Aviation Accident Summaries

Aviation Accident Summary CEN13FA196

South Bend, IN, USA

Aircraft #1

N26DK

HAWKER BEECHCRAFT CORPORATION 390

Analysis

According to the cockpit voice recorder (CVR), during cruise flight, the unqualified pilot-rated passenger was manipulating the aircraft controls, including the engine controls, under the supervision and direction of the private pilot. After receiving a descent clearance to 3,000 feet mean sea level (msl), the pilot told the pilot-rated passenger to reduce engine power to maintain a target airspeed. The cockpit area microphone subsequently recorded the sound of both engines spooling down. The pilot recognized that the pilot-rated passenger had shutdown both engines after he retarded the engine throttles past the flight idle stops into the fuel cutoff position. Specifically, the pilot stated "you went back behind the stops and we lost power." According to air traffic control (ATC) radar track data, at the time of the dual engine shutdown, the airplane was located about 18 miles southwest of the destination airport and was descending through 6,700 feet msl. The pilot reported to the controller that the airplane had experienced a dual loss of engine power, declared an emergency, and requested radar vectors to the destination airport. As the flight approached the destination airport, the cockpit area microphone recorded a sound similar to an engine starter spooling up; however, engine power was not restored during the attempted restart. A review of the remaining CVR audio did not reveal any evidence of another attempt to restart an engine. The CVR stopped recording while the airplane was still airborne, with both engines still inoperative, while on an extended base leg to the runway. Subsequently, the controller told the pilot to go-around because the main landing gear was not extended. The accident airplane was then observed to climb and enter a right traffic pattern to make another landing approach. Witness accounts indicated that only the nose landing gear was extended during the second landing approach. The witnesses observed the airplane bounce several times on the runway before it ultimately entered a climbing right turn. The airplane was then observed to enter a nose low, rolling descent into a nearby residential community. The postaccident examinations and testing did not reveal any anomalies or failures that would have precluded normal operation of the airplane. Although the CVR did not record a successful engine restart, the pilot was able to initiate a go-around during the initial landing attempt, which implies that he was able to restart at least one engine during the initial approach. The investigation subsequently determined that only the left engine was operating at impact. Following an engine start, procedures require that the respective generator be reset to reestablish electrical power to the Essential Bus. If the Essential Bus had been restored, all aircraft systems would have operated normally. However, the battery toggle switch was observed in the Standby position at the accident site, which would have prevented the Essential Bus from receiving power regardless of whether the generator had been reset. As such, the airplane was likely operating on the Standby Bus, which would preclude the normal extension of the landing gear. However, the investigation determined that the landing gear alternate extension handle was partially extended. The observed position of the handle would have precluded the main landing gear from extending (only the nose landing gear would extend). The investigation determined that it is likely the pilot did not fully extend the handle to obtain a full landing gear deployment. Had he fully extended the landing gear, a successful single-engine landing could have been accomplished. In conclusion, the private pilot's decision to allow the unqualified pilot-rated passenger to manipulate the airplane controls directly resulted in the inadvertent dual engine shutdown during cruise descent. Additionally, the pilot's inadequate response to the emergency, including his failure to adhere to procedures, resulted in his inability to fully restore airplane systems and ultimately resulted in a loss of airplane control.

Factual Information

HISTORY OF FLIGHTOn March 17, 2013, at 1623 eastern daylight time, a Hawker Beechcraft model 390 (Premier IA) business jet, N26DK, serial number RB-226, collided with three residential structures following an aborted landing attempt on runway 9R located at the South Bend Airport (SBN), South Bend, Indiana. The private pilot and pilot-rated-passenger, who were occupying the cockpit seats, were fatally injured. An additional two passengers, who were seated in the cabin area, and one individual on the ground sustained serious injuries. The airplane was registered to 7700 Enterprises of Montana, LLC, and operated by Digicut Systems of Tulsa, Oklahoma, under the provisions of 14 Code of Federal Regulations Part 91 while on an instrument flight rules flight plan. Day visual meteorological conditions prevailed for the business flight that departed the Richard Lloyd Jones Jr. Airport (RVS), Tulsa, Oklahoma, at 1356 central daylight time. According to air traffic control (ATC) information, after departing RVS, the accident flight proceeded toward the intended destination while receiving normal ATC services. The flight was eventually cleared to a final cruise altitude of 41,000 feet (FL410). The cockpit voice recorder (CVR) contained about 31 minutes of cockpit conversation/audio and radio communications. At 1545:31, the beginning of the CVR recording, the pilot was discussing the airplane's fuel status and how much fuel would be required for the return flight. The pilot continued to explain and demonstrate various flight management system functions to the pilot-rated-passenger. At 1546:08, the pilot-rated-passenger remarked "a lot of stuff to learn." The pilot continued to explain and demonstrate the features of the flight management system, the use of his mobile tablet as an electronic flight bag, and the airplane's various weight limitations. At 1552:17, the pilot established contact with Chicago Air Route Traffic Control Center and reported being level at FL410. The controller subsequently cleared the flight to descend to 24,000 feet (FL240). After receiving the descent clearance, the pilot and pilot-rated-passenger discussed how to initiate a descent using the autopilot's vertical speed mode. The pilot explained how to use airplane pitch and engine power and to maintain a desired airspeed during the descent. At 1555:22, the pilot stated "we're up more speed, so we got to get our power back. gettin' ready to start beeping at us. got to bring it back." At 1555:27, the CVR recorded a sound similar to the airspeed overspeed warning for 13.5 seconds. At 1555:31, the pilot-rated-passenger asked the pilot, "just pull it way back?" The pilot replied, "well, just get it out of the line. and we got to get it so, that it trends -- there you go -- there you go -- now give it -- it ends, there you go." The pilot continued to explain how to maintain a desired airspeed. At 1555:55, the pilot-rated-passenger remarked, "I just hate chasin' the darn thing." The pilot replied, "huh, how many hours you got flying this jet?" The pilot-rated-passenger stated, "well, I know, but I'm just saying it's just, you know, uncomfortable. Creates alarm in the back -- throttle up, throttle down." The pilot then explained how to setup a descent while maintaining a specified airspeed. At 1557:29, the pilot-rated passenger stated, "so, pull back?" The pilot replied, "little bit. little bit. keep working it back 'cause that tells you where you're gonna be in six seconds. so, right now, you're going to be at the line in six seconds, so you want to continue to trend back. so yeah. so, just take two seventy or something like that." At 1557:53, the pilot told the pilot-rated-passenger to "just keep us out the red." At 1558:08, the controller cleared the flight direct to South Bend. After acknowledging the direct clearance, the pilot told the pilot-rated-passenger how to program the flight management system to proceed direct to the destination airport. The pilot then discussed the airplane's indicated airspeed, ground speed, and how to cross-check the airplane's flight attitude with the backup cockpit instrumentation. At 1559:24, the Automatic Terminal Information Service (ATIS) recording is audible over the radio channel. At 1559:42, the pilot-rated-passenger asked the pilot if they needed to engage engine heat. The pilot replied that they would wait until they get an ice indication light. At 1600:34, the pilot-rated-passenger asked the pilot "okay. pull back on the power?" At 1601:35, the controller cleared the flight to descend and maintain 20,000 feet (FL200). At 1602:13, the pilot discussed the current weather conditions that he had obtained from the ATIS recording, the expected wind correction during the approach and landing, the minimum descent altitude during the instrument approach, and the landing reference speed. At 1603:22, the controller asked the pilot to expedite a descent to 17,000 feet mean sea level (msl). At 1603:51, the pilot told the pilot-rated-passenger "watch your speed" and "very good, very good. great speed management." At 1605:08, a sound similar to the altitude alert was heard, the pilot announced "thousand away" and told the pilot-rated-passenger "okay, now we can come nose back up." At 1605:29, the pilot stated "let's go to the stop... to the click (detent)... MCT (maximum continuous thrust)." At 1606:14, the CVR recorded a sound similar to the airspeed overspeed warning that lasted for 11.4 seconds. At 1606:20, the pilot stated "that's what a check pilot will do, is he'll give you three things to do... when he knows you're trending in the wrong direction." At 1606:32, the pilot said "your throttles." At 1606:49, the controller cleared the flight to expedite a descent to maintain 11,000 feet msl. After acknowledging the descent clearance, the pilot and pilot-rated passenger continued to discuss how to maintain airspeed during a cruise descent. At 1607:23, the controller asked the pilot for a ride report. The pilot replied that the weather conditions had been "smooth all the way." At 1607:52, the pilot told the pilot-rated-passenger to maintain 290 knots. The pilot-rated-passenger replied "okay, where is it?" The pilot responded "two ninety would be more power." At 1608:44, the controller issued a heading change for traffic sequencing. The pilot then explained how to promote a waypoint using the flight management system and how to plan for a descent to the selected waypoint. At 1610:11, the controller cleared the flight direct the destination airport and to contact South Bend Approach Control. At 1610:32, the pilot established communications with South Bend Approach Control and reported being level at 11,000 feet msl. The approach controller cleared the flight direct to KNUTE, the outer marker for the instrument landing system (ILS) runway 9R instrument approach, but to expect a visual approach to the airport. The pilot then explained how to promote KNUTE as the next active waypoint within the flight management system, and how to plan for the descent to the waypoint. At 1611:45, the approach controller cleared the flight to descend and maintain 10,000 feet msl. At 1613:07, the approach controller cleared the flight to descend and maintain 3,000 feet msl. After receiving the descent clearance to 3,000 feet msl, the pilot told the pilot-rated-passenger "let's power back. let's bring it back to uh -- let's trend toward uh two twenty, two ten." The pilot-rated-passenger acknowledged and the pilot replied "and we'll have to come way out of it to do that." At 1613:30, the cockpit area microphone recorded a sound consistent with a decrease in engine speed. The pilot then verbalized a descent checklist and turned on the seatbelt cabin chime. At 1614:14, the pilot told the pilot-rated-passenger "we gotta get -- just pull -- just pull the power out." At 1614:18, the pilot-rated-passenger asked, "just pull it on down?" The pilot replied, "yeah, let's -- let's get back to two hundred (knots)." At 1614:21, the cockpit area microphone recorded another sound consistent with a decrease in engine speed. At 1614:26, the cockpit area microphone recorded the sound of two clicks. At 1614:27, there was a brief interruption in electrical power, an autopilot disconnect chime, and two unidentified tones. According to ATC radar track data, at 1614:28, the final radar return with an accompanying mode-C altitude return was recorded at 6,700 feet msl. At that time, the flight was located about 18 miles southwest of the destination airport. At 1614:29, the pilot said "uh-oh" and the pilot-rated-passenger replied "what?" At 1614:33, the sound similar to the landing gear warning horn was heard for 3.5 seconds. At 1614:35, the pilot told the pilot-rated-passenger "you went back behind the stops and we lost power." (The airplane throttle quadrant had a mechanical stop at the flight idle power position, which required lifting finger levers, or pull-up locks, to further retard the throttles into the fuel cut-off position.) At 1614:43, the pilot said "okay let's see here... boost pumps are on... okay we are dead stick." At 1614:56, the sound similar to the landing gear warning horn was heard for 10.9 seconds. At 1615:01, the approach controller told the pilot to turn five degrees left for runway 9R and to report when he had the airport in sight. At 1615:02, the cockpit area microphone recorded a sound similar to an engine starter/generator spooling up; however, according to a sound spectrum study, engine power was not restored during the attempted restart. At 1615:08, the pilot told the approach controller, "uh... South Bend, we have an emergency, two six delta kilo. dead engines, dead stick, no power." The controller asked if he needed assistance and the pilot replied "affirm." Between 1615:19 and 1615:27, there was a sustained electrical power interruption to the CVR. At 1615:30, the controller asked for the pilot's intentions and the pilot replied "uh, we've lost all power and we have no hydraulics." At 1615:32, there was the sound similar to an altitude alert. At 1615:38, the controller stated that the airport would have emergency equipment standing-by and asked if the airplane was controllable. At 1615:42, the pilot replied "ah, barely controllable." The controller told the pilot that all of the runways were available for landing and issued the current wind condition. At 1615:53, the pilot told the controller "uh, we have no navigation. if you could give us a vector please... we have no heading either. which -- you're gonna have to tell us which way to fly." The controller replied that the airplane was about 9 miles from the airport, which was at the 12-o'clock position. At 1616:09, the pilot-rated-passenger stated "there's the airport" and the pilot responded "Where? -- Okay." At 1616:12, the sound similar to the landing gear warning horn was audible until the end of the CVR recording. At 1616:13, the approach controller told the pilot to turn left 10 degrees. At 1616:16, the pilot replied "two six delta, turning left." At 1616:32, the CVR stopped recording while the airplane was still airborne with both engines still inoperative. No additional voice communications were received from the accident airplane. The approach controller continued to transmit radar vectors toward runway 9R without any response from the accident pilot. At 1618:59, the approach controller told the accident airplane to go-around because the main landing gear was not extended. (The tower controller had informed the approach controller that only the nose landing gear was extended) The accident airplane was then observed to climb and enter a right traffic pattern for runway 9R. The airplane made another landing approach to the runway with only the nose landing gear extended. Several witnesses observed the airplane bounce several times on the runway before it ultimately entered a climbing right turn. The airplane was then observed to enter a nose low, rolling descent into a nearby residential community. PERSONNEL INFORMATION--- Pilot --- According to Federal Aviation Administration (FAA) records, the pilot, age 58, held a private pilot certificate with single and multi-engine land airplane and instrument airplane ratings. He was type-rated for the Hawker Beechcraft model 390 (Premier IA) business jet. His last aviation medical examination was completed on January 22, 2013, when he was issued a third-class medical certificate. The medical certificate had a limitation that it was not valid for any certificate classification after January 31, 2014. A search of FAA records showed no previous accidents, incidents, or enforcement proceedings. The pilot's flight history was reconstructed using a partially completed pilot logbook, a spreadsheet flight log, several applications for his FAA pilot certificates and ratings, and a spreadsheet history of the flights that had been completed in the accident airplane. The pilot began his primary flight instruction on January 21, 2011. On April 29, 2011, when he applied for his private pilot certificate, he reported having 71 hours total time. On February 5, 2012, when he applied for his instrument rating, the pilot reported having 314 hours total time. On February 26, 2012, when he applied for his multi-engine rating, the pilot reported having 330 hours total time. On May 4, 2012, when he applied for his type-rating in the Hawker Beechcraft model 390, the pilot reported having 450 hours total time. According to additional flight documentation, after he had received his type-rating, the pilot accumulated an additional 163.7 hours in the accident airplane. The pilot's total flight experience was estimated to be about 613.7 hours, of which at least 171.5 hours were completed in the same make/model as the accident airplane. According to training records, from April 29, 2012, through May 4, 2012, the pilot attended initial type-rating training for the Hawker Beechcraft model 390 airplane at The Jetstream Group, located in Chino, California. The course consisted of 41 hours of ground training, 8 hours of flight briefing/debriefing, and 7.8 hours of flight training in the Hawker Beechcraft model 390 airplane. On May 4, 2012, the pilot obtained his type-rating following a 2.1-hour oral examination and a 2.0 hour checkride with a FAA designated pilot examiner. --- Pilot-Rated-Passenger --- According to FAA records, the pilot-rated-passenger, age 60, held a private pilot certificate with single and multi-engine land airplane and instrument airplane ratings. His last aviation medical examination was completed on August 3, 2005, when he was issued a third-class medical certificate with the limitation for corrective lenses. A search of FAA records showed no previous accidents, incidents, or enforcement proceedings. A review of available logbook information indicated that the last recorded flight was completed on September 28, 2008. At that time, the pilot-rated-passenger had accumulated 1,877.2 hours total flight experience, of which 1,705.3 hours were listed as pilot-in-command. He had accumulated 1,576.2 hours in multi-engine airplanes and 301 hours in single-engine airplanes. He had accumulated 92.4 hours in actual instrument conditions and 517.6 hours at night. His last recorded flight review and instrument proficiency check was completed on September 19, 2006, in a Beech model 60 twin-engine airplane. A review of available information did not reveal any logged flight experience in turbine-powered business jets. According to an affidavit provided by the pilot's son following the accident, the pilot-rated-passenger was not an employee of the operator, nor was he employed as a pilot for the accident flight. He was reportedly a friend of the pilot who shared a common interest in aviation. He reportedly did not have an official role on the accident flight, and as such, was considered a pilot-rated-passenger. AIRCRAFT INFORMATIONThe accident airplane was a 2008 Hawker Beechcraft model 390 (Premier IA) business jet, serial number RB-226. Two Williams International model FJ44-2A turbofan engines, each capable of producing 2,300 pounds of thrust at takeoff, powered the airplane. The airplane had a maximum takeoff weight of 12,500 pounds. The airplane was equipped for operati

Probable Cause and Findings

The private pilot's inadequate response to the dual engine shutdown during cruise descent, including his failure to adhere to procedures, which ultimately resulted in his failure to maintain airplane control during a single-engine go-around. An additional cause was the pilot's decision to allow the unqualified pilot-rated passenger to manipulate the airplane controls, which directly resulted in the inadvertent dual engine shutdown.

 

Source: NTSB Aviation Accident Database

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