Accident on 5/25/2009 12:00:00 AM in Yeehaw Junction, FL
Tail Number: N8001V
Aircraft Type: BEECH C90A
Serial Number: LJ-1265
Visibility: 10 statute miles
Wind Velocity: 6 knots
Wind Gusts: knots
Sky Condition: NONE at feet
Total Injuries: 0
Total Fatal Injuries: 0
NTSB No.: ERA09FA304
HISTORY OF FLIGHT
On May 25, 2009, about 1146 eastern daylight time, a Beech C90A, N8001V, registered to Rockwood LLC, operated by Executive Airlink, Inc., was landed hard during a forced landing in a field near Yeehaw Junction, Florida. Visual meteorological conditions prevailed at the time and an instrument flight rules (IFR) flight plan was filed and activated for the 14 Code of Federal Regulations (CFR) Part 135 non-scheduled, domestic, passenger flight from Ocean Reef Club Airport (07FA), Key Largo, Florida, to Orlando Executive Airport (ORL), Orlando, Florida. The airplane was substantially damaged and there was no injury to the certificated airline transport pilot and co-pilot, or two passengers. The flight originated from 07FA about 1104 hours.
Earlier on the day of the accident, the accident flightcrew flew the accident airplane to 07FA to pick up two passengers; the flight was uneventful. The flight departed 07FA for ORL with approximately 1,600 to 1,800 pounds of fuel on-board, and at approximately 1108, the flightcrew established contact with the Miami Air Route Traffic Control Center (ARTCC), and advised the controller that the flight was climbing from 5,000 to 16,000 feet.
The flight continued towards the destination airport and the pilot-in-command (PIC) reported that while in the “Miami area”, he noticed the amber crossfeed light was illuminated on the annunciator panel. They looked at the emergency procedures checklist for boost pump failure but the PIC reported he did not comply with the checklist and did not change the fuel control configuration. At that time they were operating with the crossfeed and both transfer pump switches in “Auto”, and both boost pumps “On.” The PIC reported he did not see any urgency and elected to continue the flight, though he did not monitor the fuel quantity gauges.
The flight was cleared to climb to 17,000 feet, then later while continuing towards the destination airport was cleared to descend to 15,000 feet. Air traffic control communications were transferred to Orlando Approach Control and at 1137, the controller advised the flightcrew to cross the BAIRN intersection at 10,000 feet which they acknowledged. At 1145:37, the flightcrew advised air traffic control that the flight needed to divert to the nearest airport. The controller advised the flightcrew of 2 nearby airports and asked them which one they would like to proceed to. The flightcrew responded and the flight was vectored towards that airport. The controller asked the flightcrew the reason to divert but there was no response; there were no further radio communications received from the flightcrew.
The PIC further stated that while descending to the assigned altitude of 10,000 feet with the autopilot engaged, approximately 15 minutes from the destination airport, they both noticed the left and right red low fuel pressure annunciator warning lights illuminated, followed by loss of power from both engines. They looked for the nearest airport and the PIC was able to restart the left engine. While attempting to restart the right engine the left engine quit again. The PIC maneuvered the airplane for a forced landing in an open field and lowered the landing gear before touchdown. He reported landing hard, bouncing, and becoming airborne momentarily. After coming to rest they evacuated the airplane. The PIC further reported that at no time during the flight did either no fuel transfer warning annunciator lights illuminate.
The co-pilot stated that when the crossfeed light came on, they looked at the checklist but did not recall any checklist for that annunciation. He stated they normally don't do challenge response with respect to the checklist and they did not do a challenge response related to the crossfeed annunciation. When the PIC used the checklist he did not read it aloud. The PIC advised him the airplane was OK and elected to continue the flight. The flight continued and both fuel pressure annunciators came on within seconds of each other. The PIC advised him that they lost power in both engines. Every light on the annunciator panel was on. The PIC performed restart procedures and he asked air traffic control for vectors. They were able to restart but had no power.
The rest of the flight was spent getting the airplane on the ground safely. When close to the ground they had a high sink rate but the gear was put down. The airplane bounced, landed, then slid sideways. They came to a stop and the PIC began securing the airplane. They all exited the airplane; the PIC was the last person to leave. The fire department arrived 1.0 to 1.5 hours later. After they arrived, they heard a buzzing sound and the PIC said both boost pumps may be still on. He did not hear either boost pump running and went into the airplane and shutdown the entire fuel panel. He turned off the transfer, boost, and crossfeed switches. He estimated he secured the panel 2 hours after the accident.
The PIC, age 46, holds an airline transport pilot certificate with rating airplane multi-engine land rating, and commercial pilot certificate with single engine land rating. His latest first class medical certificate was issued on November 3, 2008, with a limitation to wear corrective lenses. He reported having a total flight time of 5,789 hours, and 725 hours in the accident make and model airplane. His total PIC time was 5,331 hours, of which 689 were in the accident make and model airplane. During the last 90 days he logged 111 hours in multi-engine airplanes, of which 27 were in the accident make and model airplane.
The PIC reported he was hired by Executive Airlink, Inc., in November 2004, and became chief pilot in July 2008. His last airman competency/proficiency check in accordance with 14 CFR Part 135.293 titled, “Initial and recurrent pilot testing requirements”, 14 CFR Part 135.297 titled, “Pilot in command: Instrument proficiency check requirements", and also 14 CFR 135.299 titled, “Pilot in command: Line checks: Routes and airports” was performed on February 17, 2009. The flight duration was recorded to be 1.5 hours and the results were listed as "Approved." The flight was in a Beech 200 airplane. He was qualified to act as PIC in Beech 200 and C90 airplanes.
The co-pilot, age 29, holds an airline transport pilot certificate with rating an airplane multi-engine land rating, and commercial pilot certificate with single engine land rating. His latest first class medical certificate was issued on January 20, 2009, with no limitations. He reported on the NTSB Pilot/Operator Aircraft Accident/Incident Report having a total time of 2,500 hours, of which 690 were in the accident make and model airplane. He indicated having 2,160 hours as PIC in all type aircraft, of which 590 were in the accident make and model airplane. In the previous 90 days he reported accruing 25 hours, of which 1 were in the accident make and model airplane.
The co-pilot reported that he was hired by Executive Airlink, Inc., approximately 1 ½ years earlier, left the company, then returned to the company in March 2009. His last airman competency/proficiency check in accordance with 14 CFR Part 135.293 titled, “Initial and recurrent pilot testing requirements”, 14 CFR Part 135.297 titled, “Pilot in command: Instrument proficiency check requirements", and also 14 CFR 135.299 titled, “Pilot in command: Line checks: Routes and airports” was performed on March 23, 2009. The flight duration was recorded to be 1.2 hours and the results were listed as "Approved." The remarks section indicated, "[second-in-command] only check must fly with [pilot-in-command]." The flight was in a Beech 200 airplane. He was qualified to act as second-in-command in Beech 200 and C90 airplanes.
The airplane was manufactured in 1990 by Beech Aircraft Corporation as model C90A, and was designated serial number LJ-1265. It was powered by two 750 shaft horsepower Pratt & Whitney PT6A-35 engines installed in accordance with a supplemental type certificate (STC), and equipped with constant speed, feathering and reversible propellers.
The airplane was maintained in accordance with an FAA Approved Aircraft Inspection Program (AAIP), consisting of four inspections each performed at 200 hour intervals. A complete inspection of the airplane is performed every 800 hours, or every two calendar years.
Inspection of electrical wiring and equipment in the cockpit (which includes the fuel control panel) is specified to occur during a Phase 3 inspection or a Biennial (2 year) inspection, depending on the owner/operator utilization of the airplane. During either inspection, the fuel control panel is required to be lowered. The Phase 3 inspection does not specifically state to inspect the terminals of either relay or the condition of the wires at either relay; although, inspection of components and wiring of the panel would be considered an accepted maintenance practice whenever the panel is opened.
The maintenance records reflect that the left boost pump was removed from another airplane (N5MK), and installed in the accident airplane on December 8, 2006. The airframe total time at that time was 6,898.8 hours and total cycles were 8,107. The last Phase 3 inspection was performed on January 10, 2008, at aircraft total time 7,621.2 hours, and 8,921 cycles. There was no entry in the maintenance records documenting maintenance performed to either no fuel transfer time delay relay.
The airplane total time at the time of the accident was 8,252.3 hours, and the total cycles excluding the accident flight were 9,531.
Review of the airplane's flight pages which contains flight and maintenance malfunction information was performed for the period March 1, 2009, through the accident date. During that time excluding the accident flight, the airplane had been operated approximately 96 hours over the course of 92 flights, and there was no record of any entry related to the left fuel boost pump or the left and right time delay relays. According to the accident PIC, on either May 20, 2009, or May 21, 2009, during a flight in the accident airplane from Orlando, Florida, to Key Largo, Florida, the left fuel boost pump was noted to be inoperative intermittently. He did not follow the checklist pertaining to boost pump failure, and elected to continue the flight. The annunciation extinguished and the flight was uneventful; he reported the discrepancy to the company which was put in the "Aircraft Discrepancy Log."
During flight with the crossfeed switch in "AUTO", failure of the left fuel boost pump causes a red colored "L FUEL PRESS" light to illuminate on the annunciator panel, and the crossfeed valve automatically opens allowing the right boost pump to supply fuel to both engines. An amber colored "FUEL CROSSFEED" light will illuminate on the annunciator panel centrally located in the glareshield, and at the same time a fuel pressure switch will sense boost pump fluid pressure and extinguish the red "L FUEL PRESS" light. The amber colored "FUEL CROSSFEED" light will remain illuminated as long as the fuel boost pump is failed or inoperative.
Inspection of the left boost pump by the company director of maintenance (DOM) revealed the intermittent discrepancy could not be duplicated; the boost pump was not removed or replaced. The airplane was approved for return to service.
The airplane's fuel supply system consists of five tanks installed in each wing. Three tanks are located outboard of each wing panel, another tank (center) is located in each side of the wing center section, and the last tank (nacelle) is located in the engine nacelle aft of the firewall. The fuel from the tanks outboard of each wing panel gravity feed to the center tank, and a transfer pump located in each center tank provides fuel to the nacelle fuel tank, which is equipped with a boost pump that provides fuel to the engine-driven high pressure fuel pump. The fuel level in the nacelle tank is automatically maintain at nearly full capacity during normal operation by a fuel transfer system whenever the fuel level in the nacelle tank drops approximately 8 gallons.
The transfer pumps are controlled by float-operated switches on the nacelle tank fuel quantity transmitters. A pressure switch, located in the fuel transfer line, will automatically turn off the transfer pump if a pressure of 1.5 to 4.25 psi is not obtained within approximately 30 seconds from the time the transfer pump switch was turned on, or if the transfer pump fuel pressure drops below 1 plus or minus 0.25 psi due to empty wing tanks or an inoperative transfer pump. A "NO TRANSFER" warning light controlled by a 30 second time-delay relay illuminates when the pump is automatically turned off. The relay is located behind a fuel control panel in the cockpit; a separate relay is installed for the left and right positions.
During normal operation, the crossfeed valve control switch located in the cockpit is in the "auto" position and the crossfeed valve is closed but is armed for automatic operation in the event of a boost pump failure. In that instance, the "Fuel Crossfeed" annunciator light will illuminate and the standby boost pressure is maintained by supplying fuel to both engines through the crossfeed valve from the operating boost pump. For example, if the left fuel boost pump fails and the crossfeed valve switch in the cockpit is in the "auto" position, fuel to both engines will be supplied by the right fuel tanks. Fuel from the fuel tanks of the inoperative side boost pump can still be supplied to its respective engine by moving the crossfeed valve control switch to the off position closing the valve and relying on the engine-driven high pressure fuel pump. Operating the engine-driven high pressure fuel pump without the aid of the boost pump is limited to 10 hours accumulated, after which the pump must be overhauled or replaced. To operate with the crossfeed valve closed with an inoperative boost pump, the pilot must determine if continuation of flight is possible.
A surface observation weather report taken at Vero Beach Municipal Airport (VRB) at 1153, indicated the wind was from 110 degrees at 6 knots, the visibility was 10 statute miles, and scattered clouds existed at 3,600 feet. The temperature and dew point were 28 and 22 degrees Celsius, respectively, and the altimeter setting was 29.94 inches of Mercury. The Vero Beach Airport is located approximately 31 nautical miles and 102 degrees from the accident site.
The flightcrew were in contact with the Miami Air Route Traffic Control Center. Radio and radar communications were lost while in contact with that facility while maneuvering at low altitude for the forced landing. There were no reported communication difficulties prior to that time.
WRECKAGE AND IMPACT INFORMATION
Examination of the accident site revealed the airplane came to rest upright in a large open pasture; the airplane was located at 27 degrees 45.711 minutes North latitude and 080 degrees 59.190 minutes West longitude. Three marks on ground associated with the landing gears depict an arching turn to the right after touchdown. The airplane came to rest approximately 978 feet from the first mark made by the landing gear. Further examination of the ground beneath both wings revealed no browning of grass beneath the left wing, but dead grass (evidence of fuel leak) was noted beneath the left outboard wing fuel tank sump drain valve.
Examination of the airplane revealed no pre or postcrash fire was noted to any component of the airplane. The right main landing gear wheel assembly was separated at outer lower trunnion, and the left main landing gear was displaced aft and outboard. The nose landing gear was extended and no visible damage was noted. The leading edge of the right horizontal stabilizer exhibited impact damage possibly from the separated right main landing gear wheel assembly. Aileron, elevator, and rudder flight control continuity was confirmed from cockpit to each control surface.
Examination of the left wing revealed the airframe fuel filter bowl was full; no contaminants were noted. The firewall shutoff valve was in the “open” position which agreed with the cockpit switch. Approximately 12 ounces of straw colored fuel were drained from the outboard wing sump drain valve. Greater than 50 gallons of fuel were drained from the nacelle and center fuel tanks; the nacelle tank was visually full. No contaminants were noted in the fuel sample taken from the nacelle tank. The outboard attach rib was separated from aft spar aft of the engine fairing, and the inboard forward spar was fractured at the nacelle, which was rotated forward and down. The upper skin aft of engine nacelle separated from aft spar. Operational testing of the boost pump revealed it did not operate using the aircraft's battery power, though battery voltage (24 volts) was noted at wires at the boost pump. The boost pump was retained for further examination.
Examination of the right wing revealed no fuel was found in the outboard wing tank when checked at the tank sump drain valve, while 16 ounces of jet fuel were drained from the center tank. A total of 42 ounces of jet fuel were drained from the nacelle tank. The airframe fuel filter bowl was drained and contained less than 2 ounces; the fuel was black in color. The firewall shutoff valve was in the “open” position which agreed with the cockpit switch. A fuel sample taken from the transfer pump drain was straw colored. The 1st rib inboard of the tip exhibited a diagonal buckle, and the upper skin was wrinkled at wing panel attachment. The engine nacelle was noted to be distorted down slightly. The boost pump operated satisfactorily when checked using available airplane battery power.
Operational testing of both fuel transfer pumps was performed using the aircraft's battery power. The testing revealed both pumped fuel into their respective nacelle tanks; however, the right no fuel transfer annunciator did not illuminate when the right center fuel tank was empty. Additionally, the transfer pump continued to operate longer than 1 minute though there was no fuel in the center fuel tank.
Examination of the fuel control panel in the cockpit revealed no damage to it or the surrounding area. The fuel control panel was lowered for inspection which revealed the No. 1 terminal of the right no transfer time delay relay was broken. Wires identified as TBI-21-XK4-1 and XK4-1-S9-6 solder joints remained attached to the separated portion of the broken terminal. The relay was properly attached to the fuel control panel. The separated terminal with attached electrical wires were connected to the remaining portion of the terminal on the relay, and with battery power applied, and transfer pump in “Auto”, and no fuel in the center tank, the no fuel transfer light came on in approximately 35 seconds and the transfer pump turned off simultaneously. Visual inspection of the left no fuel transfer time delay relay revealed it too was properly attached to the fuel control panel. Inspection of the relay using a mirror revealed no evidence of any discrepancies. While carefully cutting tie wraps to remove the left relay, a wire from the No. 6 terminal separated; the No. 6 terminal is to ground. The left and right no transfer time delay relays were retained for further examination.
Before the fuel in either wing were sump drained, examination of the cockpit revealed that with airplane battery power applied and the fuel quantity selector positioned to total, the left and right fuel quantity indicators indicated 650 pounds and off scale low, respectively. With airplane battery power applied and the fuel quantity selector positioned to nacelle, the left and right fuel quantity indicators indicated 400 pounds and 0 pounds, respectively. The right nacelle tank was then sump drained and approximately 4 gallons of fuel were added to it; the fuel quantity gauge did reflect the added fuel amount with the fuel quantity total test switch in the “nacelle” position.
Examination of both engines was performed by a representative of the engine manufacturer with Federal Aviation Administration (FAA) oversight. The inspection of both revealed the engine ignition system functionally checked satisfactory per the engine maintenance manual procedures; both igniters operated properly. The gas generator of both engines rotated freely and did not produce abnormal noises when turned by hand via the starter-generator cooling fan. This method rotated all accessory drive gears, rear mounted accessories, the engine compressor and compressor turbine. The power section of both engines rotated freely and did not produce abnormal noises when turned by hand via the propeller. This method rotated all reduction gearbox gears, accessory drive gears, front mounted accessories and power turbine.
Visual inspection of the left and right propellers revealed all blades were bent at varying degrees and lengths from the propeller hub.
MEDICAL AND PATHOLOGICAL INFORMATION
Postaccident toxicology testing of the pilot and co-pilot was not performed.
TESTS AND RESEARCH
Examination of the left boost pump at the manufacturers facility with FAA oversight revealed the unit operated initially when electrically powered, but failed to operate when later tested electrically. Disassembly inspection of the boost pump revealed the upper motor brushes had worn to the point that their travel along the brush card slot had been restricted due to the shunt wire catching the side of the brush card slot. During normal operation, the motor brushes develop a smooth contour matching the curvature of the armature’s commutator. In this case the upper motor brushes exhibit multiple contours due to cocking within the brush card slot due to the brush shunt wire catching on the brush card. The lower motor brushes exhibited normal wear conditions. Removal of the upper brush card exposed the motor’s upper commutator. Two of the commutator bars are extremely pitted. This design fuel pump contains two pumping elements. One a centrifugal impeller and the other a positive displacement vane pump. Both were noted to be in good condition.
Examination of the left and right no fuel transfer time delay relays was performed at the Safety Board's Materials Laboratory located in Washington, DC. The examination of the right relay revealed the wires from terminals 1, 6, and 8 had completely severed from the terminal, while the wire for terminal 3 was still attached. All wires appeared to have been attached or previously attached to the terminals by solder. All of the wires were still attached to the terminals except the wire on Terminal 6, which occurred during removal of the left relay. Examination of the wires for both relays revealed there were no signs of arcing on any of the wires from either relay. None of the conductors had recognizable fracture features. On some of the conductors, there was some deformation consistent with tensile overstress. Others had significant bending adjacent to the fractures. When an undamaged section of wire was subject to tensile overstress in the laboratory, the conductors for these wires did not show typical fracture signatures such as “cup and cone” formation.
Review of the emergency procedures section of the Pilot's Check List indicates that for boost pump failure (fuel crossfeed, fuel pressure annunciator), the steps are:
1. Inoperative Fuel Boost Pump – Off
2. Determine whether continuation of flight with crossfeed open is possible.
3. To continue flight with crossfeed closed, satisfactory operation may be obtained by:
a. Reducing power
b. Descending to a lower altitude
c. Waiting for fuel to cool.
A note at the bottom of the check list indicates the Pilot's Operating Handbook and FAA Approved Airplane Flight Manual contains more detailed procedures which must be followed.
Review of the emergency procedures section of the Pilot's Operating Handbook and FAA Approved Airplane Flight Manual revealed a section associated with boost pump failure. A note indicates that when operating with the crossfeed in "Auto", "a boost pump failure will be denoted only by the illumination of the FUEL CROSSFEED annunciator. To identify the failed boost pump, momentarily placed the crossfeed in the closed position. The FUEL PRESS annunciator on the side of the failed boost pump will illuminate. Then place across the crossfeed switch in the open position. The fuel pressure annunciator will then extinguish." The steps of the checklist further indicate:
1. Inoperative Fuel Boost Pump – OFF
2. Determine whether continuation of flight with crossfeed open is possible.
Postaccident, the airframe manufacturer representative inspected the fuel control panels of two production airplanes of the same make and model as the accident airplane. Both airplanes exhibited chafing and/or contact of the wires of the no fuel transfer time delay relay against a nearby structural member. The wires of one airplane contacted the structural member while closing the fuel control panel, and the wires of the second airplane were contacting the adjacent structural member even after the fuel control panel was closed, and also exhibited evidence of chafing against a mounting screw.
The airframe manufacture has taken corrective action for airplanes that are in production related to the condition of the no fuel transfer time delay relay wires contacting the structural member. Additionally, they have expanded the electrical wiring inspection in the King Air Model 90, 200, and 300 Series Maintenance Manual under chapter 20-12-00.
Approximately 4 days before the accident the left boost pump was noted by the accident pilot to be intermittent. Maintenance checked the pump but could not duplicate the intermittent discrepancy and the airplane was approved for return to service. Shortly after takeoff during the accident flight while operating with the crossfeed switch in the "Auto" position, the left boost pump became inoperative and the "Fuel Crossfeed" annunciator correctly illuminated alerting the flightcrew that the right boost pump was supplying fuel from the right fuel tanks to both engines. An adequate supply of fuel was available in the left fuel tanks which could have directly supplied the left engine had the flightcrew closed the crossfeed valve, but the pilot in command (PIC) continued the flight with fuel only supplied from the right fuel tanks. While descending, both engines lost power due to fuel starvation. The PIC maneuvered the airplane for a forced landing in an open field and landed hard, bounced, and came to rest upright. Postaccident inspection of the airplane revealed internal components of the left boost pump were worn resulting in an inoperative boost pump and the right no fuel transfer time delay relay was inoperative due to a broken terminal at the relay. Had the right no fuel transfer annunciation system been operative, it is likely that the flightcrew would have diverted earlier for an uneventful landing at a suitable airport. While inspection of the electrical wiring and components in the cockpit (includes the fuel control panel) occurs during a Phase 3 inspection required to be performed every 800 hours, the failures of the wires and terminal at the right no fuel transfer time delay relay was due to bending which occurred with repeated opening and closing of the panel. Postaccident inspection of 2 production airplanes of the same make and model revealed discrepancies with chafing of the relay wires against a nearby structural member.
The failure of the flightcrew to recognize that both engines were being supplied fuel only from the right wing fuel tanks resulting in loss of power in both engine due to fuel starvation. Contributing to the accident were the inoperative the left auxiliary fuel pump, the inoperative right no fuel transfer time delay relay, and inadequate manufacturing of the electrical wires associated with the left and right no fuel transfer time delay relays.