New NTSB Accident Brief on 2013 Beechcraft Premier I crash
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New NTSB Accident Brief on 2013 Beechcraft Premier I crash
According to the Daily Mail Online:
<http://www.dailymail.co.uk/news/article-3546248/Ex-Oklahoma-quarterback-took-controls-private-jet-pilot-friend-accidentally-turned-engine-crashed-three-houses-killing-injuring-residents.html>
"A jet crashed in Indiana in 2013 after Steve Davis, the former Oklahoma Sooners quarterback, turned the engine off mid-flight and the pilot failed to follow proper procedure, a new report has confirmed.
"The Beechcraft Premier I private jet, owned by Oklahoma businessman Wes Caves, was trying to land at South Bend Regional Airport, Indiana, when it ploughed into a neighborhood, destroying three houses.
"Caves, 58, was in the craft along with Davis, 60, when it came down. Both were killed in the crash. And the new report reveals exactly why.
"The report, released by the National Transportation Safety Board (NTSB) and hosted by WSBT [a CBS TV station in Indiana], doesn't name anyone, but says an 'unqualified pilot-rated passenger' at the controls of the plane caused a malfunction that resulted in a crash.
"An earlier WSBT report identified Davis as the man behind the gearstick, with Caves advising him, using a transcript of the black box recording made by the NTSB.
"Davis had a private pilot certificate and had flown single and multi-engine land airplanes, but had logged no flight time in a business jet, the report said."
The April 14, 2016 NTSB Aviation Accident Brief (<http://www.wsbt.com/blob/view/-/39083292/data/1/-/g20fp9z/-/Iowa-Street-plane-crash-report--2-.pdf>) on this accident says:
"According to the cockpit voice recorder (CVR), during cruise flight, the unqualified pilot-rated passenger was manipulating the aircraft controls, including the engine controls, under the supervision and direction of the private pilot. After receiving a descent clearance to 3,000 feet mean sea level (msl), the pilot told the pilot-rated passenger to reduce engine power to maintain a target airspeed. The cockpit area microphone subsequently recorded the sound of both engines spooling down. The pilot recognized that the pilot-rated passenger had shutdown both engines after he retarded the engine throttles past the flight idle stops into the fuel cutoff position. Specifically, the pilot stated "you went back behind the stops and we lost power." According to air traffic control (ATC) radar track data, at the time of the dual engine shutdown, the airplane was located about 18 miles southwest of the destination airport and was descending through 6,700 feet msl. The pilot reported to the controller that the airplane had experienced a dual loss of engine power, declared an emergency, and requested radar vectors to the destination airport. As the flight approached the destination airport, the cockpit area microphone recorded a sound similar to an engine starter spooling up; however, engine power was not restored during the attempted restart. A review of the remaining CVR audio did not reveal any evidence of another attempt to restart an engine. The CVR stopped recording while the airplane was still airborne, with both engines still inoperative, while on an extended base leg to the runway. Subsequently, the controller told the pilot to go-around because the main landing gear was not extended. The accident airplane was then observed to climb and enter a right traffic pattern to make another landing approach. Witness accounts indicated that only the nose landing gear was extended during the second landing approach. The witnesses observed the airplane bounce several times on the runway before it ultimately entered a climbing right turn. The airplane was then observed to enter a nose low, rolling descent into a nearby residential community. The postaccident examinations and testing did not reveal any anomalies or failures that would have precluded normal operation of the airplane. Although the CVR did not record a successful engine restart, the pilot was able to initiate a go-around during the initial landing attempt, which implies that he was able to restart at least one engine during the initial approach. The investigation subsequently determined that only the left engine was operating at impact. Following an engine start, procedures require that the respective generator be reset to reestablish electrical power to the Essential Bus. If the Essential Bus had been restored, all aircraft systems would have operated normally. However, the battery toggle switch was observed in the Standby position at the accident site, which would have prevented the Essential Bus from receiving power regardless of whether the generator had been reset. As such, the airplane was likely operating on the Standby Bus, which would preclude the normal extension of the landing gear. However, the investigation determined that the landing gear alternate extension handle was partially extended. The observed position of the handle would have precluded the main landing gear from extending (only the nose landing gear would extend). The investigation determined that it is likely the pilot did not fully extend the handle to obtain a full landing gear deployment. Had he fully extended the landing gear, a successful single-engine landing could have been accomplished. In conclusion, the private pilot's decision to allow the unqualified pilot-rated passenger to manipulate the airplane controls directly resulted in the inadvertent dual engine shutdown during cruise descent. Additionally, the pilot's inadequate response to the emergency, including his failure to adhere to procedures, resulted in his inability to fully restore airplane systems and ultimately resulted in a loss of airplane control.
Updated at Apr 14 2016 7:43AM"
<http://www.dailymail.co.uk/news/article-3546248/Ex-Oklahoma-quarterback-took-controls-private-jet-pilot-friend-accidentally-turned-engine-crashed-three-houses-killing-injuring-residents.html>
"A jet crashed in Indiana in 2013 after Steve Davis, the former Oklahoma Sooners quarterback, turned the engine off mid-flight and the pilot failed to follow proper procedure, a new report has confirmed.
"The Beechcraft Premier I private jet, owned by Oklahoma businessman Wes Caves, was trying to land at South Bend Regional Airport, Indiana, when it ploughed into a neighborhood, destroying three houses.
"Caves, 58, was in the craft along with Davis, 60, when it came down. Both were killed in the crash. And the new report reveals exactly why.
"The report, released by the National Transportation Safety Board (NTSB) and hosted by WSBT [a CBS TV station in Indiana], doesn't name anyone, but says an 'unqualified pilot-rated passenger' at the controls of the plane caused a malfunction that resulted in a crash.
"An earlier WSBT report identified Davis as the man behind the gearstick, with Caves advising him, using a transcript of the black box recording made by the NTSB.
"Davis had a private pilot certificate and had flown single and multi-engine land airplanes, but had logged no flight time in a business jet, the report said."
The April 14, 2016 NTSB Aviation Accident Brief (<http://www.wsbt.com/blob/view/-/39083292/data/1/-/g20fp9z/-/Iowa-Street-plane-crash-report--2-.pdf>) on this accident says:
"According to the cockpit voice recorder (CVR), during cruise flight, the unqualified pilot-rated passenger was manipulating the aircraft controls, including the engine controls, under the supervision and direction of the private pilot. After receiving a descent clearance to 3,000 feet mean sea level (msl), the pilot told the pilot-rated passenger to reduce engine power to maintain a target airspeed. The cockpit area microphone subsequently recorded the sound of both engines spooling down. The pilot recognized that the pilot-rated passenger had shutdown both engines after he retarded the engine throttles past the flight idle stops into the fuel cutoff position. Specifically, the pilot stated "you went back behind the stops and we lost power." According to air traffic control (ATC) radar track data, at the time of the dual engine shutdown, the airplane was located about 18 miles southwest of the destination airport and was descending through 6,700 feet msl. The pilot reported to the controller that the airplane had experienced a dual loss of engine power, declared an emergency, and requested radar vectors to the destination airport. As the flight approached the destination airport, the cockpit area microphone recorded a sound similar to an engine starter spooling up; however, engine power was not restored during the attempted restart. A review of the remaining CVR audio did not reveal any evidence of another attempt to restart an engine. The CVR stopped recording while the airplane was still airborne, with both engines still inoperative, while on an extended base leg to the runway. Subsequently, the controller told the pilot to go-around because the main landing gear was not extended. The accident airplane was then observed to climb and enter a right traffic pattern to make another landing approach. Witness accounts indicated that only the nose landing gear was extended during the second landing approach. The witnesses observed the airplane bounce several times on the runway before it ultimately entered a climbing right turn. The airplane was then observed to enter a nose low, rolling descent into a nearby residential community. The postaccident examinations and testing did not reveal any anomalies or failures that would have precluded normal operation of the airplane. Although the CVR did not record a successful engine restart, the pilot was able to initiate a go-around during the initial landing attempt, which implies that he was able to restart at least one engine during the initial approach. The investigation subsequently determined that only the left engine was operating at impact. Following an engine start, procedures require that the respective generator be reset to reestablish electrical power to the Essential Bus. If the Essential Bus had been restored, all aircraft systems would have operated normally. However, the battery toggle switch was observed in the Standby position at the accident site, which would have prevented the Essential Bus from receiving power regardless of whether the generator had been reset. As such, the airplane was likely operating on the Standby Bus, which would preclude the normal extension of the landing gear. However, the investigation determined that the landing gear alternate extension handle was partially extended. The observed position of the handle would have precluded the main landing gear from extending (only the nose landing gear would extend). The investigation determined that it is likely the pilot did not fully extend the handle to obtain a full landing gear deployment. Had he fully extended the landing gear, a successful single-engine landing could have been accomplished. In conclusion, the private pilot's decision to allow the unqualified pilot-rated passenger to manipulate the airplane controls directly resulted in the inadvertent dual engine shutdown during cruise descent. Additionally, the pilot's inadequate response to the emergency, including his failure to adhere to procedures, resulted in his inability to fully restore airplane systems and ultimately resulted in a loss of airplane control.
Updated at Apr 14 2016 7:43AM"
I am a mechanic, and maintained a Premiere for several years for a 135 operator.
The throttles have levers that must be lifted to pull them down into the cut-off position. They are in a position where an inexperienced pilot could easily activate them inadvertently, and require very little upward pressure to unlock.
As the report noted, the engine generators do not come on automatically when the engines start (or restart). The generator switch has to be physically moved to the reset position to toggle the generators online. Placing the battery switch in the "standby" position would have been the correct action on a dual engine shutdown - it provides emergency power to a few critical systems - but not moving it back to the normal position once an engine is restarted would have prevented the essential bus from being properly powered.
Also, the Premeire has hydraulic spoilers which (in addition to the normal spoiler function) act as roll spoilers to assist in banking at lower airspeeds. Those are controlled by a computer, which has to pass a series of self-tests when powered on. Those tests can only be done on the ground after engine start, involving moving the yoke full left, then full right. Most likely, the incident aircraft had no roll spoilers available after the shutdown. (The ailerons would still work - they are strictly mechanical).
On top of that, the flaps are ALSO controlled by a computer, and it is extremely "fussy" as well. If electrical power is interrupted while the flaps are in transit, they will lock in whatever position they were in at the time. If that happens, they can only be reset on the ground, by removing a large panel on the belly to physically press not one, but two reset buttons.
Not my favorite airplane by any means. I was glad when the one our company owned was sold. When everything is working properly, they are very docile and easy to fly, but malfunctions can cascade quickly when things go wrong.
The throttles have levers that must be lifted to pull them down into the cut-off position. They are in a position where an inexperienced pilot could easily activate them inadvertently, and require very little upward pressure to unlock.
As the report noted, the engine generators do not come on automatically when the engines start (or restart). The generator switch has to be physically moved to the reset position to toggle the generators online. Placing the battery switch in the "standby" position would have been the correct action on a dual engine shutdown - it provides emergency power to a few critical systems - but not moving it back to the normal position once an engine is restarted would have prevented the essential bus from being properly powered.
Also, the Premeire has hydraulic spoilers which (in addition to the normal spoiler function) act as roll spoilers to assist in banking at lower airspeeds. Those are controlled by a computer, which has to pass a series of self-tests when powered on. Those tests can only be done on the ground after engine start, involving moving the yoke full left, then full right. Most likely, the incident aircraft had no roll spoilers available after the shutdown. (The ailerons would still work - they are strictly mechanical).
On top of that, the flaps are ALSO controlled by a computer, and it is extremely "fussy" as well. If electrical power is interrupted while the flaps are in transit, they will lock in whatever position they were in at the time. If that happens, they can only be reset on the ground, by removing a large panel on the belly to physically press not one, but two reset buttons.
Not my favorite airplane by any means. I was glad when the one our company owned was sold. When everything is working properly, they are very docile and easy to fly, but malfunctions can cascade quickly when things go wrong.
Last edited by JRBarrett; 19th Apr 2016 at 14:23. Reason: Typo
Most jets with fuel cutoff functions integrated into the power levers have lock release mechanisms mounted on the back of the lever, where one has to drop the thumb down to lift the lock paddle upwards. (Falcons are one example). That design is much more foolproof.
The Beech 400A has a similar "trigger" style lock release on the power levers. The Premiere has quite a few design similarities to the Beechjet. (The nose gear is almost identical between the two aircraft for example). But, since the 400A is not certified for single pilot operation, I suppose there is less chance that a non-rated passenger would be sitting on the right side, "playing pilot".
Last edited by JRBarrett; 20th Apr 2016 at 14:22. Reason: Clarification
