New details reveal the incident occurred during a skydiving operation at Raeford West Airport (NR20) in North Carolina. The pilots were on approach to pick up another group of skydivers with second in command (SIC) Crooks flying. According to the NTSB report, the approach was stable until the aircraft descended below the tree line and encountered wind shear. Crooks initiated a go-around, but before establishing a climb, the right main landing gear struck the runway surface and then detached.

The pilots then declared an emergency and requested to divert to a larger airport. The pilot in command (PIC) took over while Crooks communicated with ATC. According to the unnamed PIC, Crooks became visibly upset following the hard landing. He proceeded to open his side cockpit window and lower the ramp in the back of the aircraft, indicating he needed air. Crooks then apologized, left his seat, removed his headset, and ran out of the airplane via the aft ramp door.

• READ MORE: NTSB Preliminary Report Sheds Light on Copilot Mid-Air Departure

According to the report, “although the PIC and operator reported that the SIC’s departure from the airplane was an intentional act, there was insufficient information to support that assertion.”

Federal investigators also noted that the PIC, who was flying with Crooks, served as the chief pilot for the operator, which could have contributed to his stress. Family members told investigators Crooks was “extremely happy” and “loved to fly,” noting that he was in “a fabulous state of mind” prior to the flight.

• READ MORE: Copilot’s Departure of Aircraft in Mid-Flight Baffles Authorities

Ultimately, investigators listed the probable cause as “the airplane’s encounter with wind shear during landing, which resulted in a hard landing and separation of the right main landing gear, and the pilot’s subsequent decision to leave his seat in flight, which resulted in his fall from the airplane.”

Editor’s Note: This article first appeared on AVweb.

The post NTSB’s Final Report Leaves Unanswered Questions in Copilot’s Fatal Fall appeared first on FLYING Magazine.

Anders, 90, was a retired military pilot and Air Force major general, Apollo-era NASA astronaut, and founder of the Heritage Flight Museum.

According to the preliminary investigation published by the National Transportation Safety Board (NTSB), a friend told investigators that Anders sent her a text message before the June 7 morning flight stating he would be flying past her house at 11:40 a.m., which was close to his old residence located on the western shore of Orcas Island.

• READ MORE: Apollo Astronaut William Anders, 90, Dies in T-34 Crash

The witness said these flights were not unusual, although the accident flight was the first time he had performed it in 2024. The witness said that Anders would sometimes rock the wings of the airplane but did not perform aerobatic maneuvers.

Radar data provided by the FAA showed a target departing Skagit Bayview Regional Airport (KBVS) at about 11:13 the morning of the accident but did not include altitude data.

The target flew west toward Orcas Island and performed a series of passes back and forth along the coastline of the San Juan Channel.

The graphics provided by the NTSB report show the aircraft flying a route back and forth along the shoreline.

The friend told investigators that she heard the airplane, then a short time later she observed it overhead traveling north along the shoreline in front of her house. The aircraft then flew behind trees and out of view, and she could hear but not see what sounded like the airplane making a left turn to the south. The airplane came back into view, rolling out on a south heading.

“It was flying over the water but higher than the previous occasions,” the witness told NTSB investigators.

After the aircraft passed, the witness saw the left wing drop, and she thought this was part

of his usual routine. However, the wing continued to drop as the airplane began to rapidly descend toward the water.

• READ MORE: 55 Years Ago, Apollo 8 Astronauts Deliver Christmas Eve Message of Unity

Another witness located along the same shoreline about a third of a mile to the north said he observed the aircraft from his deck. He began to record the aircraft with his phone.

“At the beginning of the recording the airplane was inverted with a slight nose down attitude and heading generally to the south,” the NTSB report said. “Over the next three seconds, the airplane had transitioned to an almost vertical dive. As the airplane approached the water, it began to pull out of the dive, now facing the opposite direction. By the time it had recovered to almost wings level, upright attitude, the airplane struck the water with its right wing tip and spun across the water on a northern trajectory.”

Video of the event shows the aircraft being torn apart by the impact.

The NTSB said that these were the only witnesses to come forward with information. The final report on the accident is still months away.

The post NTSB: Witness Provides Details Leading Up to Fatal T-34 Crash appeared first on FLYING Magazine.

The aircraft was equipped with Tamarack Aerospace Group’s active technology load alleviation system (ATLAS), which operated independently of other airplane systems.

The system included the installation of Tamarack active camber surfaces (TACS), which are aerodynamic control surfaces mounted on the wing extensions that either hold their position in trail with the wing or symmetrically deploy trailing edge up or trailing edge down to alleviate structural loads. The TACS are actuated by the TACS control units (TCUs) and are not controlled by the pilot.

The winglets are designed to improve aircraft stability and fuel efficiency. 

The Accident

According to the NTSB report, on November 30, 2018, the Citation took off from Clark Regional Airport (KJVY) in Jeffersonville, Indiana, en route to Chicago Midway International Airport (KMDW). There was one pilot and two passengers on board.

IMC prevailed, and the flight was on an IFR flight plan. Data provided by the aircraft’s ADS-B showed the airplane climbing to an altitude of about 1,400 feet then turning left to the assigned fix and continuing to climb. 

The pilot contacted ATC and was assigned 10,000 feet. The pilot then activated the autopilot and selected the assigned altitude as the aircraft continued to climb. As it passed through 3,000 feet, it began rolling to the left at a rate of approximately 5 degrees per second.

After the onset of the roll, the airplane was at an airspeed of about 240 knots. When the airplane reached about 30 degrees of left bank, the autopilot disconnected, accompanied by an aural alert. The autopilot was designed to automatically disconnect at 45 degrees of bank.

One second later, the cockpit voice recorder (CVR) recorded a statement by the pilot consistent with surprise, which the NTSB determined was likely made in response to the autopilot disconnect or the bank angle. The NTSB surmised that based on the pilot’s reaction, the roll to the left was uncommanded.

Both the climb and bank angle continued until an altitude of about 6,100 feet, then the aircraft entered a rapid descent, and the bank angle increased to almost 90 degrees.

The CVR picked up the airplane’s enhanced ground proximity warning system, including eight “bank angle” annunciations and one “overspeed warning” annunciation. 

About 23 seconds after the autopilot disconnected, the pilot made a mayday call, shouting that he was “…in an emergency descent unable to gain control of the aircraft.” The final ADS-B data point indicates the airplane was at an altitude of about 1,000 feet, airspeed of about 380 knots, and 53-degree left bank. The airplane impacted terrain in a wooded area about 8.5 miles northwest of the departure airport. The total time from the beginning of the uncommanded roll to impact was about 35 seconds.

In the initial final report issued in 2021, the NTSB cited the probable cause of the accident as the “asymmetric deployment of the left wing load alleviation system for undetermined reasons, which resulted in an in-flight upset from which the pilot was not able to recover.”

Tamarack took issue with the agency’s findings, saying in particular that the report suggested the devices moved in a manner that is physically impossible, and witness marks found on the wreckage were caused by impact damage.

As previously reported by FLYING in 2022, Tamarack Aerospace Group presented this information to the NTSB. However, the manufacturer alleges the safety board did not consider the information and instead released the probable cause of the accident four days later.

Tamarack filed a petition challenging the NTSB findings that suggested the company’s winglet design contributed to the accident. In its petition Tamarack alleged the agency made “erroneous findings that are unsupported by the factual record, inconsistent with engineering principles or proven to be physically impossible.” 

The petition also questioned the NTSB’s inability to determine the experience level of the pilot in command (PIC). The PIC had an airline transport pilot certificate and a Cessna 525 (Citation) type rating. But since the pilot’s logbook was not located, his experience could not be determined.

By failing to locate his logbook, Tamarack suggests the NTSB did not follow its own published recommended procedures used on all aircraft accidents.

Tamarack called on the NTSB to reopen the investigation in order to “reconsider and modify its findings.” The agency complied.

On February 23, the NTSB published a revised aviation investigation final report. It noted that after the autopilot disconnect, the “pilot’s statements were consistent with startle and surprise and, although he made no statements that described actions he was taking, his statement in the mayday call of ‘unable to gain control’ is likely consistent with the pilot having taken some actions to regain control but an increasing recognition that they were not effective.”

Investigators noted that, according to a supplement to the flight manual emergency procedures, during an ATLAS inoperative condition in flight, the pilot is to move the throttles to idle and extend the speedbrakes to reach an airspeed below 161 knots. Warnings indicate that speed reduction is the first priority in these failure conditions, and large aileron input may be required if an ATLAS failure at high indicated airspeed includes a TACS runaway.

Investigators stated that the aircraft continued to climb after the autopilot disconnect, consistent with the engine being at a high power setting. During the descent, airplane systems warned of an overspeed condition, and the last data point revealed the airplane was traveling about 380 knots.

“Thus, it is unlikely that the pilot moved the throttles to the idle position as directed by the flight manual supplement,” the NTSB report said.

The report also pointed out the pilot did not reduce engine power or deploy the speedbrakes. The probable cause of the accident is listed as the “pilot’s inability to regain airplane control after a left roll that began for reasons that could not be determined based on the available evidence.”

Tamarack president Jacob Klinginsmith said the company was “very pleased” the NTSB decided to grant its petition for reconsideration. 

“[The NTSB has] taken steps to correct multiple technical errors in the original investigation,” said Klinginsmith. “This reversal shows the NTSB has the courage, professionalism, and proper process to make these corrections, and for that we applaud the NTSB.”

The post NTSB Revises Probable Cause of 2018 Citation Crash appeared first on FLYING Magazine.

The pilots were killed, but the passengers and cabin attendant escaped before the jet was destroyed by fire.

What Happened

According to the NTSB, earlier in the day the aircraft launched from Naples Municipal Airport (KAPF) in Florida, destined for Ohio State University Airport (KOSU) in Columbus. The Bombardier CL-600 was operated by Ace Aviation Services doing business as Hop-A-Jet, a charter service.

The accident happened when the aircraft was returning to Florida at the end of the day. Before departure from KOSU the aircraft was serviced with 350 gallons of fuel.

• READ MORE: 2 Killed in Florida Challenger Accident

According to information gleaned from preliminary ADS-B flight track data and air traffic control, around 3 p.m. EST the flight crew contacted the tower at KAPF while maneuvering for approach to Runways 23.

At 3:08 p.m. when the jet was about 6.5 miles north of the airport at an altitude of 2,000 feet and a ground speed of 166 knots, ATC cleared the jet to land on Runway 23. The aircraft turned for the base leg of the pattern, which put the aircraft on a 5-mile final.

Preliminary review of the information recovered from the airplane’s flight data recorder indicates that at 3:09:33 the first of three master warnings was recorded flagging a problem with oil pressure in the left engine. This was immediately followed by an oil warning from the right engine, then the system alerted pilots with illumination of a “master warning” light on the glareshield, a corresponding red message on the crew alerting system page, and a triple chime voice advisory “engine oil.”

At 3:10 when the aircraft was at approximately 1,000 feet msl and had slowed to 122 knots the crew declared an emergency and notified ATC that it had lost both engines.The aircraft was on a shallow intercept angle for final approach. ATC acknowledged the call, clearing the jet to land.

The crew replied it was not going to be able to make the runway. This was the last transmission. The aircraft was at an altitude of 900 feet and ground speed of 115 knots. The ADS-B showed the aircraft was over Interstate 75 in Naples, Florida. The highway runs north-south, putting it perpendicular to the assigned runway at KAPF.

It was rush hour on a Friday afternoon, and there were lots of cars on the interstate. Dashcam video submitted to the NTSB captured the final seconds of the flight, showing the jet in a shallow left turn as it descends. The jet leveled its wings before it touched down in the southbound lanes.

The left main landing gear touched down first in the center of the three lanes, and then the right main landing gear touched down in the right lane. The jet rolled through the breakdown lane and into the grass shoulder area before impacting a concrete sound barrier. The airplane caught fire, sending up a large cloud of black smoke.

The Crew

The flight crew of the jet included a captain, first officer, and cabin attendant. The cabin attendant told NTSB investigators that after the aircraft came to rest, she realized the cabin and emergency exits were blocked by fire, so she directed the passengers to the tail section of the airplane, and they evacuated through the baggage compartment door. The cabin attendant, the two passengers on board, and a motorist sustained minor injuries. The captain and copilot did not survive.

The captain held an airline transport pilot certificate with ratings for airplane single and multiengine land, with multiple type ratings. He also held a first-class medical certificate. His employer reported that he had accrued 10,525 total hours of flight experience, of which 2,808 hours were in the accident airplane make and model.

The first officer also held an airline transport pilot certificate with ratings for airplane single and multiengine land, with multiple type ratings. He also held a first-class medical certificate. His employer reported he had 24,618 total hours of flight experience, of which 138 hours were in the accident airplane make and model.

Airplane Information

According to FAA maintenance records, the accident airplane was manufactured in 2004 and was powered by two GE CF34 Series turbofan engines. Its most recent continuous airworthiness inspection was completed on January 5 at 9,763 total hours of operation.

Wreckage Information

Most of the aircraft was consumed by fire, but all major components of the airplane were accounted for. The wreckage reportedly smelled of jet-A fuel, and the ground was soaked with it.

The cockpit center console was found separated from the main wreckage. Both engine throttle levers were found near the “idle” stop position. The flap selector handle was found in a position consistent with 45-degree flap extension.

The left wing was nearly entirely consumed by post-impact fire. There was evidence the right wing had impacted the vertical steel I-beam of a highway sign. The outer portion of the wing had been torn off. The right wing fuel boost pump was located; the left wing fuel boost pump was not.

The airplane’s tail section was largely intact but was damaged by the post-impact fire. The vertical fin, horizontal stabilizer, and elevator control surfaces were all intact.

NTSB investigators noted the engines were still attached, and approximately 16 ounces of liquid with an odor and appearance consistent with jet-A fuel was drained from the aft tail fuel tank. The sample contained about a half ounce of what appeared to be water.

The auxiliary power unit fuel filter bowl was removed for visual inspection of the fuel and filter. No debris was noted in the drained fuel and the filter appeared clean. The fuel was retained for further analysis.

The engines also were removed for further examination. No pre-impact anomalies were discovered during the teardown and examination of the left engine, the oil filter appeared in good condition, and no particles were observed within the pleats.

During the examination of the right engine NTSB investigators did not find any structural anomalies or damage. However, the fuel filter bowl displayed evidence of thermal discoloration, although the filter appeared clean with no debris or foreign material within the pleats. Fuel samples were collected from various points throughout the fuel system, and it was noted the fuel from the fuel filter bowl and heat exchanger displayed a yellowish tint, while the other fuel samples were clear. The odor of the samples was consistent with jet-A. In addition, the main fuel inlet port exhibited a small, yellow-colored debris particle. The oil filter appeared in good condition, and no particles were observed within the pleats.

Both engines were retained for additional examination.

Editor’s Note: This information is preliminary and is subject to change. It can take anywhere from a year to 18 months for the NTSB to determine the cause of an accident.

The post NTSB Releases Preliminary Report on Florida Jet Accident appeared first on FLYING Magazine.

According to local broadcast news outlets, there were five people on board the Bombardier Challenger 600 which was flying from Ohio State University Airport (KOSU) in Columbus to Naples, then intended to continue on to Fort Lauderdale. The aircraft had left Ohio around 12:30 p.m.

According to Robin King, director of communication with the Naples Airport Authority, the Challenger was on approach to the airport when the flight crew radioed the airport reporting they had lost power in both engines. That was the final transmission just before the accident at 3:10 p.m.

The airplane came down on the interstate which runs north-south. Authorities have not said if the fatalities were persons in cars or in the aircraft.

Video and photographs of the scene showed fire and black billowing smoke and lines of cars in backed up traffic. Authorities have closed down a six mile stretch of the highway. It is expected to stay closed for at least 24 hours.

According to the FAA, the aircraft registration number of the Bombardier Challenger 600 is N823KD, which according to FAA records is owned by East Shore Aviation LLC out of Fort Lauderdale. Initial reports quoted by the Tampa Bay Times indicate the aircraft was operated by Hop-a-Jet Worldwide Charter.

The FAA and the National Transportation Safety Board are investigating the accident.

This is a developing story. More information will be published as it becomes available.

The post At Least 2 Killed in Florida Challenger Accident appeared first on FLYING Magazine.

Those words come from a statement from the FAA, which announced Thursday that it has formally notified Boeing that it is conducting “an investigation to determine if [the company] failed to ensure completed products conformed to its approved design and were in a condition for safe operation in compliance with FAA regulations.”

The investigation is a result of an incident on January 5 when an Alaska Airlines Boeing 737 Max 9 (737-9) lost a door plug in mid-flight, resulting in a rapid decompression of the aircraft and an emergency landing.

The airline immediately grounded its fleet of 737 Max 9s. Within hours the FAA grounded the model countrywide. This has resulted in hundreds of flight cancellations and delays for United Airlines and Alaska Airlines, which utilize the design. 

The FAA stated that the aircraft will not return to the skies until they have been inspected and found to be safe, noting “the safety of the flying public, not speed, will determine the timeline for returning the Boeing 737-9 Max to service.”

The FAA added: “Boeing’s manufacturing practices need to comply with the high safety standards they’re legally accountable to meet.”

• READ MORE: Boeing Subcontractor Scrutinized Over Door Plug Failure

In a letter sent to Boeing on Wednesday, the agency said that it had recieved notification of “additional discrepancies on other Boeing 737-9 airplanes” and noted these circumstances “indicate that Boeing may have failed to ensure its completed products conformed to its approved design and were in a condition for safe operation in accordance with quality system inspection and test procedures.”

The letter noted Boeing has 10 business days to respond to the FAA.

This is a developing story. FLYING will continue to provide updates as they are made available.

The post FAA Scolds Boeing Over Door Plug Decompression Incident appeared first on FLYING Magazine.

According to the investigative publication The Lever, the complaint was filed on December 19 in federal court in New York state on behalf of investors in Spirit AeroSystems. The complaint alleges that employees of the aerostructure manufacturer repeatedly warned corporate officials about “sustained quality failures” and “excessive amounts of defects,” but their concerns were ignored.

Employees allegedly discussed that it was only a matter of time before one of these substandard parts made it onto a jet delivered to a customer. Among the parts made by Spirit AeroSystems is the door plug that is used to turn a space for an optional emergency exit into a window. From the interior of the cabin it looks like the other windows. From the exterior the outline of the door is clearly seen on the fuselage.

On January 5 the left door plug of Alaska Airlines Flight 1282 blew off the aircraft as it climbed through 16,000 feet, resulting in violent decompression. The airplane had just taken off from Runway 28L at Portland International Airport (KPDX) in Oregon. The flight crew declared an emergency and the aircraft returned to the airport. There were no serious injuries among the 177 on board.

• READ MORE: Alaska Airlines Grounds 737 Max Fleet Following Explosive Decompression

The door plug was located adjacent to seats 26A and 26B. Both were heavily damaged, and parts of them expelled from the aircraft along with personal items such as cellphones. According to the New York Post,  a 15-year-old boy identified was seated in 25A, the window seat in the row directly ahead of the door plug when it blew—the force sucking the shirt off his back. When the wind died down, he relocated to a seat away from the gaping hole in the airplane and, like others on board, put on a supplemental oxygen mask. As it was impossible to talk over the noise, the woman sitting next to the boy used a cellphone as a tablet, and they communicated by text. He said he was OK but had some scrapes. They posed for a selfie at the end of the ordeal.

Since the event, the FAA has grounded all 150 Boeing 737 Max 9 aircraft and instructed operators to inspect them. Both Alaska Airlines and United Airlines utilize the 737 Max 9 and have reported finding loose bolts.

The National Transportation Safety Board (NTSB) recovered the door plug on Monday along with other bits and pieces torn from the aircraft. They are being shipped to the NTSB laboratory in Washington, D.C., where they will be put under a microscope for examination.

• READ MORE: NTSB Finds Missing 737 Max 9 Door Plug in Teacher’s Backyard

According to Clint Crookshanks, an aerospace engineer with the NTSB who is part of the structures team on this investigation, explained that the door plug is held in place by 12 stop pads that interface with 12 pins to prevent it from blowing out of the fuselage. The door is installed using guide tracks and roller guides then secured with four bolts. Crookshanks noted the guide tracks were fractured, but as of yet, the NTSB has not determined if the bolts gave way or if they were even installed.

The investigation has revealed the aircraft was delivered to Alaska Airlines in October 2023, and according to flight trackers, had logged approximately 145 flights at the time of the accident.

The NTSB has verified there were three maintenance write-ups made by the crews for air pressurization warning lights. This is a triple redundant system, with a primary and secondary that control cabin pressure by computer and a third system controlled manually. Maintenance issues were reported on December 7, January 3, and January 4.

The FAA allows aircraft to fly with these maintenance issues since it is considered a triple redundancy.

The NTSB said it will be investigating whether the warning lights were “correlated in any way to the expulsion of the door plug and the rapid decompression. The agency said  the probe into the blowout could take months.

• READ MORE: NTSB Identifies Part That Failed on 737 Max 9

Boeing said it is aiding the NTSB in the investigation. On Tuesday, company CEO and president Dave Calhoun held a safety meeting via webcast, addressing the employees and noting how the event shook him “to the bone” when he saw the image of the blowout.

“I didn’t know what happened to whoever was supposed to be in that seat next to that hole,” Calhoun said. “I got kids. I got grandkids, and so do you. This stuff matters. Everything matters. Every detail matters. I know I am preaching to the choir here. It’s not a lecture by any stretch. It is a reminder of the seriousness at which we have to approach our work.”

Calhoun added that Boeing has been in touch with its customers, who are understandably anxious and have grounded their fleets as a precaution.

“They did it quickly to prevent another potential accident,” he said. “We have to demonstrate with our actions that every Boeing airplane is safe in the sky. We are starting from a very anxious moment with our customers, and we have to deal with that reality.”

Boeing said it wants to continue to play a key role in the NTSB investigation, providing it with information to help determine the cause of the accident.

“They are as good as it gets,” Calhoun said of the agency. “I trust them every step of the way.”

In the meantime, the FAA is working with operators to develop an inspection process. FLYING reached out to Spirit AeroSystems and were referred to a statement on the company website: “Spirit AeroSystems has been working closely with our customer since the event with Alaska Airlines Flight 1282 on [January] 5. A Spirit team is now supporting the NTSB’s investigation directly. As a company, we remain focused on the quality of each aircraft structure that leaves our facilities.”

The post Boeing Subcontractor Scrutinized Over Door Plug Failure appeared first on FLYING Magazine.

The catastrophe was recorded by a number of surveillance cameras, some located not far from the point of impact. Video showed the airplane airborne, initially drifting left, then yawing left to an extreme sideslip angle before rapidly rolling into an inverted dive. The sequence took just a few seconds. Once the left wing had dropped, the low altitude made recovery impossible.

The crew had not reported any trouble to the tower. National Transportation Safety Board (NTSB) investigators reconstructed the event by analyzing surveillance videos and the sound spectrum of the engines captured as background noise by the cockpit voice recorder, as well as extracting data from the airplane’s ADS-B and terrain awareness warning systems. They concluded the critical left engine had spooled down for some reason, and the pilot had reacted by pressing on the left rudder pedal rather than the right. Only the combination of asymmetric thrust with added rudder, the NTSB found, could bring the airplane to the extreme yaw angle observed in the videos, as asymmetric thrust alone would not have been sufficient.

The only communications between the two pilots recorded during the accident sequence were an exclamation of “What in the world?” by the pilot flying and the copilot’s statement, three and a half seconds later, that “You just lost your left engine.” (The King Air is a single-pilot airplane. The copilot frequently flew with the pilot to gain experience, but was not permitted to touch the controls when passengers were aboard.)

The NTSB suspected the spooldown of the left engine might have been caused by a faulty friction setting on the left power lever, which could have allowed it to creep backward during the takeoff roll. This is a known susceptibility of King Airs; the power levers are spring-loaded toward idle, each has its own friction knob, and they rely on positive friction to keep them from drifting. The power quadrant was too badly damaged in the post-crash fire to allow investigators to tell anything about the position of the left power lever or the friction settings. Uncommanded power rollbacks on the PT6-series engines can have other causes, however, which would not necessarily be detectable in a severely burned wreckage, and so the attribution to the friction setting remained speculative.

The quadrant frictions are a checklist item, but the CVR recording disclosed no pre-takeoff briefing and none of the expected checklist or V-speed callouts. According to other pilots who had flown with him, the pilot, 71, a 16,450-hour ATP, was “not strong on using checklists” and “just jumped in the airplane and went.” He was, on the other hand, “super strong” on knowledge of the airplane, in which he had logged 1,100 hours. According to the pilot who administered his most recent proficiency check, he had performed well on the simulated engine failure on takeoff. The check ride took place in the airplane, however, not in a simulator, and so as a safety precaution the engine cut, which had been briefed in advance, did not occur until the airplane was safely airborne and climbing. A successful performance under such controlled circumstances did not guarantee success in exigent ones.

The NTSB’s reconstruction of the takeoff showed the pilot had rotated at 102 kias, slightly below the V1 (go/abort) speed of 106 kias and 8 knots below the calculated rotation speed of 110 knots. The airplane was fully airborne at 106 kias and was at around 110 kias when the power began to roll back. The airplane drifted left, reaching a maximum altitude of 100 feet. Three seconds later, it was at 70 feet and the airspeed was 85 knots. One second later, it plunged through the hangar roof.

The standard procedure for loss of an engine in the King Air 350 is to establish a positive rate of climb with a pitch angle of 10 degrees, retract the landing gear, and feather the propeller on the inoperative engine while maintaining V2 (minimum safe climb speed with an engine out) to 400 feet agl. Above 400 feet, the airplane is allowed to accelerate, the flaps are retracted, and the climb continues at 125 kias.

None of this happened, however, because the pilot, in spite of his lifetime of flying experience and countless successful proficiency checks, stepped on the wrong rudder pedal.

• READ MORE: Objection Overruled

There was a time when the NTSB often cited fatigue as a contributing factor in accidents, but at some point it must have become obvious that plenty of well-rested pilots crashed too, so unless a pilot literally fell asleep at the wheel, fatigue could never be proved to have been a link in a causal chain. In this case, the pilot had a history of severe sleep apnea. To the extent that the FAA was aware of it, the agency had taken no action, although in principle the condition could have been disqualifying. The NTSB turned its back on this opportunity to invoke fatigue. “No evidence,” the agency wrote, “indicates that the pilot’s medical conditions or their treatment were factors in the accident.”

I would have expected the NTSB’s finding of “probable cause” to be something like “…the pilot’s inappropriate reaction to a loss of power in the left engine, which resulted in loss of control.” Instead, it blamed “the pilot’s failure to maintain airplane control,” which seems rather vague and generic. Among the contributing factors, “failure to conduct the airplane manufacturer’s emergency procedure” is a little misleading, since he did begin to execute the procedure but bungled it. The agency added his “failure…to follow the manufacturer’s checklists during all phases of operation,” even though the only link between checklists and the crash was the hypothetical faulty friction setting for which there was no material evidence. Two King Air pilots with whom I discussed the accident were skeptical of the friction theory because they said matching torques on two PT6s during takeoff involves enough fiddling with the power levers that it would be impossible for the pilot to be unaware of a sloppy-feeling lever.

I suspect the NTSB wanted to blame the accident on the pilot not being a by-the-book kind of person. None of his associates the NTSB interviewed suggested he was reckless or incompetent—quite the opposite. The problem with pinning the accident on a personality trait of the pilot is that the mistake of stepping on the wrong rudder pedal is not connected in any obvious way to that. It seems more like one of those random human mistakes we all sometimes make—but hope we will never make at a critical moment.

Note: This article is based on the National Transportation Safety Board’s report of the accident and is intended to bring the issues raised to our readers’ attention. It is not intended to judge or reach any definitive conclusions about the ability or capacity of any person, living or dead, or any aircraft or accessory.

This column first appeared in the August 2023/Issue 940 print edition of FLYING.

The post King Air 350 Accident Proved to Be Fatal Misstep appeared first on FLYING Magazine.

On Monday, NTSB Chair Jennifer Homendy thanked the public and local law enforcement for helping find the door plug that flew off Alaska Airlines Flight 1282 shortly after takeoff from Runway 28L on Friday. The aircraft made an emergency landing at Portland International Airport (KPDX).

There was no loss of life, but the 171 passengers, two pilots, and four flight attendants were understandably shaken up, noted Homendy, adding that the flight crew acted heroically in the chaotic situation.

According to preliminary information the NTSB gathered, the explosive decompression was the result of the failure of  a door plug located in Row 26 of the Boeing 737 Max 9. The door plug is a space in the fuselage that allows for an additional emergency exit door to be installed if the customer desires. Alaska Airlines and United Airlines, the two largest U.S. customers for the Boeing 737 Max 9, have opted for fuselages with door plugs. From inside the cabin, you cannot tell there is an option for a door.

When the door plug on the left side of Alaska Airlines flight 1282 blew out, seats 26A and 26B, which were adjacent to the door plug, were empty. Parts of the seats were ripped away, and the remaining seat frames twisted by the force of the decompression. There was damage throughout the cabin but no serious injuries.

The door plug was found over the weekend in a Portland neighborhood west of the airport. Bob Sauer, a high school science teacher, discovered it in his backyard. The NTSB recovered the door Monday. Since it was dark when the incident happened, residents west of KPDX didn’t know there were parts of the aircraft falling from the sky until the light of day. When Sauer realized what it was, he sent a photo of it to the NTSB at witness@ntsb.gov. One of his neighbors, meanwhile, found part of a headrest from a seat on her back patio, and two cellphones were found nearby. There were no reports of injuries or damage from the falling objects.

• READ MORE: NTSB Finds Missing 737 Max 9 Door Plug in Teacher’s Backyard

During the Monday NTSB briefing, Clint Crookshanks, an aerospace engineer and part of the agency’s structures team, explained the design of the door plug, stating it is held in place by 12 stop pads on the opening that interface with 12 stop pins on the plug to prevent it from blowing out of the fuselage.

The installation of the door plug requires guide tracks and roller guides to get it into position. There is a hinge on the bottom of the door plug that allows it to be moved out approximately 15 degrees for maintenance. There are four stop bolts designed to keep it from moving upward and disengaging the stops.

“The exam to date has shown that the door did in fact translate upward, [allowing] all 12 stops became disengaged allowing it to blow out of the fuselage,” Crookshanks said. “We found that both guide tracks on the plug were fractured. We have not yet recovered the four bolts that restrain it from its vertical movement, and we have not yet determined if they existed there. That will be determined when we take the plug to our lab in Washington, D.C.”

The search for evidence continues, said Homendy.

“We are still looking for the bottom hinge fitting and a spring,” she said. “It is a pretty large spring. The fitting is a green circular piece with a hole in it.”

The NTSB will put the parts under microscopic examination in an effort to determine why the failure occurred.

Flight Telemetry Tells the Story

Although the cockpit voice recorder (CVR) was overwritten because it was not removed from the aircraft before its two-hour cycle was up, investigators do have information gleaned from the Flight Data Recorder (FDR) for the January 5 flight.

At 17:06:47 p.m., Flight 1282 took off from Runway 28L at KPDX.

At 17:12:33, the recorded cabin pressure dropped from 14.09 to 11.64 PSI. The aircraft was at approximately 14,083 feet at an airspeed of 271 knots. At this time, the cabin altitude greater than 10,000 feet warning was activated.

At 17:12:34, the master caution activated as the cabin pressure dropped to 9.08 PSI. The aircraft was at an altitude of 14,850 feet.

The aircraft reached a maximum altitude of 16,320 feet then began a descent to 10,000 feet and returned to KPDX.

Homendy noted that the agency aircraft systems team is focusing on the cabin pressure control system, as there were three occasions when the auto pressurization light illuminated. She said this computer-run system has a triple redundancy with one primary cabin pressure controller, a secondary controller, and a manual controller. If the primary and secondary computer-run systems fail, the crew activates the system manually to maintain safe cabin pressurization.

“If either one of the computer systems is inoperative, the FAA allows the operator to continue flying the aircraft,” Homendy said.

The NTSB has verified the maintenance logs of the aircraft that indicate the redundant system “operated as designed on December 7, January 3, and January 4.” The flight crew notified maintenance of the warning light illumination as required, but it has not been determined if the warning lights were “correlated in any way to the expulsion of the door plug and the rapid decompression.”

The investigation into the blowout could take months.

In the meantime, the world’s 737 Max 9 fleet is grounded, resulting in hundreds of flight cancellations and delays. The FAA is working with operators to develop an inspection process.

Alaska Airlines, the FAA, Boeing, and Spirit Aero, the makers of the fuselage of the 737 Max 9, are working together to identify the issues so that the aircraft can safely return to flight.

The post NTSB Identifies Part That Failed on 737 Max 9 appeared first on FLYING Magazine.

The loss of the door plug resulted in what has been described as “explosive decompression.”

During a media update Sunday, Homendy noted that the teacher took photographs of the refrigerator-sized door and contacted the agency via witness@NTSB.gov.

Homendy described the door plug as a “yellowish green on one side, which might make it blend into the vegetation, and white on the other, measuring 26 by 43 inches and weighing 63 pounds.”

The NTSB chief called the door plug a crucial piece of evidence in the investigation into what caused the incident aboard Alaska Airlines Flight 1282. The aircraft took off from Portland International Airport (KPDX) just before 5 p.m. PST on Friday, then as the aircraft climbed through 16,000 feet en route to Ontario, California, the door plug blew off the aircraft, triggering explosive decompression.

• READ MORE: Alaska Airlines Grounds 737 Max Fleet Following Explosive Decompression

The door plugs are located in row 26 of the aircraft. The seats adjacent to the left side door plug were not occupied at the time. Homendy noted the force of the decompression damaged seats and sucked loose items, such as cellphones, out of the aircraft. No serious injuries were reported to the 177 persons on board.

During the media update, Homendy stressed that the part that departed the aircraft was a door plug and not a door, because it is not usable for entry and egress of the aircraft. The right-side door plug, which is still on the aircraft, is undergoing a detailed inspection on Monday.

The agency is working with Boeing to obtain technical information about the door plug and shared a description of the part, stating it has two hinges on the bottom that allow it to open for inspection about 15 degrees. In addition, the door plug has “12 stop fittings, six on each side, which are essentially circles on the door plug that line up with circles on the airliner. The purpose of these stop fittings is to prevent the door plug from being pushed out of the airframe.”

According to Homendy, the NTSB’s structures team spent the weekend studying damage to the aircraft and what are called “witness marks” on the airframe and identifying components that will be sent back to the agency structures lab for analysis. The components will be inspected under a microscope to look for paint marks, fractures, deformation, and evidence of shearing.

The aircraft systems are also under scrutiny, as the team noted the auto pressurization light illuminated on flights on December 7, January 3, and January 4. The flight crew followed procedure, activating the backup and reporting the issue to the airline’s maintenance staff. It was checked out by maintenance, and the aircraft returned to service with restriction that it not be flown to Hawaii as a precaution.

Homendy said the airline had ordered an additional maintenance inspection of the light, but it was not completed before the decompression flight.

The NTSB has requested documentation of “all defects of the aircraft since its delivery on October 31 of 2023.”

Damage to the Aircraft

According to the NTSB, there was no external damage to the aircraft. However, there was on the interior, including torn parts of plastic trim and insulation and damaged interior plastic windows—none of which is considered structural in nature. Damage was reported in rows 33, 32, 31, 27, 26, 25, 12, 11, 4, 3, 2, and 1.

The door plugs are located in row 26 on the 737 Max 9. The headrests from seats 26A and 25A were torn, the seats were “torqued,” and the seat back and tray table of 26A are missing. Homendy noted seats 26A and 26B were not occupied during the flight, adding, “We have 178 seats on this plane, 171 had passengers in them.”

The oxygen masks were deployed as a result of the decompression. Homendy said the tubing for oxygen masks in 26A and 26B were found sheared off.

There were three infants aboard the flight being held in the laps of their caregivers. They were not harmed, but Homendy noted that while the FAA permits children under the age of 2 to be held on the lap of an adult during flight, the NTSB, FAA, and Alaska Airlines recommend that caregivers carry their children in car seats, purchasing a seat for the infant and strapping them in just as they would in an automobile.

Four unaccompanied minors also were on the flight. Homendy said that when the incident happened, the flight attendants were very focused on making sure the minors had their lap belts and oxygen masks on and praised them for their actions during the emergency. Homendy said the NTSB is gathering information from the flight attendants as part of the investigation.

The Flight Deck

According to Homendy, the flight crew reported hearing a loud bang, and the flight deck door sprung open. The copilot “jolted forward, losing her headset, and the captain lost part of his.” They immediately put on their oxygen masks. The quick reference, laminated checklists that were in front of both pilots were sucked out of the aircraft, so the captain grabbed the quick reference handbook kept in a pocket on the flight deck and handed it to the first officer.

The flight deck door slammed against the lavatory door, and was pinned there, but there was no one inside. It took a flight attendant three tries to get the flight deck door closed. Communication between the flight deck and cabin was very difficult because of the noise.

The Investigation

The cockpit voice recorder (CVR) and flight data recorder (FDR) were sent to the NTSB lab on Sunday. The information on the FDR is helping the agency narrow the search area for evidence.

Businesses and homeowners in the area have been asked to check their roofs for parts of the aircraft or other items that may have been ejected from the jet. Two cellphones were found along a road in the vicinity of the door plug.

Homendy noted that citizens in the area were using drones to search for evidence, and she asked that homeowners and businesses with security cameras to check for any video of the event, which happened at 5:11 p.m. PST on Friday.

“If you see something, please report it to us, [at] witness@ntsb.gov, or please call local authorities,” Homendy said.

Homendy said the investigation may be hampered somewhat because the CVR would be no help.

“[It was] completely overwritten,” she said. “There is nothing on the cockpit voice recorder. …There was a lot going on the flight deck, and on the airplane it was a very chaotic event. The circuit breaker for the CVR was not pulled. The maintenance team went out to get it, but it was at the two-hour mark, and it was completely overwritten—at two hours, it rerecords over it.”

She noted that since 2018 the NTSB has done four investigations where the CVRs were overwritten, among them a situation in San Francisco when an Air Canada flight came within 60 feet of landing on a taxiway where four other aircraft, carrying a total of 1,000 people, were holding. The Air Canada flight executed a go-around.

Homendy said the NTSB is appealing to the FAA to increase the time on CVRs from two hours to 25, “which is consistent with Europe and many other countries.” She added that the time used to be 30 minutes before overwriting took place.

The FAA has released a Notice of Proposed Rulemaking (NPRM) to extend the CVR overwrite time on newly manufactured aircraft but not on aircraft already in use. Homendy suggested the FAA adjust the NPRM to include retrofitting of aircraft already in service, pointing out that airliners often have a lifespan of 40 years or more.

“I am calling on the FAA to change the rulemaking for 25-hour CVRs, not just new but retrofitting aircraft,” she said. “If the FAA won’t do it, we hope Congress will in the FAA authorization bill to ensure that it does happen.”

Homendy added that the NTSB may be on the Portland scene for weeks.

Alaska Airlines immediately grounded all of its 737 Max 9s  following the incident.

A few hours later, the FAA grounded all 737 Max 9 aircraft, mandating they be inspected immediately. As a result, there have been hundreds of flight cancellations for airlines that fly the 737 Max 9, among them Alaska and United.

Spirit AeroSystems, the Wichita, Kansas, manufacturer of the Boeing 737 Max jets, is assisting in the investigation. Boeing also has a technical team supporting the NTSB probe.

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