LAX08MA277

The pilot’s failure to maintain terrain clearance during takeoff for undetermined reasons.

The purpose of the accident flight was to transport medical personnel back to their base of operation in Cedar City, Utah. One witness (a rated pilot) at the departure airport reported seeing nine people exit a passenger van with four plastic file boxes and three silver cases. The accident pilot and his nine passengers boarded the twin-engine turboprop airplane. The witness and another witness (also a rated pilot) heard the airplane take off and indicated that the takeoff sounded normal. About 15 minutes later, one of the witnesses observed smoke in the distance that was later determined to be the accident location. The airplane impacted hilly terrain about 1.2 miles south of the departure airport, left of and less than 100 feet above the elevation of the takeoff runway. The initial impact occurred on steep, upsloping terrain on the opposite side of a gully. The airplane impacted the rising terrain in a slight right-wing low, but significantly nose-high, attitude close to the slope of the terrain. There were no witnesses to the accident and no recorded data sources to assist investigators in determining what occurred to induce the accident sequence. The entire flight occurred below the floor of air traffic control radar coverage for the area. The airplane was not equipped with flight recorders, nor was it required to be by the Federal Aviation Administration (FAA). On February 9, 2009, the National Transportation Safety Board (NTSB) issued Safety Recommendation A-09-11, which asked the FAA to require all existing turbine-powered, nonexperimental, nonrestricted-category aircraft that are not equipped with a flight data recorder (FDR) and are operating under 14 Code of Federal Regulations (CFR) Parts 91, 121, or 135 to be retrofitted with a crash-resistant flight recorder system. The crash-resistant flight recorder system should record cockpit audio (if a cockpit voice recorder [CVR] is not installed), a view of the cockpit environment to include as much of the outside view as possible, and parametric data per aircraft and system installation, all to be specified in European Organization for Civil Aviation Equipment (EUROCAE) document ED-155, “Minimum Operational Performance Specification for Lightweight Flight Recorder Systems,” when the document is finalized and issued. On April 17, 2009, the FAA responded that it established a proof-of-concept study, which provided valuable information on the potential use of a cockpit image recording system on aircraft that require a digital FDR and/or a CVR and for aircraft that are currently not required to carry any type of data recording equipment and that the United Kingdom Civil Aviation Authority also accomplished a proof-of-concept study. The FAA further stated that a EUROCAE working group has been developing a minimum operational performance specification for lightweight recording systems that can be installed on unequipped aircraft, and the working group intended to publish a document in June 2009 that will provide performance considerations for lightweight aircraft data recording systems, cockpit audio recording systems, aircraft image recording systems, and data link recording systems. The FAA indicated that it will conduct a comprehensive review of the document and consider developing a technical standard order (TSO). In addition, the FAA stated that manufacturers from the general aviation community have been discussing current flight data management technology and developing such systems. On August 27, 2009, the NTSB responded that it is aware of the FAA’s participation in two proof-of-concept studies and that the published findings for those studies have provided valuable information. The NTSB acknowledged the FAA’s involvement with the EUROCAE working group and noted that ED-155 was approved and published by EUROCAE in August 2009; however, the FAA must still develop a TSO. Safety Recommendation A-09-11 was classified “Open—Acceptable Response,” pending the FAA’s issuance of a TSO that includes the specifications of ED-155. Although the airplane was substantially damaged in the postcrash fire, investigators established flight control continuity with the surviving airframe and components found at the accident scene. All major airplane components were identified in the debris field, indicating that an in-flight structural failure had not occurred. Inspection and disassembly of the engines revealed no evidence of mechanical malfunctions. Propeller signatures were consistent with a high power level being symmetrically delivered by both engines at the time of impact. The ground scars and the 284-foot-long debris field were consistent with a groundspeed slightly above the aerodynamic stall speed of 89 knots and indicate that the airplane was under control at the time of the accident. The investigation did not identify any evidence of poor maintenance or operations. According to the performance charts in the Beech A100 King Air Pilot’s Operating Manual (POM), the maximum allowed takeoff weight of the accident airplane for the environmental conditions on the day of the accident (a hot day and high altitude) was 10,500 pounds. However, calculations determined that the weight of the airplane was 10,842.5 pounds at the time of the accident. While the airplane was 342.5 pounds over the maximum allowed takeoff weight to guarantee single-engine rate of climb capabilities, it was not over the maximum gross takeoff weight of 11,500 pounds. The aircraft performance study found that with both engines and propellers operating, the airplane was capable of taking off, climbing to, and maintaining a safe altitude at its weight of 10,842.5 pounds. Based on the POM, the pilot would have expected an adequate airplane performance margin given the environmental conditions on the day of the accident. The direction of the wreckage dispersal indicates that the airplane’s energy path was on a heading of 144 degrees at the time the airplane impacted the terrain. If the pilot had intended to take a direct course to Cedar City, he likely would have made a right turn to a course of 235 degrees after takeoff from runway 21. However, the wreckage and energy path of the airplane were to the left of the runway centerline, indicating that shortly after takeoff, the pilot made a left turn. Two possible scenarios were considered to account for the wreckage location being significantly south of the direct course to the intended destination. First, the pilot could have been making a left turn back to the airport. The other possibility is that the pilot was flying the airplane south to avoid an area of restricted airspace, R-6413, located 6 miles to the west of Canyonlands Field Airport. The accident pilot was properly trained, was current, and held the appropriate certificates for the activities in which he was engaged as a commercial pilot for the operator. A review of FAA medical records and interviews with the pilot’s spouse revealed no preexisting medical conditions. However, the pilot’s autopsy noted severe coronary artery disease, with the near complete occlusion of one coronary artery. Due to the extent of the pilot’s thermal injuries, it was not possible to determine if a cardiac event or other debilitating condition had occurred during the brief accident flight. Several witnesses at the departure airport on the day of the accident who saw or interacted with the accident pilot reported that he appeared to be in a good mood, was very willing to engage in conversation, and did not display any indications of physical ailments. In addition, a low level of carboxyhemoglobin was detected in the pilot’s blood toxicology sample, which is consistent with the pilot briefly surviving the impact sequence long enough to have been exposed to the products of combustion from the postcrash fire. The accident airplane was operated under 14 CFR Part 91, Subpart F, and under National Business Air

HISTORY OF FLIGHT On August 22, 2008, about 1750 mountain daylight time, a Beech A100 (King Air), N601PC, impacted hilly terrain about 1.2 miles south of the Canyonlands Field Airport (CNY), Moab, Utah, shortly after takeoff. The Leavitt Group Wings, LLC., owned and operated the airplane under the provisions of 14 Code of Federal Regulations (CFR) Part 91. The certificated commercial pilot and nine passengers were killed. The airplane was substantially damaged during the impact sequence and post crash fire. Visual meteorological conditions prevailed for the cross-country flight that was destined for Cedar City Regional Airport (CDC), Cedar City, Utah. No flight plan had been filed. According to a representative from the Leavitt Group Wings, LLC., Southwest Skin and Cancer LLC., leased the airplane under a timeshare agreement with the Leavitt Group Wings, LLC. Once a month, Southwest Skin and Cancer medical personnel would travel to the company's satellite clinics and provide care to residents in the area. The trips were normally a day in length, with an early morning departure from Cedar City. Medical personnel would work all day at one of the satellite clinics and then return to Cedar City in the evening. Witness Information There were no known witnesses to the accident sequence. Two pilots were at the airport, awaiting the arrival of their passenger. One pilot remained indoors in the lounge area, while the other pilot was outside of the terminal. Both pilots recalled seeing the pilot. The pilot waiting in the lounge spoke briefly to the accident pilot about flying, but did not hear the engines start up or hear the airplane depart. The pilot outside of the terminal heard the engines start up, as well as heard the airplane depart. Both pilots reported also seeing passengers arrive at the airport. The pilot outside of the terminal was talking on the the telephone when he saw a passenger van arrive at the airport. He observed 9 people exit the van with 4 plastic file boxes and 3 silver cases. The pilot did not observe the passengers board the airplane, but was outside when the engines were started. He stated that it was too loud to continue his telephone conversation so he returned to the airport lobby. The witness stated that there were no unusual sounds emanating from the engines. About 15 minutes later, the pilot that had been on the telephone went outside and observed smoke in the distance. Several people at the airport on the day of the accident reported either seeing or interacting with the accident pilot. They all reported that he was in what appeared to be a good mood, very willing to chat, and did not display any indications of having any physical ailments. PERSONNEL INFORMATION The pilot, age 41, held an Airline Transport Pilot (ATP) certificate with airplane single and multi-engine land ratings. The ATP certificate was issued on July 31, 2008. The pilot also held a flight instructor certificate with ratings for airplane single-engine land and instrument airplane. The pilot had recently received a type rating for the Eclipse EA-500S. An examination of the pilot's logbook revealed that he had accumulated 1,817.5 hours of flight time as of August 15, 2008. Of that total time, 855.8-hours were in multi-engine airplanes and 698.1 hours were in turboprop airplanes. The pilot had flown 38.4 hours in the preceding 30 days before the accident; 32.8 hours were in the Eclipse EA-500S. The pilot had completed his Beech C-90/A100 Beech (King Air) initial training on October 21, 2005, and his most recent recurrent training in the King Air was completed on September 30, 2007. Both his initial training and recurrent training were performed at the Recurrent Training Center, Savoy, Illinois. On June 13, 2008, the pilot completed Eclipse Aviation Upset Recovery Training, which consisted of two flights (1.4 hours) in an L-39C Albatross. From August 2 to August 15, 2008, the pilot accumulated 32.8 hours in the Eclipse 500 while participating in Eclipse Factory Training, which included flying with an Eclipse mentor pilot. The accident pilot was first hired by Leavitt Group Wings, LLC., on October 10, 2005. On August 31, 2006, he left the company to fly for Sky West Airlines; however, after a few months he was furloughed. On November 6, 2006, he was rehired at Leavitt Group Wings, LLC. The pilot held two positions with the Leavitt Group; he was a corporate pilot with Leavitt Group Wings, LLC., and an information technology (IT) specialist with the Leavitt Group. 72-hour History According to the pilot's spouse, on August 19, he flew from Cedar City, Utah, to Santa Monica, California, with three other Leavitt Group Wings, LLC, members. While in Santa Monica the pilot worked in his IT capacity at Pridemark-Everest, a Leavitt Group insurance agency, in Santa Ana, California. He returned to Cedar City on the evening of August 20, arriving home between 1900 and 2000, and going to bed at his normal bed time of 2200. On August 21, he worked a normal day in his IT capacity, and did not fly. According to his wife, his normal routine was to provide a light breakfast for the passengers he was flying, and he therefore spent the evening of August 21 preparing food for the next day's early morning flight. He went to bed between 2200 and 2300. On August 22, the morning of the accident, he left the house by 0615. Around 1630 the pilot called his wife saying that they were getting ready to leave Moab, and that he expected to be home between 1900 and 1930. His wife stated that he appeared to be in a good mood during the conversation, and that he did not mention any physical ailments. According to the Leavitt Group Wings, LLC. records, while performing maintenance on their cellular phone system, the account belonging to the pilot was identified. The company provided the Safety Board with the last contact their system had with the pilot's cellular phone, which was on August 22, 2008, at 1745:23. Right Front Seat Passenger The individual occupying the copilot's seat (front right seat) was a 60-year-old medical doctor employed by Southwest Skin Cancer Group. A search of the Federal Aviation Administration (FAA) database did not reveal any records associated with the passenger. Family members reported that he had some interest in aviation but had never been trained to operate an aircraft or other similar aspects of flight. AIRCRAFT INFORMATION The airplane was a 1975 Beech A100, serial number B-225. The airplane was maintained and inspected in accordance with 14 CFR Part 91.409(f) (3). The operator utilized the Raytheon Aircraft Beech King Air 100 Series Scheduled inspection Program, as per Beech King Air Maintenance Manual 5-00-00/5-20-00. A review of the airplane’s logbooks revealed that the last inspection, a Phase II inspection, had been performed on July 18, 2008. As of that date, the airframe total time was 9,263.3 hours, with 8,674 total cycles, and the Hobbs meter reading of 1,512.4 hours. The twin-engine airplane was equipped with Walter Engine Incorporated turboprop engines, which were installed on the airframe on May 31, 2005, in accordance with the Walter engines supplemental type certificate (STC) SA02036CH. The engines were maintained in accordance with the Walter Engine Maintenance Manual 0982302. Both engines had the same part number 100-590038-17. The left engine had a serial number of 044022, and the right engine serial number was 051001. Both engines' total time since new was recorded as 879.1 hours at the last phase inspection dated July 18, 2008. The engine manufacturer has a 300-hour inspection maintenance schedule. On October 9, 2007, at 677.4 hours, the left engine fuel control was repaired. On July 18, 2008, at 879.1 hours, the right engine fuel control was repaired. Additional 300-hour inspections took place on August 30, 20