Accident 1: Beechcraft BE-58, N959CM
In October 2019, a Beechcraft BE-58, N959CM, was involved in an accident near Ocala, Florida, that led to its destruction. The plane was registered as a private flight, and the pilot and two others suffered fatal injuries. An individual who was on the ground also sustained fatal injuries. Before the fateful day, the pilot had flown to the Ocala international airport with his friend, who confirmed that the flight was normal (NTSB, n.d.). However, it was reported that the right engine’s fuel flow meter had constant fluctuations that would hit the zero mark. The pilot later engaged a mechanic to determine the possibility of instrument indication issues. After the maintenance, they performed several tests to ascertain its effective operation.
Analysis of the Beechcraft BE-58, N959CM accident
The Federal Aviation Administration’s study of air traffic control communications determined a taxi clearance at 1124 and requested information about a block of airspace to conduct maintenance tests. It was explained to the pilot that there were no off-limits locations and that he could go wherever he pleased. The pilot replied that the test would be performed west of the airport. The pilot was permitted to make a right turn to the west after the test and take off, but he refused to do so. The pilot turned left into an easterly heading after the controller gave the clearance again a few seconds later, which, this time, the pilot did not acknowledge (NTSB, n.d.). The pilot ignored the controller’s repeated instructions to continue on a path toward the west. After observing that the aircraft kept heading east, the controller enquired about the pilot’s intentions. About two minutes after departure, the accident happened a few seconds later.
After it took off, the jet was seen by numerous witnesses. Some witnesses revealed it was moving north at a minimal altitude before diving into an inverted slope. The left propeller was not turning, according to one witness, and the airplane was on fire, according to another. According to GPS data recovered from the wreckage, the jet made a left turn and failed to climb above 418 feet in altitude. TA The jet appeared to have rotated counterclockwise before hitting the roadway. The wings struck a moving automobile, according to a video found in a vehicle parked close to the crash site. Later, the jet skidded before coming to rest in an empty lot. According to estimates, the rudder deflected 20°±4º to the left, or the rotational direction, immediately before hitting the ground. No engine or airframe smoke or fire could be seen in the footage. According to the pilot’s biographical information, he had flown for roughly 7800 hours, and in October 2019, he finished a flight review (NTSB, n.d.). However, the Federal Aviation Administration issued him a third-class medical certification with a restriction on corrective lenses.
Impact Information
According to the on-site investigation, the airplane went around 150 feet from the first point of impact. A post-impact fire destroyed the fuselage, and all significant airplane parts were found there. The flaps and landing gear were retracted, revealing the continuity of the ailerons, elevators, and rudder from each control surface to the cockpit. The plane’s nose, fuselage, engines, propellers, and wings left an imprint on the ground not far from the initial place of contact (NTSB, n.d.). Three clear slash marks were seen on the asphalt close to where the right engine hit the road, consistent with propeller contact. Another slash mark was seen near the area where the left engine hit the road. In addition to having their respective fuel tanks punctured, both wings were damaged by collision. Each wing’s fuel tank’s valves and fuel selector lever were in working order. The left engine, which was still attached to the airframe, was severely thermally and had impact damage. The camshaft gear had suffered impact damage, which prevented the crankshaft from rotating all the way. Subsequent borescope engine examination, pistons, and cylinders established a lack of any anomalies. Thermal and impact stresses led to damage to the throttle metering assembly. According to an inspection, the throttle and metering assembly spring was intact, maintained tension, and worked normally despite the throttle control arm being inserted backward from the correct position. On the engine, no more anomalies or parts that would prevent typical engine functioning were found (NTSB, n.d.). The three-bladed propeller assembly was severely impacted, and part of the hub’s connection to the crankshaft was still intact. Only one blade was still fastened to the hub; the others had broken off and were discovered amid the debris. The attached blade had curling at the tip and chordwise scratches (NTSB, n.d.). The fuel flow transducer still had heat damage and was linked to its installation site. The gasoline flow inlet nut was hand-movable and finger-tight, but the fuel line and nut had heat damage. The air was blown into the inlet and freely flowed through the transducer while the transducer was removed and examined. Disassembling the transducer revealed no blockages or other irregularities.
Probable Cause and Findings
The NTSB established the potential cause of the accident as a failure of the pilot to maintain control of the plane due to an acute medical condition or impairing medication. A toxicology examination of the pilot’s body and blood samples by the FAA’s Forensic Sciences Laboratory revealed the presence of diazepam and its psychotropic metabolites, nordiazepam and oxazepam, in the pilot’s liver and muscle tissue. Valsartan, a non-sedating treatment for high blood pressure, was also found in the muscle and liver. The pilot’s chest blood was toxicology tested for the medical examiner’s office, and diazepam, nordiazepam, and delta-9- tetrahydrocannabinol (THC) were found at 96, 94, and 0.69 nanograms per milliliter (ng/mL), respectively (NTSB, n.d.). Diazepam is a sedating benzodiazepine that can only be obtained with a prescription and is a regulated medication used to treat anxiety, seizures, muscle spasms, and alcohol withdrawal.
Persona Opinion on Preventing Its Occurrence
The accident could have been prevented if the pilot had undergone effective training and education to help recognize the signs and symptoms of acute medical events and understand the risks associated with impaired medications. The aviation industry should take proactive approaches to provide pilots with the knowledge and skills to recognize and manage medical conditions and medications that can impair their ability to fly safely. The Beechcraft BE-58, N959CM accident could have been prevented if a risk assessment had been conducted to evaluate the pilot’s medical history and current medication use to determine the risk associated with their flying (NTSB, n.d.). It is important to consider the type of medication, the dosage, and the potential side effects that can impair a pilot’s flying abilities. The effective airline could have ensured that the pilot was not flying when the risk an acute medical event that could impair cognition function. Although the pilot had covered approximately 7800 hours of flight experience and had completed a flight review, he had received a third-class medical certification with a corrective lens limitation from the Federal Aviation Administration (NTSB, n.d.). It is essential for airlines to be aware of the potential for medical emergencies and have plans in place to respond quickly and effectively in case of an emergency. The airline management should ensure Pilots suffering from acute medical events or who have been prescribed impairing medications are subjected to follow-up evaluations to ascertain their fitness to fly. Qualified medical professionals with specialized aviation medicine training should conduct the evaluation. Follow-up should be thorough and consider the pilots, medical history, current medication use, and the potential for future medical events. Upon deeming the pilot unfit to fly, the airline should take appropriate actions to ensure that the safety of passengers and the crew is not compromised. Therefore, Beechcraft BE-58, N959CM accident could have been prevented if proactive measures to manage the risk related to acute medical events and the use of impairing medication were taken to account. This would have ensured safety and maintained the passenger’s confidence in their travel.
Accident 2: Piper PA-31, N400JM
In March 2019, a 62 years old pilot died in the lazing wreckage where a Piper PA-31-350, N400JM, was destroyed when it hit a terrain in Madeira, Ohio. The plane was operated under the provisions of Title 14 Code of Federal Regulations Part 91 as a commercial aerial observation flight. Radar data from the (FAA) showed that after taking off from LUK, the aircraft flew a number of survey tracks before heading northwards to fly survey tracks close to Ohio (English, 2021). The voice exchanges revealed that the pilot contacted air traffic control (ATC) requesting a route to LUK because of a fuel issue. The controller questioned the pilot whether he needed help with the fuel problem, but he replied that it would be fine. He then reminded the pilot that many airports were close to LUK, and the pilot replied that he would let the controller know if the fuel problem reappeared. The pilot informed the tower operator through a radio call that the plane had fuel issues but hoped to make it to the port (National Transpiration Safety Board, n.d.). The plane was 8 miles north of LUK then, flying at the height of 1,850 feet. The pilot soon informed the controller of the uncertainty of the plane making it to the airport but made no more transmissions after that.
Analysis of Piper PA-31, N400JM Accident
Radar data showed that the jet’s estimated ground speed decreased between 1513 and 1516 from around 140 to 98 knots, and its estimated ground track was about 200 degrees. According to radar data, the plane was 180 feet from the fairway at 1516:27, 1,050 feet above sea level, and traveling at an estimated ground speed of 82 knots (National Transpiration Safety Board, n.d.). The aircraft’s last position on radar was around 550 feet from the scene. Witnesses said the plane’s engine sputtered twice before generating a loud pop noise. After sputtering, an eyewitness claimed that the jet was on its left end, flying crooked. The observers also revealed that the jet was low as it swerved to the left and nosedived into the area. The aircraft then struck a tree and a home’s property. After the collision, a neighboring resident’s witness heard the impact, went to the scene, and saw smoke originating from the left engine. A video taken at 15:22 on the witness’ cell phone showed the left engine’s vicinity covered in flames t (National Transpiration Safety Board, n.d.). The witness revealed that after close to three minutes, the airplane was completely engulfed in flames.
Analysis of the pilot’s resume revealed he had several cases of misconduct. It was revealed that in 2001 he was expelled from school after a fight with a fellow instructor. In 2003, the pilot lost control of a Cessna 172 while training a new pilot. The pilot continued the power-off fall to 20 feet after failing to stop at 500 feet AGL. They were just slightly hurt, but the plane was destroyed because they could not recover and hit the ground. The flight’s president reported that the pilot was overconfident and positioned himself where he lacked options.
The fuel issue was evidently seen onboard since the left engine had coughed to a standstill. The family members also reported that the pilot knew of the fuel problem with N400JM. Forensic analysis indicated there was a leakage or pump failure. At the accident site, there lacked any fuel evident in the left wing in or outbound. An interview with company pilots showed that there lacked a direct approach to monitoring fuel quality in the nacelle tank. An organizational pilot revealed that the plane contained fuel leakages in the left wing (National Transpiration Safety Board, n.d.). He submitted a photo of the fuel in the hangar captured a few days before the fate occurred. There were no means to immediately monitor the amount of fuel in the nacelle cylinder while the aircraft was in flight, and there was no obvious sign that the fuel pumps were working, according to company pilots interviewed after the disaster (English, 2021). Company pilots reported utilizing various fuel management techniques in aircraft fitted with a nacelle fuel cylinder. Some pilots filled their primary fuel tanks up, while others only utilized them for one to two hours before switching to the auxiliary tanks.
Probable Causes
The TSB found that the left engine’s lack of gasoline was the most likely cause of the accident. The pilot failed to maintain the lowest controllable speed, which led to a loss of engine power and airplane control.
How the Accident Could Be Prevented
Fuel starvation results when the fuel cannot reach the engine due to some prevailing conditions. The accident could have been prevented if the fuel had been well-managed. The pilot could have ensured the airplane’s fuel tanks were filled before taking the flight and that there was an appropriate balance to avoid uneven weight distribution. This could have been achieved by using fuel quantity gauges and carefully monitoring fuel levels during the flight. The use of a checklist is also key in helping prevent fuel starvation accidents. According to company pilots interviewed after the disaster, there were no means to immediately track the amount of fuel in the nacelle cylinder while the aircraft was in flight. There was also no obvious sign that the fuel pumps were working (National Transpiration Safety Board, n.d.). Pilots must use checklists to ensure they have completed all necessary fuel-related checks before takeoff and during flight. The checklists should include fuel quality, quantity, transfer, and flow. By using checklists, pilots can reduce the risks that could lead to fuel starvation accidents. Although the pilot had extensive experience in the field, he failed to follow instructions to prevent the accident. Therefore training is a critical component of preventing fuel starvation. Based on the NTSB research, the pilot failed to feather the right pop. Feathering significantly reduces drag and acts as the standard process after shutting down the engine. In this scenario, the problem enhanced drag on the left side, affecting efficiency and control. The right engine kept going since it had fuel left. Pilots could have prevented the accident by employing appropriate procedures if they had received adequate training on fuel management techniques.
The NTSB discovered that the corporation provided no training and lacked any defined fuel management methods. The training should include identifying the signs of fuel starvation, calculating fuel consumption, and transferring in case of imbalances. By providing pilots with the necessary training and knowledge, airlines can help reduce the risks of fuel starvation accidents. The pilot turned down the offer of vectors to a nearby safe airfield and proceeded on the one remaining operable engine toward his intended target. (National Transpiration Safety Board, n.d.) The accident could have been prevented if the pilot had monitored fuel levels and consumption throughout the flight. If the pilot had realized any fueling issue, he could have taken immediate action, such as diverting to the nearby airport or declaring an emergency. Improving fuel indicators and warning systems can also help prevent fuel starvation accidents. In this case, the system could have alerted the pilot to potential fuel issues such as contamination or imbalances. This would have given him enough time to take appropriate action and ensure a safe landing. Therefore, the Piper PA-31 N400JM accident could have been prevented if proactive measures to manage the fuel starvation risk had been considered. This would have ensured the pilot’s safety and prevented the airplane’s destruction. Relevant bodies such as the be vigilant and keen in ensuring companies and the pilots follow the right procedures in maintaining and operating the aircraft to ensure preventable accidents do not occur.
In conclusion, flight accidents are preventable through proper safety procedures and adherence to regulations. The pilot of the Beechcraft BE-58, N959CM, could not maintain control of the airplane due to an urgent medical condition or interfering drugs. Piper PA-31, N400JM accident resulted from fuel starvation to the left engine. Airlines should implement policies to monitor and regulate the use of medications by pilots to ensure they are not impaired while on the flight. Additionally, proper fuel management procedures, including careful pre-flight planning and monitoring of fuel levels during flights, can help prevent starvation accidents. While accidents can still occur despite best efforts, proper safety procedures and adherence to regulations can help prevent these accidents.
References
English, D. (2021). After the accident: Piper Navajo Crashes after fuel starvation. https://www.planeandpilotmag.com/news/pilot-talk/after-the-accident-piper-navajo-crashes-after-fuel-starvation/
National Transpiration Safety Board. (n.d.). Aviation Investigation Final report. file:///C:/Users/user/Downloads/Report_ERA19FA124_99098_4_13_2023%2011_21_37%20AM.pdf
NTSB. (n.d.). Aviation Investigation Final report. file:///C:/Users/user/Downloads/Report_ERA20FA022_100509_4_13_2023%2011_38_34%20PM.pdf
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