NTSB Factual Report

HISTORY OF FLIGHT

On December 10, 2004, approximately 1940 mountain standard time, a Mitsubishi MU-2B-60 twin-engine turbo-prop airplane, N538EA, operated as American Check 900 (ACT 900), was destroyed when it impacted terrain following a loss of control while maneuvering near Centennial Airport (APA), Englewood, Colorado. The airplane was registered to and operated by Flight Line, Inc., Watkins, Colorado. Night visual meteorological conditions prevailed at the time of the accident. The unscheduled domestic cargo flight was being operated under the provisions of Title 14 CFR Part 135 under an instrument flight rules flight plan. The airline transport pilot and pilot-rated passenger sustained fatal injuries. The flight departed APA at 1936, and was en route to Salt Lake City International Airport (SLC), Salt Lake City, Utah.

According to Federal Aviation Administration (FAA) Centennial Air Traffic Control Tower (ATCT) transcripts and Denver Air Route Traffic Control Center (ARTCC) radar data, at 1929:27, the local controller cleared ACT 900 to taxi to runway 35R, and the pilot acknowledged the instruction. At 1933:09, the pilot informed the local controller they were ready for takeoff at the end of the runway. At 1935:05, the controller instructed ACT 900 to "full length runway three five right position and hold..." At 1936:04, the controller cleared ACT 900 for takeoff on runway 35R, and the pilot acknowledged the takeoff clearance. At 1936:56, the controller instructed ACT 900 to turn left to a heading of 280 degrees, and the pilot acknowledged the instruction.

At 1937:02, the airplane was approximately 500 feet agl, and the local controller instructed the pilot to contact Denver departure control; the pilot acknowledged the request. At 1937:36, the airplane was approximately 900 feet agl, and the pilot stated, "...we need to uh go around back in the pattern and come back in on uh either three five right or left please." At 1937:42, the controller stated, "...make a right turn make well you already your left turn keep keep un left turn and uh make left traffic for runway three five right." At 1937:53, the controller asked, "uh mitsubishi nine hundred uh are you do you require any assistance?" The pilot responded, "negative for right now uh just need to get in as soon as possible." At 1938:03, the controller stated, "o k say nature of the problem." At 1938:11, the pilot stated, "stand by one minute."

At 1938:31, the airplane was approximately 500 feet agl, and the pilot reported, "tower americheck nine hundred declaring emergency we've got an air an engine ta shut down uh please roll the equipment." At 1938:49, the controller cleared ACT 900 to land on runway 35R and stated the rescue/fire equipment was responding. At 1939:19, the controller requested from ACT 900 the souls on-board and fuel remaining. The airplane was approximately 400 feet agl, and the pilot responded, "two souls on board uh nineteen hundred pounds of fuel." At 1939:47, the controller stated, "americheck nine hundred you you can go ta two eight if you can do it." There was no response from ACT 900. At 1940:00, a transmission from an unknown source stated, "wind check". No further communications were received from ACT 900.

According to the controller-in-charge statement, "I saw ACT 900 turn base, overshoot final, and finally turn north. The aircraft lights made an abrupt nose down turn and the MU2 was gone." According to the local controller statement, "I cleared [pilot] to land on [runway] 35R. He overshot the base to final turn and went down east of the [runway]."

A witness, located in an airplane at APA who was monitoring the radio communications, reported he observed the airplane make the turn to base, "however, they shot through the final approach course, headed approximately due east." He stated the airplane was approximately 500 feet agl. While the airplane was on base leg, the witness observed the airplane continue to the east in a shallow descent with the left wing slightly low until it went out of the witness's sight. The witness stated he could tell the left wing was slightly low based on looking at the red position light and the rotating beacon.

Another witness, located in a vehicle traveling south on a nearby road, stated she observed the airplane at "less that 75 feet [agl], an average height, in my opinion, had the airplane been aligned with runway 35R to land. The airplane appeared to be flying on its side, as if to make a hard left turn. It then leveled out briefly, and I could see the bottom of the fuselage. Considering the darkness, I did not see the landing gear deployed... As the airplane passed my side window, I heard an aggressive throttle and the airplane make an immediate sharp bank to the left and descended to the ground. The airplane was descending as the speed increased. The impact appeared to be just less than a 45 degree angle, nose first." Approximately 5 minutes after the crash, rescue personnel arrived on the accident scene.

Another witness, located in a vehicle traveling north on the nearby road, stated he observed the airplane flying "very low". He stated, "just before impact, [the airplane] banked left and down."

PERSONNEL INFORMATION

The pilot, age 28, who was seated in the left front seat position, held an airline transport pilot certificate, issued June 24, 2002, with an airplane multi-engine land rating, and a private pilot certificate with an airplane single-engine land rating, issued September 10, 1996. The pilot's most recent FAA first-class airman medical certificate was issued on September 1, 2004, and contained a limitation for corrective lenses.

The pilot's logbook was used to document the pilot's flight experience. The pilot's total flight time at the time of the accident was 2,495.8 hours, with 1,864.2 hours in multi-engine airplanes. The pilot had accumulated 363.8 total hours in the accident airplane make and model, of which all were recorded as pilot-in-command. In the 90 days preceding the accident, the pilot had accumulated 206.5 total flight hours, all of which were in the accident airplane make and model; and 70.1 total hours in the 30 days preceding the accident.

According to the "Remarks, Procedures, Maneuvers, Endorsements" section in the pilot's logbook, one engine inoperative operations and other multi-engine maneuvers were recorded as having been conducted on October 15, 1998, on an undocumented date in 1998, and on March 3 and March 7, 1999. Both entries were recorded as having been conducted in a Piper PA-34-200 airplane. On February 5, 2003, the pilot recorded in the remarks section of the logbook, "Engine Failure", which was listed as occurring on a flight in a Piper PA-31-310. No additional one engine inoperative operations were documented.

In the logbook remarks section, on April 21, 2001, "Part 135 Checkride" in a Piper PA-31-350 was documented; on June 19 - 23, 2003, "Simuflite Training Level D Simulator" was documented; on June 28, 2002, "135 Check" in a Beech BE-200 was documented; and on January 29, 2003, "Check Ride" in a Piper PA-31-350 was documented. No check ride entries were documented in the logbook for the accident aircraft make and model.

On June 30, 2004, the pilot recorded the first entry in the logbook for a flight (APA to SLC) in the accident airplane make and model. No documentation was noted in the "Remarks, Procedures, Maneuvers, Endorsements" section of the pilot's logbook for the accident airplane make and model.

The operator provided the pilot's personnel records to the NTSB investigator-in-charge (IIC). A review of the records revealed the operator hired the pilot in January 2003. The pilot completed the operator's "initial new-hire" training in the Piper PA-31 model airplane on January 29, 2003. According to the flight training records, on the second of three training flights, the instructor noted, "Very good, stalls, single engine work, precision [and] non-precision approaches."

The pilot completed the operator's "initial new-hire" training in the accident airplane make and model on July 12, 2004. The initial training consisted of 44 hours ground school, which included: Basic Indoctrination (Operator, Airman - Specific), Emergency Training (General Situation, Drill Training), Hazardous Materials, and Aircraft Ground (General Subjects, Aircraft Systems, Systems Integration). In addition to the ground training, the pilot completed 8.1 hours recorded as flight training. A review of the operator's flight training record revealed five training flights were conducted on July 1, 8, 9, 10, and 11. The training flights on July 1, 8, 9 were not recorded in the pilot's personal logbook. During the second and last training flight, landings "From Precision Approach with Most Critical Engine Inop." were conducted; during the third and forth flight, climbs "One-engine inoperative" were conducted; during the second and fifth flight, en route "With a Powerplant Inoperative" were conducted; during the fifth flight, approaches "ILS/One-engine Inoperative" and missed approaches "With Powerplant Failure" were conducted. During the first and fourth flights, systems procedures (emergency) "Powerplant Failure/Fire" were conducted. The second and third training flights were conducted in the accident airplane.

On July 12, 2004, the pilot completed a FAR 135 Airman Competency/Proficiency Check. The flight was conducted from Helena Regional Airport (HLN), Helena, Montana, to APA with a total flight time of 2.3 hours.

A review of the pilot's previous employment records revealed the pilot completed single-engine inoperative training in Piper PA-31 airplanes in April 2001, and in a Beech BE-300 simulator in June 2002.

The pilot-rated passenger, age 25, who was seated in the right front seat position, held a commercial pilot certificate with airplane single-engine land, airplane multi-engine land, and instrument ratings. He also held a flight instructor certificate with an airplane single-engine land rating and advanced ground instruction privileges. The passenger's most recent FAA first-class airman medical certificate was issued on October 22, 2003, and contained no waivers or limitations. According to the operator, the pilot-rated passenger was on board the accident airplane for aircraft familiarization training (The operator stated new-hire pilots would receive approximately 25 hours of aircraft familiarization prior to the initial training). The passenger had no pilot-related responsibilities during the accident flight. A review of the operator's pilot profile for the passenger revealed he had accumulated 857.0 total flight hours, of which 218.9 hours were in multi-engine airplanes.

Attendance records of Mitsubishi Heavy Industries America, Inc. (MHIA), which in conjunction with SimCom, conducts Pilot's Review of Proficiency (PROP) seminars for pilots, owners and operator's of MU-2 airplanes, did not reflect the pilot or pilot-rated passenger had attended any of the PROP seminars. According to MHIA, the purpose of the PROP seminar is to improve pilot awareness and decision making skills, meet other MU-2 operators and learn more about how to operate an MU-2 safely and to better understand the various support programs available for the MU-2.

AIRCRAFT INFORMATION

Between 1967 and 1986, 703 Mitsubishi MU-2B airplanes were assembled in the US. Two variants, known colloquially as the long-body and short-body versions, were built during the production run. All models were manufactured using two AirResearch (or Garrett) TPE 331 series turboprop engines. Horsepower of the TPE 331 engines, as installed on MU-2B airplanes, progressively increased to an airframe limit of 715 shaft horsepower (shp) through the various TPE 331 "dash" models installed on the airplanes. The TPE 331 engine exhaust also produces approximately 148 pounds of jet thrust, the total engine output-as installed on MU-2B's is often expressed as equivalent shaft horsepower (eshp), which varied from 605 eshp to a maximum of 778 eshp on the MU-2B fleet.

The long-body version has increased cabin area, the result of a fuselage redesign, which increases the overall length of the aircraft from 33 feet 3 inches to 39 feet 5 inches. Wingspan and area remained unchanged over the production life of the airplane. During the production period, maximum gross takeoff weights increased from the original MU-2B-10's 8,930 pounds to the MU-2B-60's 11,575 pounds. All versions were certificated for single-pilot operation, and did not require a copilot.

FAA certification of the Mitsubishi MU-2B was originally accomplished under the provisions of the Bilateral Airworthiness Agreement between the US and Japan, dated February 1, 1963. In accordance with Part 10 of the Civil Air Regulations (currently 14 CFR 21.29), FAA Type Certificate (TC) A2PC was issued for the MU-2B on November 4, 1965. The airplanes were initially shipped to the US as completed airframe kits; engines and other accessories were then added and the airplanes were test flown and released. Interior furnishings, additional avionics, and instruments were usually added after the airplane was released by Mitsubishi's US representative, which was originally Mooney Aircraft Corporation.

On September 12, 1973, Mitsubishi Aircraft International, Inc. (MAI) submitted an application for type certification of the MU-2B under the provisions of 14 CFR 21.21. The stated intent was to place control of the type design data with MAI at San Angelo, Texas, and to place direct responsibility for specific approval of type design, and changes thereto, with the FAA, rather than through the Japan Civil Aviation Bureau and bilateral agreements. Exemption number 1951 was granted on February 4, 1974, to permit use of the same certificating regulations as were used for airplanes manufactured under TC A2PC. On January 20, 1976, FAA type certificate approval A10SW was granted for the MU-2B-25 and -35 models. Subsequent approval was granted for -26, -26A, -36, -36A, -40, and -60 models, as part of TC A10SW.

The accident airplane, a long-body Mitsubishi MU-2B-60, serial number 1538SA, was a high performance, high wing, semi-monocoque design airplane. The airplane was powered by two 715-horsepower Honeywell TPE331-10-511M turboprop engines (serial numbers P36414C and P-36284C). The airplane was equipped with 4-bladed, Hartzell HC-B4TN-5GL single acting, hydraulically operated, constant speed with feathering and reversing capability, propellers. The airplane was equipped with flight controls for the left and right seats.

The airplane was issued a standard airworthiness certificate on September 1, 1981. The airplane was registered to the operator on June 18, 1999, and was maintained under a FAA approved airworthiness inspection program. According to maintenance records obtained from the operator, on November 14, 2004, at a total airframe time of 12,606.6 hours (Hobbs 5,775.2), the airframe underwent 100-, 200-, and 12,500-hour inspections that were completed in accordance with Mitsubishi Inspection Requirements MR-0179-2.

On February 15, 2004, the left engine, serial number P-36414C, was installed on the airframe. According to the engine logbook, on November 18, 2004, the engine oil was changed, the oil filter and fuel filter were replaced, the igniter plugs were inspected, and a Spectrometric Oil Analysis Program (SOAP) entry was recorded. The SOAP result was the following: "Normal Sample - Continue Sending Samples at the Recommended Interval." At the time of the November 18, 2004 maintenance, the left engine had accumulated 8,468.9 hours and 9,241 cycles since new; 2,799.7 hours and 2,622 cycles since overhaul; and 857.8 hours since hot section inspection.

On February 25, 2004, the right engine, serial number P-36284C, was installed on the airframe. According to the engine logbook, on November 18, 2004, the oil filter and fuel filter were replaced, the igniter plugs were inspected, and a SOAP entry was recorded. The SOAP result was the following: "Important!! Inspect This Engine Immediately!!!!" The sample contained shiny M50 steel platelets, a material used i

NTSB Probable Cause

the pilot's failure to maintain minimum controllable airspeed during the night visual approach resulting in a loss of control and uncontrolled descent into terrain. A contributing factor was the precautionary shutdown of the left engine for undetermined reasons.