RAYTHEON AIRCRAFT COMPANY 58

Full 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, respectively, before the accident.

The SIC was on the operator’s flight schedule for the 2 nights before the accident. His duty times were 12.2 and 10.5 hours on each of the previous nights, and he accrued 8.9 and 6.5 hours of flight time during those periods. At the time of the accident, he had been on duty for 11.1 hours and had flown 6.5 hours.

The SIC had previously flown several times with the PIC while being evaluated for hire by Quest Diagnostics and checked out in the company’s operations. At the time of the accident, the SIC had flown six legs as SIC on other Quest Diagnostics flights in a similar make and model airplane.

According to a company statement, the SIC completed no formal flight training (externally contracted or syllabus-based) in 2009, and his records showed no formal training in the Beech 58, or any other aircraft, since joining the Quest Diagnostics flight department in December 2008 as a “contract,” or part-time, pilot. According to Quest Diagnostics, the SIC had received training in accordance with its FOM. His 18 total evaluations, including two made by the accident PIC, indicated that he met the company’s qualification standards.

AIRCRAFT INFORMATION

According to FAA and maintenance records, the airplane was manufactured in 1999 and had accumulated 3,131.7 total flight hours at the time of its most recent annual inspection on May 27, 2009. The Beech 58 was usually operated as a single-pilot airplane, unless the total flight time exceeded 7 hours, the flight required more than seven landings and 5 hours of flight time over an 8-hour period, or directed otherwise by management, as outlined in the Quest Diagnostics FOM.

On April 10, 2008, both the left and right unfeathering accumulators, which provide oil pressure to the propellers to bring them quickly out of the feathered position, were disconnected from their respective propeller systems. According to the airplane’s type certificate, the unfeathering accumulators were “optional equipment” and only a log book entry was required for removal or deactivation of the systems. Quest Diagnostics’ director of maintenance stated that the removal/deactivation of the accumulators occurred to “streamline engine maintenance” and to standardize the fleet (only 3 of the 13 company Beech 58 airplanes had unfeathering accumulators). He stated that, in addition, the flight simulators used at SimCom International for training Quest Diagnostics pilots were not equipped with unfeathering accumulators.

METEOROLOGICAL INFORMATION

At 0330, the weather reported at TEB included clear skies and winds from 170 degrees at 6 knots, visibility 10 miles, temperature 27 degrees C, and dew point 23 degrees C.

WRECKAGE AND IMPACT INFORMATION

On-site examination of the wreckage revealed that the cockpit, cabin, and both wings were consumed by fire and that the tail section was separated from the main wreckage. Control cable continuity was established from the flight control surfaces to their respective cable breaks and to the cockpit area. All cable, pulley, and bellcrank separations were consistent with overload.

The right propeller was separated from its engine crankshaft but remained with the engine. The left propeller was still attached to its engine. Both engines remained in their nacelles but were damaged by impact and fire. The blades of both propellers appeared in a position consistent with the feathered position. The wreckage was recovered from the site for a detailed examination.

TEST AND RESEARCH

The wreckage was examined on August 25, 2009. Examination of the landing gear actuator/motor revealed a position consistent with the down-and-locked position. The flap actuators were measured, and the measurements were consistent with the flaps in the approach position.

The fuel selector valves were disassembled, and each was intact and absent of water and debris. Both selectors were found in positions consistent with their respective fuel tanks.

The left engine was rotated by hand at the crankshaft and continuity was established through the powertrain and the valvetrain to the accessory section. Magneto timing was confirmed, but sparks could not be produced at all terminal leads due to fire damage.
The right engine was rotated by hand at the pneumatic pump drive and continuity was established from the accessory section to the powertrain and the valvetrain. Magneto timing was confirmed, and sparks were produced at all terminal leads.

Both propellers were disassembled, and a detailed examination of both propeller systems revealed that the left propeller was in the feathered position at impact and that the marks on the right propeller were consistent with it being in the feathered position at impact. Both propeller governors were in the full-advance position. All damage was due to impact forces, and no mechanical anomalies were noted.

ORGANIZATIONAL AND MANAGEMENT INFORMATION

Quest Diagnostics, Incorporated, an independent clinical medical testing company, assumed operation of its flight department following the acquisition of SmithKline Clinical Laboratories in 1999. SmithKline had originally formed the corporate flight department in 1982 for executive transport. In 1988, the mission of the flight department was expanded to include the pickup of medical specimens from health care providers for delivery to medical testing laboratories.

The Quest Diagnostics fleet comprised 30 airplanes, including 13 Hawker Beechcraft Corporation model 58, 6 Mitsubishi MU-2, 4 SOCATA TBM 700, 3 Pilatus PC-12, 1 Hawker Beechcraft Corporation 800XP, 1 Dassault Falcon 2000, 1 Eclipse Aviation 500 Jet, and 1 Cessna Aircraft 310.

According to the director of air logistics (DOL), who runs the flight department, the department averaged 28,000 flight hours per year transporting medical specimens and an additional 400 flight hours per year transporting company executives. According to the DOL, “We fly to 63 cities a night, flying 131 legs. Ninety eight percent are single pilot, 2 percent are dual pilot. We’ve grown so much that at the level we are now, we are an airline. We are the largest part 91 operator in what we do.”

Training

Company PICs would audition and informally train and evaluate part-time, contract pilots for potential full-time positions with the company in the Beech 58; however, Quest Diagnostics did not have a published training syllabus. The PICs did not have to possess a flight instructor certificate. If a PIC did have a flight instructor certificate, it did not have to be current. The PICs filled out a spreadsheet-style grade slip and offered their opinions on the performance and suitability of the contract pilots for full time employment. Quest Diagnostics representatives stated that no formal training program or evaluation (or checkride) for advancement was outlined in the FOM. According to flight department managers, pilots were advanced based on group consensus and whether openings existed in the flight department.

In an interview, a former training manager for the Quest Diagnostics flight department stated that, when the Beech 58 airplanes were added to the fleet to replace the Cessna 310 airplanes, “…they [Quest Diagnostics] didn’t want to send anyone to school, so I wrote an in-house training program for the Baron. It was an hour of ground school and an hour or less in the airplane. Their philosophy for multiengine airplanes was if you had training in one that was good for the other.” Regarding this training philosophy, the company cited 14 CFR 61.167, which states, “[a]n airline transport pilot may instruct other pilots in air transportation service in aircraft of the category.” According to the FAA, Quest Diagnostics did not hold an air operator’s certificate under 14 CFR Part 121, 125, or 135, and, therefore, the regulation did not apply to the company.

Accident History

A review of the NTSB accident database revealed that the SmithKline/Quest Diagnostics flight department has had five accidents since its inception, three of which resulted in a total of four fatalities.

NYC94FA166 - Blain, Pennsylvania, September 3, 1994:

The NTSB determined that the probable cause of this accident was, in part, “the pilot’s impairment of judgment and performance due to drugs.” A contributing factor in the accident was fatigue. The pilot had worked a full 8-hour shift on his construction job before the flight and had been awake for 19 hours at the time of the accident.

MIA97LA087 - Calhoun, Georgia, February 27, 1997:

The NTSB determined that the probable cause of this accident was the “PIC’s improper fuel management and improper positioning of the fuel selector valve to the empty fuel tank.” Contributing factors in the accident were, “the PIC’s improper in-flight planning and decision, his failure to list an alternate airport, and his decision to allow the newly hired copilot to perform instrument approaches in marginal weather which led to numerous instrument approaches and missed approaches.”

ATL03FA082 - Mobile, Alabama, April 24, 2003:

The NTSB determined that the probable causes of this accident were the “improper installation of the power control linkage on the engine fuel control unit by maintenance personnel…and the pilot’s failure to follow emergency procedures and his intentional engine shutdown which resulted in a forced landing and subsequent in-flight collision with a light pole.”

NYC04LA044 - Reading, Pennsylvania, December 6, 2003:

The NTSB determined that the probable cause of this accident was “the pilot’s improper decision to not apply de-icing fluid to the wings prior to takeoff, which resulted in snow/ice contamination on the top of the wings, a stall mush, and a forced landing in an open field.”

2004 Safety Audit and Subsequent Actions

After the accidents in 2003, the Flight Safety Foundation (FSF) conducted a safety audit of Quest Diagnostics’ flight operations. The FSF report contained 100 findings and 184 recommendations. Of the findings, 52 were classified under FSF nomenclature as “major,” 32 as “minor,” and 16 as “informational.” The findings addressed the following areas: maximum flight hours, pilot minimum qualifications, pilot workloads and use of dispatchers, crew day breeches and waiver authority, scheduling, checklist standardization and usage, weight and balance completions, pilot training, and carbon dioxide hazards. The following supporting areas were also addressed: hazardous materials, aircraft records, maintenance discrepancies, hangar and facilities, security, refueling, and fire-fighting equipment.

Some findings of note included the following:

-Excessive Flight Hours: Pilots sought to accrue flight hours quickly for promotion and exceeded limits, which led to tired SICs who became a liability due to fatigue. The recommendation called for stricter adherence to duty- and flight-hour limits.

-Pilot Qualification: No new-hire standards addressing hours of experience existed. The recommendation called for greater fidelity in qualification for both hire and advancement.

-Checklist Usage: The FOM called for checklist usage, but the audit team assessed that checklists were not used. The recommendation called for stricter use and compliance.

-Pilot Distraction: The audit team assessed that the company injected itself in pilot domains of rest and performance and needed greater adherence to a 40-hour work week, the FOM, and addressing pilot concerns beyond the “Don’t Screw it Up” approach.

In 2008, the company safety officer incorporated a safety management system (SMS) approach to the FOM. According to the endorsement titled, “Corporate Commitment to the Culture of Safety,” in the front of the company’s FOM, one of the company’s fundamental beliefs is, “All levels of corporate management, without exception, are held responsible and accountable for Quest Diagnostics Flight Operations’ safety performance; beginning with the Chief Executive Officer (CEO).” The endorsement states that a core element of the company’s safety program was “an established Safety Management System working in conjunction with clearly communicated policies and procedures…to promote our safety goals.” A note stated, “The Chairman and CEO stresses the importance of safety in Quest Diagnostics Flight Operations. All company personnel, including managerial employees, are expressly prohibited to bring undue influence or pressure to bear on the flight crew at any time during their decision making process.” Lastly, it stated, “THE FINAL AUTHORITY REGARDING SAFETY RESTS WITH THE PIC.” The FOM was endorsed and signed by the Chairman and Chief Executive Officer of Quest Diagnostics. Nine current and former employees were asked if they felt that the SMS had improved the safety climate in the Quest Diagnostics flight department. Most of them responded that the program had not improved the safety of the flight operations.

In May 2009, the Quest Diagnostics flight department was registered with the International Business Aviation Council for the implementation of the International Standard for Business Aircraft Operations.

FAA Oversight

The NTSB requested information from the FAA regarding flight standards district office oversight of large Part 91 operators. According to the FAA, “There are no specific oversight requirements for non-certificated 14 CFR part 91 operators contained in FAA Order 1800.56J [‘National Flight Standards Work Program Guidelines’]. However, the FAA uses national work program guidelines and local office work programs to incorporate the surveillance of non-certificated entities.” FAA records indicate that, from 2002 to 2009, there were seven program records pertaining to Quest Diagnostics in the FAA’s Program Tracking and Reporting Subsystem.