Passenger Causes DUAL ENGINE FAILURE | Accident Case Study

private owner flying jet aircraft is nothing new owner operated jets fly thousands of uneventful miles every day but when a well-meaning owner and pilot of a Business Jet invites his friend and two passengers for a flight a routine trip takes a terrible turn this is the story of a perfectly good airplane a dual engine failure and why the cockpit is no place for a casual attitude in the early afternoon of March 17th 2013 a hawker beachcraft Premier 1A Business Jet November 26 Del tequilo departs Tulsa Oklahoma on an IFR flight to Southbend Indiana mild weather on Route and clear skies with good visibility at the destination promises a smooth St Patrick's Day flight four people are on board the flight to South Bend the pilot in command for this part 91 flight is 58 old Tulsa businessman Alex Carson Premier 26 Del kilo is registered under Alex's business his friend Mark Ellis occupies the front right seat Alex met Mark at University in the early 1970s and they recently reconnected through their shared passion for Aviation Alex is eager to share his enthusiasm for his jet with his friend Mark is also an instrument a multi-engine rated Private Pilot but has no turbine airplane experience two other passengers are riding along in the premier's cabin The Climb is uneventful up to a cruising altitude of flight level 410 at 3:52 p.m. eastern Daylight time Chicago Center requests 26 Delta kilo to descend and maintain flight Level 240 followed by a clearance to 11,000 ft Center hands 26 Delta kilo off to Southbend Approach at 4:10 p.m. Southbend approach instru 26 Delta kilo to fly direct to the outer marker for Runway Niner right for a visual approach South approach prier jet 26 Delta kilo 11,000 prier 26 Delta kilo South approach proceed direct to new the outer marker forway n right and they'll have lower clearing traffic for the visual approach n right direct to n for 09 right 6th kilo at 4:13 p.m. approach clears 2 six Delta kilo down to 3,000 ft or 6 Delta kilo does set to maintain 3,000 3,000 6 Del kilo the premiere is only a few minutes away from Landing two minutes later November 26 Dela kilo calls up approach and delivers alarming news they've lost power in both [Music] engines Dead stick no power there six Delta kilo Roger uh did you need assist six Del kilay attention uh we've lost all power and we have no Hydraulics 6 K rer have equipment standing by uh is your craft uh controllable uh barely controllable the approach controller calls Southbend Tower to inform them of the dire situation the tower calls for emergency vehicles to be at the ready 26 Delta kilo lost all the power he's barely able to control his airplane you need to roll the trucks now Alex asks approach control for help uh we have no navigation if you could give us a vector please ATC informs Alex that they're heading in the right direction F Delta Q Roger maintain your present heading south you're directed right at southin airport 12:00 and N miles at 4:16 p.m. the approach controller tells Alex to turn 10° left to which he replies K turn left 26 Delta kilo stops responding to ATC but the aircraft is still Airborne unsure whether 26 Del kilo can receive audio approach clears the airplane to land six Delta kilo if you can hear me you are cleared for the visual approach Runway 9 or right or any Runway at South Bend all runways are available at South Bend my six Delta kilo if you're still with me you can remain this frequency again you are about a 3 m final Runway 9 right as the premiere approaches the airport the tower controller notices that 26 Delta kilo's main landing gear is not extended even though 26 Delta kilo reported losing all engine power the tower controller calls for a goar around 26 Delta kilo South Bend uh 26 Delta kilo no gear no gear go around if you hear South Bend no gear Tower informs the approach controller of the gear up situation who also tells to six Delta kilo to go around six Delta kilo go around you have no gear six Delta kilo if you can hear me go around sometime between 4:16 and 419 p.m. November 26 Delta kilo regained power from at least one of the engines allowing it to abort the landing and perform a climbing right turn the approach controller asks 26 Delta kilo to ident and shortly after the flash appears on their radar screen it appears November 26 Delta kilo can receive audio but is unable to transmit 26 Delta kilo thanks for the ident uh if you'd like to remain in the pattern that's fine I cannot hear any of your Transmissions anything you want to do right now is fine I do not see your altitude um just as the heads up but uh vehicles are standing by at South Bend November 26 Delta kilo makes right traffic for Runway Niner right during the second Landing attempt the tower notices the main landing gear is still retracted only the nose gear is extended they relay this information to approach control kilo Tower says it appears your nose gear only is down appears just your nose gear is down it's unknown whether or not Alex hears this transmission but he proceeds with the landing attempt anyway as 26 Delta kilo impacts the runway with only the nose gear extended it begins to bounce a witness reports that the airplane skipped like a rock across water about four or five times before taking off again the airplane makes a climbing right turn before entering a nose low rolling descent at 4:23 p.m. November 26 Del kilo impacts residential housing near the airport boundary sou sou crashed Alex and Mark are killed on impact incredibly the passengers in the cabin surviv surved with serious injuries a person on the ground is also seriously injured how can a sophisticated Business Jet like the premiere lose both engines simultaneously although Alex was able to restart at least one of the engines it appears he was unable to regain electrical power or fully extend the landing gear investigators soon discovered a key piece of evidence that would explain how the tragic events on board November 26 Delta kilo unfolded and what they learned was shocking November 26 Delta kilo was equipped with a cockpit voice recorder or CVR cvrs are not required on board part 91 aircraft but many airplanes that frequently operate under part 135 like corporate Jets have these devices factory installed the CVR recorded conversations between the pilot and front seat passenger interactions with air traffic control and ambient sounds picked up within the cockpit environment it records the last 30 minutes of audio in a continuous loop the CVR recording allowed investigators to create a clear picture of the events leading up to the crash of November 26 Delta kilo the recording begins at 3:45 p.m. eastern Daylight time while the aircraft is on Route Alex explains some of the premier's flight planning considerations to Mark most of the conversation simply shows Alex's excitement in talking about his jet but on closer inspection some of his comments are concerning for example Alex tells Mark that the premier's landing gear is engineered for a maximum Landing weight of 13,000 lb but that he doesn't have a problem Landing over that limit as for the published maximum weight he says I don't pay a whole lot of attention to it Alex's willingness to operate the airplane outside publish limits indicates several hazardous attitudes however his actions during The Descent were even more alarming to investigators at 3:52 p.m. Chicago Center instructs November 26 Delta kilo to descend and maintain flight Level 240 instead of ending the Casual cockpit chat and preparing for the approach Alex instructs Mark to use the autopilot and thrust levers for descent although Mark is a licensed private pilot he hasn't logged a flight in over four years he's also not typ rated in the premiere and has no jet experience moreover Alex is not a flight instructor and this is not a train training flight flight instructors know that an airplane's cockpit makes a terrible classroom unsurprisingly Mark struggles to control the premier's engines as the air speed rapidly increases Alex does not take control instead he allows Mark to exceed the airplane's maximum speed for 13.5 seconds the premier's over speed warning is clearly picked up by the [Music] CVR the premier's Emergency Operations section of the airplane flight manual outlines the procedure to follow in case of an overs speed one thrust idle two extend the speed brakes three if the aircraft is in a nose low attitude disconnect the autopilot and carefully pitch up to level flight instead Alex remains completely hands-off as the over speed warning blares Mark asks Alex for further instructions on the thrust levers just pull it way back well just get it out of the line and we got to get it so that the trends there you go the over speed warning seems to have shaken Mark's nerves he says I just hate chasing the darn thing Alex appears unfazed by the overp speed event he tries to reassure Mark with a joke about his lack of turbine airplane experience how many hours you got flying this jet well I know but I'm just saying it's just you know it's just uncomfortable creates creates an alarm in the back thrw up trle down his light-hearted teasing does little to dispel Mark's discomfort Mark seems uneasy manipulating the aircraft's controls Alex ignores his friend's concerns and continues to involve him in the flight operations at 4:03 p.m. Chicago Center instructs 26 Delta kilo to descend and maintain 177,000 ft as the airplane approaches the target altitude Alex instructs Mark to increase the power to maximum continuous thrust now let's go to the stop okay to The Click MCT good as the premiere accelerates Alex tells Mark to dial in the local altimeter setting while distracted by the altimeter Mark fails to notice the Jet's swiftly increasing speed 40 seconds later 26 Ste the kilo exceeds the maximum speed once again for 11.4 seconds the overp speed warning sounds once again Alex is unbothered by the overspeed emergency he seems to imply that the altimeter distraction was intentional that's what a check pilot will do is he'll give you three things to do right but he knows you're trending in the wrong direction 5 seconds after the overs speeed warning stops Alex gives the thrust controls back to mark your throttles at 4:13 p.m. 26 Delta kilo is cleared from 10,000 ft down to 3,000 ft Alex tells Mark to reduce thrust and slow the premiere to around 210 knots let's power back let's bring it back to uh let's Trend towards uh 220 210 okay and we'll have to comb way out of it to do that the CVR picks up the sound of a reduction in engine RPM as Alex runs through the 10,000 ft checks he asks Mark to reduce speed to 200 knots just pull pull power out just pull it on down yeah let's get back to 200 as Mark pulls back on the thrust levers he either intentionally or inadvertently pulls up on the finger locks the locks normally prevent the levers from moving past the idle the tent instead of reducing the power to idle Mark moves the thrust levers into the fuel shut off position this action causes an immediate loss of engine power interrupting the airplane's electrical system and disconnecting the autopilot the airplane is at 6,700 FT and still 18 Mi Southwest of the Southbend Airport Alex quickly realizes what has happened uhoh what you went back behind the stops and we lost power his focus is now divided between navigating to the airport and restarting the engines at low altitude the correct course of action would be to run the air start checklist it explains the correct procedure to restart an engine in Flight if the airplane is flying at least 200 knots there is sufficient air flow to spin the engine up for a relight below 200 knots the pilot must engage the starter November 26 Delta kilo's exact speed during the engine shutdown is unknown but it's likely to have been around 200 knots or greater however the CVR doesn't record Alex reading a checklist or performing the correct restart actions about 40 seconds after engine shutdown the CVR records the engine starter spooling up however a sound Spectrum analog is indicates that the engine ignition was not on as required for an air start and that the restart did not [Music] succeed shortly after 26 kilo's emergency transmission to Southbend approach the CVR loses power for 8 seconds during this time frame 26 Delta kilo can still receive audio from ATC and transmit what caused the power Interruption to the CVR the answer requires a closer look at the premier's electrical system a key part of the investigation two electrical buses power the premier's main aircraft systems the essential bus and the standby bus the essential bus Powers the systems critical to aircraft operations including most flight instruments Communications and navigation radios landing gear and engine starters it also Powers the CVR in case the essential bus fails the premiere has a standby bus this bus Powers the minimum amount of equipment required to safely land the aircraft neither the landing gear extension system nor the landing gear status lights will work flaps and anti-skid braking will also be unavailable during normal flight operations the engine-driven generators power the essential and standby buses if the generators are inactive the 24volt main battery provides power if the essential bus loses power the standby bus has its own battery that provides at least 30 minutes of eer mergency power to limited equipment a battery switch in the cockpit can be set to on or standby the on position uses the main battery and the standby position uses the standby battery if the pilot selects the standby position without the generator's running power to the essential bus will be lost investigators concluded that a power Interruption to the essential bus caused the 8-second loss of CVR audio the report suggests the most likely reason is the pilot manually moving the battery switch from on to standby the investigators also found the slightly bent battery switch in the standby position in the aircraft wreckage de-energizing the essential bus inhibits the starter and ignition systems which prevents engine restart after the CVR comes back online November 26 Delta kilo is still without engine power and navigation equipment a minute later the CVR cuts off for the final time [Music] without the CVR to tell the story and no further radio calls from the airplane investigators had to piece together what happened during November 26 Delta kilo's final 7 Minutes sometime between the CVR failure and the go-around Alex managed to restart the left engine this implies that power was reestablished to the essential bus enabling the ignition system why then was the landing gear only partially extended well investigators found the emergency manual gear extension handle partially pulled out this explains why only the nose gear was extended the handle needed to be pulled several inches more to deploy the main gear however it doesn't explain why Alex didn't extend the gear using either main battery power or the left generator after engine restart the premiere is designed to fly on one engine if Alex went around because of a gear extension issue the first time why did he not climb to altitude Circle and troubleshoot investigators could not find a reason for 26 Delta kilo's immediate return for another Landing attempt the aircraft's improper configuration made a safe landing essentially impossible the n pb's final report identifies two probable causes for this accident first is the private pilot's inadequate response to the Dual engine shutdown during crew's descent second the NTSB includes the Pilot's decision to allow the unqualified pilot rated passenger to manipulate the airplane controls the NTSB also emphasized the Pilot's failure to adhere to procedures which ultimately resulted in his failure to maintain airplane control during the same single engine go around the NTSB could not find any evidence of mechanical issues that would have caused the crash all of the evidence points towards a fairly inexperienced Jet Pilot who made several unfortunate errors in judgment these errors resulted in a situation that exceeded his aircraft knowledge hindering his ability to respond promptly and correctly while a dual engine failure at low altitude is extremely rare following the correct procedures would like have resulted in a safe landing the air start checklist outlines the engine restart procedure including the steps the pilot must take to reestablish generator power it is the Pilot's responsibility to ensure that they are able to remember and execute emergency memory items and locate appropriate checklists of course the accident sequence began long before the engines were shut down the Pilot's decision to allow an unqualified passenger to operate the aircraft set disaster in motion regulations and procedures exist for a reason to keep us and those who depend on us safe airmanship involves more than stick and Rudder skills it requires us to use good judgment and be masters of our aircraft at all times Aviation is unforgiving of pilots who do not meet these high standards on every single flight thanks for watching and fly safely

Channel: Pilot Institute Airplanes

Views: 423,152

Keywords: flight training, online ground school, pilot institute, pilot institute ground school, private pilot made easy, instrument ground school, FAA written exam, Ground School, Pilot Institute, Private pilot training, Instrument training, IFR training, Commercial pilot training, accident case study, air crash investigation, ntsb accident, ntsb investigation, faa investigation, airplane accident, airplane crash, crash investigation, accident analysis, mayday, engine failure

Id: b-PDWUTcb9Y

Length: 19min 57sec (1197 seconds)

Published: Wed Jun 12 2024