NTSB Final Report Addison King Air Crash

it's monday may 24th my name is juan brown you're watching the blanco lyrio channel and today we finally have the final ntsb report on the king air crash in addison texas that took place on june 30th 2019 nearly two years ago that took the lives of 10 people [Music] one of the first questions many people have is why does it take the ntsb so long to produce these reports well it's a government bureaucracy for one thing but another thing is the ntsb does not have all the data on part 91 and part 135 operations there is not the same level of requirements as a part 121 airline operations to have recordable data on board the aircraft now in this particular accident which was operated under part 91 general aviation this aircraft did in fact have a cockpit voice recorder and that helped to explain a lot of what happened in this accident however without the rest of the data regarding the engines and the systems on board the aircraft the ntsb has to do an exhaustive study studying the data that they have from flight recorders and adsb and recreating a lot of these events and that takes a lot of time and they also have to wait for a lot of manufacturers oem folks to send the wreckage out to to have it completely analyzed the ntsb cannot leave any stone unturned they have to come into these accidents with an open mind a blank sheet and ensure that every single possibility has been eliminated before they come down to the probable cause in this case they had to determine was there anything wrong with the engines on this aircraft that could have caused this loss of thrust on the left engine which started this whole disaster to unfold and sure enough just as we suspected this accident boils down to a simple case of pilot error so let's review some of the facts from the ntsb final report and then i'll help you put the links of the chain together as in any accident there's a long chain of events that has to fall perfectly into place as the swiss cheese model illustrates in accident investigation all the holes in the swiss cheese all the barriers have to be penetrated in order for an accident to occur and this is a classic case now let's read from the analysis here in the final report the pilot co-pilot and eight passengers departed on a cross-country flight in the twin engine airplane one witness located on the ramp eyewitness reports a very key part of the investigation reported that the airplane sounded underpowered immediately after takeoff like it was at a reduced power setting another witness stated the airplane sounded like it did not have sufficient power to take off a third witness described the rotation as steep and another witness reported thinking that the airplane was performing aerobatics digital video from multiple cameras both on and off the airport showed the airplane rolled to its left before reaching a maximum altitude of 100 feet above ground level and then it descended and impacted an airport hangar in an inverted attitude about 17 seconds after takeoff and an immediate explosion followed sound spectrum analysis of data from the airplane's cockpit voice recorder cvr so here's where they're getting all the data they've got the video data from the airport and then the cockpit voice recorder provided an excellent amount of data and from the cvr they're able to do the sound spectrum study regarding the power on the engines which the that data they don't have sound spectrum analysis of data from the airplanes cvr estimated that the propeller speeds were at takeoff power about 1700 to about 1714 rpm to 1728 rpm at liftoff about seven seconds later the propeller speeds diverged with the left propeller speed decreasing to about 1688 rpm and the right propeller decreasing to about 1707 rpm so both engines are coming back on the power and the left engine coming back considerably based on the airplane's estimated calibrated airspeed of about 110 knots in the propeller rpm when the engines diverged the estimated thrust in the left engine decreased to near zero while the right engine continued operating at slightly less than maximum takeoff power analysis of the available data estimated that two seconds after the propeller speed deviation this is a turboprop aircraft the airplane's side slip angle was nearly 20 degrees that's the pilot error during the first five seconds after the propeller speed deviation the airplane's roll rate was about five degrees per second to the left its roll rate then rapidly increased to more than 60 degrees per second before the aircraft rolled inverted witness marks on the left engine and propeller the reduction in propeller speed and the aircraft's roll to the left suggests that the airplane most likely experienced a loss of thrust in the left engine shortly after takeoff well that we noted that the day that the accident occurred the airplane manufactures engine out procedure well he didn't do it examination of the wreckage found both main landing gear in a position consistent with being extended and the left propeller was unfeathered completely opposite of what you're supposed to do in the event of an engine failure on takeoff thus the pilot failed to configure the airplane once the left engine thrust was reduced calculations based on the airplane side slip angle shortly after the propeller speed deviation determined that the thrust of symmetry alone was insufficient to produce that 20 degree side slip angle based on an evaluation of thrust estimates provided by the propeller manufacturer performance data provided by the airplane manufacturer it is likely that the pilot applied left rudder just the opposite of what he was supposed to do before applying right rudder seconds later however by then the aircraft's roll rate was increasing too rapidly and its altitude was too low to recover and when you review the cvr data you hear confusion in the cockpit the pilot saying what in the world and three seconds later the co-pilot in the right seat had the right answer he says you've lost your left engine in addition ntsb investigation estimated that the rotation occurred before the airplane had attained vr rotation speed in other words he rotated too soon which decreased the margin to the minimum controllable airspeed and likely lessen the amount of time available for the pilot to properly react to the reduction of thrust and maintain aircraft control although the airplane was slightly over its maximum takeoff weight at departure its rate of climb was near what would be expected at near the maximum weight in the weather conditions on the day of the accident therefore the weight exceedance likely was not a factor in the accident the aircraft was loaded about 600 pounds over its maximum gross weight for this cross-country flight and as we discussed earlier the aircraft was fairly well loaded with fuel as well as folks like to often fill up at their home base and save the fuel or tanker the fuel through even though they they're putting on more fuel than they need for the for the round trip or for the one-way trip though the aircraft was overweight by about 600 pounds the ntsb determined that the center of gravity was within limits but very near the aft limit so after an exhaustive teardown of the engines and flight controls the ntsb found that there was basically nothing wrong with the aircraft nothing wrong with the engines given the lack of call outs for checklists on the cvr cockpit voice recorder and the pilot's consistently reported history of not using checklists this is a complicated twin you're basically a single pilot ifr complex turboprop aircraft and this 71 year old pilot is not using checklists he's got a lot of experience he's got over a thousand hours in the type of aircraft complacency family over familiar he's not using his checklists it's possible that the pilot did not check or adjust the setting of the power lever friction locks before the accident flight which led to uncommanded movement of the throttle in other words the ntsb suspects that the throttles simply crept back more on that in a minute although the co pilot reportedly had flown with the pilot many times previously and was familiar with the b300 he was not type rated in the airplane and he's not required to be for this part 91 operation and he was not allowed by the pilot to operate the flight controls when passengers were on board so the 71 year old pilot is not even using proper crm procedures in bringing the co-pilot on board the aircraft as a proper crew member assisting you with command and control of the aircraft it's another one-man band show type operation like mac mccauley in the b-17 where you just sit there be quiet build fly in time and do what i tell you that's not how you run a cockpit that's not how you do crm crew resource management therefore the co-pilot may not have checked and adjusted the friction setting before the flight's departure in addition to the lack of call outs for checklists on the cvr the pilots did not discuss any emergency procedures there was no takeoff briefing as a result they did not have a shared understanding of how to respond to the emergency of losing thrust in an engine during takeoff although the co-pilot verbally identified the loss of left engine in response to the pilot's confused reaction to the airplane's performance shortly after takeoff it is likely the co-pilot did not initiate any corrective flight control inputs possibly due to the pilot's established practice of being the sole operator of the flight controls when passengers were on board okay let's talk about friction locks on throttles for a moment most all aircraft have some form of a throttle friction lock because and during cruise flight you're going to want to set that and forget it for the most part set your rpm and set your throttle but on landing and take off i want that throttle lock loose this is the throttle lock on a luscum or most of these small aircraft i tighten it up like cranking it clockwise i loosened up counterclockwise so on takeoff or landing i want that kind of loose and a lot of folks ask me what are you pushing on with your index finger when you're flying the lust well that's how i modulate the throttle it's like how you handle your uh hand if you're playing a musical instrument where do you put your hand to play the instrument you can't just grab it like this you don't it's too coarse of a control you need to fine tune your control so i can pull out the throttle by pushing with my index finger that's what's going on in the luscum and even more importantly as you were learning to fly what did your instructor have you do on takeoff and landing he always had you keep your hand on the throttle at all times even though it's pinned forward you're holding that throttle forward to prevent it from creeping back if you were to ever as a student pilot take your hands off the throttle and grab the stick what did a good instructor do he'd pull that throttle back on you and force you to keep your hand on that throttle at all times why just like in the event of this addison accident in the event of a some kind of an emergency you need to react quickly to that throttle and you also need to prevent that throttle from creeping back on you and maintain the power setting that you want so what did the 71 year old pilot in the left seat do in the king air he had some notoriously bad habits that folks were that the ntsb was able to determine via interviewing folks that knew this pilot he would typically of course he did everything himself he wouldn't allow the guy in the right seat to back him up on the throttles at all like in a normal crm environment he instead would push the throttles up himself and then he would take his hands off the throttles grab the yoke and do an abrupt rotate with both hands on the yoke there is never a need to rotate a king air or any of these aircraft with two hands on the yoke you should always have your hands on the throttle at all times and you have plenty of muscle in one arm to handle the rotation of the aircraft so let's line up all the pieces of swiss cheese first you have an operational problem with the bad pairing of pilots you got the 71 year old pilot in the left seat i keep emphasizing his age because the retirement age at airlines is 65 and not that that's a bad thing but it is what it is you got the 71 year old pilot in the left seat and then you got the younger pilot in the right seat and the older pilot does not allow the junior pilot to manipulate the controls or a system in crm when passengers are on board number two we've got a full flight we've filled up with fuel we're about 600 pounds over gross weight at the aft limit or at or near the aft limit of the center of gravity for the aircraft number three we got a crew or at least a aircraft commander a pilot in the left seat that does not use checklists is not checking the throttle friction control number four there is no takeoff emergency briefing what are you going to do and work together as a crew in the event of an engine failure on takeoff number five once the throttles begin to diverge the pilot in the left seat makes the wrong rudder input at the critical phase of flight not only does he remove his hands from the throttles and grab the yoke and rotates abruptly and too early he is then confused by the loss of thrust in the left engine only the pilot in the right seat correctly identifies the problem you're losing power in the left engine what about the auto feather system in the king air the auto feather system is designed for an engine failure if you manually bring the throttle back you don't want that to automatically feather the propeller on you so if the throttles are sliding back the auto feather system is not going to automatically feather that engine and then finally with the right seater condition did not touch the controls with passengers on board nobody is manning the engine room nobody is pushing the throttles back up on the two perfectly good engines and the right seater is also reluctant or is not willing to get on the controls and straighten things out during this critical phase of flight instead the left seater sees that ground rush coming up and exacerbates the problem with up elevator and right aileron until that aircraft simply snap rolls right in to that hanger so i hope this gives you a better understanding of the ntsb final report and what happened to the king air in addison texas back in 2019 a completely preventable accident pilot error thanks so much for your support of this channel and especially those of you on patreon that make this content possible because anytime we talk about the loss of life this content is demonetized by youtube thank you so much for your support we're here to learn not to criticize see you here so [Music] speaking of learning if you learning to get your pilot's license and are watching the blanco lyrio channel good on you and if you are studying for your ground school and or practical private pilots exam i highly recommend using the finer points flight training app it's an apple app available on your ipad and it makes learning for these tests real fun and easy much easier than just slogging it through the books all on your own if you're an older pilot like me and have forgotten most of everything that you learned from your private pilot's license or maybe your bfr is coming up this finer points flight training app makes a great great review check it out you

Channel: blancolirio

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Length: 19min 14sec (1154 seconds)

Published: Tue May 25 2021