade broke free from the left engine’s N1 first-stage turbofan and was ingested, causing catastrophic damage that was contained within the cowling. The engine’s FADEC computer immediately shut it down. The cockpit voice recorder captured a loud bang and then stopped functioning due to severe vibrations logged by the flight data recorder. Ten seconds later, the crew retarded both throttles halfway, advanced and then retarded the left, and advanced the left again while pulling the right back to idle. Nine seconds after that, the right engine’s run switch was turned off. The flight data recording ended 17 seconds later, about 45 seconds before the crew alerting system’s red “DUAL ENGINE OUT” warning is believed to have illuminated.

The AIB report notes that the airplane was about 17 nm from Kabul International Airport, 28 nm from Forward Operating Base Shank, and 38 nm from Bagram Airfield, putting all three within gliding distance. However, in their initial mayday call its crew stated that they were “proceeding direct” to their base at Kandahar Airfield some 230 nm southwest. It’s assumed that they attempted several restarts while descending on that heading but were unsuccessful. Thirteen minutes after the failure, they announced their intention to land at FOB Sharana, but they came up 21 nm short, touching down in an open field crossed by three-to-six-foot berms and ditches.  The airplane was destroyed and both pilots killed when it struck a berm.

The mission commander, a 46-year-old lieutenant colonel, was a current E-11A instructor and evaluator pilot. His 4,763.9 hours of military flight experience included 1,053.3 in that model, 504.2 of which were as an instructor. The copilot was a 30-year-old captain who had logged all of his 27.6 hours of E-11A time within the preceding 30 days, receiving his basic qualification just 10 days before the accident. His 1,343.5 military flight hours included 755.1 as an instructor in the T-6.

“Ambiguous” Temporary Lighting Faulted in Undershoot

Beechcraft 200, July 9, 2020, Cairns, Australia – The crew of a Royal Flying Doctor Service King Air 200 mistook the reflection of the safety car’s headlights from traffic cones marking the works limit line of the Runway 15 construction zone for that runway’s displaced threshold, leading them to touch down short of the actual threshold. The King Air’s right main tire struck and broke a temporary unidirectional runway end light marking the temporary departure end of Runway 33, which as required was masked to make it invisible to traffic arriving from the north. There were no injuries to any of the five people on board, and damage to the aircraft was limited to scuff marks on the tire. 

The threshold of Runway 15 had been displaced 1,856 meters (6,089 feet) for ongoing repaving and grooving work, leaving 1,300 meters (4,265 feet) available. The runway was generally closed at night during construction but available to the RFDS by prior arrangement. After departure on the homeward segment of a three-leg patient transport flight, the pilot advised air traffic control of their expected arrival in Cairns around 0013 local time.  Cairns Tower subsequently radioed the duty airport safety officer (ASO). After checking the runway, taxiway, and displaced threshold lights, the ASO drove to the holding point on Taxiway B3, angling his car’s headlights about 45 degrees from runway orientation to the traffic cones, which were fitted with retroreflective bands the ASO described as lighting up “incredibly brightly…[with] a bright white light extending across the runway.” The pilots aimed to touch down two runway edge lights beyond what they took to be the threshold, and the ASO saw them land about 60 meters (200 feet) too short.

Closed-circuit footage showed that the runway edge lights were extinguished prior to the displaced threshold, suggesting that the pilots were referencing taxiway edge lighting instead. After the incident, the airport replaced the cones with non-reflective equivalents, barred directing vehicle headlights at the active runway during aircraft operations, and disabled all airfield lighting short of the displaced threshold. The same crew landed on the same runway several nights later and reported no ambiguity identifying the usable portion of the runway.