Story ID: 004
Accidents: March 2022
By: David Jack Kenny
Caption: Preliminary and final accident reports, March 2022
Word Count: 1581
Preliminary Reports
Metroliner Lost in Apparent Engine Failure

Swearingen SA-226AT, Dec. 10, 2021, Manchester, New Hampshire – The solo pilot was killed and the airplane destroyed after a reported engine failure during a nighttime ILS approach to Runway 06 of the Manchester Boston Regional Airport (KMHT). Nine seconds after that transmission, radar and radio contact were lost with the airplane about one-quarter mile from the runway threshold. Prevailing weather included 10-mile visibility under a broken layer at 1,700 feet.

The wreckage was found on a sand jetty in the river. There was no debris path but there was a crater in the sand about six feet long, three feet wide, and two feet deep. A post-crash fire had consumed the cockpit, cabin, and both wings. The NTSB preliminary report indicates that the left propeller “did not exhibit rotational damage” while “the right propeller blades appeared to be at or near the feathered position.”

Premature Turn Preceded Colorado CFIT

Piper PA-46-500TP, Dec. 10, 2021, Steamboat Springs, Colorado – Archived ADS-B data showed that the single-engine turboprop flew the intermediate segments of the GPS-E approach to Steamboat Springs more than 500 feet below the procedure’s minimum altitudes, then initiated a left turn similar to the missed approach procedure at the last intermediate waypoint some 2.2 miles short of the missed approach point. The solo pilot was killed and the airplane destroyed when it struck Emerald Mountain at an elevation of 8,172 feet, just 1,290 feet above airport elevation. Weather conditions included one-mile visibility at night under a 1,200-foot overcast. Minimum visibility for the approach was 1-1/4 miles for Category A aircraft and 1-1/2 miles for Category B.

The flight departed Cody, Wyoming, at 17:05 local time on an IFR flight plan to Steamboat Springs. At 17:57, the pilot was cleared for the GPS-E approach. To assure terrain clearance, the procedure requires crossing the final approach fix at or above 9,700 feet and the last waypoint no lower than 8,740 feet. Minimum descent altitude is 8,140 feet (1,258 feet above ground level) and the missed approach point is the Runway 32 threshold. The missed approach procedure begins with a climbing left turn to 11,300 feet en route to a holding fix. However, the flight crossed the final approach fix at 9,100 feet and descended to 8,200 feet by the last waypoint, where it began a 180-degree left turn while continuing to descend. It reached 7,850 feet before starting to climb again. The last ADS-B data point was recorded at 18:08:49 at an indicated altitude of 8,125 feet about 3.5 miles north of the accident site.

Charity Flight Ends in Tragedy

Bell 206B-3 JetRanger III, Dec. 30, 2021, Livingston, Texas – One passenger was killed, the pilot was seriously injured, and the two remaining passengers suffered minor injuries when the helicopter went down on a brush pile following an apparent loss of yaw control. Survivors said that the deceased passenger had won the sightseeing flight in a charity auction and asked the pilot to fly to his childhood home about 25 nm east-northeast of the Livingston airport. When low cloud cover required them to turn back, the pilot instead flew over the passenger’s current home and brought the helicopter to a hover over trees, facing south.

The helicopter began rotating to the right, which a surviving passenger realized was not a deliberate maneuver by the pilot. After two complete revolutions, the main rotor blades struck trees and the helicopter fell to the ground, coming to rest on its left side on a pile of brush left by land-clearing operations. The engine continued to run, so after attending to the pilot and front-seat passenger, a rear-seat passenger “began turning any switch he could find to the ‘off’ position” until the engine stopped. Winds at the nearest reporting station 31 nm away were recorded as being from 160 degrees at three knots.

All Onboard Survive Medevac Crash

Eurocopter EC 135 P2+, Jan. 11, 2022, Drexel Hill, Pennsylvania – The pilot suffered serious injuries but the patient, medic, and flight nurse escaped unhurt after the helicopter crashed onto the grounds of a church in the Philadelphia suburbs. The flight was en route from the Chambersburg, Pennsylvania Hospital Heliport to the Children’s Hospital of Philadelphia. Radar track data showed that it descended from 3,500 to 2,800 and then 1,500 feet while approaching the Children’s Hospital helipad, then disappeared from radar six seconds after entering a series of attitude and altitude excursions.

Two witnesses described the helicopter as “very low … very loud.” One said it “banked right and left out of control, then appeared to straighten” before disappearing from view. The other saw it “in a nose-down attitude…far less than 1,000 feet above the ground…rotating around its longitudinal axis.” Doorbell camera footage showed it descending steeply with “small but rapid changes in each axis” before leveling off and striking the ground in a slightly nose-high attitude, severing the tailboom.

The pilot’s interview was postponed due to his medical condition. The flight medic recalled that they were within 10 minutes of landing and that he and the flight nurse were on their feet attending to the patient when he heard a loud bang and the helicopter rolled hard to the right. He recalled it rolling inverted, “perhaps multiple times,” pinning himself and the flight nurse to the ceiling while internal communications were lost. The helicopter then leveled off long enough for the medical crew to secure the patient and strap in prior to touchdown. The flight nurse first evacuated the patient and then the pilot, while the medic shut down the engines.

Downloaded engine monitoring data showed no anomalies during the flight, and initial examination of the wreckage did not reveal any mechanical failure prior to impact.
Final Reports
Short Approach, Student Workload Cited in Training Undershoot

Cessna 551 SP, April 24, 2019, Siegerland Airport, North Rhine-Westphalia, Germany – Germany’s BFU concluded that excessive student workload during an abbreviated 1.5-nautical-mile traffic pattern led to an unstabilized approach with an excessive descent rate and insufficient airspeed. The Citation II touched down 5.2 meters (17 feet) short of the Runway 13 threshold following a visual approach on the fourth circuit of a type-rating training flight. Both legs of the main landing gear collapsed and the left wing hit the runway, damaging the left fuel tank and igniting a fire that consumed most of the left wing before airport firefighters could extinguish it. Both the 35-year-old student and his 70-year-old instructor were able to evacuate the aircraft without injury.

The previous three landings followed ILS approaches to Runway 31, beginning with a straight-in approach on arrival from the Reichelsheim airport. Radar track data showed that the following two circuits were flown with an outbound leg of about nine nm to intercept the localizer before capturing the glideslope. All three descent paths were stable at groundspeeds ranging from 112 to 128 knots with a slight tailwind. After the third landing, the tower controller reversed pattern direction in response to a shift in the wind from southwest to east. The Citation took off from Runway 13 at 14:34 local time, reaching 1,500 feet above ground level on the downwind leg in left traffic. 

It descended 700 feet while maneuvering to enter a 1.5-nm final approach leg as the pilots completed the approach and landing checklists. In the last 22 seconds captured by radar, groundspeed decayed from 106 to 81 knots while its descent rate increased to 500 feet per minute. Both student and instructor told investigators that the airplane seemed too low and they advanced the thrust levers as the sink rate increased but too late for the engines to spool up enough to arrest the descent. 

The BFU noted that the student had passed his written exam for the C551 type rating the previous week. His jet experience was limited to one flight in the same airplane the previous day, making it likely that lack of familiarity with the cockpit layout and procedures increased his workload during the final circuit. An inoperative precision approach path indicator (PAPI) and optical illusions arising from upsloping terrain under the final approach course and a runway wider than that at Reichelshelm could also have contributed to a perception that the airplane was too high.

Wear and Hard Landing Implicated in Gear Collapse

Mitsubishi MU-2B-40, June 18, 2021, Haguenau Airport, Bas-Rhin, Alsace, France – “Slight signs of fatigue failure” were found around the edges of a pin that fractured after touchdown, allowing the nose gear to collapse. The pin connected the actuator to the nose gear drag strut. The 69-year-old pilot also acknowledged having landed “hard” and characterized the airplane as “difficult to land.” His 4,350 hours of flight experience included about 2,000 hours in the accident airplane, seven of them in the previous three months. Following the collapse, the airplane slid some 400 meters (1,300 feet) down the runway. The accident occurred in a three-knot crosswind on dry pavement. 

The BEA’s report noted that over the previous decade, Mitsubishi has documented one or two nose gear failures per year, leading the company to issue a series of Service Notices and Service Recommendations regarding the inspection, adjustment, and replacement of the nose gear locking system. The pin in question was not specifically addressed. The airplane’s maintenance provider reported that the nose gear locking system had last been inspected on Sept. 3, 2019, as directed by the most recent Service Recommendation. The numbers of landings and flight hours since then were not reported in the English translation of the final report.