NTSB Factual Report

**Modifications were made to this report on 10/31/2011. Please see the public docket for this accident to see a list of changes.**

HISTORY OF FLIGHT

On July 5, 2009, about 1002 eastern daylight time, a Pilatus PC12/45, N578DC, registered to Nicholas Elliott & Jordan LLC, impacted in a pasture near Raphine, Virginia, following an in-flight loss of control. Instrument meteorological conditions (IMC) prevailed at the altitude of the start of the in-flight loss of control and an instrument flight rules (IFR) flight plan was filed and activated for the 14 Code of Federal Regulations (CFR) Part 91 personal flight from Teterboro Airport (TEB), Teterboro, New Jersey, to Tampa Executive Airport (VDF), Tampa, Florida. The airplane was destroyed by impact and the certificated private pilot and three passengers were killed.

According to a chronological summary of communications, the pilot received his IFR clearance while on the ground at the departure airport. The certified copy of the voice transmission indicated the pilot was informed to expect flight level (FL) 260 ten minutes after departure. A transcription of communications indicated that the flight was cleared for takeoff about 0823, and after takeoff, air traffic control (ATC) communications were transferred to several ATC facilities while the flight proceeded towards the destination airport.

At approximately 0906, while in contact with the Washington Air Route Traffic Control Center (Washington ARTCC), the pilot advised the controller that he was at FL 260. While in communication with the same facility, he later requested clearance to climb to FL 280, followed by a request to climb to FL 300; both climb clearances were approved. The pilot climbed to FL 300 and at 0942, while continuing towards the destination airport, the pilot asked the controller if he was indicating any weather radar returns on the controller’s scope. The controller informed the pilot that a line of radar returns 30 miles wide was located about 60 to 70 miles ahead of his position. The flight continued towards the destination and at approximately 0953, the pilot asked the controller if the ground based weather radar depicted a clear area of weather. The controller responded that ground based weather radar was depicting heavy weather ahead of the airplane’s position using clock positions three and nine for reference. The pilot then requested to deviate 40 to 50 degrees to the right which was approved. The NTSB ATC Radar Study indicates the airplane deviated to the right and at approximately 0954, ATC communications were transferred from the R52 sector to the R37 sector of the Washington ARTCC.

The transcription of communications further indicated that at approximately 0955, while in contact with the R37 sector controller of the Washington ARTCC, the pilot requested clearance to climb to FL320, which was approved. The NTSB ATC Radar Study indicated that from approximately 0953, to 1000, the airplane continued on a southwesterly heading and climbed to FL308. At 0959:47, while flying at FL308, the pilot informed the controller that he was turning back direct to JOINN intersection, which the controller acknowledged. The NTSB ATC Radar Study indicates the airplane turned left and at approximately 1000, ATC communications were transferred back to the R52 sector controller. At 1000:54, while at approximately FL312, the pilot advised the controller, “roger I’m ah gonna need a little dg heading I lost my panel I’m in the uh in the weather.” The controller questioned the pilot about what he had lost and whether he needed a heading. The pilot did not clarify for the controller what panel he was referring to but responded that he needed a heading. The controller then questioned whether the pilot was clear of weather to his right and he replied he was. The controller provided a heading of 230 degrees, for radar vectors to the JOINN intersection.

The NTSB ATC Radar Study indicated that between approximately 1001, and 1001:38, the airplane proceeded in a southerly direction with altitude deviations noted. The transcription of communication indicated that at 1001:26, the pilot informed the controller, “and my altitude’s gonna move a little bit.”

The controller immediately advised the flight crew of an airliner (call sign Blue Streak 503) that was climbing below the accident airplane to stop their ascent, and to maintain FL290. The captain of Blue Streak 503 reported that while climbing through FL 260, he and his first officer heard the pilot of the accident airplane make a report that he had “lost a panel.” At no point during the entire event did the crew of Blue Streak 503 receive an advisory or resolution advisory on their Traffic Alert and Collision Avoidance System (TCAS) display. The accident airplane’s heading on their TCAS display appeared to curve around on their Multi Function Display. The weather conditions at FL 260 were solid IMC with no icing, and the on board weather radar depicted some green (light precipitation) in the area even though there was no rain on the windscreen. There was no convective activity depicted on their weather radar, and the ride conditions consisted of light chop. Shortly after the accident, Blue Streak descended to FL 240, on a heading of 180 degrees, and encountered VMC with an overcast layer below.

The controller then asked the accident pilot to advise him if he would be unable to maintain above FL300 due to traffic. The transcription of communications indicated the pilot did not reply and the controller then repeated the partial call sign of the airplane. The pilot responded at 1001:54, “I’m in a a descent” with the remainder of the comment unintelligible. There was no further recorded transmission from the accident pilot.

The NTSB ATC Radar Study indicated that between 1001:38, and 1002:29, the airplane was in a right descending turn. Between 1001:38, and 1002:06 (last radar return with altitude reported), the airplane descended from FL 307, to FL 221, or a loss of 8,600 feet in 28 seconds, and between 1001:34, and 1002:29, the airplane completed a 360 degree right, descending turn. The accident site was located approximately 162 degrees and 0.81 nautical mile from the last radar return at 1002:38.

A person on the ground heard a sound that he associated with a jet type engine in distress. He went outside and looked up but was unable to see anything. He went back inside and again heard a similar sound, with a sound that he thought was an airplane climbing and then descending. The sound then went silent followed by a deep thud.

PERSONNEL INFORMATION

The pilot, age 56, held a private pilot certificate with rating(s) for airplane single and multi-engine land, and instrument airplane. The private pilot certificate with airplane single engine land rating was issued June 30, 1981, and the instrument rating was added to his private pilot certificate on February 18, 1988. The multi-engine land rating was added on July 15, 1988. He was last issued a third class medical certificate with no limitations on May 1, 2009.

Review of a pilot logbook that begins with an entry dated May 10, 1999, and a carry forward time of approximately 469 hours, to the last entry dated February 8, 2009, revealed he logged a total time of approximately 1,873 hours, of which approximately 1,050 were in turbine powered aircraft. His first logged flight in the accident make and model airplane occurred on August 29, 2001; he recorded accumulating approximately 715 hours in the accident make and model airplane. Of the 715 hours in the accident make and model airplane, approximately 711 were as pilot-in-command. His last logged instrument proficiency check performed by SimCom occurred on August 22, 2008, and his last logged instrument flight was on January 30, 2009. Recent instrument experience could not be determined based on entries in his pilot logbook, though he did fly to San Diego, California, in June 2009.

According to the Vice President & General Counsel for SimCom, Inc., the pilot received training at their Orlando facility in a PC-12 airplane in 2004, 2005, and 2006. He received training at their Scottsdale, Arizona, facility in a PC-12 airplane in August 2008. Additionally, from 1999 to 2004, he received training from SimCom in a Piper Meridian and Piper Mirage airplanes. There was no record that he received training there in 2007.

A review of the records associated with the training in August 2008, revealed four flights totaling 6.0 hours, conducted during the course of 2 days. The stick pusher system, Attitude and Heading Reference System (AHRS), Electronic Flight Instrument System (EFIS), and flight instruments review during the ground instruction each consisted of 18 minutes coverage. Failure of the AHRS and unusual attitude recovery were each covered during separate flights; the result for both was listed as satisfactory.

AIRCRAFT INFORMATION

The airplane was manufactured in June 2004 by Pilatus Aircraft Limited as model PC-12/45, and was designated serial number 570. It was powered by a Pratt & Whitney PT6A-67B 1,000 maximum continuous horsepower engine and equipped with a four-bladed Hartzell single acting, hydraulically controlled, constant speed propeller with feathering and reverse pitch capability. The airplane was configured in executive club seating consisting of 6 passenger seats, and equipped with a stall warning stick pusher system which utilizes angle of attack (AOA) vanes installed on the leading edges of both wings.

At the time of manufacture and at the time of the accident, flight and navigation instruments installed on the pilot’s side of the instrument panel consisted of two independent 5-inch electronic flight instrumentation system display units (DU’s) installed above each other in the center of the instrument panel, an airspeed indicator installed to the left of the upper DU, a remote magnetic indicator (RMI) installed to the left of the lower DU, an altimeter installed to the right of the upper DU, and a vertical speed indicator installed to the right of the lower DU. A standby attitude gyro was installed on the left side of the pilot’s instrument panel, and is powered from the battery bus and emergency power system (EPS) bus. A course deviation indicator (CDI) was installed beneath the standby attitude gyro. With respect to the co-pilot’s side of the instrumental panel, two DU’s, one above the other, were installed in the center of the panel. The airplane was also equipped with two symbol generators, and two AHRS components installed beneath the cabin floor panel near Frame 25.

With respect to the DU’s, they are the primary source for flight information. The upper DU is identified as an electronic attitude director indicator (EADI), and the lower DU is identified as an electronic horizontal situation indicator (EHSI). The EADI and EHSI are electronically identical; however, the EADI (upper) incorporates a slip-skid inclinometer. During normal operation, the upper DU (EADI) functions as an electronic attitude indicator, and the lower DU (EHSI) functions as an electronic horizontal situation indicator. Additionally in normal operation, the pilot and co-pilot DU’s each are supplied data from its respective Attitude and Heading Reference System (AHRS) component.

The symbol generator is a remote mounted processor that receives information from flight systems and navigation data directly or through data converter adapters, and is a compartmented component. One compartment provides data to the EADI, while the other compartment provides data to the EHSI. Data such as aircraft attitude, heading, rate of turn, and respective valid flags are received from the AHRS and angle of attack information are received from the Stick Pusher Warning Unit. The information received at each symbol generator is processed and displayed graphically on its respective DU’s. The symbol generator monitors the system for faults using continuous Built-In-Test (BIT) and if errors are detected, the errors are displayed on the DU’s. The pilot’s symbol generator is connected to the autopilot system.

The AHRS supplies pitch, roll, heading and turn rate information to the EADI, EHSI, and the RMI. The system maintains accurate indications in all aircraft attitudes. The magnetic sensing unit is installed in the right wing.

The pilot’s EADI and EHSI serial number (S/N) at manufacture were 4689 and 4688, while the co-pilot’s EADI and EHSI S/N at manufacture were 4690 and 4686. The maintenance records indicate that on May 12, 2005, at airplane total time 245.3 hours, the co-pilot’s EADI and EHSI were swapped from top to bottom and vice versa. The maintenance records also reflect that on January 6, 2006, at airplane total time 323.2 hours, the co-pilot’s lower DU (EHSI) was removed and an exchanged unit (S/N 4696) was installed. There was no further maintenance record entry pertaining to either the pilot’s or co-pilot’s DU’s. Additionally, there was no record that either AHRS or symbol generator were removed and replaced since the airplane was manufactured.

At the time of manufacture, the Nos. 1 and 2 symbol generators were S/N 5343 and 5356, and the Nos. 1 and 2 Attitude Heading and Reference System units were S/N 1251 and 1228, respectively.

The last pitot static and altimeter testing in accordance with (IAW) 14 CFR Part 91.411, and the last transponder test IAW 14 CFR Part 91.413 were performed on June 19, 2008. The pilot’s altimeter was tested to 35,000 feet.

Further review of the maintenance records revealed the airplane was last inspected in accordance with an annual inspection, using the manufacturer’s maintenance manual, on June 22, 2009. At that time, the airplane had accumulated 723.7 hours of total time. No determination could be made as to how much time the airplane had been flown from the annual inspection to the time of the accident.

The airplane’s maximum operating altitude and indicated airspeed specified in the Flight Manual are 30,000 feet mean sea level, and 236 knots respectively.

METEOROLOGICAL INFORMATION

According to the NTSB Meteorology Factual Report, the eastern central National Weather Service (NWS) Surface Analysis Chart for 1100 EDT (1500Z) on July 5, 2009, depicted a low pressure system with a central pressure of 1012-hectopascals (hPa) over northwestern North Carolina along a frontal wave, with a stationary front extending eastward from the low and then turning to a cold front over eastern North Carolina. A stationary front also extended southward from the low and then westward turning into a warm front across eastern Tennessee into Kentucky. The station models surrounding the accident site in Virginia depicted east to northeast wind of 5 knots, light to moderate rain, overcast sky, temperatures in the mid 60’s (degrees Fahrenheit) with temperature-dew point spreads of 2 to 3 degrees F.

The NWS Weather Depiction Charts for 0900 (1300Z) and 1200 EDT (1600Z) depicted an area of instrument flight rule (IFR) conditions along and north of the frontal systems extending from southern Illinois, Indiana, and Ohio, through most of Kentucky, West Virginia, and Virginia by a shaded contour line. Surrounding that area was an area of marginal visual flight rules (MVFR) conditions indicated by an unshaded contour. The closest visual flight rule (VFR) conditions were depicted over northeastern and eastern Virginia without a contour line. The accident site was located within the area of IFR conditions with the surrounding stations reporting visibility restrictions in light to

moderate rain with ceilings as low as 300 above ground level (agl).

The regional radar mosaic chart for 1100 EDT (1500Z), depicted a large area of echoes extending from Kentucky eastward across West Virginia, Virginia to the Maryland Atlantic coast. The maximum echoes reached 35 to 45 dBZ over central Virginia in the immediate vicinity of the accident site.

The closest weather reporting facility to the accident site was from Shenandoah Valley Regional Airport (SHD), Staunton, Virginia, located approximately 24 miles northeast of the accident site at an elevation of 1,201 feet. The airport was equipped with an Automated Weathe

NTSB Probable Cause

The pilot's failure to maintain control of the airplane while in instrument meteorological conditions following a reported instrumentation failure for undetermined reasons.