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NTSB investigation record

ERA09LA469

Completed

Raytheon aircraft company 58· N167TB

Date
August 21, 2009
Location
Teterboro, NJ
Conditions
VMC
Record
Published September 25, 2020

Primary finding

Probable cause

The complete loss of thrust due to the second-in-command’s (SIC) inadvertent feathering of both propellers during a high-speed, low-altitude approach. Contributing to the accident was the pilot-in-command’s inadequate monitoring of the SIC’s performance. Chairman Hersman and Member Rosekind did not approve this probable cause. Chairman Hersman filed a dissenting statement, which Member Rosekind joined. Member Rosekind filed a dissenting statement, which Chairman Hersman joined. Member Sumwalt filed a concurring statement, which Vice Chairman Hart and Member Weener joined. The statements can be found in the public docket for this accident.

Investigator assessment

Analysis narrative

The airplane was operating as a corporate flight transporting medical specimens on a night, visual approach in visual meteorological conditions when the accident occurred. The flight was scheduled to be a single-pilot operation conducted under the provisions of 14 Code of Federal Regulations Part 91, and the pilot-in-command (PIC) had been assigned to the flight. Although the second-in-command (SIC), also a Quest Diagnostics pilot, was not assigned to the flight, he asked the PIC if he could accompany him on the flight to gain familiarization with operations into Teterboro Airport. Typically, the PIC flies the airplane from the left seat; however, the PIC on this flight allowed the SIC to occupy the left seat and fly the airplane. The investigation could not determine if the pilots had coordinated responsibilities for the flight before departure or if the PIC was providing additional training to the SIC during the flight. Radar data indicated that, while on the base leg of the traffic pattern, the airplane had an airspeed of about 204 knots, which exceeded the maximum flap extension speed by more than 50 knots and the maximum landing gear extension speed by more than 80 knots. According to the SIC, during this critical portion of the approach to landing, the nonflying PIC remained focused on providing familiarization of the airport and city environment to the SIC, who was flying the airplane, and the PIC failed to monitor the airplane’s airspeed. After the SIC recognized the airplane’s excessive approach speed close to the runway environment, he attempted to slow the airplane. However, he inadvertently retarded the propeller levers and feathered the propellers instead of retarding the throttle levers. Recognizing the resultant loss of thrust, the PIC challenged the SIC’s actions and stated that both engines had experienced power loss. The airplane’s unfeathering accumulators had been removed; therefore, it was not possible for either pilot to quickly unfeather the propellers and reestablish engine power. Approaching the runway centerline at both low altitude and high airspeed and with the propellers feathered, the pilots were unable to slow the airplane and descend before overflying the runway. The airplane crossed the runway threshold at 300 feet and 186 knots (90 knots more than the approach speed of 96 knots), departed airport property, struck objects, and burst into flames. Chairman Hersman and Member Rosekind did not approve this brief. Chairman Hersman filed a dissenting statement, which Member Rosekind joined. Member Rosekind filed a dissenting statement, which Chairman Hersman joined. Member Sumwalt filed a concurring statement, which Vice Chairman Hart and Member Weener joined. The statements can be found in the public docket for this accident.

Source record

Factual narrative

HISTORY OF FLIGHT On August 21, 2009, about 0305 eastern daylight time, a Hawker Beechcraft Corporation model 58 airplane, N167TB, collided with terrain during an attempted landing at Teterboro Airport (TEB), Teterboro, New Jersey. The pilot-in-command, a certificated airline transport pilot, was fatally injured (he died from his injuries on September 04, 2009). During the accident flight, the PIC allowed a certificated commercial pilot to occupy the left seat in the airplane, which is typically the PIC’s position. The second-in-command (SIC) sustained serious injuries. The airplane was destroyed by impact and postcrash fire. The flight was registered to and operated by Quest Diagnostics, Inc., under the provisions of 14 Code of Federal Regulations (CFR) Part 91. Visual meteorological conditions (VMC) prevailed for the flight, and an instrument flight rules flight plan had been filed. The flight departed from Pottstown Limerick Airport, Pottstown, Pennsylvania, at 0252. The airplane was certificated for single-pilot flight operations, and the flight was originally scheduled as a single-pilot flight. Air traffic control (ATC) records from the Federal Aviation Administration (FAA) revealed that ATC cleared the airplane for the Cedar Grove visual approach to runway 1, which is 7,000 feet long and 150 feet wide and is equipped with high-intensity runway edge lighting and visual approach slope indicator guidance. Radar data showed the airplane approaching from the west on an extended left base for runway 1 at 1,400 feet mean sea level (all altitudes are reported in mean sea level) and 204 knots ground speed. Examination of the approach chart revealed that the airplane should have maintained a 138-degree ground track and passed on the south side of Giants Stadium before it turned north (left) and aligned with runway 1. The radar data showed that, instead, the airplane maintained 204 knots and descended to 1,300 feet within 1 mile of the airport before it turned north toward the airport. The airplane then flew past the runway extended centerline and, at 600 feet and 1/2 mile from the airport, the airplane’s ground speed was 178 knots. The airplane corrected back to its left, aligned with the extended runway centerline, and crossed the runway threshold at 300 feet and 186 knots. (The published landing approach speed, for an airplane that weighs 5,400 lbs with the flaps down [30°], was 95 knots. The maximum landing gear extension speed was 152 knots. The maximum flap extension speed was 122 knots.) The airplane then passed over the center of the runway at 100 feet and 160 knots. Witnesses stated that the airplane flew the length of the runway at low altitude before it overshot the departure end, departed airport property, struck a sign and a tree, and burst into flames. According to the Quest Diagnostics Flight Operations Manual (FOM), “After 1,000 feet AGL [above ground level], no Quest Diagnostics Flight Operations pilot will continue an approach unless: the landing checklist has been completed, the aircraft is fully configured for landing, and the airspeed is on target.” ATC reported that all communications with the airplane were routine, that no emergency was declared by the crew, and that no communications were received from the accident airplane after it was cleared to land. The PIC was never interviewed because of the extent of his injuries. On August 26, 2009, the SIC was interviewed in his hospital room by FAA aviation safety inspectors, and the conversation was recorded on audio tape. A review of the recording revealed that the SIC had originally been assigned to fly another route in another airplane, but the airplane experienced mechanical problems and returned to the Quest Diagnostics base at Reading Regional Airport, Reading, Pennsylvania. He then arranged with the PIC to accompany him on the flight to TEB to gain some experience on a different route. (The PIC was the only required crewmember for the flight. The NTSB notes that, although the term "SIC" is typically used to refer to a required crewmember for aircraft or operations requiring more than one pilot, as described in 14 CFR 61.55(a), the operator referred to the accompanying pilot as the SIC in operational and postaccident documents.) According to the SIC, as the airplane approached TEB, it was in VMC on an extended left base for landing on runway 1. He stated that he was flying the airplane from the left seat as the PIC was pointing out several visual checkpoints, talking about noise abatement, and placing special emphasis on “the Meadowlands [Giants Stadium].” He stated that he advised the PIC that he, the SIC as the flying pilot, “had better slow down.” He further stated, “I brought the power down, I made a left turn, and [the PIC] freaks out, ‘What have you done? You’ve lost both your engines!’” He added that the PIC repeated himself “four times.” The SIC then described “dive-bombing” for the runway, discussing whether to notify ATC, attempting engine restarts, and fighting over the flight controls with the PIC. At no time did he describe calling for a Before Landing checklist, exchanging call and response items with the PIC, or configuring the airplane for landing. After consulting with an attorney, the SIC recanted all of his previous statements. On May 12, 2010, he provided a written statement in which he stated that the PIC asked for and took control of the airplane 2 miles before reaching TEB and that the airplane was operating normally at that time. He further stated, “I did not feather the propellers.” He stated that the PIC asked him to help start the engines and that, other then turning the engine No. 1 and 2 start switches; he did not touch the controls for the remainder of the flight. PERSONNEL INFORMATION A review of FAA airman records revealed that the PIC held an airline transport pilot certificate with a rating for airplane multiengine land and a commercial pilot certificate with a rating for airplane single-engine land. He held a flight instructor certificate with ratings for airplane single-engine, multiengine, and instrument airplane. His most recent first-class FAA airman medical certificate was issued on January 2, 2009, and he reported 15,000 total hours of flight experience on that date. Upon expiration after 6 months, the PIC’s medical certificate automatically became a second-class medical certificate, which was all that was required for the flight. According to Quest Diagnostics records, the PIC had accrued 15,628 total flight hours, 2,241 hours of which were in the accident airplane make and model. He had flown 168 and 50 hours (113 and 39 hours in the accident airplane make and model) in the 90 and 30 days, respectively, before the accident. The PIC was a full-time Quest Diagnostics employee and was among the most senior captains in the department. He was on the operator’s flight schedule for the 3 nights before the accident. His duty times were 11.7, 6.5, and 6.6 hours on each of the previous nights, and he accrued 7.6, 3.7, and 1.1 hours of flight time during those periods. At the time of the accident, he had been on duty for 4.7 hours and had flown 3.2 hours. The SIC held a commercial pilot certificate with ratings for airplane single-engine land, multiengine land, and instrument airplane. His most recent FAA first-class medical certificate was issued on November 18, 2008, and he reported 1,350 total hours of flight experience on that date. Upon expiration after 6 months, the SIC’s medical certificate automatically became a second-class medical certificate, which was all that was required for the flight. According to Quest Diagnostics, the SIC had accrued 1,575 total flight hours, 607 hours of which were in the accident airplane make and model. He had flown 225 and 71 hours (146 and 53 hours in the accident airplane make and model) in the 90 and 30 days

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