CEN19MA190

The pilot’s failure to maintain airplane control following a reduction of thrust in the left engine during takeoff. The reason for the reduction in thrust could not be determined. Contributing to the accident was the pilot’s failure to conduct the airplane manufacturer’s emergency procedure following a loss of power in one engine and to follow the manufacturer’s checklists during all phases of operation.

The pilot, co-pilot, and eight passengers departed on a cross-country flight in the twin-engine airplane. One witness located on the ramp at the airport reported that the airplane sounded underpowered immediately after takeoff “like it was at a reduced power setting.” Another witness stated that the airplane sounded like it did not have sufficient power to takeoff. A third witness described the rotation as “steep,” and other witnesses reported thinking that the airplane was performing aerobatics. Digital video from multiple cameras both on and off the airport showed the airplane roll to its left before reaching a maximum altitude of 100 ft above ground level; it then descended and impacted an airport hangar in an inverted attitude about 17 seconds after takeoff and an explosion immediately followed. After breaching a closed roll-up garage door, the airplane came to rest on its right side outside of the hangar and was immediately involved in a postimpact fire. Sound spectrum analysis of data from the airplane’s cockpit voice recorder (CVR) estimated that the propeller speeds were at takeoff power (1,714 to 1,728 rpm) at liftoff. About 7 seconds later, the propeller speeds diverged, with the left propeller speed decreasing to about 1,688 rpm and the right propeller speed decreasing to 1,707 rpm. Based on the airplane’s estimated calibrated airspeed of about 110 knots and the propeller rpm when the speeds diverged, the estimated thrust in the left engine decreased to near 0 while the right engine continued operating at slightly less than maximum takeoff power. Analysis of available data estimated that, 2 seconds after the propeller speed deviation, the airplane’s sideslip angle was nearly 20°. During the first 5 seconds after the propeller speed deviation, the airplane’s roll rate was about 5° per second to the left; its roll rate then rapidly increased to more than 60° per second before the airplane rolled inverted. Witness marks on the left engine and propeller, the reduction in propeller speed, and the airplane’s roll to the left suggest that the airplane most likely experienced a loss of thrust in the left engine shortly after takeoff. The airplane manufacturer’s engine-out procedure during takeoff instructed that the landing gear should be retracted once a positive rate of climb is established, and the propeller of the inoperative engine should be feathered. Right rudder should also be applied to balance the yawing moment imparted by a thrust reduction in the left engine. Examination of the wreckage found both main landing gear in a position consistent with being extended and the left propeller was unfeathered. The condition of the wreckage precluded determining whether the autofeather system was armed or activated during the accident flight. Thus, the pilot failed to properly configure the airplane once the left engine thrust was reduced. Calculations based on the airplane’s sideslip angle shortly after the propeller speed deviation determined that the thrust asymmetry alone was insufficient to produce the sideslip angle. Based on an evaluation of thrust estimates provided by the propeller manufacturer and performance data provided by the airplane manufacturer, it is likely that the pilot applied left rudder, the opposite input needed to maintain lateral control, before applying right rudder seconds later. However, by then, the airplane’s roll rate was increasing too rapidly, and its altitude was too low to recover. The data support that it would have been possible to maintain directional and lateral control of the airplane after the thrust reduction in the left engine if the pilot had commanded right rudder initially rather than left rudder. The pilot’s confused reaction to the airplane’s performance shortly after takeoff supports the possibility that he was startled by the stall warning that followed the propeller speed divergence, which may have prompted his initial, improper rudder input. In addition, the NTSB’s investigation estimated that rotation occurred before the airplane had attained Vr (rotation speed), which decreased the margin to the minimum controllable airspeed and likely lessened the amount of time available for the pilot to properly react to the reduction in thrust and maintain airplane control. Although the airplane was slightly over its maximum takeoff weight at departure, its rate of climb was near what would be expected at maximum weight in the weather conditions on the day of the accident (even with the extended landing gear adding drag); therefore, the weight exceedance likely was not a factor in the accident. Engine and propeller examinations and functional evaluations of the engine and propeller controls found no condition that would have prevented normal operation; evidence of operation in both engines at impact was found. Absent evidence of an engine malfunction, the investigation considered whether the left engine’s thrust reduction was caused by other means, such as uncommanded throttle movement due to an insufficient friction setting of the airplane’s power lever friction locks. Given the lack of callouts for checklists on the CVR and the pilot’s consistently reported history of not using checklists, it is possible that he 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. Although the co-pilot reportedly had flown with the pilot many times previously and was familiar with the B-300, he was not type rated in the airplane and was not allowed by the pilot to operate the flight controls when passengers were on board. Therefore, the co-pilot may not have checked or adjusted the friction setting before the flight’s departure. Although the investigation considered inadequate friction setting the most likely cause of the thrust reduction in the left engine, other circumstances, such as a malfunction within the throttle control system, could also result in loss of engine thrust. However, heavy fire and impact damage to the throttle control system components, including the power quadrant and cockpit control lever friction components, precluded determining the position of the throttle levers at the time of the loss of thrust or the friction setting during the accident flight. Thus, the reason for the reduction in thrust could not be determined definitively. In addition to a lack of callouts for checklists on the CVR, the pilots did not discuss any emergency procedures. 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 the 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 flight controls when passengers were on board. The investigation considered whether fatigue from inadequately treated obstructive sleep apnea contributed to the pilot’s response to the emergency; however, the extent of any fatigue could not be determined from the available evidence. In addition, no evidence indicates that the pilot’s medical conditions or their treatment were factors in the accident. In summary, the available evidence indicates that the pilot improperly responded to the loss of thrust in the left engine by initially commanding a left rudder input and did not retract the landing gear or feather the left propeller, which was not consistent with the airplane manufacturer’s engine out procedure during takeoff. It would have been possible to maintain directional and lateral control of the airplane after the thrust reduction in the left engine if right rudder had been commanded initially rather than left rudder. It is possible t

According to people who knew both pilots, they had flown together many times before the accident flight. Although the B-300 is certificated for single-pilot operation, an acquaintance of the pilot reported that he was not comfortable flying the B-300 as a single pilot and that he always had a co-pilot for his flights. The Pilot The accident pilot completed recurrent training in the accident airplane (N534FF) on March 23, 2019, at Rich Aviation Services, Fort Worth, Texas. The training consisted of 2.7 hours in the airplane, including abnormal and emergency procedures, and ground training on the airplane’s systems, which included—but was not limited to—engine/propellers, performance, and weight and balance. During a postaccident interview, the flight instructor for the accident pilot’s most recent recurrent training stated that it was the only time he had flown with the pilot. They briefed the entire profile before the flight; it was a good briefing of everything they planned to accomplish on the flight. The accident pilot performed well on the simulated single-engine failure on takeoff. Because they were training in the airplane rather than a simulator, the instructor did not reduce power on one of the engines on the runway for safety reasons. The instructor waited to reduce engine power until the airplane had a positive rate of climb, had reached about 200 to 300 ft agl, and the landing gear were coming up. This maneuver, like all the others, was prebriefed. The instructor stated that the accident pilot was “super strong” on knowledge about the airplane and nothing about his performance during the training stood out. If the instructor had to point out an area where the accident pilot was weak, it was on the airplane’s avionics. They spent extra time with the external power connected to go over the avionics in the airplane. The accident pilot demonstrated a good attitude during the training and accepted advice and coaching well. The recurrent training also accomplished a flight review and instrument proficiency check. The instructor stated that it was obvious to him that the pilot was a career professional pilot and had gone through professional training before. Several pilots who knew the accident pilot and flew with him in the past were interviewed. Regarding the accident pilot’s takeoff rotation technique, two pilots reported that he used two hands during the rotation. None of the pilots interviewed reported that the accident pilot asked them to back him up on or guard the power levers during the takeoff or rotation. One pilot reported that the accident pilot had an aggressive rotation technique and that he would “pull up abruptly” at rotation. Another pilot reported that the accident pilot “was not strong on using checklists.” Another mutual acquaintance of the accident pilot and co-pilot stated that the accident pilot did not like to use a checklist and “just jumped in the airplane and went.” The business partner of the accident pilot reported that he was “bad about using checklists” and that he would not use checklists as much if he was familiar with the airplane. His business partner also reported that the accident pilot generally would not do a weight and balance calculation if he was familiar with the airplane and usually verbalized V speeds. Information to develop a 72-hour history for the pilot was not available. The Co-pilot The co-pilot was not type rated in the B-300. He completed recurrent training in the B-200 simulator on May 14, 2019, at Rich Aviation Services, Fort Worth, Texas. The training consisted of 2 hours in the simulator, including abnormal and emergency procedures, and ground training on airplane systems, which included—but was not limited to—engine/propellers, performance, and weight and balance. The systems training also included Beech F90 and Beech C90/B-200 differences training. During a postaccident interview, the flight instructor for the copilot’s most recent recurrent training recalled that the co-pilot was “low time” but was building experience and did a “fine job.” He performed well with radio communications, use of checklists, and understanding procedures. The flight instructor stated that he typically emphasized V1 cuts (that is, simulated engine failure at takeoff) in recurrent training and that this material was emphasized during the co-pilot’s simulator training. The co-pilot was described as “very, very particular” and “by the book” during postaccident interviews with pilots who knew him. A mutual acquaintance of the accident pilot and co-pilot stated that the co-pilot did “a great job in the right seat” and was “like a sponge” with “great flying habits.” According to the co-pilot’s wife, the co-pilot flew with the accident pilot most of the time and reportedly enjoyed flying with him. The pilot never allowed the co-pilot to manipulate the flight controls in flight if passengers were on board. The co-pilot’s wife stated that he did not express any concerns with the pilot’s flying abilities and did not discuss any aircraft systems issues with her. EE Operations LLC, a subsidiary of a family-owned business, purchased the accident airplane on March 21, 2019. According to the chief financial officer (CFO) of EE Operations LLC, the airplane was primarily used for family business and personal travel and was exclusively operated under 14 CFR Part 91. No evidence was found indicating that the airplane was operated for compensation or hire. EE Operations LLC had an aircraft management agreement with the accident pilot’s company, S&H Aircraft LLC, to manage all maintenance and flight scheduling, maintain the airplane’s records, and provide pilot services. According to the CFO of EE Operations LLC, the accident pilot managed the day-to-day operation of the airplane through his company. EE Operations LLC compensated the accident pilot for his management and pilot services, and S&H Aircraft LLC hired and compensated the co-pilots used in the airplane’s operation. Since the airplane was operated exclusively under Part 91, oversight by a Federal Aviation Administration principal operations inspector was not required. Before its sale to EE Operations LLC, the airplane underwent phase 1 through 4 inspections, special inspections, service bulletin and airworthiness directive compliance, and engine and propeller maintenance at Textron Aviation Services in Wichita, Kansas. Maintenance records showed that the work on the airplane was completed on March 22, 2019. The airplane had 624.2 hours and 423 cycles at the time of the sale and accumulated about 67.03 hours and 31 cycles from that time to the day of the accident. The accident airplane was equipped with two pilot seats and a nine-passenger-seat cabin (including the aft, belted lavatory seat). It had left and right overwing exits at row 2 and an aft overwing exit across from the lavatory seat. Engines The accident airplane was powered by two Pratt & Whitney Canada PT6A-60A gas turbine engines driving Hartzell HC-B4MP-3C propellers. The Hartzell HC-B4MP-3C propellers on the airplane were four-bladed, hydraulically operated, steel hub, constant-speed propellers with full feathering and reversing capabilities and a normal in-flight operating range of 1,450 to 1,700 rpm. Oil pressure from a propeller governor was used to move the blades toward low pitch (reduced blade angle). Blade-mounted counterweights and a feathering spring moved the blades toward high pitch/feather in the absence of governor oil pressure. The propeller incorporated a beta mechanism that actuated when blade angles were lower than the flight idle position. As installed on the B-300, selected propeller positions will result in the following blade angle settings: Reverse -14.0° (+/- 0.5°) Beta actuation/low pitch 15.4° (+/- 0.1°) Flight idle 12.9º to 11.8º Ground idle ˜ 2º Feather