Contributor - Safety

David Jack Kenny

<h1><b>Preliminary Reports</b></h1>
<h2><b>Flap Setting May Have Been Missed in Runway Excursion</b></h2>
<h3>Hawker 900XP, July 20, 2024, Telluride, Colorado</h3>
<p>The twin jet that was damaged when it ran off the end of Runway 27 at Colorado’s Telluride Regional Airport (KTEX) during an aborted takeoff apparently was not configured for departure as the pilot had calculated, according to the NTSB preliminary report of the July 20 accident. The report also noted that weather data indicated the aircraft might have attempted to take off with a tailwind.</p>
<p>The two pilots were not injured in the accident, but the lower fuselage was substantially damaged when the aircraft traveled over the engineered material arresting system (EMAS) and came to a stop about 150 feet from the runway threshold. They were on a repositioning flight without passengers to Miami Executive Airport (KTMB) after completing an on-demand passenger flight earlier in the day, landing on KTEX’s Runway 9.</p>
<p>For takeoff, the crew selected 7,111-foot Runway 27, as recommended by a Telluride operations notice. “Performance calculations showed a takeoff roll between 6,800 to 6,900 feet would be needed with flaps set to 15 degrees,” according to the NTSB report. “There were 1,253 gallons of fuel onboard.”</p>
<p>When the airplane had not attained 75% of the planned takeoff speed halfway down the dry runway, the pilot decided to abort. “The brakes, air brakes, and thrust reversers were used, however the airplane did not slow down,” the NTSB said. “Maximum braking was then applied, and the airplane began to depart the runway to the right” before rolling on to the EMAS.</p>
<p>After the crew exited the airplane, the pilot saw the wing flaps fully retracted. A review of video from an Automated Weather Observing System camera (located just to the north of the sole runway) showed an “extended windsock with an easterly wind.”</p>
<p>The airport, which is located on a 1,000-foot mesa with rising terrain on all quadrants, had the following restrictions in place at the time of the accident: “RY 09/27 RCMD TKOF RY 27; LAND RY 09 AND AVOID POPULATED AREAS. RY 09/27 GRADE–.08 ON RY ENDS, -1.3 TO APPROX MIDPOINT THEN +.75.”</p>
<h2><b>‘Unusual’ Sounds Preceded Takeoff Crash</b></h2>
<h3>Cessna 550 Citation II, Aug. 20, 2024, Odessa, Texas</h3>
<p>A pilot-rated witness reported that the corporate jet’s engines sounded “unusual” during the takeoff run immediately preceding the fatal accident and that it flew down the last third of 5,003-foot Runway 16 at an altitude of about 10 feet in a near-level attitude.</p>
<p>The pilot and only passenger were killed and one person on the ground was seriously injured when the Citation struck power lines and a single-story restaurant, leaving its right main gear in the building’s roof. The airplane struck two garages and came to rest about 150 yards further south, igniting a fire that consumed most of the wreckage.</p>
<p>Skies were reported clear with 10 miles visibility. Winds were from 190 degrees at 7 knots. The parking brake valve was found in the disengaged position, and a cockpit voice recorder was located and sent to the NTSB recorders lab.</p>
<h1><b>Final Reports</b></h1>
<h2><b>Vision Jet Upset in Thunderstorm</b></h2>
<h3>Cirrus SF50, Sept. 9, 2022, Saint Cloud, Florida</h3>
<p>The pilot’s decision to continue an instrument approach into the Kissimmee, Florida Gateway Airport (ISM) despite two ATC advisories of “heavy to extreme” precipitation along the final approach course resulted in the single-engine jet’s penetrating an active thunderstorm cell, causing a series of violent altitude excursions. The pilot and one passenger escaped with minor injuries and the second passenger was uninjured after the pilot deployed the Cirrus Airframe Parachute System (CAPS).</p>
<p>The Part 91 personal flight departed the Miami-Opa locka Executive Airport at 14:12 local time. En route the pilot obtained ISM’s ATIS broadcast, which reported light rain and ceilings between 3,800 and 4,600 feet. At 14:48:34, the controller advised of heavy to extreme precipitation over the final approach course to Runway 33 and asked whether he wished to continue or divert. He chose to continue and requested the RNAV approach to Runway 33. He later reported having been in visual conditions.</p>
<p>Flying the final approach course at 2,000 feet, the airplane pitched up to 13 degrees and slowed to 100 knots. An aural warning advised the pilot to “put more power.” He disconnected the autopilot and applied full takeoff thrust; the airplane pitched up and climbed at nearly 5,000 feet per minute, “well beyond [its] performance capability,” in the storm’s updrafts.</p>
<p>The Electronic Stability and Protection system engaged with the jet in a 28-degree nose-up attitude; the pilot added nose-down input only to have it pitch up and climb again. He deployed the CAPS at 3,150 feet with the airplane in a 45-degree left bank; the Cirrus descended into a marsh and rolled over.</p>
<p>The 57-year-old private pilot reported 982 hours of flight experience including 325 in the SF50, 192 as pilot-in-command. Further details were not reported by the NTSB.</p>
<h2><b>Medical Incapacitation Cited in Survey Pilot’s Death</b></h2>
<h2>Airbus AS350 B3, Nov. 9, 2022, Kitsault, British Columbia, Canada</h2>
<p>An incapacitating medical event of undetermined nature resulted in the solo pilot crashing into trees while attempting to return to base from a geophysical survey flight over mountains. After completing the last of six low-level survey passes, the pilot contacted the equipment operator by VHF radio to report that he “was unwell and shivering uncontrollably.”</p>
<p>He had experienced similar symptoms two evenings earlier, about 38 hours before the accident flight, but had improved after resting during the intervening day and dispatched himself as fit to fly.</p>
<p>The survey work involved low-speed, low-altitude flights using a 680-pound, 58-foot-diameter transmitter-receiver antenna array suspended 140 feet below the helicopter on a cargo hook. The equipment can only be used in favorable weather: light and stable winds, good visibility, and high ceilings.</p>
<p>The 18,825-hour solo pilot had logged nearly 13,000 hours in type that included “extensive flight experience…in mountainous terrain and with the survey loops attached.”</p>
<p>Tracking data from the helicopter’s Guardian Mobility Flightcell DZMx satellite/cellular unit showed that 16 minutes before the crash, the pilot had activated its EMER mode, which shortened reporting intervals from two minutes to one, sent text and email alerts to base, and added a “Distress” tag to the aircraft’s registration on the tracking site. None of those were noticed by company personnel.</p>
<p>The flight track began meandering eight minutes before the crash, diverging 60 degrees from the inbound course. The equipment operator drove to the staging area to meet the helicopter, arriving at 11:01, and could hear it until the noise ended abruptly at 11:11. One minute later an ELT signal reached the Joint Rescue Coordination Centre in Victoria, B.C. Searchers located the wreckage less than four hours later just two miles from the staging area, finding the helicopter destroyed and the pilot deceased.</p>
<h2><b>Night Instrument Failure Precipitated Air Ambulance Crash</b></h2>
<h3>Beechcraft King Air C90A, Dec. 15, 2022, Kaupo, Hawaii</h3>
<p>Thirteen minutes after departure on an interisland positioning flight in dark night conditions, the King Air’s vertical gyro failed in cruise flight at 13,000 feet, in turn causing failure of the pilot’s Electric Attitude Director Indicator (EADI) and autopilot disconnection. The pilot did not declare an emergency or even report the instrument failure to ATC, but attempted to continue hand-flying the airplane by reference to the copilot’s attitude indicator. During the next five minutes, as ATC “issued varying instructions,” the airplane alternately rolled right and left and entered a 1,000-fpm that increased to 3,500 fpm.</p>
<p>Seven minutes after the failure, with the airplane banked 65 degrees, ATC asked the pilot to verify his heading. The bank increased to 90 degrees and airspeed built to 260 knots while he attempted to reply. The cockpit’s Appareo video recording system captured “a loud metallic bang…consistent with an in-flight separation of the empennage from the fuselage.” A witness flying a Piper PA-44 from Hilo to Honolulu reported seeing the King Air well above him to the north, descending from 13,000 to 8,000 feet before entering a steepening spiral descent until it struck the water. The pilot and both medical crew members were killed.</p>
<p>The 47-year-old airline transport pilot held privileges for both multiengine airplanes and helicopters with three jet type ratings. His certification records also included six Notices of Disapproval prior to his hiring due to “multiple unsatisfactory training events,” three each in airplanes and helicopters. During his initial training by the operator, he received unsatisfactory ratings in five of six training sessions. In three years of employment, he had failed three of his six six-month proficiency checks. After the accident, the company’s director of operations reviewed his file and acknowledged that it wasn’t “what [he] would consider a normal training record.”&nbsp;</p>


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