Wichita, KS, USA
N52SZ
RAYTHEON AIRCRAFT COMPANY B200
The airline transport pilot was departing for a repositioning flight. During the initial climb, the pilot declared an emergency and stated that the airplane "lost the left engine." The airplane climbed to about 120 ft above ground level, and witnesses reported seeing it in a left turn with the landing gear extended. The airplane continued turning left and descended into a building on the airfield. A postimpact fired ensued and consumed a majority of the airplane. Postaccident examinations of the airplane, engines, and propellers did not reveal any anomalies that would have precluded normal operation. Neither propeller was feathered before impact. Both engines exhibited multiple internal damage signatures consistent with engine operation at impact. Engine performance calculations using the preimpact propeller blade angles (derived from witness marks on the preload plates) and sound spectrum analysis revealed that the left engine was likely producing low to moderate power and that the right engine was likely producing moderate to high power when the airplane struck the building. A sudden, uncommanded engine power loss without flameout can result from a fuel control unit failure or a loose compressor discharge pressure (P3) line; thermal damage prevented a full assessment of the fuel control units and P3 lines. Although the left engine was producing some power at the time of the accident, the investigation could not rule out the possibility that a sudden left engine power loss, consistent with the pilot's report, occurred. A sideslip thrust and rudder study determined that, during the last second of the flight, the airplane had a nose-left sideslip angle of 29°. It is likely that the pilot applied substantial left rudder input at the end of the flight. Because the airplane's rudder boost system was destroyed, the investigation could not determine if the system was on or working properly during the accident flight. Based on the available evidence, it is likely that the pilot failed to maintain lateral control of the airplane after he reported a problem with the left engine. The evidence also indicates that the pilot did not follow the emergency procedures for an engine failure during takeoff, which included retracting the landing gear and feathering the propeller. Although the pilot had a history of anxiety and depression, which he was treating with medication that he had not reported to the Federal Aviation Administration, analysis of the pilot's autopsy and medical records found no evidence suggesting that either his medical conditions or the drugs he was taking to treat them contributed to his inability to safely control the airplane in an emergency situation.
HISTORY OF FLIGHTOn October 30, 2014, at 0948 central daylight time, a Raytheon Aircraft Company King Air B200 airplane, N52SZ, impacted the FlightSafety International (FSI) building located on the airport infield during initial climb from Wichita Mid-Continent Airport (ICT), Wichita, Kansas. The airline transport pilot, who was the sole occupant, was fatally injured, and the airplane was destroyed. Three building occupants were fatally injured, two occupants sustained serious injuries, and four occupants sustained minor injuries. The airplane was registered to and operated by Gilleland Aviation, Inc., Georgetown, Texas, under the provisions of 14 Code of Federal Regulations Part 91 as a ferry flight. Visual meteorological conditions prevailed, and an instrument flight rules (IFR) flight plan was filed. The flight was originating from ICT at the time of the accident and was en route to Mena Intermountain Municipal Airport (MEZ), Mena, Arkansas. The ICT air traffic controllers stated that the accident flight was cleared for takeoff on runway 1R and instructed to fly the runway heading. After becoming airborne, the pilot declared an emergency and stated that the airplane "lost the left engine." The airplane then entered a shallow left turn, continued turning left, and then descended into a building. A controller called aircraft rescue and firefighting on the "crash phone" just before impact. The controllers observed flames and then black smoke coming from the accident site. Witnesses in the Cessna Service Center building on the east side of runway 1R also observed the airplane departing runway 1R. They indicated that the airplane then porpoised several times before making a left turn. The airplane continued the left turn, barely cleared the top of a hangar on the west side of runway 1R, and then descended into a building. The witnesses reported that the landing gear was extended and that they could not clearly hear the sound of the engines. The airplane's altitude appeared to be less than 150 ft above ground level (agl). Airport surveillance video cameras captured the last 9 seconds of the flight. The videos showed that the airplane was turning left and in a nose-left sideslip as it overflew a hangar. The cameras showed that the airplane was about 120 ft agl when it impacted the FSI building, and a postimpact explosion and fire ensued. PERSONNEL INFORMATIONThe pilot, age 53, held an airline transport pilot (ATP) certificate with ratings for airplane single-engine and multiengine land. On August 4, 2014, he was issued a Federal Aviation Administration (FAA) second-class medical certificate with the limitation that he must wear corrective lenses. The pilot's flight time logbook was not located during the investigation. At the time of his August 2014 medical examination, he reported a total flight time of 3,067 hours with 200 hours in the preceding 6 months. A review of the pilot's flight training records from FSI, dated September 18, 2014, revealed that he had accumulated 3,139 total flight hours, 2,843 hours of which were in multiengine airplanes. The King Air B200 did not require a type rating. From September 4 to 19, 2014, the pilot received Beechcraft King Air 300 series initial training at FSI, Wichita, Kansas. The training was specifically for the King Air 350 Proline 21 model and included 58.5 ground training hours, 12 briefing hours, 14 pilot-flying simulator hours, and 12 pilot-not-flying hours. During the course, the pilot reviewed and completed the required emergency procedures. The pilot satisfactorily completed the course with an examination that included 2.5 hours written/oral examination time and 2.2 simulator flying hours. On September 19, 2014, the pilot was issued an FAA ATP temporary airman certificate with the following ratings and limitations: airplane multiengine land ratings for Beechcraft (BE)-300, BE-400, Cessna (CE)-525, Dassault Falcon (DA)-10, Learjet (LR)-45, LR-60, LR-JET, Mitsubishi (MU)-300 airplanes; second-in-command privileges only for BE-400, CE-525, DA-10, LR-45, LR-60, LR-JET, and MU-300 airplanes; and private pilot privileges for airplane single-engine land. AIRCRAFT INFORMATIONThe accident airplane was bought by Gilleland Aviation, Inc., Georgetown, Texas, on October 28, 2014. The King Air B200 was a six-seat, low-wing, multiengine airplane manufactured in 2000. The airplane was powered by two Pratt & Whitney PT6A-42 turboprop engines that each drove a Hartzell four-bladed, hydraulically operated, constant-speed propeller with full feathering and reversing capabilities. The propeller blade angle settings for this installation were -11.0° ± 0.5° reverse, 18.2° ± 0.1° low, and 85.8° ± 0.5° feather. On October 30, 2014, at 0740, the airplane was refueled at ICT by Signature Flight Support. The two outboard fuel tanks (usable 193-gallon capacity each) were reported to have been filled to capacity. The two auxiliary fuel tanks (usable 79-gallon capacity each) were reported to be empty. The fueling receipt noted that 57 gallons of Jet A fuel were added to the left main tank and that 53 gallons of Jet A fuel were added to the right main tank. Maintenance A review of the airplane maintenance records found that major scheduled maintenance was completed at Hawker Beechcraft Services, Wichita, Kansas, on October 22, 2014. The maintenance included left and right engine hot-section inspections and an overhaul of the right propeller. At the time of the accident, the airplane had accumulated 1.4 hours and 2 cycles since it was released to service on October 22, 2014. The review found no maintenance record discrepancies that would have affected the operation or performance of the airplane. Postmaintenance Test Flights During the October 22, 2014, Hawker Beechcraft postmaintenance test flight, the following discrepancies were noted: The left throttle lever was ahead of the right by about 1/4 of the lever knob. The cabin environmental system pressurization leak rate was high. All other systems functioned normally. The engine interturbine temperature (ITT) gauge indications were split, indicating that one of the engines was operating more efficiently than the other; however, both engines were able to achieve maximum power per the pilot's operating handbook (POH) performance charts with no temperature ITT exceedance. Maintenance was performed to address the throttle matching and cabin environmental system discrepancies, and a second maintenance test flight was conducted on October 27, 2014. During the flight, it was noted that the throttle lever mismatch was corrected. The environmental system bleed air valves (flow packs) pressurization leak rates were acceptable, although one was weaker than the other when tested independently. No other anomalies were noted. Following the flight, maintenance personnel confirmed that the left flow pack output was higher than the right. Both sides of the system passed maintenance manual and ground operational checks. To better understand these findings, the airplane owner agreed that the left and right environmental system flow packs, electronic controllers, and thermistors should be swapped. Rudder Boost System The airplane was equipped with a rudder boost system to aid the pilot in maintaining directional control in the event of an engine failure or a large variation of power between the engines. The rudder cable system incorporated two pneumatic rudder-boosting servos that would actuate the cables to provide rudder pressure to help compensate for asymmetrical thrust. During operation, a differential pressure valve would accept bleed air pressure from each engine. When the pressure varied between the bleed air systems, the shuttle in the differential pressure valve would move toward the low pressure side. As the pressure differential reached a preset tolerance, a switch on the low pressure side would close, activating the rudder boost system. The system was designed only to help compensate for asymmetrical thrust; the pilot was to accomplish appropriate trimming. The system was controlled by a toggle switch, placarded "RUDDER BOOST – OFF" and located on the pedestal below the rudder trim wheel. The switch was to be turned on before flight. A preflight check of the system could be performed during the run-up by retarding the power on one engine to idle and advancing power on the opposite engine until the power difference between the engines was great enough to close the switch that activates the rudder boost system. Movement of the appropriate rudder pedal (left engine idling, right rudder pedal would move forward) would be noted when the switch closed, indicating that the system was functioning properly for low engine power on that side. The check was to be repeated with opposite power settings to check for movement of the opposite rudder pedal. Moving either or both of the bleed air valve switches in the copilot's subpanel to the "INSTR & ENVIR OFF" position would disengage the rudder boost system. Autofeathering System The airplane was equipped with an autofeathering system that provided a means of automatically feathering the propeller in the event of an engine failure. The system was armed using a switch on the pilot's subpanel placarded "AUTOFEATHER – ARM – OFF – TEST." With the switch in the "ARM" position and both power levers above about 90 percent N1, the green L and R AUTOFEATHER annunciators located on the caution/advisory panel would illuminate, indicating that the system was armed. If either power lever was not above about 90 percent N1, the system would be disarmed, and neither annunciator would be illuminated. When the system was armed and the torque on a failing engine dropped below about 410 ft-lbs, the operative engine's autofeather system would be disarmed. When the torque on the failing engine dropped below about 260 ft-lbs, the oil was dumped from the servo, and the feathering spring and counterweights feathered the propeller. For King Air B200 airplanes equipped with Hartzell propellers, the propeller autofeather system must be operable for all flights and be armed for takeoff, climb, approach, and landing. A preflight system test, as described in the King Air POH, Section IV, "NORMAL PROCEDURES," was required. Since an engine would not actually be shut down during a test, the AUTOFEATHER annunciator for the engine being tested would cycle on and off as the torque oscillated above and below the 260 ft-lbs setting. Emergency Procedure The King Air B200 POH outlined an Engine Failure During Takeoff (at or above V1) Takeoff Continued procedure, which stated, in part, the following: 1. Power –> maximum allowable 2. Airspeed –> maintain (takeoff speed or above) 3. Landing gear –> up Note: If the autofeather system…is being used, do not retard the failed engine power lever until the autofeather system has completely stopped the propeller rotation. To do so will deactivate the autofeather circuit and prevent automatic feathering. 4. Propeller lever (inoperative engine) –> feather (or verify that propeller is feathered if autofeather is installed) METEOROLOGICAL INFORMATIONAt 0953, the automated weather observation at ICT reported wind from 350 degrees and 16 knots, visibility of 10 miles, a few clouds at 15,000 ft, temperature 59° F, dew point 37° F, and altimeter setting 30.12 inches of Mercury. AIRPORT INFORMATIONThe accident airplane was bought by Gilleland Aviation, Inc., Georgetown, Texas, on October 28, 2014. The King Air B200 was a six-seat, low-wing, multiengine airplane manufactured in 2000. The airplane was powered by two Pratt & Whitney PT6A-42 turboprop engines that each drove a Hartzell four-bladed, hydraulically operated, constant-speed propeller with full feathering and reversing capabilities. The propeller blade angle settings for this installation were -11.0° ± 0.5° reverse, 18.2° ± 0.1° low, and 85.8° ± 0.5° feather. On October 30, 2014, at 0740, the airplane was refueled at ICT by Signature Flight Support. The two outboard fuel tanks (usable 193-gallon capacity each) were reported to have been filled to capacity. The two auxiliary fuel tanks (usable 79-gallon capacity each) were reported to be empty. The fueling receipt noted that 57 gallons of Jet A fuel were added to the left main tank and that 53 gallons of Jet A fuel were added to the right main tank. Maintenance A review of the airplane maintenance records found that major scheduled maintenance was completed at Hawker Beechcraft Services, Wichita, Kansas, on October 22, 2014. The maintenance included left and right engine hot-section inspections and an overhaul of the right propeller. At the time of the accident, the airplane had accumulated 1.4 hours and 2 cycles since it was released to service on October 22, 2014. The review found no maintenance record discrepancies that would have affected the operation or performance of the airplane. Postmaintenance Test Flights During the October 22, 2014, Hawker Beechcraft postmaintenance test flight, the following discrepancies were noted: The left throttle lever was ahead of the right by about 1/4 of the lever knob. The cabin environmental system pressurization leak rate was high. All other systems functioned normally. The engine interturbine temperature (ITT) gauge indications were split, indicating that one of the engines was operating more efficiently than the other; however, both engines were able to achieve maximum power per the pilot's operating handbook (POH) performance charts with no temperature ITT exceedance. Maintenance was performed to address the throttle matching and cabin environmental system discrepancies, and a second maintenance test flight was conducted on October 27, 2014. During the flight, it was noted that the throttle lever mismatch was corrected. The environmental system bleed air valves (flow packs) pressurization leak rates were acceptable, although one was weaker than the other when tested independently. No other anomalies were noted. Following the flight, maintenance personnel confirmed that the left flow pack output was higher than the right. Both sides of the system passed maintenance manual and ground operational checks. To better understand these findings, the airplane owner agreed that the left and right environmental system flow packs, electronic controllers, and thermistors should be swapped. Rudder Boost System The airplane was equipped with a rudder boost system to aid the pilot in maintaining directional control in the event of an engine failure or a large variation of power between the engines. The rudder cable system incorporated two pneumatic rudder-boosting servos that would actuate the cables to provide rudder pressure to help compensate for asymmetrical thrust. During operation, a differential pressure valve would accept bleed air pressure from each engine. When the pressure varied between the bleed air systems, the shuttle in the differential pressure valve would move toward the low pressure side. As the pressure differential reached a preset tolerance, a switch on the low pressure side would close, activating the rudder boost system. The system was designed only to help compensate for asymmetrical thrust; the pilot was to accomplish appropriate trimming. The system was controlled by a toggle switch, placarded "RUDDER BOOST – OFF" and located on the pedestal below the rudder trim wheel. The switch was to be turned on before flight. A preflight check of the system could be performed during the run-up by retarding the power on one engine to idle and advancing power on the opposite engine until the power difference between the engines was great enough to close the switch that activates the rudder boost system. Movement of the appropriate rudder pedal (left engine idling, right rudder pedal would move forward) would be noted when the switch closed, indicating that the system was functioning properly for low engine power on that side. The check was to be repeated with opposite power settings to check for movement of the opposite rudder pedal. Moving either or both of the bleed air valve switches in the copilot's subpanel to the "INSTR & ENV
The pilot's failure to maintain lateral control of the airplane after a reduction in left engine power and his application of inappropriate rudder input. Contributing to the accident was the pilot's failure to follow the emergency procedures for an engine failure during takeoff. Also contributing to the accident was the left engine power reduction for reasons that could not be determined because a postaccident examination did not reveal any anomalies that would have precluded normal operation and thermal damage precluded a complete examination.
Source: NTSB Aviation Accident Database
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