Story ID: 004
Business Aircraft Accident Reports: October 2023
By: David Jack Kenny
Caption: Preliminary and final accident reports, October 2023
Word Count: 1598
Learjet Destroyed in Simulated Engine FailureLearjet 35A, May 15, 2023, Hohn Military Airport, Germany
The flight instructor and pilot receiving instruction were killed after losing control during a planned simulated engine failure during initial climb. Within six seconds after reducing thrust from the right engine at an airspeed of about 160 knots, the airplane yawed, rolled right, and crashed 200 meters (650 feet) north of Runway 26, exploding on impact. Witnesses described its trajectory as “a sort of snap roll.”
The Learjet was intended to be the third of six, all flown by the same operator, to take off in quick succession. The purpose was to conduct practice instrument approaches to help train local air traffic controllers. The accident flight was also intended as a combined instrument proficiency and type--rating check for the 62-year-old pilot flying, an 11,955-hour ATP with 8,083 hours of Learjet experience and a Learjet 20/30 instructor rating. The 58-year-old instructor also held an ATP and Learjet type instructor rating; 6,265 of his 10,349 hours of career experience were flown in Learjets.
Review of the cockpit voice recorder (CVR) showed that the airplane took off at 12:47:34. Five seconds later the instructor advised that “you will lose the right engine,” which the pilot flying acknowledged with “Copy, gear up.” Thrust was reduced on the right engine while the left maintained takeoff power. At 12:47:44 the pilot flying called for “Damper on.” A string of profanities and one low-altitude warning filled the remaining 11 seconds of the recording. The 1993-model jet had been flown earlier that day by a different crew who reported no anomalies except “sluggishness” in the primary yaw damper, leading them to revert to the secondary.
Passenger Makes Successful Emergency LandingPiper PA-46-500TP, July 15, 2023, Vineyard Haven, Massachusetts
The 68-year-old passenger successfully brought the airplane back for a gear-up emergency landing after its 79-year-old pilot became incapacitated and lost consciousness following a go-around from Runway 6 at Martha’s Vineyard Airport. The pilot was airlifted to Boston, where he died on July 20. The passenger, who held no piloting credentials, suffered minor injuries, and the airplane’s left wing was fractured during the landing. The NTSB reported that the pilot was operating under authority of “a special issuance medical certificate which required that the pilot supply extensive documentation of his health conditions.”
Maintenance Error Implicated in Helicopter WreckBell 407, Aug. 1, 2023, Charleston, South Carolina
Missing hardware from the tail rotor control lever assemblies is suspected in the loss of yaw control. The Charleston County Sheriff’s Office helicopter struck the ground adjacent to Runway 15 at Charleston International Airport “at a high rate of descent” during an attempted emergency landing, severing the tail boom. The pilot suffered minor injuries.
Thirty-five minutes into a positioning flight from Sumter, S.C., the helicopter developed a slow right yaw, which the left pedal did not arrest. The pilot recalled that “It felt like the pedals were not connected.” He declared an emergency with the control tower and set up for a straight-in approach to Runway 15, but while crossing the threshold at about 20 feet, the right yaw resumed. The pilot lowered collective, reduced throttle, and tried to maintain a level attitude until touchdown.
FAA inspectors who examined the wreckage found that one of two bolts securing the tail rotor control lever assemblies was gone; the other was loose and missing the cotter pin that should have secured its nut. The bolts were last removed and reinstalled during maintenance work on June 28, five weeks and 15 flight hours before the accident.
Ten Killed in Malayasian Approach CrashBeechcraft 390, Aug. 1,7 2023, Elmina, Sungai Buloh, Malaysia
An automobile driver, a motorcyclist, and all eight on board died when the chartered jet crashed onto a highway within two minutes of receiving clearance to land at Kuala Lumpur’s Sultan Abdul Aziz Shah Airport. Two pilots and six passengers, including a Pahang state assemblyman, were on board. Photographic evidence suggests that the jet crashed in a steep nose-low attitude, scattering highly fragmented wreckage across the highway and into adjoining woods.
The accident occurred in mid-afternoon, at about 14:49 local time. Prevalent weather conditions were not immediately reported, but photographs from the scene show good visibility under broken ceilings.
Fire Crew Lost to Spar FailureBeech C90, July 10, 2021, Wikieup, Arizona
A fatigue fracture of the lower spar cap led to separation of the outboard section of the left wing during a firefighting support flight, causing the deaths of the pilot and an air tactical group supervisor. ADS-B data showed that the King Air orbited the fire for about 45 minutes 2,300 feet above ground level before abruptly descending. One witness saw it hit the side of a ridgeline in a steep dive; another saw the outboard left wing fall to the ground. The wing section was found 0.79 miles northeast of the main wreckage.
Several months earlier, an eddy current (EC) inspection conducted during scheduled maintenance identified a crack in a fastener hole in the left wing’s lower forward spar cap. The operator tried to correct this by reaming the hole oversized, but a follow-up EC still indicated a crack. The operator then contacted the manufacturer and was advised that this necessitated replacement of “the center section forward spar cap, center section forward lower fittings and both outboard main spar assemblies.” 
Instead they chose to repair the spar under the guidance of an FAA designated engineering representative. The repair involved further oversizing the hole and installing an external doubler. Follow-up testing by a commercial EC inspector suggested that the repair was successful, with no crack indications there or elsewhere.
However, examination of the fracture surface found that it emanated from a nearly 2.5-inch fatigue crack beginning at the lower spar cap’s aft inboard fastener hole. The crack was probably visible at the last inspection, making it likely that EC testing of that hole was not performed. The NTSB noted that while this was not the same area where the repair was made, the spar would have been replaced had the operator followed the manufacturer’s guidance.
Stall During Circling Approach Killed SixBombardier CL-600-2B16, July 26, 2021, Truckee, California
The crew’s decision not to request the straight-in GPS approach to Runway 11 after determining that Runway 20 of the Truckee--Tahoe Airport was too short for their landing weight precipitated the sequence of events that ended with the jet stalling in from 175 feet, killing all six on board. Though under no time or fuel constraints to expedite landing, the pilots instead chose to accept a GPS approach to Runway 20 and circle despite degraded visibility in heavy wildfire smoke. They did not brief the circling approach.
After the first officer located the airport, the jet began a turn to downwind at 162 knots, 44 above their landing reference speed, but rolled out early on a diagonal track toward the extended centerline. 
Though the airplane was high, fast, and untenably close to the runway, the pilots attempted to salvage the approach rather than going around, overshooting the extended centerline and turning back toward the runway while simultaneously trying to slow the airplane and increase its descent rate. The stick shaker and stick pusher engaged twice in the last eight seconds of the flight. The jet rolled to a 111-degree left bank as the left wing stalled, then hit the ground north of the runway in a 146-degree right bank.
Though the operator held a Part 135 certificate, the flight was operated under Part 91. The 43-year-old captain, a 5,680-hour ATP with 235 hours in type, had signed an employment contract with the operator but was not yet on their payroll, flying under contract prior to onboarding. The 56-year-old first officer, a 14,308-hour ATP with 4,410 in make and model, had been hired as a contract pilot for the accident flight. The NTSB report did not specify whether they had previously flown together.
Maintenance Error Confirmed in Fatal Sikorsky CrashSikorsky S-61N, Feb. 22, 2022, Kekaha, Hawaii
The NTSB attributed a catastrophic loss of pitch control to the failure of maintenance personnel to install the required nut and cotter pin on the bolt attaching the fore/aft servo input link to the bellcrank, and of the company quality assurance inspector to notice that discrepancy. All four on board were killed and the helicopter destroyed when it gradually began to pitch nose-down at an altitude of 200 feet, striking the ground nose-first in a near-vertical attitude. A post-crash fire consumed most of the fuselage.
The helicopter was operated under contract to the U.S. Navy to retrieve inert training torpedoes from the Pacific and return them via sling load to the Pacific Missile Range Facility. Archived ADS-B data showed that after collecting the torpedo, the ship flew back towards the designated drop-off point, then began a gradual turn toward the northeast. Multiple witnesses reported that its turn toward the drop-off point ended unexpectedly just before it pitched down into the ground.
Examination of the wreckage found that the bolt securing the fore/aft servo’s clevis to the bellcrank rod end bearing was partially backed out and cocked at an angle that would have caused an uncommanded nose-down input the pilot could not correct. 
The nut and associated bushing, washers, and cotter pin were not present, and the bolt showed no evidence of fractures or deformation. The servo had been installed on Dec. 28, 2021 and the installation signed off by the operator’s quality assurance inspector. The helicopter had flown 7.5 hours since. ζ