NTSB Factual Report

HISTORY OF FLIGHT

On December 17, 2013 at 1924 eastern standard time (EST), a Raytheon Aircraft Company 390, N50PM, was destroyed when it impacted trees and terrain, and was consumed by an explosion and post-crash fire while returning to land at Fulton County Airport – Brown Field (FTY), Atlanta, Georgia. The airplane departed at 1920. Night visual meteorological conditions prevailed and an instrument flight rules (IFR) flight plan was filed for the flight to New Orleans Lake Front Airport (NEW), New Orleans, Louisiana. The private pilot and sole passenger were fatally injured. The personal flight was conducted under the provisions of Title 14 Code of Federal Regulations Part 91.

According to statements from the fixed base operator (FBO) personnel where the airplane was parked, the aircraft was towed from a nearby maintenance facility and parked on their ramp about 1720. At 1738, the pilot called to request 250 gallons of fuel with Prist and the aircraft was fueled about 1755. The pilot and passenger arrived at the FBO about 1900 and parked their vehicle next to the airplane. After the luggage was placed in the airplane, the pilot informed FBO personnel that a marshaler was not necessary, which personnel reported as "not unusual for him."

Security camera video captured the airplane parked on the ramp and the pilot and passenger arriving in a personal vehicle. The video footage revealed only the front portion of the airplane, but showed the pilot conversing with ramp personnel for a few moments, then walking out of the video frame towards the left wing tip. A few moments later, the video showed the pilot walking around the right wing towards the front of the airplane, turning around and reversing his route coming back into the video frame near the front of the left wing near the cabin door. The cabin door was closed and the video captured movement through the left side cockpit windows. A few minutes later, the airplane's strobe lights were illuminated. Several moments later, the airplane's taxi lights were illuminated and the airplane was recorded taxiing from the parking ramp. Due to lamp light reflection off the side windows, it could not be conclusively determined who was seated in the pilot seat or co-pilot seat; however, the silhouette that was observed appeared to be that of an individual wearing a ball cap. The pilot was observed wearing a ball cap as he entered the airplane prior to closing the door; no ball cap was observed being worn by the passenger.

According to the cockpit voice recorder (CVR) recording, the pilot contacted the FTY Federal Aviation Administration (FAA) Air Traffic Control Tower (ATCT) ground controller at 1902:12 and requested the IFR clearance. At 1903:12 the clearance was read back by the pilot and taxi clearance was requested and granted. During the taxi out, various personal conversations were recorded between the pilot and passenger as well as the pilot missing a turn during the taxi and the ground controller providing him a modified taxi clearance. At 1908:54, the pilot requested "a couple of minutes here at the end…" From 1909:10 to 1916:07, various test tones were recorded including several "lift dump fail" test tones. During that time, the pilot also asked the passenger if she had his phone. A photograph was found in the pilot's phone of the warning light configuration. Meta data revealed that the photograph was recorded at 1906 on the date of the accident; however, it could not be conclusively determined if the noted time was accurate. At 1916:36, the pilot requested takeoff clearance. At 1919:19, takeoff clearance was issued by the ATCT controller and acknowledged by the pilot. At 1920:15, the cockpit area microphone recorded the sound of two engine igniters which continued until the end of the recording. At 1920:47, the passenger asked "did you put heat on?" to which the pilot replied "why is that?" At 1920:55, the ground proximity warning system (GPWS) warned "to low terrain to low terrain." At 1921:02, the pilot notified the ATCT that "we're gonna need to come back now we've got a problem here." The controller cleared the airplane to enter right traffic for runway 26 and asked if the pilot need emergency assistance. At 1921:32, the pilot replied "negative" on the assistance. At 1921:33, the controller stated, "Premier five zero papa mike they put a hold message on your flight plan that way you can reuse it if you want to go later just let me know." At 1921:39, the pilot replied, "sounds good appreciate it." At 1922:42, the flight was issued landing clearance and traffic to follow. At 1922:51, the pilot replied, "cleared to land number two fifty five mike thank you," which was the last recording from the airplane to the ATCT. From 1922:53 until the end of the recording, several GPWS audible warnings were given including "pull up pull up pull up" and the pilot stating "I don't know what that's sayin." The airplane crashed while on the downwind leg for runway 26.

PERSONNEL INFORMATION

According to FAA records, the pilot held a private pilot certificate with a rating for single-engine land, multiengine land, and instrument airplane, and he held a type rating in the accident airplane. He held a third-class medical certificate which was issued on April 17, 2013 and contained restriction, "76 – not valid for any class after." At the time of that medical examination, the pilot reported 7,700 total hours of flight experience and 35 hours of flight experience within the preceding 6 months. The pilot further reported, on the medical certificate application, that he was diagnosed with coronary artery disease and had had a heart attack in April 1996, which was treated with angioplasty and stent placement. The pilot's stress test, conducted on April 11, 2013, revealed no evidence of ischemia. He further reported that his medications included aspirin, atenolol, losartan, and simvastatin.

According to the FAA medical case review, the pilot's reported medication of Atenolol and losartan were used to treat high blood pressure and were marketed as Tenormin and Cozaar. Simvastatin was a cholesterol lowering medication marketed as Zocar and Aspirin is a non-steroidal anti-inflammatory medication used to treat pain and fever, it also inhibits blood clots and helps prevent occlusion of the coronary arteries.

According to information provided by the pilot's company representative, the pilot's most recent logbook entry was dated June 27, 2013. At that time he had accumulated a total of 7,200.6 hours total flight experience, of those hours 1,030.1 hours of flight experience in "Jet;" however, it could not be accurately determined how many of those hours were in the accident aircraft make and model.

A search was conducted on the passenger and revealed no evidence of any FAA pilot or medical certification.

AIRCRAFT INFORMATION

According to FAA records the airplane, Serial No. RB-80, was issued an airworthiness certificate on September 20, 2003 and was registered to the corporation on November 7, 2003 as N50280. The registration number was changed to N50PM on December 24, 2003. The corporate registration listed the accident pilot as the president. It was equipped with two Williams-Rolls FJ44-2A engines. The left engine, also known as engine No. 1, serial number 105067, was placarded for 2,300 pounds of thrust. The right engine, also known as engine No. 2, serial number 105070, was placarded for 2,300 pounds of thrust. According to maintenance records dated December 16, 2013, four (4) maintenance items were recorded and signed off as completed. At the time of the entry, a recorded hobbs was 712.9 hours. On December 23, 2011 a recorded "A" airframe inspection was accomplished with a reported total time of 621.2 flight hours.

METEOROLOGICAL INFORMATION

The 1940 recorded weather observation at FTY, was considered a "Speci" and included wind from 230 degrees at 6 knots, visibility 10 miles, clear skies, temperature 12 degrees C, dew point 01 degrees C, and barometric altimeter 30.13 inches of mercury.

The 1853 recorded weather observation at FTY included wind from 240 at 4 knots, visibility 10 miles, clear skies, temperature 13 C, dew point 0 C, and barometric altimeter 30.13 inches of mercury.

According to the U.S. Naval Observatory, on the day of the accident, official sunset was at 1731, the end of civil twilight was at 1759, and official moonrise was at 1808. The moon phase was full.

AIRPORT INFORMATION

The airport in a publically owned airport and at the time of the accident had an FAA operating control tower. The airport was equipped with three runways designated as runway 8/26, 9/27, and 14/32. Runway 8/26 was reported as "in good condition" and runway 9/27 and 14/32 was reported as "in fair condition." Runway 8/26 was 5,797-foot-long by 100-foot-wide, runway 9/27 was 2,801-foot-long by 60-foot-wide, and runway 14/32 was 4,158 -foot-long by 100-foot-wide. The airport was surveyed at 841.1 feet above mean sea level.

FLIGHT RECORDERS

Cockpit Voice Recorder (CVR)

The CVR was forwarded to the NTSB Vehicle Recorders Laboratory in Washington, DC for readout. The CVR was a L-3 Fairchild FA-2100-1010; however, the serial number could not be determined. The thirty-minute digital recording consisted of four channels of audio information. Excellent quality audio information was recorded from both occupants' microphones and cabin/PA and good quality audio information was recorded from the cockpit area microphone. The exterior of the unit exhibited extensive heat and structural damage. Removal of the outer case revealed the interior crash-protected case did not exhibit any heat or structural damage. The memory ribbon cable that connected the memory to the external electronics was burned and not useable. A new ribbon cable was soldered to the accident memory, the memory boards were disassembled, cleaned and examined for damage, with no damage noted. The digital audio was successfully downloaded from the memory board. A CVR group was convened and a transcript was developed and is located in the public docket for this accident.

The entire recording was transcribed and the recording began at an unknown time and ran approximately one minute with no one in the cockpit of the aircraft. Electrical power was cycled and the verbatim transcript began at 18:55:07. The recording contained events from startup, taxi, takeoff, climb, and the accident sequence. The airplane started to taxi at 1903:22 to the departure runway and remained short of the runway from 1908:54 to 1919:24 while the pilot addressed some aircraft system issues. During the flight the pilot received several obstacle, terrain , and bank angle warnings from the enhanced onboard ground proximity warning system. The pilot also received several stall warnings from the aircraft during the flight. The recording ended at 1924:02.

Enhanced Ground Proximity Warning System (EGPWS)

The EGPWS was a Honeywell MK V EGPWS and an exterior examination revealed the unit had sustained heat exposure with charring to the unit's housing. An interior inspection revealed no heat or impact damage to the circuit boards and the data was extracted by the NTSB Recorders Laboratory. The unit was designed to record events triggered by exceeding preset limits in 7 different modes, 3 of the modes required urgent attention by the flight crew. Once a limit was exceeded, a new event would be recorded at one sample per second that included 20 seconds before and 10 seconds after the exceedance. The accident flight data recording was triggered by 13 EGPWS alerts over two separate periods of time. The first period of time contained one, "Too Low Terrain" alert during the accident flight's takeoff. The second period of time contained 12 alerts spanning a time of about 50 seconds. The initial alert, during the second period of time, was a "Caution Obstacle" alert that was triggered by a smokestack, located 3 miles to the northeast of the airport and about 1,200 feet laterally from the airplane's recorded flight path. Two subsequent "Obstacle Pull-Up" warnings were recorded 4 and 15 seconds following the initial warning. For more detailed information on the EGPWS, please refer to the "EGPWS Factual Report" located in the public docket for this accident.

Flight Management Computer (FMC)

The FMC was a Rockwell Collins FMC-3000, Part No. 822-0883-701. An exterior examination of the unit revealed impact and thermal damage and an interior examination revealed the condition of the circuit board was acceptable to be placed into a test fixture. After being loaded into the test fixture, the unit failed to power up, and additional troubleshooting revealed the circuit board had damage consistent with impact damage. The damaged parts were replaced and the data was partially recovered. Some of the data was determined to be corrupted; however, an Angle of Attack (AOA) fault was displayed on the Cockpit Display Unit (CDU) prior to the accident flight's takeoff. Further research revealed that had the source of the AOA fault come from the flight management system, the FMC would have logged the fault in the data. For more detailed information on the FMC, please refer to the "Flight Management Computer Factual Report" located in the public docket for this accident.

Maintenance Data Computer (MDC)

The MDC was a Rockwell Collins MDC -3000, Part No. 822-1139-021. An exterior examination of the unit revealed impact and thermal damage to the casing and an interior examination revealed the primary circuit board contained flexure damage. The circuit board sustained damage that prohibited directly inserting it into a test fixture. Special connectors were utilized to connect the board to a test bench, and the data was downloaded successfully. The accident flight was identified as two faults were logged at 1921. The faults logged were "FMC 2 – NO BUS TO IOC" and a fault for the TCAS (Traffic Collision Advisory System). The FMC fault could be concluded as a nuisance fault when generated by the aircraft with only one FMC installed, as was with the accident airplane. The TCAS fault was also likely a nuisance fault and was reported as "fairly common" during the startup sequence and timing within the system. For more detailed information on the MDC please refer to the "Maintenance Data Computer Factual Report" located in the public docket for this accident.

Air Data Computer (ADC)

The airplane was equipped with two ADC units. Both units were manufactured by Rockwell Collins as the ADC-3000, Part No 822-1109-016. The Serial No. on the units were 12WYB and 13TVC. Exterior examination revealed impact damage to the housing and foreign object debris from impact. The memory chip on the unit with Serial No. 12WYB was damaged and data could not be recovered. The circuit board from the unit with Serial No. 13TVC was removed and data was successfully recovered. The recovered data included 44 flights and revealed only normal weight on wheel transition in the log and no failures were logged. The ADC indicated that the unit was shut down and powered up twice on the ground prior to the event flight. The unit further recorded the last weight on wheels transition (take-off) 25 minutes after having been powered up and no record of returning to "on-ground."

WRECKAGE AND IMPACT INFORMATION

The main portion of the airplane came to rest upright and in a moderately wooded area within a drainage ditch. An impact crater was located approximately 45 feet from the main wreckage along the debris path. Within the crater was the windscreen section, and the No. 1 (left pilot side) window was spider-webbed but remained intact. The wreckage was located about 3 miles on a 043 degree course from the threshold of runway 26 and came to rest facing toward the direction of travel. The debris path was approximately 250 feet in length and on a heading of 095 degrees.

The initial tree strike location was located approximately 80 feet above ground level (agl) and consisted of the left wingtip including the navigation light. The second tree impact location was located approximately 50 feet agl and consisted of the right wingtip including the navigation light. The initial ground impact point, along the debris path, contained the

NTSB Probable Cause

The pilot's failure to maintain airplane control while maneuvering the airplane in the traffic pattern at night. Contributing to the accident was the pilot's impairment from the use of illicit drugs.