### 1 

## AAIPU# A10

- 01312



# AIR ACCIDENT INVESTIGATION

AND PREVENTION UNIT

CIVIL AVIATION DEPARTMENT

NASSAU, N. P., BAHAMAS



# AIRCRAFT ACCIDENT REPORT

LOSS OF CONTROL & UNCONTROL FLIGHT INTO TERRAIN

ACKLINS BLUE AIR CHARTER

CESSNA 402C 

# C6

- NLH

LAKE KILLAR NEY, NASSAU, N.P., BAHAMAS OCTOBER 5, 2010Air Accident Investigation and Prevention Unit

Final Report C6

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### Bahamas Department of Civil Aviation Air Accident Investigation and Prevention Unit

P. O. Box AP

- 59244 Lynden Pindling International Airport Nassau N. P., Bahamas



# AIRCRAFT ACCIDENT REPO RT

CESSNA 402C 

# C6

- NLH

LOSS OF CONTROL & UNCONTROLLED FLIGHT INTO TERRAIN

LAKE KILLARNEY

, NASSAU, N. P., BAHAMAS

OCTOBER 5 , 2010

Abstract: This report outlines the circumstances involving the accident of Lebocruise Air Limited [ Acklins Blue Air

Charte r 1 ] aircraft C6

- NLH

, a Cessna 402C aircraft which crashed shortly after becoming airborne from Runway 14 at Lynden Pindling International Airport into Lake Killarney, Nassau

, Bahamas on October 5, 2010

. Safety and security issues in this

report addresses t he use of unauthorized air charter operators, inadequate pilot training

, inadequate security procedures at Fixed Based Operations

, inadequate aircraft maintenance, CAD oversight and surveillance of unauthorized / non

- certified

commercial air transportation operations , weight and balance and non compliance with search and rescue requirements

.

1 Acklins Blue Air Charter is not a Bahamas recognized Air Taxi OperatorAir Accident Investigation and Prevention Unit

Final Report C6

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## Bahamas Department of Civil Aviation Air Accident Investigation and Prevention Unit

The Air Accident Investigation and Prevention Unit (AAIPU) is a unit within the Flight Standards Inspectorate (FSI), the regulatory unit of the Bahamas Civil Aviation Department (BCAD)

.

The AAIPU‟s function is to promote and improve safety and public confidence in the aviation industry through

excellence in:

 independ ent investigation of aviation accidents and other safety occurrences

 safety data recording, analysis and research

 fostering safety awareness, knowledge and action.

The AAIPU does not investigate for the purpose of apportioning blame or to provide a mea ns for determining liability.

The AAIPU performs its functions in accordance with the provisions of the Bahamas Civil Aviation (Safety) (Amendment) Regulations (CASAR) 2010 , Schedule 19, International Civil Aviation Organization (ICAO) Annex

13 and, wher e applicable, relevant international agreements.

The Flight Standards Inspectorate established in 2001, is mandated by the Ministry of Tourism and Aviation to investigate air transportation accidents and incidents, determine probable causes of accidents and incidents, issue safety recommendations, study transportation safety issues and evaluate the safety effectiveness of agencies and

stakeholders involved in air transportation.

The AAIPU makes public its actions and decisions through accident reports, s afety studies, special investigation reports, safety recommendations and safety alerts

. When the AAIPU issues a safety recommendation, the person, organization or agency must provide a written response within 90 days. That response must indicate whether th e person, organization or agency accepts the recommendation, any reasons for not accepting part or all of the recommendation, and details of any proposed safety action to give effect to the recommendation.

Copies of accident reports can be obtained by con tacting:

Captain Patrick L. Rolle

Director Bahamas Department of Civil Aviation

P. O. Box N975 Nassau N. P., Bahamas (242) 326

- 0339/40Air Accident Investigation and Prevention Unit

Final Report C6

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## Bahamas Department of Civil Aviation Air Accident Investigation and Prevention Unit

Table of Content s

GLOSSARY OF ABBREVIATIONS USED IN THIS REPORT

................................ ........................... 8

DEFINITIONS

................................ ................................ ................................ ................................ ...... 9

TITLE

................................ ................................ ................................ ................................ .................. 11

SYNOPSIS

................................ ................................ ................................ ................................ .......... 12

1.0 Factual Information:

................................ ................................ ................................ .................. 14 1.1 History of the Flight

................................ ................................ ................................ ................. 14 1.1.0 Background

................................ ................................ ................................ ....................... 14 1.1.1 Early Morning Activity

................................ ................................ ................................ ...... 14 1.1.2 Accident Flight Preparations

................................ ................................ .............................. 15

1.1.3 Ground Maneuvers

................................ ................................ ................................ ............ 15

1.1.4 The Take

- off

................................ ................................ ................................ ...................... 15 1.1.5 Eyewitnesses Evidence

................................ ................................ ................................ ...... 16 1.2 Injuries to Persons

................................ ................................ ................................ .................... 18 1.3 Damage to Aircraft

................................ ................................ ................................ ................... 18 1.4 Other Damage

................................ ................................ ................................ .......................... 18

1.5 Personnel Information

................................ ................................ ................................ .............. 19

1.5.1 Pilot

................................ ................................ ................................ ............................... 19

1.5.2 Second Pilot

................................ ................................ ................................ ................... 19

1.6 Aircraft Information

................................ ................................ ................................ ................. 20

1.6.1 Genera l

................................ ................................ ................................ .............................. 20 1.6.2 Aircraft Description

................................ ................................ ................................ ........... 20 1.6.3 Engines

................................ ................................ ................................ .............................. 20

1.6.4 Propellers

................................ ................................ ................................ .......................... 21 1.6.5 Flight Controls

................................ ................................ ................................ ................... 21 1.6.6 Aircraft Fuel System

................................ ................................ ................................ .......... 22 1.6.7 Weight and Balance

................................ ................................ ................................ ........... 22 1.6.8 Weighing Report

................................ ................................ ................................ ............... 23

1.6.9 Limitations

................................ ................................ ................................ ........................ 23

1.6.9.1 Operating Speeds

................................ ................................ ................................ ..... 23 1.6.10 Maintenance History of the Aircraft

................................ ................................ ................. 23

1.6.11 Maintenance His tory of the Left Engine and Propeller

................................ ..................... 23 1.6.12 Maintenance history of the Right Engine and Propeller

................................ .................... 24 1.7 Meteorological Information

................................ ................................ ................................ ...... 24 1.8 Aids to Navigation

................................ ................................ ................................ ................... 25Air Accident Investigation and Prevention Unit

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### 1.9 Communications

................................ ................................ ................................ ...................... 25

1.10 Aerodrome Information

................................ ................................ ................................ .......... 25

1.10.1 Nassau Airport Development Company (NAD)

................................ .............................. 25

1.10.2 Aircraft Rescue and Firefighting

................................ ................................ ..................... 26

1.10.3 Air Traffic Control

................................ ................................ ................................ ......... 26 1.11 Flight Recorders

................................ ................................ ................................ ..................... 26

1.12 Wreckage and Impact Info

................................ ................................ ................................ ..... 26 1.12.1 General Wreckage Description

................................ ................................ ........................ 26 1.12.2 Fuselage

................................ ................................ ................................ .......................... 28 1.12.3 Engines and Propeller

................................ ................................ ................................ ...... 28 1.12.4 Wings

................................ ................................ ................................ .............................. 28 1.12.5 Empennage and Flight Controls

................................ ................................ ....................... 29 1.12.6 Damage to Seats and Cabin Floor

................................ ................................ ................... 29

1.12.7 Fuel Selection

................................ ................................ ................................ .................. 30

1.12.8 Left Console Panel

................................ ................................ ................................ ........... 30 1.13 Medical and Pathological

................................ ................................ ................................ ....... 32

1.14 Fire

................................ ................................ ................................ ................................ ......... 32 1.15 Survival Aspects

................................ ................................ ................................ ..................... 32

1.15.1 First Aid

................................ ................................ ................................ .......................... 32 1.15.2 Fire Service and Emergency Response

................................ ................................ ............. 33

1.16 Tests and Research

................................ ................................ ................................ ................. 34

1.16.1 #2 Cylinder Analysis:

................................ ................................ ................................ ..... 34

1.16.2 Left En gine Analysis

................................ ................................ ................................ ...... 34

1.16.3 Right Engine Analysis

................................ ................................ ................................ .... 34

1.16.4 Human Factors Research and Analysis

................................ ................................ ........... 34

1.16.5 Weight and Balance Scenarios

................................ ................................ .................... 34

1.16.6 Flying over Gross Weight

................................ ................................ ............................... 36

1.16.7 Airplane Perfo rmance

................................ ................................ ................................ . 37 1.17 Organizational and Management Information

................................ ................................ ......... 37

1.18 Additional Information

................................ ................................ ................................ ....... 37

1.18.1 Acklins Blue Air Charter

................................ ................................ ................................ 37 1.18.2 CAD Oversight of Acklins Blue Air Charter

................................ ................................ ...... 37

1.18.5 Perfo rmance Category

................................ ................................ ................................ .... 38

1.18.6 Emergency Procedures

................................ ................................ ................................ .... 38

1.18.7 Pre accident CAD Actions

................................ ................................ .............................. 38

1.18.8 Post Accident Recommendations / Safety Alerts Issued

................................ .................. 39

1.18.9 Post accident Airport Authority Actions

................................ ................................ .......... 39

1.18.10 Post accident CAD /FSI Actions

................................ ................................ ................. 39

1.18.11 Post accident EFS Actions

................................ ................................ ........................... 40

1.18.12 Post accident NAD Actions

................................ ................................ ......................... 40

2.0 Analysis

................................ ................................ ................................ ................................ .... 41

2.1 Overview

................................ ................................ ................................ ................................ .. 41

2.1.1 Flight reconstruction

................................ ................................ ................................ .......... 41 2.1.2 Wreckage Analysis

................................ ................................ ................................ .............. 42 2.1.3 The Initiating Event

................................ ................................ ................................ ............. 42

2.2 Oth er Factors

................................ ................................ ................................ ............................ 43 2.2.1 Aircraft Loading

................................ ................................ ................................ ................ 43

2.2.2 Pre

- take

- off Events

................................ ................................ ................................ ............ 43Air Accident Investigation and Prevention Unit

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### 2.2.3 Flap Position

................................ ................................ ................................ ...................... 44 2.3 Event Timing

................................ ................................ ................................ ........................... 44 2.4 Before the Initiating Event

................................ ................................ ................................ ........ 44

2.4.1 The Take

- off.

................................ ................................ ................................ ..................... 44

2.4.2 The Initial Climb

................................ ................................ ................................ ............... 45 2.5 The Initiating Event

................................ ................................ ................................ .................. 45

2.5.1 The position of the aircraft when the misfiring was heard.

................................ .............. 45

2.6 Practical engine failure identification

................................ ................................ ................. 46

2.7 Events between the initiating event and the left turn

................................ ............................... 46 2.7.1 Control of Bank Angle

................................ ................................ ................................ ....... 46

2.7.2 Climb Performance

................................ ................................ ................................ ............ 46 2.8 Condition of the engine in flight

................................ ................................ ............................... 47

2.8.1 Right Engine

................................ ................................ ................................ ................. 47

2.8.2 Operating the wrong propeller lever

................................ ................................ ............... 47 2.9 Events during the Turn

................................ ................................ ................................ ............. 47

2.9.1 Loss of Control

................................ ................................ ................................ ........... 48

2.10 The loss of power from the left engine

................................ ................................ ................ 48 2.10.1 Summary of left and right Engine Analysis

................................ ................................ ........ 48

2.10.2 Left Hand Engine No. 2 Cylinder Analysis

................................ ................................ ..... 49

2.10.3 Left Engine Serial Number 248270 Analysis

................................ ................................ .. 55

2.10.4 Right Engine Serial Number 290209 Analysis

................................ ................................ 58

2.11 Training and testing for pilots of light piston engine aircraft

................................ ............... 61

2.11.1 The forced landing option

................................ ................................ ............................... 61 2.11.2 The pilot‟s decision to return

................................ ................................ ........................... 61

2.11.3 Engine failure traini ng and testing in light twin engine aircraft

................................ ....... 62 2.12 The Implications of Performance Category C

................................ ................................ ......... 63

2.13 ATC Tower Controller

................................ ................................ ................................ ........... 63 2.14 Survivability

................................ ................................ ................................ ........................... 63

2.14.1 Aircraft Seating

................................ ................................ ................................ .............. 63

2.15 S ituational Awareness

................................ ................................ ................................ ........ 64 2.16 CAD Oversight

................................ ................................ ................................ ....................... 64

2.17 Summary

................................ ................................ ................................ ............................ 65

3.0 Conclusions

................................ ................................ ................................ ................................ .. 66 (a) Findings

................................ ................................ ................................ ................................ . 66 (b) Causal Factors

................................ ................................ ................................ ....................... 68

4.0 Recommendations:

................................ ................................ ................................ ....................... 69

5.0 APPENDICES:

................................ ................................ ................................ ......................... 71 Appendix 5.1 Cylinder Factual Report (NTSB)

................................ ................................ .............. 71 Appendix 5.2 Left and Right Engine Factual Report (TCM)

................................ ........................... 72 Appendix 5.3 Acklins Blue Companies

................................ ................................ .......................... 73 Appendix 5.4 Acklins Blue Air Charter

................................ ................................ ......................... 73 Appendix 5.5 Acklins Blue Air Charter

................................ ................................ ......................... 74 Appendix 5.6 ATC tower transcr ipt

................................ ................................ ............................... 75 Appendix 5.7 Flight Plan Form

................................ ................................ ................................ ...... 76 Appendix 5.8 Fuel Uplift Slip

................................ ................................ ................................ ........ 77 Appendix 5.9 Alert Issued

................................ ................................ ................................ .............. 78 Appendix 5.10 Engine Failure after Take

- off Checklist

................................ ................................ .. 80 Appendix 5.11 Crash Air craft Diagram

................................ ................................ .......................... 81Air Accident Investigation and Prevention Unit

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### Appendix 5.12 Reference Aircraft Diagram

................................ ................................ .................... 81 Appendix 5.13 CASR Regulation Part X, Regulation 67.

................................ ............................... 82 Appendix 5.14 CASR Regulation Part X, Regulation 68

................................ ................................ 82 Appendix 5.15 Aerodrome Chart Nassau, Bahamas

................................ ................................ ........ 83 Appendix 5.16 Aeronautical Information Circular 100/2005

................................ .......................... 84 Appendix 5.17 Cessna 402C Dual Manifold Pressure Gauge

................................ ............................ 85 Appendix 5.18 Alert SA/A10

- 01312/002/10

- 9

- 10 Historical Information

................................ ........ 86 Appendix 5.19 CRASH SITE DIAGRAM

................................ ................................ .................... 88

Figure 1 and 2 C6

- NLH Pre and Post Accident

................................ ................................ ................................ 16 Figure 3 Eye witness account of the accident

................................ ................................ ................................ .... 17 Figure 4 C402C Seating diagram

................................ ................................ ................................ ..................... 20 Figure 5 Fuselage post accident

................................ ................................ ................................ ........................ 28 Figure 6 Left Console

................................ ................................ ................................ ................................ ...... 30 Figure 7 Actual console Panel for C6

- NLH

................................ ................................ ................................ ...... 31 Figure 8 Fuel Selector Valves Left and Right E ngine

................................ ................................ ....................... 31 Figure 9 Power Quadrant

................................ ................................ ................................ ................................ . 31 Figure 10 Center of Gravity Graph / Envelope

................................ ................................ ................................ ... 35 Figure 11 Normal Take

- off Distance

................................ ................................ ................................ ................ 44Air Accident Investigation and Prevention Unit

Final Report C6

- NLH Page 8 GLOSSARY OF ABBREVIATIONS USED IN THIS REPORT When the following terms are used in this report, they h ave the following meanings;

AAIPU Air Accident Investigation and Prevention Unit

AEC Airmotive Engineering Corporation, A division of Danbury Aerospace

ADDS Aviation Digital Data Service

- Report by Meteorological Department AGL/agl Above ground level

AOC Air Operator Certificate Holder

ARFF Airport Rescue and Fire Fighting Service

ATC / ATS Air Traffic Control / Air Traffic Services

AVGAS Aviation Gasoline

CAD Civil Aviation Department

CASR Bahamas Civil Aviation (Safety) Regulations (April 17, 2001)

CMI Continental Motors, Inc., formerly Teledyne Continental Motors

C of A Certificate of Airworthiness

C of R Certificate of Registration

CG Center of Gravity

DAS Danbury Aerospace Deg /  Degrees

DCA Director of Civil Aviation

DST Daylight S avings Time (+4 hours to convert to UTC)

EC i Engine Components, Inc., a division of Danbury Aeropsace

EOC Emergency Operations Center

EFS Executive Flight Support

FAA Federal Aviation Administration

FBO Fixed Base Operator / Operation

FSI Flight Stand ards Inspectorate

FSS Flight Service Station

g Gravity at standard sea level

ICAO International Civil Aviation Organization

KIAS knots indicated airspeed

kt Knot(s)

LBS/lbs Pounds

MYNN Lynden Pindling International Airport

MET Meteorological Office / Department

METAR Weather Report furnished by Meteorological Department

MTOW Maximum take

- off weight

MYNN ICAO identifier for Lynden Pindling International Airport Nassau, Bahamas

MYSM Cockburn Town, San Salvador Int‟l Airport

NAD Nassau Airport Deve lopment Company

NM or nm Nautical Miles

NTSB National Transportation Safety Board

PMH Princess Margaret Hospital

RBDF Royal Bahamas Defense Force

RBPF Royal Bahamas Police Force

SAP Superior Airparts

TRACON Terminal Radar Approach Control

USA/US United S tates of America

VFR Visual Flight Rules

VMC Visual Meteorological Conditions

UTC / Z Universal Coordinated Time / Zulu timeAir Accident Investigation and Prevention Unit

Final Report C6

- NLH Page 9 DEFINITIONS When the following terms are used in this report, they have the following meanings as per CASR 2001 and ICAO

Ann ex 13;

“Aircraft Accident”

– means an occurrence associated with the operation of an aircraft which takes place between the time any person boards the aircraft with the intention of flight and all such persons have disembarked, and in which any person suff ers death or serious injury, or in which the aircraft receives substantial damage or the aircraft is missing or completely inaccessible.

"Fatal injury"

- means any injury which results in death within 30 days of the accident.

“Flight recorder”

- Any type o f recorder installed in the aircraft for the purpose of complementing accident/incident investigation.

"Incident"

- means an occurrence other than an accident, associated with the operation of an aircraft, which affects or could affect the safety of opera tions.

“Investigation”

- A process conducted for the purpose of accident prevention which includes the gathering and analysis of information, the drawing of conclusions, including the determination of causes and, when appropriate, the making of safety reco mmendations.

“Serious injury"

- means any injury which:

 Requires hospitalization for more than 48 hours, commencing within 7 days from the date the injury was received;

 Results in a fracture of any bone (except simple fractures of fingers, toes, or nose);

 Causes severe hemorrhages, nerve, muscle, or tendon damage;

 Involves any internal organ; or

 Involves second or third degree burns, or any burns affecting more than 5 percent of the body surface.

 Involves verified exposure to infectious substances or injur ious radiation.

“Serious incident”

- An incident involving circumstances indicating that an accident nearly occurred.

“State of Design”

- The State having jurisdiction over the organization responsible for the type design

“State of Manufacture”

- The S tate having jurisdiction over the organization responsible for the final assembly

of the aircraft.

Stall

- An accelerated stall is a stall that occurs while the aircraft is experiencing a load factor higher than 1 (1g), for example while turning or pulling up from a dive. In these conditions, the aircraft stalls at higher speeds than the normal stall speed (which always refers to straight and level flight). C onsidering for example a banked turn

, the lift required is equal to the weight of the aircraft plus extra lift to provide the centripetal force necessary to perform the turn.

"Substantial damage"

- means da mage or failure which adversely affects the structural strength, performance, or flight characteristics of the aircraft, and which would normally require major repair or replacement of the affected component. Engine failure or damage limited to an engine i f only one engine fails or is damaged, bent failings or cowling, dented skin, small punctured holes in the skin or fabric, ground damage to rotor or propeller blades, and damage to landing gear, wheels, tires, flaps, engine accessories, brakes, or wingtips are not considered "substantial damage" for the purpose of this Report.Air Accident Investigation and Prevention Unit

Final Report C6

- NLH Page 10 

### September 30 , 2011

Captain Patrick L. Rolle

Director

Bahamas Civil Aviation Department

P.O. Box N

- 975
Nassau, N.P.,

Bahamas

Sir

I am duty

- bound to submit this report on the circumstances of the fatal accident involving C6

- NLH



### , a
Cessna 402C aircraft 

### , registered in the Bahamas to Lebocruise Air Limited, and operated by Acklins Blue

Air Charter Ltd 2



### ., Nassau , N.P., Bahamas . This accident occurred on October 5 , 2010 at 12 : 36 pm l ocal

time (1636 UTC) in waters of Lake Killarney, approximately 1⁄4 mile from the approach end of Runway 27 at Lynden Pindling Int‟l Airport, Nassau N. P., Bahamas.

This report is submitted pursuant to Part XII, Regulation 80, and Schedule 19 of the Bahamas Civil Aviation (Safety) (Amendment) Regulation (CASR 20 1 0 ) and in accordance with Annex 13 to the

Convention on International Civil Aviation Organization (ICAO).

In accordance with Annex 13 to the Convention on International Civil Aviation (ICAO), and Sch edule 19 of the Bahamas Civil Aviation (Safety) (Amendment) Regulations (CAS A R), t he fundamental purpose of such investigations is to determine the circumstances and causes of these events, with a view to the preservation of life and the avoidance of simila r occurrences in the future. It is not the purpose of such investigations to apportion blame or liability.

This report contains facts which have been determined up to the time of publication. I nformation is published to inform the aviation industry and th e public of the circumstances surrounding this accident.

The contents of th is r eport may be subject ed to alteration s or correction s if additional factual

information becomes available.

Regards

Delvin R. Major Investigator in Charge Air Accident Investig ation and Prevention Unit

Bahamas Department of Civil Aviation Lynden Pindling International Airport Nassau, N. P., Bahamas

2 Acklins Blue Air Charter was not a Bahamas recognized Air Taxi OperatorAir Accident Investigation and Prevention Unit

Final Report C6

- NLH Page 11



## BAHAMAS CIVIL AVIATION DEPARTMENT

AIR ACCIDENT INVESTIGATION AND PREVENTION UNIT

TITLE

Registered Owner: Lebo cruise Air Limited

Operator: Acklins Blue Air Charter / Nelson Hanna

Manufacturer: Cessna Aircraft Company

Aircraft Type : Cessna Model 402C

Nationality: Bahamas

Registration: C6

- NLH

Place of Accident: In waters of Lake Killarney, a ppro ximately 1⁄4 mile from the approach end of
Runway 27 (MYNN ) of Lynden Pindling International Airport, Nassau, Bahamas

Date and Time : October 5 , 2010 at 16 36 UTC (12:36pm DST)

Notificatio n: D C A, NTSB, ICAO, FAA, Cessna Aircraft Company and Continental Moto rs, Inc., formerly Teledyne Continental Motors

Investigating Authority : Civil Aviation Department
Air Accident Investigation and Prevention Unit

Investigator in Charge: Delvin R. Major

Accredited Representative s : Mr. Tim Mon ville

– NTSB

Mr. Derek Nas h

– NTSB

Technical Advisors: Mr. Randall S. Mainquist

– Cessna Aircraft Company

. Mr. Rodney Martinez

– Continental Motors Inc.

Mr. James Jelinski

– FAA

Mr. James L. Tubbs

– Danbury Aerospace [EC i cylinder manufacturer]

R eleasing Authority: Dir ector of Civil Aviation Department , Nassau, N. P., Bahamas

Date of Draft Report Publication : July 7 , 2011Air Accident Investigation and Prevention Unit

Final Report C6

- NLH Page 12 

### SYNOPSIS

On October 5, 2010 about 1636 UTC / 12:36pm Eastern Daylight Time (EDT), C6

- NLH a Cessna 402C aircraft registered to Lebocruise Air Limited and operated by Acklins Blue Air Charter/Nelson Hanna crashed into lake Killarney shortly after becoming airborne from runway 14 at Lynden Pindling International Airport, Nassau, New Providence, Bahamas. The airplane sustained substantial damages by impac t forces. The pilot, copilot and seven (7) passengers aboard the airplane received fatal injuries. The aircraft was on a passenger carrying flight from Lynden Pindling Int‟l Airport ( MYNN ) to Cockburn Town, San Salvador, Bahamas (MYSM). The aircraft was

on a visual flight rules flight plan. Visual meteorological conditions prevailed at the time of the accident.

The official notification of the accident was made to the Manager of the Flight Standards Inspectorate at Lynden Pindling Int'l Airport, Nassau, N. P., Bahamas shortly thereafter

. T he investigation began the same day at approximately 1655 UTC upon notification of the IIC

. The investigation was conducted by the Bahamas Civil Aviation Department [BCAD], Inspector Delvin R. Major (Investigator

- in

- Charge ) of the Air Accident Investigation and Prevention Unit (AAIPU)

, Management of BCAD and Flight Standards Inspectorate (FSI),

Airworthin ess Inspectors, Operations Inspectors, Human Factors and other administrative staff

. Valuable

assistance was also receive d from the National Transportation Safety Board (NTSB), the Federal Aviation Administration (FAA) and Manufacturers of the aircraft and engine components.

T hree (3) Air Operator Certificate (AOC) holders at the Domestic Section of Lynden Pindling Int'l Ai rport stated that on the day of the accident flight ; one of the victims of the accident aircraft approached each of them individually at different times, requesting a quote and their availability to conduct a charter flight to Cockburn
Town, San Salvador

, Bahamas

.

Each AOC hold er reported that they declined to conduct the charter because by looking at the amount of luggage and other equipment that accompanied the passengers and the size of the passengers that wanted to travel, in their

estimation the comb ined weight appeared to be in excess of the weight that their respective aircraft (Cessna 402C and Hawker Beechcraft B100) c an accommodate

. A fter the AOC holders declined to conduct the charter

, sometime thereafter

, the same individual that was arranging t he flight with the previous AOC holders made

contact with Nelson Hanna / Acklins Blue Air Charter where arrangements were made to conduct the charter flight

.

The aircraft type certificate allowed for t he aircraft to be operated by one ( 1 ) pilot, but the fatal flight was operated by a crew of two (2) pilots (according to eyewitness reports). T he aircraft actual weight and center of gravity was unknown. As far as could be determined, the takeoff weight exceeded the maximum weight allowed of 6,850 pounds b y more than 500 pounds. This excess in weight also placed the center of gravity of the aircraft outside of the safe envelope / limits for flight allowed by the manufacturer.

The flightcrew t was given instructions by ATC to taxi from the business aviation a pron (Executive Flight Support) for a takeoff on Runway 14 at intersection Foxtrot. (Intersection Foxtrot is 2,000 feet beyond the

t hreshold of Runway 14

, with a take

- off r un available of 9,353 feet

. (Runway 14

- 11,353 feet long by 150 feet

wide , see Appendix 5.15 ).

According to eyewitness reports

, from the initiation of takeoff power up to the point when the aircraft lost control

white smoke was observed trailing behind the left engine of the aircraft. Eyewitness es also reported that the take off appeared normal with gear being retracted shortly after takeoff and the aircraft seemed to be struggling t o climb. T he a ircraft was seen at a low height, turning in a left direction over the lake as if trying to return fo r a landing at the airport. The bank of the aircraft changed from shallow to very steep to almost perpendicular to the ground, gears were extended and almost immediately the aircraft lost control and nose dived into the lake

inverted. It cart wheeled , com ing to rest upright, approximately 1⁄4 mile from the approach end of runway 27. The aircraft came to rest on an approximate heading of 210 degrees.Air Accident Investigation and Prevention Unit

Final Report C6

- NLH Page 13 Eyewitness also reported hearing the engine run for a few seconds after the aircraft made contact with the wa ter of the lake. There were no reports from the pilot to ATC of an emergency or any abnormalities with the aircraft or its systems after takeoff.

The flight plan form filed for this flight listed one (1) soul on board ; however, there were 7 additional o ccupants including a “second pilot” discovered onboard the accident flight the day of the accident

. The aircraft‟s recovery and search for luggage, equipment and additional victims commenced shortly after the accident. This effort however, was hampered b y inclement weather, rough lake conditions and darkness. On October 6 th , the day after the crash, aircraft recovery continued. Family members of an additional person believed to be on board, advised the authorities that there was a ninth (9 th ) person on b oard. Search to recover any additional bodies continued but search and recovery efforts proved fruitless. On October 7 th , the second day after the crash, the body of the ninth (9 th ) victim was found in the marshes and recovered from the southwestern end of the lake in the vicinity of where

the fatal crash occurred.

The investigation identified the following causal factors:

The left engine of C6

- NLH suffered a mechanical failure of the #2 cylinder, and therefore could not produce rated shaft horsepower. N o indication of total loss of power with the left engine reported.

The electrical and engine control switches for the right engine of C6

- NLH were found in the “OFF” position; therefore the aircraft was incapable of climbing on the power of one engine al one.

The excess weight above the maximum weight allowed for takeoff may have been an important factor in the aircraft‟s inability to gain adequate altitude after takeoff.

Previous discrepancies existed with the left engine not producing power when requi red to which both pilots were made aware prior to the accident flight.

A total loss of thrust occurred once the right engine was secured and a steep turn was initiated with gear down and the left engine already developing insufficient shaft horsepower to sustain lift.

The pilot attempted to return to the departure airfield but lost control of the aircraft during a turn to the left.

Several s afety and security recommendations were made during the course of this investigation

.Air Accident Investigation and Prevention Unit

Final Report C6

- NLH Page 14 

## 1.0 Factual Information :

1.1 History of the Flight

On Tuesday October 5, 2010 at 12:36 EDT (1636 UTC 3 ) a fixed wing, twin

- engine, Cessna 402C aircraft Bahamas registration C6

- NLH, serial number 402C 0458

, crashed into waters of Lake Killarney shortly after

becomi ng airborne from runway 14 at Lynden Pindling International Airport ( MYNN ) , Nassau, New Providence,

Bahamas

. The pilot

, second pilot and seven (7 ) passengers on board were fatally injured . The airplane sustained substantial damage as a result of the impac t and post impact crash sequence

. The crash occurred at approximate

coordinates 28  ̊ 02.218 ‟ N and 077  ̊ 27.150 ‟ W. The passenger carrying flight departed at 12:35 EDT (1635 UTC). The destination was Cockburn Town, San Salvador, Bahamas. The flight was opera ted on a Visual Flight Rules (VFR 4 ) flight plan. Visual meteorological conditions (VMC) prevailed at the time of the accident. This was the second flight of the day for the aircraft and crew. This flight was a charter flight conducted by an operator that was not recognized / authorized by the Bahamas to perform charter work.

1.1.0 Background

The pilot and copilot‟s duty or other activities up to 24 hrs prior to the accident, with the exception of the flight that took place prior to the accident flight, is unknown. The aircraft remained in the open air on the business aviation ramp at Lynden Pindling Int‟l Airport where it is normally parked. Although the aircraft was certified for single

- pilot operation, it was reported that there was a crew of two Baha mian pilots on the accident flight. It was reported that the pilot (Mr. H anna) operated a significant portion of fligh ts himself; however

, the same pilot often accompanied him as his co

- pilot

. The co

- pilot was qualified to fly the generic group of aircraft to which C6

- NLH belonged, but he was not qualified to operate revenue flights in a 402C as a single pilot . H e had not undergone the requisite type specific checks and test

. As he was “time

- building” his duties sh ould have been chiefly to assist the pilot with radio telephony and administration; consequently, a more appropriate description for his role was „second pilot‟.

After returning to Nassau, arrangements were made for Acklins Blue Air Charter to fly passengers and their luggage and equipment to San Salvador, Bahamas. This was the flight that crashed resulting in nine fatalities. After loading the aircraft with passenger and luggage the aircraft obtained ATC clearance for VFR departure before taxiing from the Fixed Based Operation (FBO), Executive Fl ight Support (EFS).

1.1.1 Early Morning Activity

O n the morning of the October 5, 2010 at 8:45am, C6

- NLH was fuelled with 80 gallons of aviation gasoline ( avgas ) by Executive Flight Support. (See Appendix 5.8 )

. A fligh t plan was filed to Treasure Cay, Abaco, Bahamas. The flight plan form listed two (2) souls on board. (It was later revealed that there were in fact six (6) souls on board for that flight)

. A t approximately 9:30 am, the pilot conducted that charter flight from Lynden Pindling Int‟l Airport to Treasure Cay

, Abaco, Bahamas (the flight prior to the accident flight)

.

One of the passenger s of that flight (who holds a USA Airline Transport P ilot rating [ATP]) reported that he paid

Mr. Hanna to conduct a charter flight to Treasure Cay, Abaco, Bahamas. The same passenger reported that he sat

in the seat behind the co

- pilot (seat #4) and he observed technical problems with the aircraft‟s left engine manifold pressure gauge needle readings (see Appendix 5.17 ) during the engine run up exercise at the runway prior to take

- off

.

3 UTC

- The 24 hour clock is used to describe the time of day, Coordinated Univers al Time (UTC) as particular events occurred.

4 Visual Flight Rules

- are a set of regulations which allow a pilot to operate an aircraft in weather conditions generally clear enough to allow the pilot to see where the aircraft is going.Air Accident Investigation and Prevention Unit

Final Report C6

- NLH Page 15 The passenger reported that he observed the left engine manifold pressure needle not reacting as it should. There was a split (or difference) of approximately 9 0 ̊ between the left engine and right engine manifold pressure reading as evidenced by the manifold pressure gauge needles. The passenger stated that he advised both pilots and they both shrugged it off as no big deal and said it will clear up once full po wer is applied. (See Eyewitness

Evidence 1.1.4 )

Having himself been involved in an aircraft incident with the exact type of manifold pressure discrepancy previously, the passenger stated that he was uneasy. However, the manifol d pressure reading eventually came up during the take

- off roll and the flight departed. The pilot was unable to land the aircraft at his destination of Treasure Cay due to bad weather. He eventually diverted and landed at Marsh Harbour International Airpo rt, Marsh Harbour, Bahamas instead. ( See Eyewitness Evidence 1.1.4 ) Aside from the enroute weather conditions that were encountered, the flight was uneventful. The crew departed Marsh Harbour and returned to Nassau.

1.1.2 Accid ent Flight Preparations

Sometime after returning from M arsh Harbour, a flight plan for C6

- NLH was filed for a flight from Nassau to San

Salvador

, Bahamas. The flight plan form was received by EFS and file d with ATC with a proposed flight time of

1 hour en route

, at an altitude of 7,500 feet and four (4) hours of fuel endurance. An additional 6 0 gallons of Aviation Gasoline (Avgas) w as loaded in the tanks of C6

- NLH by Executive Flight Support at 12:06pm. ( See Appendix 5.8 )

. The flight plan form listed one (1) soul on board. ( Post accident

, eight (8) bodies were recovered from the crash. All occupants received fatal injuries. On Thursday October 8, 2010 two (2) days after the accident, a ninth body was recovered from the wat ers )

. ( See Appendix 5.7 Flight Plan Form )

.

The crew prepared for their flight without assistance of the EFS staff with the exception of a ramp agent who carried and loaded a box weighing approximately 30 pounds on the aircraft. The ramp agent confirmed that the

co

- pilot was the one that loaded the aircraft and he did not see what was loaded in the luggage compartments. He further stated that he observed the pilot while at the aircraft make some adjustments to seats 7 a nd 8 ( the double

seats at the entrance door of the aircraft )

. ( See seating diagram figure 4 ) Apart from this encounter

, no personnel at
EFS paid much attention to the aircraft or the preflight activities of the crew.

The passengers gained access to the ai rcraft through the EFS‟ facility . However, no one at the facility ‟s desk knew who they were , who took them out to the aircraft or what aircraft the y boarded. No personnel at EFS knew who boarded the aircraft or where they were seated on the aircraft. No pe rsonnel knew if the luggage or equipment was weighed or whether or not a weight and balance document was prepared . The crew did not leave a copy of a weight and balance document with EFS

.

1.1.3 Ground Maneuvers

At 16:31 hrs the secon d pilot * 5 requested ATC clearance for the flight to San Salvador and shortly thereafter

clearance for taxi to the Foxtrot Int ersection of Runway 14. The flight crew was cleared to taxi and to hold short of the runway and then to contact Nassau Tower controller.

1.1.4 The Take

- off

At 16:35:15 Clearance to take

- off was given and the second pilot acknowledged the clearance

. While on the take

off roll and prior to becoming airborne, eyewitnesses observed white smoke trailing behind the left engine of the

aircraft. Additional witness reported hearing sounds like a misfiring engine and observing intense white smoke during the take

- off

, progressively getting worse just after lift

- off.

5 * The voice recorded on ATC tapes making contact with ATC from taxi through the final transmission to land was not the voice of Mr.

Nelson Ha nna. Luggage handlers at Executive Flight Support confirmed that a co

- pilot was on board the aircraft and the co

- pilot was responsible for loading the aircraft with luggage prior to departure. Post accident investigations revealed that the copilot was a p ilot employed with the RBDF who was time building. They both had recently just returned from a flight to Treasure Cay, Abaco, Baha mas.Air Accident Investigation and Prevention Unit

Final Report C6

- NLH Page 16 The aircraft appeared to become airborne near intersection of Runway 14 and taxiway Bravo1 and commenced a left turn just prior to the intersection of the two runways (27 and 32).

At 16:36:15 ATC tower controller advised the pilot that he needed him to return as there was white smoke trailing

behind his left engine. The pilot acknowledges and state d t he y were returning. At 16:36:24 the tower controller questioned the pilot if he was able to return and land on runway 27. The co pilot of C6

- NLH replied in the

affirmative. The tower controller then approved the pilot to re turn to runway 27

. There were no further recorded communications from the flight crew of C6

- NLH. The aircraft crash ed a short time later

. (See Eyewitness

Evidence 1.1.5 for more information)

. According to ATC tower tapes and transcription, at no time did the flight

crew of C6

- NLH repor t an emergency or any abnormalities with any engine or instrumentation

.

Figure 1 and 1 C6

- NLH Pre and Post Accident

1. 1. 5 Eye witnesses Evidence

( All eye witnesses evidence presented here are from persons in the aviation f ield and / or knowledgeable of aviation procedures and terminology)

A passenger ( USA rated airline pilot ) who had just chartered the aircraft the morning of the crash stated that while the pilots were conducting the run

- up checks at the runway

, prior to t ake

- off , he observed technical problems w ith the manifold pressure gauge needle readings for the left engine. Concerns were raised with the pilots and he was advised that the problem would go away once full power was applied

. He stated that the needles of the right and

left engine manifold pressure gauge were at odds with each other by approximately 90 degree difference ( See Appendix 5.17

). The right needle of the manifold pressure gauge responded appropriately when the powe r lever

was manipulated, but the left needle was slow to respond or did not respond at all. Eventually, the needle

indications matched each other and once the pilot s were satisfied

, the aircraft departed. In addition to the discrepancy observed with the e ngine, navigational instrument s in the aircraft

, required for instrument meteorological conditions (IMC) flight were inoperative

. The weather at the time was Instrument Meteorological Conditions (IMC). In his opinion

, as a professional pilot, the passenger stated that the aircraft was un

- airworthy

.

A mechanic who was standing on the ramp near Executive Flight Support (EFS) at the time of the crash, told investigators that he observed the airplane take off from MYNN on runway 14, heading south. He stated th at he

observed white smoke trailing behind the aircraft. When he “looked at the aircraft again it appeared to be experiencing engine trouble”. He observed the aircraft banking to the left with landing gears in the down position. He stated he believe d the airplane was attempting to land on runway 27, but the aircraft was flying

abnormal. The witness further stated that he believed the aircraft went into a stall and that is when he believes the pilot lost control of the aircraft. He then saw the aircraft fl ipped upside down and plunged into the lake. He saw and heard a loud explosion.Air Accident Investigation and Prevention Unit

Final Report C6

- NLH Page 17 Another eye witness

, who is an ATC ground controller, stated “I observed aircraft C6

- NLH which departed at 1633, with white smoke trailing behind the left engine. The pilot made a left turn attempting to return to the field. It was then that I noticed that the aircraft began

an immediate descent and ditched into waters at the approach end of runway 27.”

A n other eye witness, who is a boat captain and private pilot

, passing on the perimeter road near to runway 14 /32 stated that he was travelling along Coral Harbour r oad / airport perimeter north bound when he observed a twin engine airplane departing the runway. The aircraft appeared to be lower than normal and

white smoke was bellowing from the left engine. He stated that he thought the odor of

the white smoke was consistent of aviation

gas.

The plane intersected his position as it crossed the perimeter fence and disappeared from view

due to the roof of his car. At that time h e believes the landing gears were up. He was again able to see the airplane from his rear

view window as it crossed the road and began to cross Lake Killarney.

The pilot started a bank over the lake prior to lowering the gears. The bank became more

se vere before finally going into a hard over and nosing into the water. The witness stated he stopped his car and ran in the direction of the crash to investigate and help. At this time he was on the phone calling 911. He advised them of the plane crash. He stated that he was the first on the scene. However, he stayed out of the water due to the presence of avgas. He stated that the plane was in the water but it was impossible to tell what attitude it was in. It was approximately 300 to 400 yards from his po sition. It appeared to be fractured into a number of pieces. According to the eye witness, personnel from the airport (NAD) were next arriving on scene followed by personnel from the police force . Eventually two persons swam out to the plane and began t he rescue prior to his departure

.

Additionally, a n eye witness who was located on the airport at the time of the accident late stated that the airplane

became airborne at i ntersection of runway 14 and taxiway B which in his estimation was a long and late ti me for an aircraft to get airborne. "At rotation the gears were up, like in a normal take

- off and white stuff sprayed at about 50 feet in climb. I noticed at climb it (aircraft) seemed nose high, and trail of white smoke from left engine." "It did not get high

, approximately 150 feet" He also stated that "it seemed weird to me, the engine made funny sound to me, like he was pulling down on the props, like the power was pulled back." “ The aircraft turned deep and rolled over to the left. I heard the engine running for about 10 seconds after it hit the water, the engine

was on
, and then stopped."

F igure 2 Eyewitness account of the accidentAir Accident Investigation and Prevention Unit

Final Report C6

- NLH Page 18 A nother eye witness ( an aviation technician ) who was located on the ramp at MYNN at the time of the accident

stated th at he saw the aircraft taxi out and became airb orne in a southeast direction. Approximately 3

- 5 minutes

after becoming airborne he stated that he could still see white smoke trailing behind the left engine. He also stated

he saw the aircraft go from a gradual lef t bank , to a more severe bank. “ It beg an a left steep bank trying to return
as to land.” “ The aircraft went from a normal left turn to a sharp turn; left wing was almost perpendicular to the ground. ” “There was a sudden flip, like a shift or a jerk to the left as though something opened like a door. ” “ At that point the aircraft continued in a barrel roll nose first, we heard the impact and water splash. ”

A pilot who was next in line for takeoff reported that while at the threshold awaiting his takeoff clearance, he

noticed the aircraft at i ntersection Foxtrot (C6

- NLH) took an unusually long time conducting its pre

- takeoff run up checks. According to this and other eye witnesses reports, from the application of power and the initiation of

the take

- off roll, (from intersection Foxtrot), throug h the take

- off, white smoke was observed trailing behind the left engine of the aircraft. The aircraft became airborne near the intersection of r unway 14 and taxiway Bravo 1

. The white smoke seemed to get worse after the aircraft became airborne.

Addition al eyewitnesses on the field at the time stated, from initiation of the take

- off roll, seeing white smoke and hearing sounds trailing behind the aircraft which sounded like the aircraft was backfiring. Eyewitnesses further stated “the gears were retracted and it appears the aircraft was struggling to climb. The aircraft made a gradual left bank increasing to a sharper bank as if trying to return for a landing. The bank continued until the wings were almost perpendicular to the ground.” “Gear was extended s omewhere in the turn and the aircraft went into a barrel roll and crashed into the lake.” Witnesses reported hearing sounds as if the pilot was pulling back on the propeller levers just prior to the crash.

Eyewitnesses ‟ stated the aircraft was approxim ately 150 to 200 feet when all of this occurred. A number of eyewitnesses in cars and at the General Aviation Center saw the aircraft after it became airborne . The majority were travelling along the airport perimeter road (Coral Harbour Road). They notice d that the aircraft was at a low height as it crossed the perimeter roa d. The aircraft commenced a bank to the left, and increased the bank sharply as if trying to return for a landing on runway 27. They saw the aircraft angle increased until it was near v ertical and then the nose dropped. They saw the aircraft enter a steep dive before disappearing behind trees and into the

lake.

1.2 Injuries to Persons

1.3 Damag e to Aircraft

The aircraft sustained substantial damage due to the impact sequence and subsequent water submersion. It was later recovered from the crash site and transported to a secure facility for the field investigation.

1.4 Other Damage

Other t han damage sustained by the aircraft and subsequent recovery efforts, no other damage was reported.

Unknown environmental damages may have been sustained by the lake due to the amount of fuel spilled as a result of the ruptured fuel tanks. Injuries Crew Passengers Others Total

Fatal 2 7 0 9

Serious

Minor/NoneAir Accident Investigation and Prevention Unit

Final Report C6

- NLH Page 19 1.5 Personne l Information

1.5.1 Pilot

43 yr old Nelson Leo Hanna , a Bahamian of Nassau

, Bahamas was listed as the pilot in command on the flight plan form filed at EFS

. Mr. Hanna was the holder of a valid Bahamas Commercial Pilot Certificate number 392
CP, issued o n 07 October, 1999 with a irplane multi

- engine l and , instrument airplane category and class rating

with no limitations. Mr. Hanna was the holder of a Bahamas second class medical certificate issued A ugust 04,

2009

. However

, he could not exercise the privile ges of his commercial pilot license as this second class medical

certificate expired on August 31, 2010. Mr. Hanna ‟s medical certificate held no medical limitations

.

Mr. Hanna received a medical examination for renewal of his second class medical certifi cate ( minimum required for commercial operations) on September 7, 2010. The medical exam results were submitted to the FSI for

renewal and re issuance of his second class medical on September 16, 2010. The Second Class Medical was processed and authorized s hortly thereafter. However, Mr. Hanna had not returned to the FSI to retrieve his Second Class Medical certificate up to the time of the accident on October 05, 2010.

He was also the holder of a US A issued commercial pilot license with airplane

- multi

- e ngine land, instrument privileges and privat e pilot privileges for airplane

- single engine land. Mr. Hanna ‟s total flying experience

recorded on the insurance documents retrieved post accident listed his total civilian flight times as in excess of
12,000 flight hours. His flying experience on this type of aircraft is listed as in excess of 10,000 hours

. Mr. Hanna‟s pilot logbook was not made available to investigators therefore an accurate up to date account of his total flight time is unknown.

The amount of hours flown by Mr. Hanna in the last 24 hr, 7 days or the last 30 days prior to the accident is

unknown with the exception of the flight conducted to Marsh Harbour

, Abaco on October 5, 2010, the same day prior to the accident flight

, which accounted fo r approximately 2 hours . FAA and CAD record s indicate there have been no violations or prior FAA /CAD recorded aviation accident history or violations against Mr. Hanna

. No records were made available to the investigation team to verify whether Mr. Hanna ha d accomplished a require d proficiency check (required of all pilots engaged in commercial air transportation ) with in the specified time frame stipulated by his insurance policy and CASR Schedule 14 .095, 14.120 or 14.180 for commercial operations.

1.5.2 S econd Pilot

Mr. Devon Storr age 27, acted as a second pilot for the accident flight as well as several previous flights with Mr.

Hanna. Mr. Storr was the holder of a valid US Commercial Pilot Certificate issued o n March 15, 2008

, with airplane m

ulti

- engin e land and inst rument airplane ratings and also held a Private P ilot Certificate with airplane single

- engine land rating . Mr. Storr was also the holder of a Bahamas Commercial Pilot Certificate number 704 CP, issued on 11 August

, 2010 with airplane multi

- e ngine land, instrument airplane category and class rating with

no limitations.

Mr. Storr was also the holder of a valid Bahamas First Class Medical Certificate issued 09 August, 2010 with no

limitations and no restrictions. The amount of hours flown by Mr. Storr in the last 24 hours, 7days, and 30 days prior to the accident

, with the exception of the flight conducted to Marsh Harbour

, Abaco on October 5, 2010, the same day

, prior to the accident flight which accounted for approximately 2 hours, could not be verified as no duty log or records were made available to the investigation team. No records were made available to verify whether

Mr. Storr had accomplished a required proficiency check (required of all pilots engaged in commercial air transportation ) within the specifi ed time frame stipulated by CASR Schedule 14.095, 14.120 or 14.180 for commercial operations.Air Accident Investigation and Prevention Unit

Final Report C6

- NLH Page 20 1.6 Aircraft Information

1.6.1 General

Aircraft C6

- NLH a Bahamas registered Cessna 402C aircraft was manufactured in 1981 by Cessna Air craft Company and designated seria l number 402C 0458

.

The aircraft was fitted with two (2) reciprocating engine s , model

number TSIO 520 VB manufactured by Teledyne

Continental Motors . The aircraft was listed in the normal category,

standard classificatio n. The aircraft

was issued an Airworthiness Certificate on May 19, 2010 by the Flight Standards Inspectorate, Nassau, Bahamas

.

The accident airplane was configured with 10 seats, 2 pilot‟s seat, and eight (8) additional seats. Six of those eight passeng er seats were single seats and 1 set of seats were a double seat which was positioned near the entrance door and was designated

seats 7 and 8. The airplane had a main entry door which was located on the left side of the aircraft aft of the left wing and a djacent to seats 7 and 8, and two emergency exits one located forward and above the left wing, next to the pilot‟s seat (seat 1) and one at seat four (which was located behind the co

- pilot‟s seat) on the right side of the aircraft, above the right wing.

T he aircraft also had a cargo door on the left side aft of the left wing, which was joined to the main entry door and adjacent to seats 9 and 10 just forward of cargo area Bay A. The cabin cargo storage area began just aft of seats 9 and 10 and was designat ed cargo areas Bay A and Bay B. Cargo areas were also located in each wing lockers aft of each respective engine nacelles. Additionally, cargo was also stored in the Nose Luggage and Avionics Bay area of the aircraft above the nose wheel storage compartmen t.

1.6.2 Aircraft Description

The Cessna 402C is a twin engine, all metal, low wing airplane with retractable tricycle landing gear. The fuselage is of semi

- monocoque 6 construction: the wing, tailplane and fin are of conventional aluminum

constructio n. The aircraft can be configured for either passenger or freight transport. In the passenger role, the two

forward seats are pilot‟s seats. A maximum of eight (8) passenger seats may be installed aft of the pilot seats. Minimum flight crew required is one (1) pilot.

1.6.3 Engines

The Cessna 402C is powered by two Teledyne Continental Motors model TSIO

- 520

- VB engines which are turbo charged, fuel injected, direct drive, air

- cooled and horizontally opposed with six cylinders each with a 520 cubic

inch di splacement. It is rated at 325 horsepower at 2700 propeller rpm and 39.0 inches hg manifold pressure to the critical altitude of 12,000 feet. Each engine is provided with an oil pump, fuel pump, vacuum pump, propeller governor, tachometer generator, start er and alternator.

6 Monocoque is a construction technique that supports structural load by using an object's exterior, as opposed to using an internal frame or

truss that is then covered with a non

- load

- bearing skin or coachwork

. Figure 3 C402C Seating diagramAir Accident Investigation and Prevention Unit

Final Report C6

- NLH Page 21 1.6.4 Propellers

P ropeller s installed on the Left and Right engine s of C6

- NLH

, were manufactured by McCauley Accessory Division Cessna Aircraft Company . The types of propellers were all metal, three

- bladed, constant speed, full

feath ering, single acting, non

- reversible, hydraulically actuated , governor regulated propellers

. Each propeller utilizes oil pressure which opposes the force of springs and counterweights to obtain correct pitch for engine load. They were both part number 0850 334

- 29 and had an operating limit of 2700 rpm maximum speed

.

Propeller S erial number 815478 was installed on the left engine and serial number 920620 was installed on the

ri ght engine of C6

- NLH. The maintenance history and t imes accumulated on both prope llers or date installed on each respective engine could not be determined . Permanent maintenance records were requested from the pilot‟s wife and other local personnel up to the publication of this final report , but none were provided

.

The engine and prop eller controls are conventional in that each engine is controlled by three levers [1. Throttle. 2. Propeller and; 3. Mixture], which are mounted on the control pedestal in pairs in the order 1, 2, and 3 from left to right. The Throttle control lever is use d to increase or decrease the engine power by moving the butterfly valve

in the fuel air control unit. The Propeller control lever is used to change the propeller pitch to maintain or set a

desire d engine rpm. The Mixture control lever is used to control t he amount of fuel to be metered by the fuel

- air

control unit.

1.6.5 Flight Controls

The flight controls consist s of the ailerons, elevators and rudder and their respective trim systems. All of these systems are constructed of aluminum and are staticall y balanced.

Each aileron is attached to the rear main wing spar at two points. The aileron is actuated by a bellcrank which is attached to a wheel in the wing. The wheel is actuated by cables attached to the pilots control wheel. When the

rudder is ac tuated, a spring assembly, interconnected to the aileron system, causes the ailerons to automatically

assist the turn

. Aileron trim is achieved by a trim tab attached to the left aileron with a full length piano type hinge. The trim tab is actuated by a p ush pull rod which is attached to a jack screw type actuator in the wing. The actuator is driven by cables attached to the trim control knob on the cockpit control pedestal. The aileron trim tab also acts as a servo tab so that aerodynamic forces on the ta b will move the ailerons to the selected position, which reduces the forces required to activate the ailerons in flight

The rudder is attached to the vertical stabilizer rear main spar at three points. The rudder is actuated by a

bellcrank attached to th e bottom of the rudder. The bellcrank is actuated by cables attached to the cockpit rudder pedals. When the rudder is actuated, a cable and spring assembly that is connected to the aileron system causes the ailerons to automatically assist the turn. The rudder trim is achieved by a trim tab attached to the lower half of the rudder with a full length piano type hinge. The trim tab is actuated by a push

- pull rod which is attached to a jack screw type actuator in the vertical stabilizer . The actuator is d riven by cables attached to the rudder trim wheel on the cockpit control pedestal. The rudder trim tab also acts as a servo tab so that aerodynamic forces on the tab will move the rudder to the selected position, which reduces the forces required to activa te the rudder in flight.

The elevator control surfaces are connected by a torque tube. The resulting elevator assembly is attached to the rear spar of the horizontal stabilizer at six points. The elevator assembly is actuated by a push pull rod which is

attached to a bellcrank in the em pennage. The bellcrank is actuated by cables attached to the pilots control wheel.

Elevator trim is achieved by an elevator trim tab attached to the right elevator with a full length piano

- type hinge. The trim tab is actuated by a push pull rod which is attached to a jack screw type actuator in the horizontal stabilizer. The actuator is driven by cables attached to the trim control wheel on the cockpit control pedestal.Air Accident Investigation and Prevention Unit

Final Report C6

- NLH Page 22 1.6. 6 Aircraft Fuel System

The fuel system consists of two main tanks outboard of each engine , two fuel selector valves and emergency shutoff valves and necessary components to complete the system. The main fuel tanks are an integral portion of the sealed wet wing. These tanks supply their respect ive engine with fuel for normal operations including take

off s and landings.

An auxiliary fuel pump, located outside the tank, provides fuel pressure for priming during engine start. In the event of an engine fuel pump failure, the auxiliary fuel pump wi ll supply fuel to the engine if the auxiliary fuel pump switches are on.

There are two fuel selector valves controlling fuel supply to the engines. They are located in the wings and are

operate d by cables from selection knobs situated on the cockpit floor between the pilots' seats. Each valve has

three selection positions ; OFF, LEFT MAIN AND RIGHT MAIN.

Normally each engine is fed from its own tank, i.e. left engine from left tank, but the valve s allow an engine to be fed from the opposite tank. This is referred to as "cross

- feed". The mechanical detents, which provide positive positioning of the valves in their three functioning positions, are built into the valves. The knobs in the cockpit

c an themselves move freely but they are constrained by the detents through the cable system.

There is also an emergency shutoff control adjacent to and immediately behind the fuel selector controls. Its

function is to isolate the fuel cross

- feed lines f rom the fuel tanks in the event of fire or landing with the gear

retracted.

C6

- NLH

, a 402C aircraft was approved for 100 (formerly 100/130) Grade Aviation Fuel (Green) and as an

alternate

, 100LL Grade Aviation Fuel (Blue). It has a tota l fuel capacity of 213.4 ( U.S. Gallons ) and 204.0 Usable Fuel (U.S. Gallons)

.

1.6.7 Weight and Balance

Three (3) Bahamas certified AOC holders at the domestic section of Lynden Pindling Int‟l Airport stated that they were approached by one of the victi ms of the accident aircraft inquiring about the price and their availability to

conduct a charter to San Salvador Bahamas

.

They (AOC) all confirmed they declined to conduct the charter because looking at the amount of luggage, equipment and size of person that wanted to travel, the combined weight exceeded the legal amount for the size aircraft that they operated ( Cessna 402C and Hawker Beechcraft B100 ) . One operator offered a larger aircraft that was able to accommodate all of the equipment and persons pr esent, but his offer was declined by the victim because the price was more than he was willing to pay.

S ometime thereafter

, arrangements were made by the same individual for Acklins Blue Air Charter to fly the passengers and their equipment and luggage to San Salvador, Bahamas

.

The accident investigators could not determine if all of the equ ipment and luggage that the victims had with them

, (that were presented to the previous 3 AOC holders) were placed on the accident aircraft. However

, all of the

person s with him were all victims of the airplane crash.

On October 5, 2010 at 8:45 am
, the aircraft was fueled adding 80 gallons of Avgas and 2 quarts of aviation oil were purchased from Executive Flight Support. On the same day at 12:06pm an ad ditional 60 gal lons of Avgas

were purchased. No indication of how much fuel was on board the aircraft prior to the additional 60 gallons that

was added

. The pilo t however listed his fuel endurance as 4 hours.Air Accident Investigation and Prevention Unit

Final Report C6

- NLH Page 23 Some luggage was recovered from the wreckage and accident si te; however, no determination could be made whether this was the total luggage and equipment that was shown to the previous AOC holders. The aircraft‟s total weight at takeoff could not be accurately determined. The center of gravity also could not be accu rately

determined due to no eyewitnesses of the loading process of the aircraft. T he investigation team was able to

determine that the aircraft had exceeded the weight and balance limitation and center of gravity envelope for the

Cessna 402C aircraft. Pos t accident calculations determined that the aircraft was over the maximum allowed weight for takeoff by more than 500 pounds. ( See Weight and Balance Scenario 1.16.4)

1.6.8 Weighing Report

No documents could be obta ined to verify whether the aircraft was weighed within the specified period as per

BASR Schedule 5 , as the aircraft permanent records were requested from the pilot‟s wife and other local personnel but they were never provided up to the publication of this report

.

1.6.9 Limitations

Maximum Ramp Weight: 6,885 pounds

Maximum Take

- off Weight: 6,850 pounds Maximum Landing Weight: 6,850 pounds Maximum Zero Fuel Weight: 6,515 pounds

1.6.9.1 Operating Speeds

The following aircraft operating speeds, expres sed in Knots Indicated Airspeed (KIAS) were relevant to the accident flight.

 Buffet onset speed (flaps UP at MTOW) 80

 Stalling Speed (power off flaps up) 80

 Minimum control speed (flaps UP) V MCA 7 80

 One engine inope rative best rate of climb s peed (V Y ) 8 104

 One engine inoperative best angle of climb speed (V X ) 109

 Blue Radial Line 9 104

1.6.10 Maintenance History of the Aircraft

The permanent maintenance records were requested from the pilot‟s wife and o ther local personnel but none was provided

. Therefore a history of the aircraft could not be determined. However, some major events such as engine overhauls, cylinder overhauls and repairs paperwork was obtain from the repair shop . Additional

information pertaining to the manufacture of the cylinders was also obtained.

1.6.11 Maintenance History of the Left Engine and Propeller

Work orders provide d by Airmotive Engineering Corp pertaining to work performed on the EC i parts was obtained, but is not a complete history

. Extensive research was performed by the NTSB and is contained in the

N T SB materials Laboratory factual report referred to in Appendix 5.1

7 This is the minimum flight speed at which the airplane is directionally controllable with one engine inoperative and with a 5 ̊ bank towards the operative engine.

8 This speed delivers the greatest gain in altitude in the shortest possible time with one engine inoperative at sea level, sta ndard day conditions and 6,850 pounds weight.

9 On e engine inoperative best rate

- of

- climb speed

, at sea level

, standard day condition and 6,850 pounds weight.Air Accident Investigation and Prevention Unit

Final Report C6

- NLH Page 24 1.6.12 Maintenance history of the Right Engine and Propeller

The permanent maintenance records we re requested from the pilot‟s wife and other local personnel but none was provided

. Therefore a history of the right engine and pro peller could not be determined

.

1.7 Meteorological Information

Weather observations are transmitted in coordinated un iversal time / Zulu time (UTC / Z). Eastern Daylight Time

is 4 hours behind UTC / Z time. Bahamas Meteorological Department at the Lynden Pindling International Airport issued the Bahamas Area Forecast 10 which originated at 1630 UTC; dated Tuesday October 5

, 2010 valid

for 12 hours from 1 8 00 UTC reported a combination stationary front along with a surface trough across the northwestern and central Bahamas producing unstable weather through the forecasted period. Significant

Weather section of the Bahamas Ar ea Forecast over the central and northwest Bahamas indicated scattered to broken clouds from 1,200 feet to 1,800 feet with towering cumulus 11 and cumulonimbus 12 clouds

. A scattered and broken layer of clouds were at 3,000 feet and 5,000 feet respectively.

A layered broken to overcast clouds were 8,000 feet and 12,000 feet up to 24,000 feet (FL240) 13 . Widespread rain was forecasted with scattered showers and thundershowers mainly in the vicinity of the trough or front in lines and clusters with towering cumul us or cumulonimbus with tops above FL180 to FL240. Ceiling 14 and / or visibility was reduced below 1,200 feet and 3 nautical miles in heavy showers, rain and thundershowers. Moderate to severe turbulence in the vicinity of all towering cumulus and cumulonim bus clouds was forecasted.

Forecasted Upper Winds and Temperature for the same time period from 1800 UTC at the 2,000 foot level in the

northwestern Bahamas were winds 030 ̊ at 28 knots , visibility unrestricted scattered clouds at 1,800 feet, scattered

clo uds at 12,000 feet, broken cloud layer at 3,500 feet, another broken layer at 10,000 feet. From the 06 October at 1200 Z expect the winds to be from 030 ̊ at 24 knots, visibility unrestricted , scattered clouds from 1,600 feet and a broken layer at 24,000 f eet.

Aerodrome Forecasts for Lynden Pindling Int‟l Airport (MYNN) indicated on the 05 October from 1600Z to the

05 October 1800Z to the 06 October at 1800Z winds from 090 ̊ at 06 kts

. The 1600Z METAR 15 (12:00pm local time) indicated that the winds were 100 degrees at 6 knots; visibility was 7 nautical miles in light rain showers. Clouds were scattered at 1,800 feet, and broken at 10,000 feet and then again broken at 24,000 feet. The temperature was 88 ̊F 16 / 31 ̊ C 17 , and the dewpoint 18 was 81  ̊ F / 27  ̊ C. The baro metric pressure 19 was 1012.2

HPA 20 and altimeter 29.89” HG. 21

10 Area Forecast

- An Aviation Area Forecast or FA encompasses the weather conditio ns over a large regional area and is considered one of the better sources of information for en route weather. It is also beneficial in verifying airport conditions at airports that do not have

terminal aerodrome forecasts.

11 Towering Cumulus Clouds

- Cumulus clouds are a type of cloud with noticeable vertical development and clearly defined edges.

Cumulus means "heap" or "pile" i n Latin . They are often described as "puffy" or "cotton

- like" in appearance.

12 Cumulonimbus Clouds

- Cumulonimbus ( Cb ) is a type of clo ud that is tall, dense, and involved in thunderstorms and other intense

weather

13 FL

- A Flight Level ( FL ) is a stand ard nominal altitude of an aircraft , in hundreds of feet . This altitude is calculated from the

International standard pressure datum of 1013.25 hPa (29.92 inHg ), the average sea

- level pressure, and therefore is not necessarily the

same as the aircraft's true altitude either above mean sea level or above ground level

.

14 Ceiling

- With respect to weather conditions, a ceiling refers to the height of the lowest obscuring cloud layer above the ground

.

15 METAR

- METAR is a format for reporting weather information.

16  ̊F / Fahrenheit

- Fahrenheit is the temperature scale proposed in 1724 by, and named after, the physicist Daniel Gabriel Fahrenheit (1686

– 1736).Air Accident Investigation and Prevention Unit

Final Report C6

- NLH Page 25 1.8 Aids to Navigation

No discrepanci es with navigational aids were known or reported.

1.9 Communications

No difficulties with internal or external communications were known or reported

.

1.10 Aerodrome Information

Lynden Pindling International Airport ( IATA : NAS

, ICAO : MYNN ), formerly known as Nassau International Airport , is the largest airport in The Bahamas , and the largest international gateway into the
country. It has an airport elevatio n of 16 feet above mean sea level. The coordinates are 25 ̊ 02‟20” N and 077 ̊

27‟58”W

. It is a major hub for Bahamasair and is located in the west ern district of New Providence Island near the capital city of Nassau . Due to a large amount of flights to the United States , the airport contains U.S. Border preclearance fac ilities allowing all US flights to operate as domestic flights upon arrival at their destination.

The name of the airport was officially changed on July 6, 2006 in honor of The Right Honorable Sir Lynden Oscar Pindling (22 March 1930

– 25 August 2000), first Prime Minister of The Commonwealth of the Bahamas

. The airport is served by runwa ys 14/32 which is oriented southeast and northwest and runway 09/27 which is

oriented east and west. Runway 14/32 is 11,353 feet long and 150 feet wide and runway 09/27 is 8,273 feet long and 150 feet wide, both are paved surfaces and constructed of aspha lt

. ( See Appendix 5.15 Aerodrome Chart)

1.10.1 Nassau Airport Development Company (NAD)

Nassau Development Company Limited was incorporated on June 6, 2006 under the provision of the Companies Act 1992. The company is a wholly

- owned subsidiary of The Airport Authority. The registered office and principal place of business is located at the Lynden Pindling International Airport, Nassau, Bahamas.

The principal functions of NAD are to manage, develop and maintain MYNN and to transform the airport into a premier world class facility in a most efficient and commercial manner. NAD commenced its operations on October 1, 2006. On October 19, 2006, NAD entered a 10 year Management Agreement with YVR Airport Services Ltd. (YVR AS), to manage, operate and maintain MYNN and to place certain executives within NAD.

On April 1, 2007 NAD entered a 30

- year Lease Agreement with the Airport Authority. In accordance with this Lease Agreement, NAD is responsible to manage

, maintain and op erate MYNN and rent is paid to the Airport Authority.

17  ̊C / Celcius

- Celsius (known until 1948 as centigrade ) is a temperature scale that is named after the Swedish astronom er Anders

Celsius (1701

– 1744).

18 Dewpoint

- The dew point is the temperature at which a given parcel of h umid air must be cooled, at constant barometric pressure , for
water vapor to condense into water.

19 Barometric pressure

- Atmospheric pressure is the force per unit area exerted against a surface by the weight of air abov e that surface in

the Earth's atmosphere

.

20 HPA

- Hectopascal (hPa), a unit of pressure equivale nt to about 1/1000 of 1 atmosphere

.

21 HG

- Hg may refer to: Mercury (element) or HgAir Accident Investigation and Prevention Unit

Final Report C6

- NLH Page 26 1.10.2 Aircraft Rescue and Firefighting

The Airport Authority at Lynden Pindling International Airport ( MYNN ) maintains a level 7 ARFF 22 facility on

the airfield for all alerts on airport property . The station is owned and operated by the Airport Authority. It is continuously staffed (24 hours) with a minimum of nine (9) firefighters. ARFF has an airport emergency plan detailing response, recovery and resolution actions in the event of an accident or in cident involving aircraft at the airport or within the boundary of MYNN

.

The station houses four (4) crash trucks, three (3) Oshkosh T1500 trucks with a capacity of 1500 gallons of water and 200 gallons of foam concentrate and one (1) Ford 550 truck with a capacity of 300 gallons of water and 20 gallons foam concentrate. Both trucks have a capacity of 400 pounds of dry chemical. ARFF personnel receive approximately 6 months of training initially and a minimum of 150 hours annually. This training is done i n phases quarterly. This refresher training is done in South Carolina in the United States of America. The training (initial and recurrent) includes but is not limited to, hot fire drills, pressure fed fuel fires, rescue simulation and apparatus operation

. The training includes practical, classroom and computer based scenarios.

1.10.3 Air Traffic Control

The ATC T at MYNN is CAD

- staffed combined terminal approach radar control (TRACON) 23 and tower with

about 1 8 0,000 operations per year . The tower cab is c ontinuously open and is located north of runway 09/27

, and southwest of runway 14/32 centered between runways 09/27 and 14/32. Air traffic control (ATC) radar data are provided by an Airport Surveillance Radar “ASR

- 8” Approach Radar System, with “ARTS 2A” Automation Software. The radar antennae head is located approximately 1 nm s outh of the Control Tower.

C6

- NLH was handled by three (3) air traffic controllers on the day of the accident: the clearance delivery controller, the ground controller and the tow er controller

, all were classified as Grade One Air Traffic Control

Officers. The ground controller notified ARFF as well as the Princess Margaret Hospital of the accident.

1.11 Flight Recorders

C6

- NLH was not fitted with a flight recorder as none was required by regulations for this type of aircraft.

1.12 Wreckage and Impact Info

1.12.1 General Wreckage Description

The airplane sustain substantial damage to the entire upper fuselage from the windshield aft to Bay A luggage compartment, left an d right engines, left and right wings, nose landing gear, nose luggage compartment and right and left elevator and horizontal stabilizer. Other damages include damages done as a result of being submerged in salt water of the lake. The wreckage path and ins trument evidenced that the airplane was on a magnetic heading of approximately 220 degrees. The aircraft was not equipped with a cockpit voice recorder; therefore no information was available of what conversation, if any, took place between the crew, duri ng the last few moments in the cockpit.

22 ARFF

- Aircraft Rescue and Firefighting (ARFF) is a special category of firefighting that involves the response, hazard mitigation, evacuation and possible rescue of passengers and crew of an aircraft i nvolved in (typically) an airport ground emergency.

23 TRACON

- A Terminal Radar Approach Control (or TRACON ) is an air traffic control facility usually located within t he vicinity of a large airport . Typically, the TRACON controls aircraft within a 30

- 50 nautical mile (56 to 93 km) radius of the airport between the surface and 10,000 to 15,000 feet (4,600 m) . A TRACON is sometimes called Approach Control or Departure Control in radio

transmissions.Air Accident Investigation and Prevention Unit

Final Report C6

- NLH Page 27 The airplane‟s main wreckage was located about 400 yards from shore in about 3 to 5 feet of water at high tide. It was approximately 1⁄4 of a mile from the approach end of runway 27. It was submerged and came to rest oriented

on an ap proximate magnetic heading of 22 0 degrees (about 60 ̊ from the westerly inbound course for runway 27 )

. The recoverable parts of the aircraft were located within the immediate area of the wreckage.

First contact with the water was made with the nose of the aircraft in a left nose down, inverted position at a high rate of speed followed by a cart wheeling mot i on where the right wing and right elevator m ade next contact (based on evidence post accident )

. The left wing tank exhibited a type of bulging deformation which showed that

it had contained a large amount of fuel at impact.

No fuel remained when the aircraft was recovered and examined. Both left and right wing fuel tanks were ruptured during the crash sequence which allowed all fuel in them to escape into the lake. Though all of the fuel

from both left and right wing tanks had escaped during or after the crash, it had not ignited and the aircraft had not been affected by fire. Fragmented airplane w reckage was found surrounding the crash site

.

A complete survey of the accide nt scene and aircra ft structure was accomplished; however, the severity of the damage precluded a complete accounting of all the aircraft structure. From this ground evidence and the crushing damage to the fuselage, cockpit, instrument panel and right wing

, it was assessed t hat at first impact the aircraft was at a steep bank with an angle in excess of 45 degrees as reported by eyewitnesses. No objective indications were obtained to quantify the speed at impact or the rate of descent.

The alternator switch for the right eng ine was found in the "OFF" position during post accident documentation. It

was one of the many switches for the right engine that was found in the “OFF” position

. Engine Serial number 248270 was installed on the left wing of C6

- NLH and serial number 290209 was installed on the right wing of

C6

- NLH. Post accident investigation revealed damage of #2 cylinder of the left engine consistent with the cylinder having experience d a mechanical failure.

The engine controls, throttle, propeller and mixture were all f ound in the full forward position which was

in consistent with the engine securing checklist. However, other steps in the engine securing checklist pertaining to the right engine were accomplished (Step 11) such as Magneto, Alternator, Battery, Auxiliary fuel pump switches,

and both Fuel selector valve knobs, all were found in the "OFF" position, which confirms that the right engine may have been intentionally or inadvertently secured without accomplishing the first steps (Step 5) in the checklist such as retarding throttle, feathering pr opeller and shutting off fuel (mixture control) on the affected engine that was going to be secured. (See Appendix 5.10 Engine Failure after Take

- off checklist).

The aircraft was not fou nd to be structurally complete post impact with all its flying controls and control surfaces normally attached. Its landing gear was extended and the gear selector handle was in the down and lock position. The flaps were retracted. Rudder, elevator and aileron trim tabs position could not be verified as the control wheel column, where they were attached, had been destroyed by impact forces.

The engine control pedestal had been partially dislodged and the control levers (throttles, propeller and mixture)

were found in line near the full forw ard position range of movement with the exception of the left throttle which

was found slightly aft of the full forward range of movement. The feathering detents were intact and showed no gross damage.

Both left and right fuel selector knobs were discovered in the "OFF" position which may have been selected by the pilot intentionally or inadvertently during the engine securing s equence or it may be possible that one or both could have been moved by the accident sequence.Air Accident Investigation and Prevention Unit

Final Report C6

- NLH Page 28 1.1 2.2 Fuselage

Examination on site revealed that the windshield, roof and both left and right walls of the fuselage had disappeared and was folded rearward to the main entry / cargo door but was still attached at the point just beyond Seats 9 and 10 and above Bay

Area A. The nose of the air plane was crushed rearward to the left.

The fuselage structure above the wing center section including both emergency exits and surrounding structures were distorted and impact damaged. The aft fuselage

, just forward of the empennage was still attached bu t exhibited severe impact damage

.

The fuselage lower structure including the floor remained intact but was damaged and separated during recovery. All cables, rudder, elevator and ailerons were accounted for in the wreckage.

1.12.3 Engines and Propell er

Both engines were Teledyne Continental Motor s TSIO

- 520

- VB

. The left engine and propeller remained attached to the left wing which was still attached to the fuselage. The right engine minus its propeller was still attached to the portion of the right wi ng that remained post accident. Preliminary inspection of both engines revealed no evidence of pre

- impact malfunction. Inspection however of the No

. 2 cylinder of the left engine revealed a mechanical failure of that cylinder. Both engines exhibited dam ages consistent with post accident recovery

efforts. The engine control pedestal received extensive damage. All control levers (throttle, propeller and mixture) were found in the full forward position. However, explanations of why all engine control levers were full forward, yet engine control switches for the right engine were found in the “OFF” position is not readily apparent. It is inconsistent with engine securing procedures in the Cessna Information Manual. A ll engine control levers were found bent to the right which further coincides with the crash sequence which was left to right as described by eyewitness statements. The control wheel for the elevator, rudder and aileron trim tabs was destroyed in the crash.

The right propeller was separated from the right engine. This may have occurred during the initial impact or subsequent post impact sequence . It however, was never recovered. The left propeller however, was still found attached to the left engine. The propeller hub received substan tial damage but was still found attached to the left propeller

. All blades for the propeller were found still attached to the propeller hub

. Evidence showed that the left propeller b lades were not feathered. Eyewitness reports states that the engine continued t o run approximately 10 seconds after water impact. The blade damage appears to be consistent with the propeller not being feathered and would account for the rotational damages found on the left propeller which would indicate that the left propeller may h ave been rotating at impact

1.12.4 Wings

Pieces of the right wing outboard of the right engine nacelle, including right wing leading edge, trailing edge, flaps, wing tip , aileron and strobe light had separated and were not recovered from the lake. W hat remained including the right wing spar was severely fragmented with pieces located throughout the wreckage path

. The left wing with engine and propeller still attached

, remained attached to the fuselage and exhibited a type of bulging

deformation and loc alized impact damages along its entire length. All fuel contained in both wing tanks escaped. Though the fuel in the left and right wing had escaped during or after the crash, it had not ignited and the left nor right wing and engines had been affected by fire. The right wing sustaine d substantially more damage than the left wing. Figure 4 Fuselage post accidentAir Accident Investigation and Prevention Unit

Final Report C6

- NLH Page 29 Both left and right landing gear were found in the down and locked position. The gear selector handle on the instrument panel confirmed that the gear was indeed selected to the do wn position. No impact damages were noted to the left and right main landing gears. The nose landing gear was separated from the fuselage possibly during the initial impact where the nose section of the airplane seemed to have received the brunt force of t he impact. The impact damage to the airplane precluded the determination of flight control continuity. However, the examination of the wreckage revealed no evidence of flight control or other system malfunction before the aircraft impacted the water. Furt her, there was no evidence of in

- flight or pre

- impact fire. There were no indications of separation of parts before initial impact. The wreckage evidence indicated that both flaps were in the retracted position at the time of the impact. Both engines were examined during the field investigation. Neither showed evidence of fire damage.

1.12.5 Empennage and Flight Controls

The left aileron of C6

- NLH received substantial damage in the accident. The entire right wing leading edge (9'10"), outboard of the right engine nacelle, as well as approximately 7'9" of the trailing edge of the right wing, outboard of the right engine nacelle and right flaps were destroyed. The right aileron was destroyed with the leading and trailing edge of the right wing. Appr oximately 4'8" of the trailing edge of the right wing, outboard of the rear right engine nacelle with wing flaps still attached was recovered. The missing wing and damages sustained to the forward attachment point and leading edge right wing outboard of th e right engine nacelle is consistent with eyewitness reports of the aircraft going inverted, nose down and cart wheeling to the right after impact. (See Appendix 5.11 Crash aircraft diagram and Appendix 5.12 Reference aircraft diagram)

The aileron trim tab on the left aileron of C6

- NLH sustained substantial damage. Additionally, the trim control knob on the cockpit control pedestal was destroyed during the crash sequence. (See Appendix 5.11 Crash aircraft diagram and Appendix 5.12 Reference aircraft diagram)

.

The vertical stabilizer, rudder and rudder trim tab remained attached to each other and the fuselage; these surfaces

e xhibited no evidence of direct impact damage however, minor damage was noted. The left horizontal stabilizer and elevator remained attached to each other and the vertical stabilizer. They exhibited some impact damage. The right horizontal stabilizer, port ion of the elevator and the elevator trim tab remained attached to each other and to the vertical fin. They exhibited evidence of severe impact damage. The rudder of C6

- NLH received minor damages however, the rudder pedals in the cockpit received substanti al damages. The rudder trim tab of C6

- NLH received minor damages. All cables were accounted for and had to be cut by investigators during the recovery effort. The control wheel located on the cockpit control pedestal was destroyed during the crash sequen ce. The lack of damage to the rudder and vertical stabilized is consistent with the nose down crash sequence eyewitnesses

described.

The right horizontal stabilizer and right elevator were bent in an upward angle approximately 30 to 40 degrees.

When co mpared to a reference 402C , it was noted that the outboard right horizontal stabilizer and the outboard right elevator were missing approximately 4'5" and a portion of the right elevator trim tab was also missing which is consistent with the aircraft going inverted and hitting nose first and cart wheeling to the right. The outboard portion of the right elevator (approximately 2.5 feet) was separated from the main wreckage and never recovered from the lake. The outboard portion of the right horizontal stabil izer was bent upward at about a 30 to 40 degree angle. (See Appendix 5.11 Crash aircraft diagram and Appendix 5.12 Reference aircraft diagram) The control wheel pedestal was destroyed in the accident sequence. All cables were accounted for and were cut by investigators during recovery and initial investigation to access other components during documentation.

1.12.6 Damage to Seats and Cabin Floor

The structural damage to the cabin and seats was assessed both at the accident site and after removal of the aircraft wreckage to the hanger. In some cases the complete lower seat frame had detached from the floorAir Accident Investigation and Prevention Unit

Final Report C6

- NLH Page 30 attachments and in one case there had been separations within the seat structure, leaving parts of the lower seat

frame attached to the cabin seat tracks. The lap straps and attachments had remained intact, retain in g the occupants in their seats . The seats and its occupants had been ejected during the crash sequence

. Two seats were

ne ver recovered and possibly lost in the lake. All seat belts of seats found were accounted for. As all passengers were ejected, no accurate indication of where each person sat in the aircraft could be established.

There was considerable evidence, in the fr ames and stringers of the lower cabin structure, that the cabin floor had been subjected to high vertical and longitudinal impact loads: the result had been rotation of the lower fuselage as

the cabin floor moved forward and downward. The only passenger se at that remained attached to the cabin floor was seat number 9, which it is assumed was either not occupied or if occupied, its occupant was not wearing the

seat belt. It could not be positively determined what proportion of the damage to the seating had o ccurred in the first impact with the water and what had occurred due to the cart wheeling of the aircraft after initial impact.

1.12.7 Fuel Selection

Both fuel sel ector valves were found in the “OFF” position . The fuselage structure below the floor ha d been crushed and distorted in the crash. This was the area of the fuselage‟s first impact with the ground and it is likely, therefore, that the cables to the selector valves may have been trapped and moved at first impact.

T he possibility that the cab le was moved prior to

, or during the impact

, before bein g trapped in the “OFF” position cannot be discounted.

1.12.8 Left Console Panel

The left console panel represented here depicts the labels for

switches and the picture that follows shows the act ual position

that those switches were found. O nly affected switches that

illustrate actions done with referen ce to the right engine which were intentionally or inadvertently secured, will be labeled here

, see le ft and right side console panel for labels of other switches

of interest

.

Switches # 5 left to right (3), which represents Left Alternator, Battery and Right Alternator.

Switches #7 left to right (2), which represents Left and Right Auxiliary Fuel (boost) pumps.

Switches #8 left to right (4), whi ch represents Left and Right

Ma gneto Switches for the Left Engine (2) and Left and Right Magneto Switches for the right engine (2)

. Figure 5 Left ConsoleAir Accident Investigation and Prevention Unit

Final Report C6

- NLH Page 31 On the console panel located on the left fuselage wall just below the emergency exit

, next to seat number 1, the investigation team

discovered that both left and right magneto switches for the right engine were found in the "OFF" position, (switches #8) see system description figure 7.

T he battery and right alternator switch ( switches # 5) for the right engine was a lso discovered in the "OFF" position see system description figure 7.

Auxiliary fuel pump for the right engine (switch #7) also found in the "OFF" position see system description figure 7

.

The left and right magneto switches for the left engine as well a s the left alternator switch for the left engine were found still in the “ON” position.

B oth fuel selector valve knobs located on the floor between the left and right pilot's seat were found in the "OFF" position.

It could not be confirmed whether t he knobs were selected by the pilot intentionally or whether they were moved as a result of the accident sequence.

R ight t hrottle lever

, left and right propeller lever as well as left and right mixture control levers were all

found in the full forward position with the exception of the left throttle lever which was found slightly aft of the full forward position, (which represents full power on that engine)

. Figure 6 Actual console Panel for C6

- NLH

Figure 7 Fuel Selector Valves Left and Right Engine

Figure 8 Power QuadrantAir Accident Investigation and Prevention Unit

Final Report C6

- NLH Page 32 1.13 Medical and Pathological

The body of the pilot and seven (7) victims were recovered the day of the accident; one person (identity unknown)

was found still alive. He sustained serious injuries and was transported to the Prince ss Margaret Hospital. He was examined by Emergency Medical Technicians on the Ambulance; however, h e succumbed to his injuries enroute. The pilot and the remaining six (6) victims were transported to the Rand Laboratory ( Morgue ) located at the Princess Margaret Hospital. On the third day after the accident

, the body of the 9 th victim was recovered from the

lake where the accident occurred. Post

- mortem examinations were performed by pathologist of the Rand Mortuary at the Princess Margaret Hospital, Nassau Bahamas on all occupants of the aircraft. The causes of death of all occupants were determined to be multiple blunt force injuries due to airplane crash

.

Specimens of liver, blood, stomach conten ts, urine and vitreous humor of listed pilot in command on record Mr. Nelson Hanna were obtained by pathologist from the Department of Pathology at the Princes s Margaret Hospital. The diagnostic specimen for toxicology was sent via DHL Express, in a Federal Aviation Administration Tox

Box Kit to the Bio

- aeronautical Sciences Research Laboratory at the Civil Aerospace Medical Institute (CAMI) at
the Federal Aviat ion Administration Mike Monroney Aeronautical Center (MMAC) 6500 South MacArthur Boulevard, Oklahoma City, Oklahoma 73169 for toxicological analysis. The analysis was to determine if there

were any pre

- existing disease, alcohol, drugs or any toxic substanc e in the pilot, which may have caused or

contributed to the cause of the accident. Forensic Toxicology Report received from CAMI indicated no carbon monoxide, and no cyanide was detected in the blood. No ethanol was detected in the vitreous humor. Salicyla te 24

was detected in the urine. It was not determined if the amount found in his system was sufficient to impair his judgment to operate the aircraft.

1.14 Fire

Examination of the wreckage concluded no fire was involved pre or post crash.

1.15 Survi val Aspects

1.15.1 First Aid

Several persons driving along the perimeter road (Coral Harbour Road) of MYNN witnessed the crash and alerted

authorities. Some of the passersby waded into the lake and proceeded to pull victims toward the shore. Search

an d Rescue facilities coordinators from Lynden Pindling International Airport, the Royal Bahamas Police Force (RBPF), the Royal Bahamas Defense Force (RBDF), National Emergency Management Agency (NEMA), and Nassau Airport Development Company (NAD) were notif ied of the accident immediately

. The RBDF and RBPF were mobilized to Lake Killarney where the accident occurred. RBDF teams arrived with water rescue equipment and additional personnel about 20 minutes post accident.

The characteristics and magnitude of the impact and subsequent destruction of the airplane indicated that the

accident was non survivable. The impact forces exceeded human tolerances and no occu py able space remained

intact. All occupied seats were detached from the floor tracks. The pilot and all passengers were ejected from the aircraft; all but two passenger s was found still strapped in their seats. One passenger initially survived the crash

. H avi ng sustained serious injuries, h e later succumbed to those injuries enroute to the Princess Marg aret Hospital. Postmortem examination of the occupants indicated that the characteristics of the fatal injuries sustained varied

24 Salicylate

- is an over the counter analgesic used in the treatment of mild pain. A ny of several widely prescribed drugs derived from salicylic acid. Salicylates exert analgesic, antipyretic, and anti inflammatory actions. The most important is acetylsalicylic acid, or aspirin. Sodium salicylate also has been used systemically, and it exerts similar effects. Many of the actions of aspirin appear to re sult from its ability to inhibit cyclooxygenase, a rate

- limiting enzyme in prostaglandin biosynthesis. Aspirin is used in a wide variety of conditions, and, in the usual analgesic dosage, it causes only mild adverse effects. Severe occult GI bleeding or gastric ulcers may occur with frequent use. Large doses taken over a long period can cause significant impairment of hemostasis.Air Accident Investigation and Prevention Unit

Final Report C6

- NLH Page 33 according to the location of the persons in the crash ed airplane. All of the injuries were consistent with

deceleration trauma of different intensity consistent with the aircraft‟s impact and breakdown pattern.

1.15.2 Fire Service and Emergency Response

According to ATC control log aircraft C6

- NLH was cleared for take

- off at 1635UTC * (12:35 l o c a l) . At

1636UTC * tower controlle r advised C6

- NLH that he “needed him to return” as “ white smoke was trailing behind his left engine. ” The pilot attempted to return and land on runway 27 and crashed in the lake. Nassau Airport Authority Aircraft Rescue and Firefighting (ARFF) vehicles and personnel, located approximately 1 mile away from the crash site, responded immediately after one rescue personnel on duty having visually observed the accident and simultaneously receiving an alarm from Nassau control tower personnel. About 3

- 4 minutes after the crash, two (2) ARFF trucks, both fire suppression vehicles (a water equipped fire truck) approximately 10 crash and rescue personnel and the chief fire officer arrived on scene. Other rescue personnel from the community, pilots from the general aviation center and passersby stopped to render assistance a few minutes later.

The first four bodies were recovered at approximately 1704 UTC (1:04pm local) approximately 30 minutes after the crash by crash and rescue personnel as well as bystanders an d pilots from the General Aviation Center. Approximately 1724 UTC, NAD was advised that a total of eight (8) bodies were recovered from the waters and brought to the shore. Approximately 30 minutes after the crash additional assistance was provided by app roximately 30 to 50 persons from the Royal Bahamas Defense Force. In all, more than 100 emergency response personnel were involved.

The aircraft wreckage site was declared a “biohazard” area, and access to the site was restricted to essential personnel on ly . The monitoring of the site and access control was provided by the Royal Bahamas Police Force. The site was guarded from the time of the accident until the final removal of the wreckage to the secure aircraft hangar at MYNN

. The procedures imposed for working in this ty pe of environment required the AAIPU

i nvestigative team, including party members, to wear personal protective gear and or take special safety precautions while working on site and during post recovery teardown and analysis

. Flight plan fo rm filed by the pilot or his agent, listed one (1) person on board. There was mass confusion about a ninth (9 th ) person that may

have been on board the aircraft. Additional search es were conducted of the area of the crash on the second day during wreckage recovery and on the third (3 rd ) day after the accident, the 9 th occupant of the aircraft was found in

the marshes of the lake.

The following notification timeline was prepared by ATC.

*At 1635 UTC NAD was notified.

At 1637 UTC PMH was notified.

At 16 39 UTC Mr. Hubert Adderley

– Manager of Flight Standards Inspectorate was notified.

At 1640 UTC Captain Patrick Rolle Director of Civil Aviation Department was notified.

At 1650 UTC Mr. Joseph Albury Deputy Director ATC was notified.

At 1655 UTC Mr. De lvin R. Major IIC was notified by the Manager of FSI.

NAD EOC running log records indicate;

*At 12:33 hrs (1633UTC ) ATC officer manning Clearance Delivery notified NAD about the accident *At 12:35 hrs (1635 UTC) EOC was activated by EOC personnel.

*Additi onally, CAD Daily Air Traffic Record lists the aircraft crash at 1633UTC / 12:33pm local. *Discrepancies noted in the above timelines as transcript from ATC Tower controller transcript records aircraft departed at 1636UTC / 12:36pm local. However, Tower da ily record of facility operation documents time of crash at 1633 UTC / 12:33pm local. (See A ppendix 5.6 ATC Tower Transcript)Air Accident Investigation and Prevention Unit

Final Report C6

- NLH Page 34 1.16 Tests and Research

Follow up examination s and testing was conducted regarding ai rcraft systems

, operations procedures and human performance

. Cylind e

r Analysis conducted in the United States at the NTSB Metallurgy Lab in Washington DC

and Engine (L eft and Right) were analyzed at Teledyne Continental Motors (TCM) Factory in Alabama. Rep orts attached in Appendix 5.1 and Appendix 5.2.

1.16.1 #2 Cylinder Analysis :

E xamination of the No. 2 cylinder from the left engine was performed at the NTSB Materials Laboratory, located
in Washington, DC.

1.16.2 Left Engine Analysis

The left engines were examined at the manufacturer‟s facility with Bahamas oversight. See Appendix 2 Left
Engine Factual Report TCM

1.16.3 Right Engine Analysis

The right engines were examined at the manufacture r‟s facility with Bahamas oversight. See Appendix 2 Right

Engine Factual Report TCM

.

1.16.4 Human Factors Research and Analysis

Research by noted authors Klein, G., (1993) Naturalistic Decision Making: Implications for Design. Wright

- Patterson Air Force base, Ohio Crew System Ergonom ics Information Analysis Center, Klein, G., (1993) A recognition primed decision (RPD) model of rapid decision making. In Klein, G., A., Orasanu, J., Calderwood, R., and Zsambok, C.E., (Eds), Decision Making in action: Models and

Methods. Norwood, New Jersey, Ablex, p. 146, Wickens, C. D., (1984) Engineering Psychology and Human Performance. Columbus
Ohio: Charles E. Merrill, p. 97 has concluded that human factors and the pilots action o nce a decision was made, played an important role in this accident. The full context of this research as applicable to this accident is contained in Analysis section 2.11.2 the pilots decision to return.

1.16.5 Weight and Balance Scenarios

W eight and balance scenarios are as follows ;  The amount of fuel in the aircraft before the additional 60 gall on s were added is unknown

. However, pilot

listed fuel on board as 4 hours duration. At a rate of 16.5 gal per hour

, per side , for 4 hours duration, the

aircr a ft would require a total of 132 gallons of fuel. 132 gallons of fuel calculated at a weight of 6 pounds per gallon

, the weight of fue l on board was 792 pounds.

o 16.5 gal per engine, per hour x 2 engine = 33 gallon per hour total

o 33 gallon per hour x 4 hours = 132 gallons of fuel on board the aircraft

o 132 gallons of fuel x 6 pounds per gallon = 792 pounds of fuel

The empty weight of the aircraft was approximately 4

, 100 pounds. The maximum takeoff weight of the aircraft is 6,850 pounds with a maximum total pa y load of 2,750 pounds

. Payload weight was the aggregated weight of the pilots, their bags, equipment , the passengers and their bagga ge and the fuel weight.

Approximately one month after the accident the baggage and equipment recovered were weighed. The re covered luggage and other items had a total weight of 282 pounds. The fuel load was 792 pounds based on above

e stimates and pilots report of 4 hour endurance. None of the passengers were weighed immediately before the flight. However, the pathologist measu red the weight of each deceased person. The total for the 9 deceased
occupants was 2,199 pounds

.Air Accident Investigation and Prevention Unit

Final Report C6

- NLH Page 35 Weights listed below were retrieved from the coroner following examination of victims, it in no way indicates or suggests the seated position occupied by each occupant in the aircraft;

 Victim #1 NLH weight 154 25 164* 26

 Victim #2 NDS weight 280 245** 27

 Victim #3 CLF weight 340
 Victim #4 CNW weight 375
 Victim #5 CM weight 230
 Victim #6 LC weight 130
 Victim #7 DRCT weight 190
 Victim #8 CLJ weight 320
 Victi m #9 JL weight 180

Total 2199

o Passenger Weight 2

, 1 99 # + (weight provided by coroner)

o Fuel Weight 792 # +

o Baggage Weight 282# (weight of luggage that was recovered)

o Payload 3, 273 # + (max wt allowed is 2,750 pound)

o Empty weight 4,100# = (weight minus pax, fuel, luggage)

Total recovered weight on aircraft 7,373 #

Total recovered weight on aircraft 7373 #

-

o Max wt allowed for T/O 6,850# = (Maximum Gross Weight)

o Amount overweight 523 #

Center of gravity cou ld not be determined as the seat each person occupied in the aircraft is unknown, and the amount of baggage and what compartment it was placed on the aircraft is unknown. As per the center of gravity graph and envelope, once weight and balance are within l imits a plotted area should fall within the designated fore

and aft limits of the envelope up to the maximum weight limit.

The center

- of

- gravity (CG) is the point at

which an aircraft would balance if it were possible to suspend it at that point. It is th e mass center of the aircraft, or the theoretical point at which the entire weight of the

aircraft is assumed to be concentrated.

Its distance from the reference datum is determined by dividing the total moment by the total weight of the aircraft. The ce nter

- of

gravity point affects the stability of the aircraft. To ensure the aircraft is safe to fly,

the center

- of

- gravity must fall within specified limits established by the

manufacturer.

Figure 9 illustrates the center of gravi ty chart established by C essna A ircraft Company for

the Cessna 402C aircraft. When the weight of

25 Weights provided by Pathologist

26 * Pilot weight obtained from pilot last medical certificate issued 07 September, 2010

27 ** Co

- pilot weig ht obtained from co

- pilot last medical issued 11 August, 2010

Figure 9 Center of Gravity Graph / EnvelopeAir Accident Investigation and Prevention Unit

Final Report C6

- NLH Page 36 the aircraft is at or below the allowable limit(s) for its configuration (parked, ground movement, take

- off, landing, etc.) and its center of gravity is within the allowable range, and both will remain so for the duration of the flight,

the aircraft is said to be within weight and balance

.

Incorrect weight and balance in fixed

- wing aircraft

When the center of gravity or weight of an aircraft is outside the acceptable range, the aircra ft may not be able to sustain flight, or it may be impossible to maintain the aircraft in level flight in some or all circumstances. Placing the CG or weight of an aircraft outside the allowed range can lead to an unavoidable crash of the aircraft.

Center of gravity out of range

When the fore

- aft center of gravity is out of range, the aircraft may pitch uncontrollably down or up, and this tendency may exceed the control authority available to the pilot, causing a loss of control. The excessive pitch may b e apparent in all phases of flight, or only during certain phases, such as take

- off or descent. Because the burning of fuel gradually produces a loss of weight and possibly a shift in the center of gravity, it is possible for

an aircraft to take off with t he center of gravity in a position that allows full control, and yet later develop an imbalance that exceeds control authority. Calculations of center of gravity must take this into account (often part of this is calculated in advance by the manufacturer a nd incorporated into CG limits).

Center of gravity is calculated as follows:

 Determine the weights and arms of all mass within the aircraft.

 Multiply weights by arms for all mass to calculate moments.

 Add the moments of all mass together.

 Divide the tota l moment by the total weight of the aircraft to give an overall arm.

The arm that results from this calculation must be within the arm limits for the center of gravity that are dictated by the manufacturer. If it is not, weight in the aircraft must be remo ved, added (rarely), or redistributed until the center of gravity falls within the prescribed limits.

Weight out of range

Few aircraft impose a minimum weight for flight (although a minimum pilot weight is often specified), but all impose a maxi mum weight. If the maximum weight is exceeded, the aircraft may not be able to achieve or sustain controlled, level flight. Excessive take

- off weight may make it impossible to take off within available runway lengths, or it may completely prevent take

- off. Excessive weight in flight may make climbing beyond a certain altitude difficult or impossible, or it may make it impossible to maintain an altitude.

1.16.6 Flying over Gross Weight 28

“The problem with operating over maximum gross weight is more one of s tructural integrity than legality.

E ngineers rate each load

- bearing structure with a certain maximum load. In the case of airplanes, that load is expressed in terms of G‟s. In the normal category, the FAA rates aircraft as capable of withstanding G load s of 3.8 in normal operations (above which the structure may be damaged) and 5.6 maximum (beyond which the structure will likely fail). To use a simple example, a normal

- category aircraft approved for a 4,000

- pound gross weight in the normal category would have a theoretical maximum structural load

- bearing capacity of 22,400 pounds. (5.6 x 4,000 pounds). If you loaded the same airplane to 5,000 pounds gross weight, the maximum load capacity doesn‟t change, so you would reduce the G

- limit from 5.6 to only 4 .5G‟s (22,400 / 5,000).

28 Excerpt from Plane and Pilot march 2011 Edition, Bill Cox, Senior Editor.Air Accident Investigation and Prevention Unit

Final Report C6

- NLH Page 37 No pilot want to fly a damaged airplane, so the more typical limitation is the lesser one, 3.8 G‟s. Here the load limit works out to 15,200 pounds at 3.8 G‟s but the G

- limit is now down to 3.1 G‟s at the higher weight

. Another

pro blem with flying an airplane well over gross weight is that while it will still fly, flight characteristics may be severely compromised in terms of roll rate, pitch response and performance. Climb rate may be seriously reduced, and service ceiling may be equally poor. Cruise speed and range also will be reduced .”

1.16.7 Airplane Performance

Eyewitnesses ‟ statements were used to estimate the airplane ‟ s performance, flight path and altitude at impact (See figure 3 and eyewitnesses statements 1.1.4 ). The airplane ‟ s pitch angle and bank angle at impact were also

established based on eye witnesses ‟ statements (section 1.1.4 ).

1.17 Organizational and Management Information

No organizational or management information presented here as Acklins Blue Air Char ter was not an authorized or recognized Air Operator Certificate Holder certified by the Bahamas Civil Aviation Department.

1.18 Additional Information

1.18.1 A ckli ns Blue A ir Charter

Post accident investigations uncovered that Acklins Blue Company was founded in 1994 by owner and proprietor

Mr. Nelson Hanna

. Although Acklins Blue Air Charter advertised its services as a Charter company see A ppendix

5.3

, Appendix 5.4 and Appendix 5.5 ) in contravention of Bahamas Civil Aviation (Safety) Regulations (CASR 2001) Part X, Regulation 67 (1)(2) and (3) and more specifically 67 (2)(a) (See Appendix 5.13 ) Acklins Blue Air

Cha rter did not obtain the required certification to operate as a certified air operator certificate holder as required by CASR 2001 Part X, Regulation 68 ( See Appendix 5.14 ).

C6

- NLH

, a 1981 Cessna 402C aircraft serial number 402C 0458 was previously registered in the United States of

America (US) as N 68361. It was deregistered from the US registry on November 27, 2002 and registered in the Bahamas On December 05, 2002. C6

- NLH was insured by Hayward Aviation Limited under a policy issued to Acklins Blue for commercial use, on demand charter, and insured for loss or damage to aircraft, third party and passenger legal liability and pilot personal accident insurance. Policy listed aircraft maintenance contracted out to

an ent ity called Nixon Aviation. The policy lists the aircraft based at Executive Flight Support, Lynden Pindling Int‟l Airport.

Aircraft utilization listed in the previous 12 months was 400 Hours. One provision of the pol icy was that recurrent training for t he pilot was to be carried out every six (6) months. No records for the pilot were made available to verify whether this requirement for recurrent training was fulfilled by Mr. Hanna to meet the requirements of his insurance policy. The policy was executed 5 December, 2009 and was to expire 4 December, 2010. Mr. Hanna‟s flight times were listed as in excess of 12,000 hours with more than 10,000 hours on type ( 402C ).

1.18 .2 CAD Oversight of Acklins Blue Air Charter

At the time of this accident, CAD oversig ht of aviation in the Bahamas

, ( which is carried out by the Flight Standards Inspectorate (FSI) , located at Lynden Pindling International Airport ) was not conducted of Acklins Blue Air Charter (ABC) as ABC had n ot initiated or completed the certification p rocess 29 as required for an Air

29 BAHAMAS CIVIL AVIATION (SAFETY) REGULATIONS SUBPART A: GENERAL

12.001 APPLICABILITY (a) This Schedule applies to the carriage of passengers, cargo or mail for remuneration or hires by persons whose principal place of business or permanent residence is located in The Bahamas.Air Accident Investigation and Prevention Unit

Final Report C6

- NLH Page 38 Operator Certificate (AOC) holder certified under Bahamas Civil Aviation (Safety) Regulations (CASR 2001) Part X 67 and 68 ( See Appendix 5.13 and Append ix 5.14 ) and Schedule 12. 015 30

I nvestigation s uncovered that advertisements were circulated and on the internet advertizing C6

- NLH as being operated in commercial air transportation by ABC airlines , located in the Executive Flight Support terminal at

MYNN

, offering personalize air transportation services throughout the Bahamas and to destinations in Cuba, the Dominican Republic, Cayman Isles and the Turks and Caicos Islands. Regular service was also offered to Eleuthera and Harbour Island using “ properly m aintained and insured 402C aircraft which can seat up to nine

passengers. ” ( See A

ppendix 5 .3

, 5.4 and 5.5 for Acklins Blue Companies websi te information )

.

CAD / FSI mandate is surveillance of certified AOC as per CASR 2001 Schedule 12. As ABC was not an AOC

holder authorized by these regulations and schedules , no surveillance by CAD/FSI was conducted. C6

- NLH was a private aircraft owned by an individual and registered to a company named Lebocruise Air Limited which is also

not an authorized AOC holder certified under the provisions of CASR 2001 Schedule 12.

1.18.5 Performance Category

The Cessna 402C aircraft was certified for single pilo t operation within Performance Group C.

1.18.6 Emergency Procedures

The emergency procedures relating to the power loss contained within the Cessna Information Manual for the

Cessna 402C see Appendix 5.10 Engine Failure a fter Take

- off

.

1.18.7 Pre accident CAD Actions

Several months prior to this accident, the Flight Standards Inspectorate established a proactive campaign where information was shared with the daily newspaper and other media outlets. Several articles were written and the department took the message to the airwaves via talk show and media houses warning the general public about the dangers of travelling with unauthorized / uncertified persons claiming to be legal air carriers. Numerous posters

w ere strategic ally placed at Fixed Base Operations and the General Aviation Center warning about the dangers of engaging in commercial air transportation using the services of unauthorized air carriers.

The Flight Standards Inspectorate additionally, engaged the assis tance of the Airport Authority and NAD with meetings and strategic planning on ways to curb the incidence of unauthorized air charter operators. List of all authorized air charter operators were distributed to the media , Fixed Based Operators and other sta ke holders at

MYNN

. Additionally, The Flight Standards Inspectorate increased airside surveillance of areas frequented by general aviation traffic and possible area of unauthorized air charter operations.

(b) This Schedule of the regulations prescribes requirements for the original certification and continued validity of air operator certificates (AOC) issued by The Bahamas.

30 BAHAMAS CIVIL AVIATION (SAFETY) REGULATIONS SUBPART B: AIR OPERATOR CERTIFICATE

12.015 COMPLIANCE WITH AN AIR OPERATOR CERTIFICATE (a) No operator may operate an aircraft in commercial air transport unless that operator holds an AOC for the operations being conducted. (b) No person may operate an aircraft in commercial air transport operations that are not authorized by the terms and conditi ons of its AOC. (c) The AOC holder s hall, at all times, continue in compliance with the AOC terms, conditions of issuance, and maintenance requirements

in order to hold that certificate.Air Accident Investigation and Prevention Unit

Final Report C6

- NLH Page 39 1.18.8 Post Accident Recommendations / Safety Ale rts Issued

As a result of the accident involving C6

- NLH on October 5, 2010

,

1. Alert SA/A10

- 01312/001/10

- 9

- 10 was issued to Stakeholders at MYNN which includes Airport Authority, NAD, Civil Aviation Department, ATC, Odyssey Aviation, and Executive Flight S upport in reference to Incomplete Flight Plan information and Inadequate security procedures that exists at Fixed Base Operations. (See Appendix 5.9 Alert)

. Additionally, correspondence s were addressed specifically to Airport Authority , CAD and NAD outlining the i nadequate security procedures and the need f or improvement.

2. Alert SA/A10

- 01312/002/10

- 9

- 10 was issued to the Flight Standards Inspectorate addressing the need to amend its information gathering document system so that it captures information that would be useful during the investigation of accidents of Bahamas Registered aircraft ( See Appendix 5.18 ) . This was

issued as a result of the unavailability of the historical aircraft re cords for C6

- NLH

.

I t s unavailability has impacted the investigation as there is no information available to support or verify

whether the aircraft was being adequately maintained in accordance with Bahamas Civil Aviation (Safety) Regulations.

1.18.9 Po st accident Airport Authority Actions

Several p ost

- accident meetings were held between the Airport Authority and stakeholders at MYNN (Executive Flight Support and Odyssey Phoenix Aviation ) . Airport Authority reports meetings and follow up meetings wer e accomplished and progress was being made with the construction and implementation of corrective action for deficient items brought to light by recommendations put forward by the safety alert SA/A10

- 01312/10

- 9

- 10 issued by the investigation team.

As a re sult of the Alert recommendations;

 An airport security program was developed by EFS

 An airport personnel training program was developed by EFS The Airport Authority commits to monitoring the progress of the implementation of recommendations put forward by Alert for both Executive Flight Support as well as Odyssey (Phoenix Aviation).

1.18.10 Post accident CAD /FSI Actions

Post

- accident

, the Flight Standards Inspectorate has;

 Amended application for Certificate of Airworthiness to capture information tha t can establish a baseline history of Bahamas registered aircraft in the event of an accident or incident and historical information is

not available or lost. This amendment addresses issues raised in Alert SA/A10

- 01312/002 /10

- 9

- 10

.

 Increased surveillance of General Aviation Center and all Fixed Based Operators.

 Strategically placed more flyers and brochures in the media as well the General Aviation and Fixed Based Operations warning about the dangers of flying with unauthorized air carriers.

 Increased its manpower by the hiring of two (2) additional aviation safety operations inspectors.

 Increased its presence by extending its work schedule to include surveillance from 6am to 6pm, Monday to Friday and on Saturdays and all holidays.

 Increased surveillance to include other islands in the Bahamas where reports of uncertified air carriers

exist.Air Accident Investigation and Prevention Unit

Final Report C6

- NLH Page 40 1.18.11 Post accident EFS Actions

On December 10, 2010 Executive Flight Support submitted to the Airport Authority and the Nassau Airport Development Company (NAD ) a draft copy of its Security Program as well as its Personnel Training Program which outlines and accounts for deficiencies discovered during the investigation and outlined in Safety Alert issued. A copy of the program is in possession of the investigati on team and is not included in this report. The Airport Authority commits to monitoring the progress of the implementation of recommendations put forward by Alert reference Executive Flight Support.

1.18.12 Post accident NAD Actions

On November 18, 2010 NAD in its commitment to address the issues raised in Safety Alert issued to them,

advised The Flight Standard Inspectorate that it had amend ed the Civil Aviation Department Form 63A1 back to its original version as outlined in Aeronautical Information Pu blication (AIP) figure ENR 1.10.1. This amendment would once again require that all items 1

- 22 on form 63A1 is now completed by person completing form 63A1. This amendment would now required that pilots once again list all persons onboard the aircraft prio r to takeoff

– this should aid in search and rescue efforts in the event of an accident in the future.Air Accident Investigation and Prevention Unit

Final Report C6

- NLH Page 41 2.0 Analysis

2.1 Overview

2.1.1 Flight reconstruction

The paucity of 'firm' data, particularly the absence of any flight data or cockpit voice recording, frustrated efforts to reconstruct precisely the flight path and sequence of events which led up to the accident. The tower controller's communication transcription pro vided significant data to determine the timing o f key events to within a few

seconds , but apart from the white smoke observed by the tower controller and his alerting the pilot of C6

- NLH, the pilot gave no indication of a problem. The aircraft was subsequently given permission to return to the field

an d accept runway 27 if able. This instruction was acknowledged by the crew and attempts were made to return to a landing by the aircraft on runway 27. There was no radar or navigation system data with which to reconstruct the flight path and so, an approxi mation was compiled based on the recollection of numerous eyewitness reports. All reports seemed to be consistent with each other. The probable flight path is illustrated on the eyewitness statement on Figure 3 and Appendix 5.19.

The aircraft was below t he weight category for which flight recorders are required to be fitted. The investigation was thus hampered by the lack of any record of the pilots' conversation, including routine and emergency checklist actions. It is highly likely that any such record would have added greatly to the understanding of this accident. Existing airworthiness requirements for modern aircraft in this category require the carriage of both a Flight Data Recorder and a Cockpit Voice Recorder, but only if they are multiengine tu rbine powered and has a maximum approved passenger seating capacity of more than nine. The 402C , having piston engines and not more than 9 passenger carrying capability , was not obliged to meet this requirement.

The accident flight was the second flight for C6

- NLH on 5 October, 2010. There was no evidence of pre

- existing failures or malfunctions in the airplane, its components or its system. However, the client on the first charter flight

of the day on C6

- NLH reported to investigators that during the engi ne run

- up
, at the runway before take

- off , there was a serious discrepancy noted between indications o f the left and right manifold pressure needles corresponding

to the left and right engines respectively as evidenced on the manifold pressure gauge

. Being a pilot himself, the client was concerned. The difference between both indications was approximately 90 degrees. The right manifold pressure needle responded accurately and timely when the right throttle lever was manipulated to a predetermined

value , howe ver the left needle lagged behind and eventually moved and caught up to the indications of the right engine despite both throttles being operated at the same time to that specific predetermined value . This discrepancy was brought to the attention of both pilots who “shrugged it off” and said “everything is ok” and “it will match up when full power is applied.” ( See Eyewitness Evidence 1.1.4 )

The pilot in command of record was properly qualified and certificated to operate the air plane on this fli ght. The specific detail of his training history was not available to the accident investigation team. No evidence was found

that he was experiencing a behavioral or physiological impairment at the time that could have caused or

contribu ted to the accident. At the time of the accident, the winds were 100 ̊ at 6kts and visibility was 7 miles

with a forecast of a combination stationary front along with a surface trough across the northwestern and central Bahamas producing unstable weather through the forecasted period. Significant Weather section of the Bahamas Area Forecast over the central and northwest Bahamas indicated scattered to broken clouds from 1,200 feet to 1,800 feet with towering cumulus and cumulonimbus clouds. Weather however, was not a factor in t his accident.

The evidence indicates that the pilot of C6

- NLH after departing runway 14 and being notified about the white

smoke trailing behind the aircraft‟s left engine, decided to return to land at MYNN and accepted the controller‟s

offer to land on r unway 27 and did not cont inue on the appropriate flight path . The accident occurred while the pilot was making a left turn and extending his landing gear in the turn to intercept runway 27. ATC was not a

factor in the accident.Air Accident Investigation and Prevention Unit

Final Report C6

- NLH Page 42 The investigation examined pilot actions to determine how a properly trained and qualified pilot with more than 10,000 flight hours in type would allow the aircraft to turn into a n engine reported as having a discrepancy

, extend landing gear while in the turn

, turn at such a low alt itude and airspeed considering the mass and balance of the

aircraft and lose control after take

- off

.

The investigation also focused on why engine control switches for the right engine were found in the “OFF” position, whether they were intentionally or i nadverten tly switched off and if so when did it occur. The investigation also considered whether the second

- pilot 31 had a role in the decision making process that resulted in the accident. Additionally, the voice of the person that was making radio transmi ssion with ATC was not the voice of the pilot and assumed to be the second pilot.

2.1.2 Wreckage Analysis

The aircraft was in the correct configuration for flight following reports of white smoke trailing behind its left engine. It had gear and flaps ret racted initially right after becoming airborne according to eyewitness reports. The impact evidence showed excessive angles of bank and nose down pitch. This confirmed eyewitness evidence that the pil ot initiated excessive bank angles, and extended landin g gear in the turn, in an attempt to return to a landing on runway 27. The rate of descent was very high at impact which would account for the extent of damage suffered by the nose of the aircraft, nose landing gear, windshield, fuselage, right elevator an d stabilizer and right wing and

its attachments (wing tip, aileron)

.

Both fuel selector valves were found at the "OFF" position and a reason for both to be so selected is not readily apparent. It is possible that had the pilot not intentionally selected t hem to that position, it might well have been moved by airframe distortion during the crash. According to eyewitness reports, the aircraft engine continued to run for approximately 10 seconds after impact. This would indicate that the engine was producing some power at impact. It is likely that the fuel selector cables were pulled during impact and / or recovery process.

2.1.3 The Initiating E vent

The first perceived abnormal event in the sequence leading to the accident was the observation of white smoke and the abnormal sounds like an engine backfiring as reported by eyewitnesses. Also

, as reported to the aircraft by

ATC

, white smoke was observed trailing behind the left engine of the aircraft. It is reasonable to believe that both engines were producin g power, as the aircraft

, prior to being notified of white smoke trailing behind the left engine and thereafter, never reported any malfunctions or advised of a ny emergency. Provided that one engine was producing full power and the other had failed and bee n correctly identified and its propeller feathered, if properly flown, the aircraft should have been able to climb, albeit slowly, and subsequently make a safe landing

back at MYNN . Therefore, the damage within the left engine would not make an accident i nevitable. It was the

loss of thrust from the right engine

, reduced horsepower on the left engine, and extension of the landing gear in a turn, the excessive rate of bank and airspeed decay that led to the loss of control. Consequently, some of the

follow ing analysis concentrates on the probability the pilot mishandled the left engine (possible) failure and in his haste to do something he inadvertently misdiagnosed and secured the wrong engine (right operating)

.

During the post accident investigation , inv estigators observed that the left and right magneto switches of the right engine as well as the alternator switch for the right engine were found in the “OFF” position. The auxiliary fuel pumps as well as both left and right fuel selector valves located b etween the pilots‟ seats were also found in the "OFF" position. Questions arise as to whether the pilot, possibly in his haste to do something, accidentally shut off electrical power to the right engine instead of the left engine as the left engine was the one reported as “emitting white smoke .” It is not known whether the right engine was shut off intentionally or inadvertently by the pilot, and if so, when in the chain of events did this occur?

31 Co

- pilot / second ( ramp agent at EFS states there was a copilot on board C6

- NLH who loaded the lu ggage on the aircraft)Air Accident Investigation and Prevention Unit

Final Report C6

- NLH Page 43 This analysis will focus on the pilot‟s decisions and perfor mance that led to this accident. Also

, focus will be made on the left engine # 2 cylinder which showed signs of mechanical failure . Questions arise as to when this cylinder failed and what impact , if any; its failure would have on total engine performance? Was its failure enough to cause an airplane to fall from the sky or did other factors play a role in the aircraft not being able to

maintain altitude once the #2 cylinder failure occurred?

2.2 Other Factors

2.2.1 Aircraft Loading

In the context o f this accident, the precise weight of the aircraft would have been relevant to the final outcome of a single engine failure. However, post accident calculations, which included the recovered luggage, fuel on board and passengers have revealed that the ai rcraft was over the maximum weight allowed for takeoff (6,850 pounds) by more than 500 pounds. ( See 1.16.4 )

2. 2.2 Pre

- take

- off E vents

The crew carried out final preparations for the flight without much help from the gro und support staff at EFS. Apart from a ramp agent who collected and placed a box on the aircraft, the two pilots performed all the routine tasks such as preflight inspection, luggage loading and embarkation of the passengers. There were no ground

crewmen or marshaller to oversee the starting and taxiing phases and no need for either. Consequently there were

no eyewitnesses to engine starting, aircraft seating assignment or which pilot occupied which seat.

A pilot who was in line for take

- off after the C6

- NLH

, reported that the pilot took an unusually long t ime at the holding point doing the pre take

- off run up check s

. (T his may have been as a result of the previous reported abnormality with the manifold pressure indication or any other number of reasons )

.

Other eyewitnesses reported aircraft abnormalities prior to takeoff. They reported hearing noises as if the aircraft was backfiring. Eyewitnesses interviewed were not able to determine if the backfiring noises were heard when the

aircraft was on the ta ke off roll or prior to the aircraft taxiing into position for takeoff. The backfiring noises heard could have been from the pilot conducting his pre

- takeoff checks prior to taxiing into position for takeoff. These checks which the pilot habitually carried out prior to takeoff, required the speed of each propeller to be increased before the feathering mechanism was exercised momentarily, possibly more than once for each propeller, and for each propeller in turn. These checks result in the propellers slowin g down and then recovering speed over a period of two or three seconds.

The main change in perceived noise results not from the change in rotational speed, but from the changes in propeller blade angle which provoke the changes in rotational speed. The se checks are unlikely to result in misfiring but the magneto test that follows may cause changes in the sound of a smooth running engine

. Each engine has two magnetos (spark generators) and each cylinder has two spark plugs. During the engine checks one magneto is temporarily isolated to assess the engine‟s ability to run on the other ignition system. Occasionally one or more of a set of spark plugs may be contaminated which results in some rough running which is not evident when running on both magnetos . The discrepancy c an often be cleared by increasing engine RPM or temporarily leaning the fuel to air ratio of the engine mixture, which may provoke some misfiring for a few

seconds.

As eyewitness location on the field could not be determined when the m isfiring noise was heard and other eyewitness close to the point of lift off of the aircraft not reporting any misfiring noise or abnormalities other then observing the white smoke , it seems likely that any engine malfunction noises were temporary and asso ciated with pre

- takeoff engine checks or spark plug contamination.Air Accident Investigation and Prevention Unit

Final Report C6

- NLH Page 44 2.2.3 Flap P osition

Whether the aircraft became airborne with the wing flaps retracted or at the take

- off position could not be positively determined . However, p ost impact observation n oted the flaps were flush with the trailing edge of the left and right wing respectively. The principal factors relevant to the choice of flap setting are runway length,

take

- off weight and obstacles in the departure direction. The aircraft has a shorter take

- off ground roll with flaps extended but if the flaps are up for take

- off , the engine failure procedure during initial climb is much simplified and the one engine inoperative climb performance is improved.

Runway 14 at Lynden Pindling International Airport is far longer that the predicted lengths required by a Cessna

402C at maximum take

- off weight

, to accelerate to take

- off speed and then decelerate to a stop on the runway. Consequently, take

- off with the flaps retracted would not have contributed to the accident sequence. However,

take

- off with the flaps extended co uld have complicat ed the engine fa ilure procedure if the power loss had occurred before the flaps were raised at the customary height because of the extra drag associated with flap depl oyment.

2.3 Event Timing

It is reasonable to assume that with other aircraft behind him waiting to depart, the pilot would have commenced

his take

- off as soon as ATC clearance to do so had been acknowledged by the second pilot. There was a slight delay from the time the aircraft was cleare d for take

- off until the time it actually departed. The aircraft became

airborne and then flew in a normal take

- off configuration

, and then at rotation

, more white smoke was observed trailing behind the left engine. T here was a brief period of climbing f light followed by a gradual bank to the left,

which turned into a steep almost perpendicular bank followed by a steep nose down descent into the lake as control was lost. The aircraft was airborne for approximately 90 s econds, during which time the pilot acknowledged the white smoke and accepted runway 27 for a return.

2.4 Before the Initiating E vent

2.4.1 The T ake

- off.

According to eyewitnesses and the ATC controller, the aircraft made a normal take

- off run whe re white smoke

was observed from the initiation of the run. The

aircraft was cleared for take

- off from intersection Foxtrot of runway 14.

The aircraft's ground roll started approximately 2,000 beyond the threshold of runway 14

, (Intersection Foxtrot ) and it became airborne either just after Intersection B ravo 1 or just about or after the intersection of runway 32/14 and runway 27/09 ( See Appendix 5.15 

### and Appendix

5.19 Airport Layout MYNN)

. Just after becoming

airbo rne the landing gear were retracted as in a

normal take

- off

.

The runway distance from the line

- up position (Intersection Foxtrot) to the intersection where the

aircraft became airborne (Intersection Bravo 1) was approximately 7,000 feet. The normal ta ke

- off distance performance data in the Cessna Information Manual

, both engines operating ( Figure 10 ) was interpolated to get a base line estimate of how much runway was required for the take

- off , using the maximum weight allowed on the

aircraft at take

- of

f of 6,850 pounds and to clear a 50 ft obstacle

. F igure 10 Normal Take

- off DistanceAir Accident Investigation and Prevention Unit

Final Report C6

- NLH Page 45 The performance data with conditions; wing flaps retracted, weight of 6,850 pounds, take

- off to clear 50 ft.

obstacle indicated airspeed of 95KIAS a pressure altitude of sea level and temperature 30  C(86  F), was used in this computation (temperature for the day and around the time of the accident was 81  F)

.

Using these figures conservatively the ground roll for the aircraft should have been approximately 2,040 feet and

if there was a 50 ft. obstacle that needed to be cleared

, the ground roll of approximately 2,560 feet would be

needed to clear that obstacle. These distances are determined using a new aircraft flown by a manufacture's test pilot. The measured take

- off is performed from a stationary start w ith wheel brakes on and full rated power on both engines. This method is often impractical at a busy airport and unnecessary at airports with long runways. Furthermore, the reliability of piston engines such as that fitted to this aircraft, benefit from g entle changes in power and such gentle changes can add as much as 100 feet or more to the take

- off run.

If a nominal increase of 100 feet for gentle power application is added to the Cessna Manual figures, the take

- off ground roll should have been in the region of 2,140 feet ( with the 50 ft. obstacle clearance ground roll, will use
2,8 00 ft. conservatively) . The difference between the calculated and reported ground roll distance is in excess of 4,000 feet which is significant. Nevertheless, where runway l ength is not a limiting factor, it would be reasonable for the pilot deliberately to remain on the runway whilst accelerating from the recommended safe single engine speed of 95 KIAS to the one engine best rate of climb speed of 104 KIAS. The distance tra velled during this acceleration could have been consistent with the extra 4,000 feet. Low engine power is an alternative explanation for the increased ground roll but it would have had to be a near symmetric loss of power for the pilot not to have

noticed it. The discrepancy reported with differential in manifold pressure readings could also be an explanation as to the extended runway use. An alternate explanation might be that the pilot deliberately chose not to use full power for the take

- off given the le ngth of the runway. However, this would have been inconsistent with operating practices therefore a deferred rotation at 104 KIAS seems the more likely explanation given the manifold pressure reading and amount of passengers and weight that may have been l oaded on the aircraft.

Whatever the reason for the prolonged ground roll, C6

- NLH became airborne from MYNN and the controller

who saw the white smoke as the aircraft climbed out advised the aircraft and asked him to return and gave him the option of runw ay 27. Had there been a malfunction on the runway or immediately after lift

- off, and whilst the landing gear was still extended and had the full length of the runway been utilized, the pilot could have adopted

the action recommended in the Cessna Manual w hich was to close both throttles and land straight ahead on the remaining runway length. Therefore, it seems probable that both engines were operating normally during the

take

- off ground roll. The pilot did not declare an emergency. If he had perceived a n engine failure, he might have said so because this would have provided the air traffic controller with important information. Since he did not specifically mention an engine failure, it is possible that he was unsure which engine was malfunctioning,

par ticularly as the left engine must have been producing some power or else the aircraft could not have climbed.

2.4.2 The Initial C limb

Assuming the pilot became airborne at 108KIAS with the flaps retracted; his subsequent action would have been

to raise the landing gear. He probably intended to accelerate to 120KIAS before reducing engine power to the recommended cruise climb setting. It is possible that the act of reducing power provoked a malfunction in the left engine and hence the failure of the nu mber 2 cylinder a nd that a symptom of that malfunction could also be the backfiring heard by the eyewitnesses.

2.5 The Initiating E vent

2.5.1 The position of the aircraft when the misfiring was heard.

The eyewitnesses were uncertain precisely where t he misfiring had occurred but had it not been during the pre

takeoff checks, it may have been somewhere after takeoff and prior to the decision to return for a landing.Air Accident Investigation and Prevention Unit

Final Report C6

- NLH Page 46 None of the eyewitness on the ground reported seeing any flames or separated component s from either engine so there was no evidence, apart from post accident examination of the engines, to indicate the source of the failure and engine noise. The examination found no faults within the right engine but mechanical failure of the number 2 cyli nder of the left engine. Thus it is possible that the misfiring or noise heard by the eyewitnesses and possibly the crew, if they did in fact hear it, or felt the loss of thrust came from the left engine but sounded or felt like it came from the right eng ine hence the decision to secure the right engine and not the left.

Another possible explanation for the misfiring could be weather related. For instance, the aircraft had recently returned from a charter to Treasure Cay where they were unable to land due to the intense weather and rain

. Water may have made its way into the fuel tank during this time or possibly during or after refueling. Although the pilot‟s standard preflight checks include a fuel check and the draining of any water from the tanks, the re was no way of knowing if the crew had drained any water from the tank sump s

. If they had not, a small quantity of water could have entered the fuel lines during taxiing or takeoff and made its way to the engine. Once in the injector lines, it could have cause a temporary interruption in power followed by misfiring or a bang from the exhaust as engine power is restored. No inference that this happened is intended. It is simply a plausible explanation and there might be other reasons for a temporary malf unction or misfiring noises heard.

2.6 Practical engine failure identification

In a twin engine light aircraft the generally accepted method of determining which engine has lost power is by rudder foot loads and displacement. In the event of one engine losing power, the aircraft tends to turn towards the failing engine and this undesired yaw must be corrected by applying rudder, which pilots learn to apply instinctively. If one of the Cessna 402 engines were to lose all its power immediately after take

- off, the rudder foot load would be heavy and the displacement significant it is difficult to mistake which foot is applying load to the rudder pedal. Once this action has been taken, pilots use a simple phrase such as „dead foot, dead engine‟ to identify the defective engine. Consequently, if an engine were suddenly to lose all its power output, there would be no need to look at the engine instrumentation to determine which engine has failed. Once the defective engine has been identified, the pilot shoul d complete the appropriate actions listed in the Cessna Information Manual. An engine failure during takeoff is the most critical time for a failure and the procedure is complex. The vital actions must be carried out swiftly and recalled from memory.

Th e pilot did not declare an emergency with ATC. If he had perceived an engine failure he might have said so because would have provided the air traffic controller with important information. Since he did not specifically mention an engine failure, it is po ssible that he was unsure which engine was malfunctioning, particularly as the left engine must have been producing some power after the misfiring noises were heard or else the aircraft could

not have climbed.

2.7 Events between the initiating event and t he left turn

2.7.1 Control of Bank Angle

As the Cessna Information Manual states, straight flight on the power of one engine is best achieved by banking 5 ̊ towards the engine under power. This bank angle would barely be noticeable to eyewitnesses so it was not possible to determine whether the p ilot adopted this procedure (if he did in fact have an engine failure). However, given his experience and qualification, the pilot would certainly have known of its relevance to his predicament as well as the requirement not to use too much bank in either direction. In this context, 10 ̊ of bank would be too much for straight flight and more than 30 ̊ bank would have been excessive for a deliberate turn.

2.7.2 Climb Performance

E yewitnesses were generally consistent in their statements that the aircraft was still climbing after it had passed over the perimeter road towards the lake until just before it increased its bank to the left, while extending itsAir Accident Investigation and Prevention Unit

Final Report C6

- NLH Page 47 landing gear. Some eyewitnesses estimated the aircrafts height at the start of the turn as about 150 to 300 feet

. However, if the eyewitnesses‟ estimates are reasonable, the aircraft must have climbed between 100 and 300 feet between the runway and the start of the turn. Consequently, for the aircraft to have continued climbing after crossing the road as many witness reported, the left engine must have been producing some useful power. In simple terms, the loss of power on the left engine, if there was one, must have been more progressive than sudden.

2. 8 Condition of t he engine in flight

2.8.1 Right E ngine

No mechanical evidence was found regarding a malfunction of the right engine. The probability that a subtle discrepancy would occur coincident with the discrepancy suffered by the left engine is highly unlikely

. Corroborating evidence that the pil ot may have perceived a discrepancy within the right engine was found within the wreckage. Both fuel selectors were found in the “OFF” position. Assuming the pilot became airborne with each selector in its respective position (left selector valve to left engine and right selector valve to right engine) , if he moved it, the only reason for him to do so would be if he thought a discrepancy with the left engine might be related to its fuel supply consequently turning the left selector to the off position inst ead of the right engine position (or cross

- feed position). In his haste

, he may have inadvertently also turn the right selector valve to the

“OFF” position when trying to secure what he may have later perceived to be a discrepancy with the right engine

ins tead. He therefore may have inadvertently secured the right engine as b oth left and right magneto s witches of the right engine were found in the “OFF” position. Alternator switch for the right engin e as well as the Battery

switch was found in the “OFF” pos ition. Auxiliary fuel pump switch for the right engine was also found in the “OFF” position.

2.8.2 Operating the wrong propeller lever

Usually the first three actions for shutting down a reciprocating engine are to close the throttle, select the RPM

lev er to feather and select the mixture to cut

- off. On some aircraft types this involves retarding three of the six engine control levers, working from left to right, retarding alternate levers. However the engine securing procedure in the Cessna Informatio n Manual is slightly different; it states the order as throttle, mixture and then propeller lever. (See Appendix 5.10)

. The difference in the order is unlikely to be significant provided that the pilot operates the leve r swiftly, but it is a complication that slightly increases the probability of operating the wrong lever.

The possibility that the pilot intended to shut down the left engine but operated the right engine levers and control switches by mistake was conside red. If the pilot had accidentally moved the wrong lever, it seems likely that he would have noticed his mistake in time to reverse his action. He would have heard the change in propeller noise and experienced a yaw to the right. The only contra

- indicatio n to this assumption would be the rudder deflection and perhaps the engine instruments. The confirmatory signs for his assumption would have been the power fluctuations from the right engine. A situation where one engine‟s power is fluctuating may be diff icult to resolve for two reasons; firstly the propeller governor tends to keep the propeller RPM constant; and secondly, when both engines have similar manifold pressures, one needle is masked by the other which overlays it. If the fluctuations are rapid, the pilot may be unable to read the „L‟ and „R‟ symbols on each needle of the twin

- needle engine

instruments. ( See Appendix 5.17 )

2.9 Events during the T urn

To some witnesses the aircraft appeared to maintain height for a few seconds during the early part of the turn before it began to descend: to others it had started to descend shortly before the turn began. Whichever recollection is correct, the aircraft had obviously stopped climbing. Moreover, the high nose attit ude in the turn reported by some eyewitnesses would have been inconsistent with sustained flight on one engine.Air Accident Investigation and Prevention Unit

Final Report C6

- NLH Page 48 The landing gear was extended during the turn and the bank angle of the aircraft was almost perpendicular to the ground as reported by some eye witnesses ‟. An attempted turn towards the airfield was also bound to reduce the aircraft‟s climb performa nce. Somewhere between the time the aircraft departed and the time it crashed the right engine was secured. If the pilot had fully realized his predic ament, at that moment he had only two choices: either a forced landing in the lake straight ahead or a gliding turn back to the airport. Even if he was as high as 500 feet, (and none of the eyewitnesses thought it was that high) given his distance and loc ation from the runway, a gliding

return was an unrealistic choice. The eyewitness reports of a rapid increase in bank angle and the aircraft‟s nose pitching into a steep descent are consistent with total loss of control. Moreover, there can be little doubt that the aircraft stalled; the stall speed in level flight was in the order of 80 KIAS but any attempt to turn tightly was likely to increase the stall speed and lead to an abrupt loss of control. The observation of the eyewitnesses when used to

calculat e the aircraft‟s height, equated it to a maximum height of approximately 100 to 300 feet above the ground. Once it had stalled at that height and without power, a crash was inevitable. The rate of descent was high and penetrating the water of the lake did much to disrupt the structural integrity of the airframe. The evidence does not indicate which engine failed (if any), but it does indicate the importance of ascertaining when the pilot secured the right engine.

2. 9.1 Loss of Control

Eyewitnesses‟ r eports of a rapid increase in bank angle and the aircraft‟s nose pitching into a steep descent are consistent with total loss of control. Moreover, there can be little doubt that the aircraft stalled; the stall speed in level flight is in the order of 80K IAS but a n y attempt to turn t ightly was likely to increase the stall speed and lead to an abrupt loss of control. Eyewitnesses‟ accounts states that the aircraft was approximately 150 to 200 feet and in some estimation as high as 300 feet above the ground. Once it had stalled at that height and without sufficient power a crash was inevitable. The extension of landing gear during this tight turn only further helps to increase

the inevitable loss of control.

2.10 The loss of power from the left engine

The left engine had suffered a major mechanical failure with the number 2 cylinder and much of the effort in the engineering investigation was devoted to understanding what had led to that failure. There was evidence of pre

existing wear. The existence of fa tigue displayed long term wear characteristics but no short term traumatic damage. A summary of left and right engine analysis follows and a full description of the engineering results contained in engineering reports app endix 5.1 and 5.2

.

2.10.1 Summary of left and right Engine Analysis

On October 6, 2010 C6

- NLH was recovered from the waters of Lake Killarney. Both engines remained attached to the fuselage. The wreckage was stored under quarantine at a hanger at Lynden Pindling International Airport, Nassau, Bahamas. Both engines were removed from the fuselage and photographed in their recovery state. Both engines were prepared for shipping to TCM for a detailed examination prior to being placed in shipping

containers. Prior to shipping the left engine, the No. 2 cylinder assembly and piston were removed, photographed and transported by hand to the NTSB Materials Laboratory, Washington DC, for a detailed examination. The No. 2 cylinder, serial number 30213

- 3, had separated into two parts between the fourth and fifth fin from the barrel end, the lower part remaining attached to the barrel. And later research of the stamps, etching and other identifying marks established the original cylinder manufacturer as Engine Components Inc. (EC i ), a division of Danbury Aerospace, both of San Antonio, Texas. The Right Engine was identified as TCM TSIO

- 520

- VB Serial Number 290209 and Left Engine as TCM TSIO

- 52 0

- VB serial Number 248270.

On October 9, 2011 preliminary inspections of both engines was accomplished by representatives of Teledyne Continental Motors at Lynden Pindling International Airport, Nassau, Bahamas. Additional photographs were taken evidencing the condition of the engines. Both engines were prepared for shippin g prior to being placed in shipping containers.Air Accident Investigation and Prevention Unit

Final Report C6

- NLH Page 49 T he Left Hand Engine No. 2 cylinder had separated into two parts between the fourth and fifth fin from the barrel end; the upper major portion of the cylinder head and the lower portion which remained attached to the barrel. Additional photographs were take n of the stamps, etching and other identifying markings and forwarded to the NTSB. The research of the stamps, etching and other identifying markings established the manufacturer of the cylinder as EC i

. EC i was notified of the accident and copies of the st amps, etching and other identi fying markings was provided. EC i completed its research of the stamps, etching and other identifying markings and supplied the historical data on the birth and history of Cylinder Serial Number 30213

- 3.

On October 18, 2010, the No. 2 cylinder assembly of the left engine was examined by personnel from the National Transportation Safety Board (NTSB) Materials Laboratory, ECi (cylinder manufacturer) and the Bahamas Civil Aviation Department.

2.10.2 Left Hand Engine No. 2 Cylin der Analysis

The Details below was taken from the NTSB MATERIALS LABORATORY FACTUAL REPORT.

Preliminary examination of the fracture faces revealed that they were partially covered by a combustion product.



### The fracture faces are illustrated in Figure 2 with the head portions, the barrel, the piston, the exhaust

valve and the intake valve identified

. Examination of the fracture faces revealed two zones displaying different surface textures, one located predominantly on the exhaust side of the cylinder head. The zone within the purple dashed line was relatively smooth and the zone outside of the dashed line displayed a rough uniformly grainy surface. The purple arrows in Figure 2 indicate distinct crack arrest marks that

were located within the smooth zone, consistent with fatigue.

The yellow arrow indicates a slightly darker arced area within the smooth zone and the blue arrows indicate radial lines that appeared to emanate from where the ends of the arced area abutted the crest of

the barrel thread.

The fracture face around the smooth zone on the lower portion of the cylinder head was solvent cleaned and is illustrated in Figure 3 with the smooth zone contained within the purple dashed line. The cleaning revealed the darker arced area indicated by t he yellow arrow which matched the darker arced area indicated by the yellow arrow in Figure 2 and is illustrated later in Figure 4. Examination of the smooth zone revealed that the fracture was relatively flat and oriented perpendic ular to the axis of the barrel; features also consistent with fatigue.Air Accident Investigation and Prevention Unit

Final Report C6

- NLH Page 50 

### Samples were removed from the cylinder head and the barrel for

detailed examination and their

sectional views are illustrated later in Figure 13. The purple dashed lines in Figure 3 indicat e the location of a lower cylinder head sample identified as “LH” and a mating barrel sample

identified as “B”. The white dashed line on the opposite side of the cylinder head in Figure 3 indicates a cut that was made in order to separate the lower head p ortion from the barrel so that sample “H”, indicated by the yellow dashed lines, could be removed. A mating sample of the upper cylinder head, identified as “UH”, was also removed and is indicated by the red dashed line in Figure 2.

The darker arced are a indicated by the yellow arrow in Figure 3 displayed a relatively smooth fracture

face that abutted the crest of the first thread on the barrel. The fractured face displayed arced crack arrest marks and ratchet marks15 consistent with fatigue. The darke r arced area is illustrated in Figure 4 with the barrel and the lower cylinder head portion identified. The red dashed line indicates a distinct termination of the darker area consistent with the engine not being operated for a significant time resulting in a cessation of crack propagation. The purple arrows indicate crack arrest marks within the darker area and outside of it. The red arrows indicate ratchet marks, within the darker area, that originate in the root of the cylinder head thread engaged wit h the first thread on the barrel.Air Accident Investigation and Prevention Unit

Final Report C6

- NLH Page 51 

### The yellow arrows indicate ratchet marks, outside of the darker area, that also originate in the root of the cylinder head thread engaged with the first thread on the barrel. The blue arrows indicate ratchet marks

simil arly indicated by the blue arrows in Figure 2. The green arrows indicate residual anti

- seize compound.

The locations of the identifications previously observed on the upper cylinder head portion are illustrated in Figures 5, 6 and 7.

Figure 5. Side vi ew of the upper head portion. Figure 5 is a side view with the intake port, the rocker cover and the rocker gasket identified. The “up” direction, as installed,

is also indicated. The white arrow indicates the serial number, 30213

- 3,

consistent with the August 2008 cylinder history and the yellow arrow in dicates the bell profile, consistent with the cylinder being the “FREEDOMTM” brand.

The left image in Figure

6 is a closer view of the rocker flange in the area indicated by the green arrow in Figure 5. The green arrow indicates the

serial number 47932

- 06,

consistent with the August 2006 cylinder history, and the white

arrow indicates the cylinder head casting revision letter, “F”.

Examination of the rocker cover revealed that it was attached to the cylinder head by two screws that were found

to be loose, consistent with the rocker cover being previously removed. The rocker cover displayed the SAP16 logo, indicated by the red arrow in the right image in Figure 6, and the word “Millennium”, indicated by the white arrow in the right image. These S AP components are consistent with them being transferre d from the SAP cylinder this EC i cylinder replaced, as indicated by the January 2010 cylinder history.Air Accident Investigation and Prevention Unit

Final Report C6

- NLH Page 52 Figure 7. The rocker space in the upper portion of the cylinder

head. The identifications previ ously observed in the rocker space are illustrated in Figure 7

wit h a red arrow indicating the EC i logo, a purple arrow indicating the casting part number, a green arrow indicating the casting revision letter and a blue arrow indicating the Oberdorfer trap ezium. The

black arrow indicates the overhaul number

41525

- 2, consistent with the January 2010 cylinder history. The yellow arrow

indicates a location on the intake valve retainer that displayed the identifications

“SA35971” and “FAA

- PMA”, consistent

wit h it being an SAP product.

As the August 2008 cylinder history

indicated that th e cylinder was overhauled

b y EC i and sold as a complete assembly, which included AEC valve assemblies, and the January 2010 cylinder history indicated that the cylinder over haul included a valve

and valve seat re

- cut, not a valve assembly replacement, the valve assemblies were

removed and examined for identifications.

Examination of the valve assembly components located p/n SA5399885 on the intake valve, p/n SA35971 on the intake retainer, p/n SA6438734A on the exhaust valve, p/n SA629117

- 1

- E on the rotator and p/n SA652984D on the intake and exhaust rocker shafts, part numbers consistent with them being SAP products. No records wer e found to indicate when the EC i va lve assembly was replaced by the SAP valve assembly.Air Accident Investigation and Prevention Unit

Final Report C6

- NLH Page 53 Figure 8. Valve gear removed from the cylinder head and the piston extracted from the barrel. The valve assembly components are illustrated and identified in Figure 8 with the pisto n, extracted from the barrel, and the piston pin, extracted from the piston. Removing combustion product from the crown of the piston revealed the part number 654840C, consistent with it being the appropriate TCM piston for the TCM

model TSIO

- 520 engine a nd agreeing with the inserted number on the Airmark parts list in the January 2010 cylinder history.

The disassembly process revealed a significant, tan colored deposit in the cylinder ports and on the valves reminiscent of soil. Such a deposit would not be present during normal operation but would be consistent with lake bed material being carried into engine cavities resulting from the aircraft impacting the lake bed. A sample of the deposit at the location indicated by the yellow arrow in Figure 8 was taken for the analysis

detailed later.

Examination of the cylinder head included the injector indicated and identified in Figure 1. The injector is illustrated in Figure 9 with the outer fitting removed to reveal the inner fitting. The

inner a nd outer o

- rings are indicated and a blue arrow indicates a mostly tan colored soil

- like deposit between the o

- rings. The inner fitting was removed from the cylinder head and an examination revealed three mostly obscured holes

in the reduced diameter betw een the o

- rings. One side of the inner fitting displayed a partially clear hole and is illustrated in Figure 10 with the inner

and outer o

- rings identified. 

### Figure 9. The injector assembly partially disassembled.Air Accident Investigation and Prevention Unit

Final Report C6

- NLH Page 54 Blue arrows indicate the deposit and a black arrow indicates a partially clear hole. The opposi te side of the inner fitting displayed two mostly obscured holes and is illustrated in Figure 11 with the inner

and outer o

- rings identified. Blue arrows indicate the deposit and black arrows indicate the two mostly obscured holes. Examination of the cen tral hole in the inner fitting revealed that it was clear of any obstruction. A sample of the deposit was taken for analysis and comparison with the sample removed from the intake valve, indicated by the yellow arrow in Figure 8. Removal of the sample

re vealed that there were 8 holes (four pair) in the inner fitting, suggesting that the cylinder would require eight holes to be operational and would not be functional with a majority of the injector holes obstructed. The presence of the soil

- like deposit wo uld also be consistent with being post impact and originating on the lake bed



### .

Details of Sample examination and testing available in attached section “ NTSB MATERIALS LABORATORY

FACTUAL REPORT ”.

On January 18, 2011 both engine s were examined at TCM, 2039 Broad Street Mobile, Alabama. The examination
of the left engine was witnessed by representatives of TCM, Bahamas CAD, Danbury Aerospace, Airmotive
Engineering Corporation, and Superior Air Pa rts, while the examination of the right engine was witnessed by personnel from TCM and Bahamas CAD.”Air Accident Investigation and Prevention Unit

Final Report C6

- NLH Page 55 2.10.3 Left Engine Serial Number 248270 Analysis

The engine exhibited impact damage, concentrated at the bottom components of the engine . The number 2 cylinder head and barrel were separated both by a fracture surface and the threaded junction. The maintenance history of the engine was unknown due to the records not being available.

Component Observation

Starter The starter rotated b y hand and was intact.

Starter Adapter The starter adapter could not be rotated by hand. The assembly was intact and the

scavenge pump gears and housing were intact and undamaged. The crankshaft to camshaft timing was verified by the alignment of the ge ar‟s timing marks. Ignition Harness All leads were frayed or damaged shielding and exhibited normal operating signatures.

L/H Magneto The left

- hand magneto cannot be turned through by hand. 12

- 23

- 08 Overhaul date. The

unit was disassembled and found to be intact and contain corrosion.

R/H Magneto The right

- hand magneto turned with associated binding. 12

- 23

- 08 Overhaul date. The unit

was disassembled and found to be intact and contain corrosion.

Oil Cooler The oil cooler was intact and exhibited corr osion and impact damage signatures. Drake air

overhaul. Additional numbers: 11

- 30

- 07, 445128, C

- 15387, 30449A, J07

- 6486

- 9.

Oil Pump The oil pump drive was intact. The oil pump cavity contained light scratches and exhibited

normal operating signatures. The oil pump gear teeth exhibited normal operating signatures. The oil pressure relief valve and seat contained no obstructions and exhibited signatures of proper seating.

Oil Filter The oil filter was intact and was not opened.

Throttle and Fuel

Control Assembly The unit exhibits corrosion and the levers were immovable by hand. Finger screen

removed and no material was present. The unit was disassembled and there was corrosion present. The internal components were found to be intact and seating proper ly. The passages where open and unrestricted.

Fuel Pump The fuel pump turned by hand, but with substantial resistance. The fuel pump drive was

intact and undamaged. The fuel pump was disassembled to examine the internal components. The internal componen ts were intact but exhibited a corrosive material.

Fuel Manifold

Valve The fuel manifold valve exhibited normal operating signatures. The manifold valve was

disassembled to examine the internal components. A jell material covered a portion of the

screen . The manifold valve plunger assembly was intact, secure and undamaged. There were no signatures of fuel stains or leakage in the vent chamber side of the diaphragm.

Fuel Nozzles and

Lines The number 2 fuel nozzle was not returned with the engine or cyl inder. The fuel nozzles 1,

3 and 6 were restricted the remaining were unrestricted and exhibited normal operating signatures. The fuel lines were intact and undamaged.

Spark Plugs The number 2 cylinder sparkplugs were returned with the cylinder and were intact. The

sparkplugs contained corrosion and combustion by

- products. The spark plugs had normal wear signatures in accordance with the Champion aviation check

- a

- plug comparison chart.

Component Observation

Alternator The alternator turned through b y hand and was intact. The drive coupling was intact and

undamaged.

Oil Sump The oil sump drain plug was not safe tied. The oil sump exhibited impact damage and was

crushed. The oil sump was drained of oil and the amount was residual. The sump contained

f oreign material.

Oil Pick

- up Tube &

Screen The oil pick

- up tube exhibited impact damage. The oil suction screen was unrestricted.

Induction System The induction risers and balance tube exhibited impact damage and corrosion. Cylinder #1 The spot putty was not evident on the cylinder hold

- down nuts. The cylinder combustionAir Accident Investigation and Prevention Unit

Final Report C6

- NLH Page 56 Cylinder #3 Cylin der #4 Cylinder #5 Cylinder #6 chamber contained combustion and corrosive deposits. The cylinder bore was intact and

corroded. The cylinder skirt was intact and undamag ed. The intake and exhaust valve heads exhibited normal deposits and operating signatures. The rocker box area had an oil residue indicating lubrication to the overhead. The cylinder overhead components (valves, rocker arms, guides, springs, retainers and shafts) were lubricated and undamaged.

Cylinder #2 The number 2 cylinder was received separately from the engine. The cylinder head and

barrel were separated both by a fracture surface and the threaded junction. Sections had been removed from the cylinde r head and barrel by the NTSB Laboratory. The fracture surfaces were examined by the TCM and NTSB Metallurgical Laboratories. The intake and exhaust valve heads exhibited normal deposits and operating signatures. The cylinder overhead components (valves, rocker arms, guides, springs, retainers and shafts) were lubricated and undamaged. Head markings

– AEC65385, 010, 020, 41525.2, 143071, G842G, 47932

- 06
No. 1, 3, 4, 5, & 6 Piston, Rings and

Pin The piston head exhibited a normal amount of combustion dep osits. These deposits had an

appearance of exposure to moisture. The piston skirt was free of scoring and damage. The piston rings were intact, free in their grooves, exhibited normal wear and operating signatures. The piston pin and plug assembly was in tact and undamaged.

#2 Piston, Rings

and Pin The piston was received separate from the engine. The piston head had been partially

cleaned. The piston skirt was free of scoring and damage. The piston rings were not installed. The piston pin and plug asse mbly was intact and undamaged.

Lifter

Intake & Exhaust The lifter faces were undamaged and exhibited normal operating signatures. The lifter

bodies were undamaged and exhibited normal operating signatures.

Crankshaft The crankshaft and counterweight ass embly was intact. The connecting rod journals, main

journals and thrust surfaces were undamaged and showed no signs of abnormal wear or lubrication distress. The crankshaft counterweight pins, plates and snap

- rings were intact. The counterweights were un damaged and had free and unrestricted movement on the hanger blades. The gear bolts were tight and safe tied and the gear teeth were undamaged. The oil transfer passages were open and unrestricted. Alternator drive face gear teeth were

intact and undama ged. The oil transfer collar was intact and undamaged. The oil transfer plug was tight and in position.

Component Observation

#1 Main Bearings The #1 (rear) crankshaft main bearings exhibited normal operating and lubrication

signatures. The bearings w ere intact and exhibited an insignificant amount of contamination and hard particle passage. There were no signs of lubrication distress.

#2 Main Bearings The #2 (intermediate) crankshaft main bearings exhibited fretting at their mating surfaces.

The bear ings were intact and exhibited an insignificant amount of contamination and hard particle passage. There were no signs of lubrication distress.

#3 Main Bearings The #3 (intermediate) crankshaft main bearings exhibited normal operating and lubrication

sign atures. The bearings were intact and exhibited an insignificant amount of contamination and hard particle passage. There were no signs of lubrication distress.

#4 Main Bearings The #4 (intermediate) crankshaft main bearings exhibited normal operating and lubrication

signatures. The bearings were intact and exhibited an insignificant amount of contamination and hard particle passage. There were no signs of lubrication distress.

#5 Main Bearings The #5 (front) crankshaft main bearings exhibited normal opera ting and lubrication

signatures. The bearings were intact and exhibited an insignificant amount of contamination and hard particle passage. There were no signs of lubrication distress.

No. 1, 2, 3, 4, 5 & 6 Connecting Rod The connecting rod assembly was i ntact and undamaged. The connecting rod nuts and

bolts were intact and secure. The connecting rod bushing exhibited normal operating and lubrication signatures.
No. 1, 2, 3, 4, 5 & 6 The connecting rod bearing exhibited normal op erating and lubrication signatures. TheAir Accident Investigation and Prevention Unit

Final Report C6

- NLH Page 57 Connecting Rod Bearings connecting rod bearings were intact and exhibited an insignificant amount of contamination

and hard particle passage. There were no signs of lubrication distress.

Camshaft The camshaft lobes exhibited normal operati ng signatures. The camshaft gear was intact

and exhibited normal operating signatures. The gear bolts were tight and safe tied and the gear teeth were undamaged. Work order numbers: DSC11052

- 1, DSI9081

- 6.

Crankcase The crankcase was intact. An epoxy mate rial was present at the number 8 and 9 backbone

(lifting eye) bolt bores. The cylinder bays were intact and undamaged. The number 2 main bearing support mating surfaces exhibited rough surfaces from fretting. The right

- hand number 2 main bearing support lock

- slot was elongated, indicating bearing shift. The remaining main bearing support mating surfaces were intact and exhibited no signs of fretting or bearing tang lock

- slot elongation. The main bearing support diameters were intact. The oil galleys an d passages in the left and right crankcase halves were intact, clear

and unrestricted.

Accessory Gears The accessory gears had continuity. The teeth were undamaged and exhibited normal

operating signatures.

Component Observation

Turbocharger The turbo charger could not be rotated by hand. The turbine housing exhibited damage to

the tailpipe flange. They were no signs of turbine housing crack or leaks. The turbine blades were intact. The center housing oil inlet and outlet fittings were intact and there were no signatures of oil leakage. The center housing was intact and there were no cracks or exhaust leaks present. The compressor housing was intact and there were no cracks present. The compressor housing was attached securely to the center housing. The compressor blades were intact and they exhibited minimal erosion signatures. Debris was present in the compressor wheel.

Controller The controller exhibits corrosion and the lever was immovable by hand. The lever was

intact and secure.

Overboost Valve The overboost valve was intact and exhibited debris in its openings.

Wastegate The wastegate (exhaust by

- pass) valve was in the full open position and the linkage was

intact. The wastegate and actuator assembly was intact and undamaged. Propeller Governo r The propeller governor could be rotated by hand, was intact and undamaged. Vacuum Pump The vacuum pump could not be rotated by hand and the unit was intact.

Note:

- Details which pertains to manufacturers, serial numbers, work orders and other specific s of individual components available in TCM
reports.Air Accident Investigation and Prevention Unit

Final Report C6

- NLH Page 58 2.10.4 Right Engine Serial Number 290209 Analysis

The engine exhibited impact damage. There was no evidence of pre

- impact abnormalities. The maintenance
history of the engine was unknown , permanent maintenance records documenting scheduled and unscheduled maintenance were

not located.

Component Observation

External inspection of engine The engine exhibited impact damage, concentrated at the bottom components of the engine.

The right

- hand accessory drive and had been fractured from the crankcase accessory

section. Exhaust System Condition: The exhaust system components that were received exhibited impact damage.

Starter The starter rotated by hand and exhibited corrosion

Starter Adapter The starter adapter could not be rotated by hand. The assembly was intact and the

scavenge pump gears and housing were intact and undamaged. The crankshaft to camshaft timing was verified by the alignment of the gear‟s timing marks. Ignition Harness All leads were frayed or damaged shielding and had been cut from the mo unting covers.

L/H Magneto The left

- hand magneto turned freely by hand. The magneto was installed and tested on the

test bench and produced a blue spark across a 7 mm gap through the full range of test bench

RPM. 05

- 13

- 08 overhaul date.

R/H Magneto The r ight

- hand magneto turned freely by hand. The magneto was installed and tested on the

test bench and produced a blue spark across a 7 mm gap through the full range of test bench

RPM. 05

- 13

- 08 overhaul date.

Oil Cooler The oil cooler exhibited impact damage . Drake air overhaul. Additional numbers: 428326,

01

- 27

- 06

Oil Pump The oil pump drive was intact. The oil pump cavity contained light scratches and exhibited

normal operating signatures. The oil pump gear teeth exhibited normal operating signatures. The oil pressure relief valve and seat contained no obstructions and exhibited signatures of proper seating.

Oil Filter The oil filter housing was cut open using the Champion cutting tool and the filter element

was cut from the canister to allow examination. The oil filter element was examined and contained an insignificant amount of material.

Throttle and Fuel Control Assembly The unit exhibits corrosion and the levers were immovable by hand. Finger screen

removed and material was present. The unit was d isassembled and there was corrosion present. The internal components were found to be intact and seating properly. The passages where open and unrestricted.

Fuel Pump The fuel pump could not be turned through by hand. The fuel pump drive was fractured b y

turning the engine through prior to removing the fuel pump. The fuel pump was disassembled to examine the internal components. The internal components were intact and exhibited corrosion damage.

Fuel Manifold Valve The fuel manifold valve exhibited im pact and corrosion damage. The cover was breached.

The manifold valve was disassembled to examine the internal components. The manifold valve plunger assembly was intact, secure and undamaged. There were no signatures of fuel stains or leakage in the v ent chamber side of the diaphragm.Air Accident Investigation and Prevention Unit

Final Report C6

- NLH Page 59 Component Observation

Fuel Nozzles and

Lines The fuel nozzles were restricted. All nozzles exhibited various degrees of distortion. The

number 5 nozzle was fractured through at the large threaded (cylinder) end. All fuel nozzle lines exhibited impact damage. The numbers 2, 4, 1 and 5 fuel lines were exhibited nozzle nut separation.

Spark Plugs The sparkplugs contained corrosion and had normal wear signatures in accordance with the

Champion aviation check

- a

- plug comparison chart. The 5B spark plug was undisturbed from the cylinder but was intact.

Alternator The alternator could not be turned through by hand and exhibited impact and corrosion

damage. The drive coupling was intact.

Oil Sump Condition: The oil sum p drain plug was not safe tied. The oil sump exhibited impact damage and was crushed. The oil sump was drained of oil and the amount was residual.

The oil was dark in color and contained earth.

Oil Pick

- up Tube &

Screen Condition: The oil pick

- up tube ex hibited impact damage. The oil suction screen was

unrestricted. Induction System The induction risers and balance tube exhibited impact damage and corrosion.

Cylinder #1 Cylinder #2 Cylinder #3 Cylinder #4 Cylinder #5 Cylinder #6 The spot putty was not e vident on the cylinder hold

- down nuts. The cylinder combustion

chamber had a normal amount of combustion deposits and the bore condition was free of scoring and undamaged. The cylinder skirt was intact and undamaged and there were no

hone marks visible in the cylinder bore ring travel area. The intake and exhaust valve heads exhibited normal deposits and operating signatures. The rocker box area had an oil residue indicating lubrication to the overhead. The cylinder overhead components (valves, rocker

arms, guides, springs, retainers and shafts) were lubricated and undamaged.
No. 1, 2, 3, 4, 5, & 6 Piston, Rings and

Pin The piston head exhibited a normal amount of combustion deposits. These deposits had an

appearance of exposure to moisture. The piston s kirt was free of scoring and damage. The piston rings were intact, free in their grooves, exhibited normal wear and operating signatures. The piston pin and plug assembly was intact and undamaged.

Lifter

Intake & Exhaust The lifter faces were undamaged an d exhibited normal operating signatures. The lifter

bodies were undamaged and exhibited normal operating signatures.

Crankshaft The crankshaft and counterweight assembly was intact. The connecting rod journals, main

journals and thrust surfaces were unda maged and showed no signs of abnormal wear or lubrication distress. The crankshaft counterweight pins, plates and snap

- rings were intact. The counterweights were undamaged and had free and unrestricted movement on the hanger blades. The gear bolts were tight and safe tied and the gear teeth were undamaged. The oil transfer passages were open and unrestricted. Alternator drive face gear teeth were intact and undamaged. The oil transfer collar was intact and undamaged. The oil transfer plug was tight a nd in position.

Component Observation

#1 Main Bearings The #1 (rear) crankshaft main bearings exhibited normal operating and lubrication

signatures. The bearings were intact and exhibited an insignificant amount of contamination and hard particle passag e. There were no signs of lubrication distress.

#2 Main Bearings The #2 (intermediate) crankshaft main bearings exhibited fretting at their mating surfaces.

The bearings were intact and exhibited an insignificant amount of contamination and hard particle passage. There were no signs of lubrication distress.

#3 Main Bearings The #3 (intermediate) crankshaft main bearings exhibited normal operating and lubrication

signatures. The bearings were intact and exhibited an insignificant amount of

contamination an d hard particle passage. There were no signs of lubrication distress.

#4 Main Bearings The #4 (intermediate) crankshaft main bearings exhibited normal operating and lubrication

signatures. The bearings were intact and exhibited an insignificant amount of contamination and hard particle passage. There were no signs of lubrication distress.Air Accident Investigation and Prevention Unit

Final Report C6

- NLH Page 60 #5 Main Bearings The #5 (front) crankshaft main bearings exhibited normal operating and lubrication

signatures. The bearings were intact and exhibited an insignificant a mount of contamination and hard particle passage. There were no signs of lubrication distress.

No. 1, 2, 3, 4, 5 & 6 Connecting Rod The connecting rod assembly was intact and undamaged. The connecting rod nuts and

bolts were intact and secure. The conne cting rod bushing exhibited normal operating and lubrication signatures.
No. 1, 2, 3, 4, 5 & 6 Connecting Rod Bearings The connecting rod bearing exhibited normal operating and lubrication signatures. The

connecting rod bearings were intact and exhibited an insignificant amount of contamination and hard particle passage. There were no signs of lubrication distress.

Camshaft The camshaft lobes exhibited normal operating signatures. The camshaft gear was intact

and exhibited normal operating signatures. Th e gear bolts were tight and safe tied and the gear teeth were undamaged. W/O# RA6732

- 1

Crankcase The crankcase was intact. The cylinder bays were intact and undamaged. The numbers 2, 3

and 4 main bearing support lower mating surfaces exhibited rough surf aces from fretting. The remaining main bearing support mating surfaces were intact and exhibited no signs of fretting. There were no signs of bearing tang lock

- slot elongation. The main bearing support diameters were intact. The oil galleys and passages in the left and right crankcase halves were intact, clear and unrestricted.

Accessory Gears The accessory gears had continuity. The teeth were undamaged and exhibited normal

operating signatures. The right

- hand accessory drive gear was not returned wit h the engine.

Component Observation

Turbocharger The turbocharger could not be rotated by hand. The turbine housing was received

separated from the main assembly. The housing intact and there was no cracks or exhaust leak signatures present. The turbi ne blades were intact. The center housing oil inlet and outlet fittings were intact and there were no signatures of oil leakage. The center housing was intact and there were no cracks or exhaust leaks present. The compressor housing was

intact and there we re no cracks present. The compressor housing was attached securely to the center housing. The compressor blades were intact and they exhibited minimal erosion signatures. Debris was present in the compressor wheel.

Controller The controller exhibits corr osion and the lever was immovable by hand. The lever was

intact and secure.

Overboost Valve The overboost valve exhibited impact damage.

Wastegate The wastegate (exhaust by

- pass) valve was in the full open position and the linkage was

intact. The wastega te and actuator assembly was intact and undamaged.

Propeller Governor The propeller governor could be rotated by hand. The lever assembly from fractured from

the unit.

Vacuum Pump The vacuum pump could not be rotated by hand and the drive was fractured from the

assembly.

Note:

- Details which pertains to manufacturers, serial numbers, work orders and other specifics of individual components available i n TCM
reports.Air Accident Investigation and Prevention Unit

Final Report C6

- NLH Page 61 2.11 Training and testing for pilots of light piston engine aircraft

2.11.1 The forced landing option

If

, instead of attempting to return to the airport, the pilot had decided to force land into the lake more or less straight ahead, the outcome might have been different. There would still have been a crash risk and probably a rapid longitudinal deceleration, but the vertical speed at impact could have been low, the wings could have been

leveled and this would have made the end of the flight far more survivable for all on board.

Piloting skills and decisions are principally the prod ucts of training and experience. Height loss is always increased in a gliding turn; and the consequences of a mishandled turn

- back are often fatal. An experienced pilot who habitually flew single

- engine light aircraft would be more likely to force land th an to turn back because he or she generally knows that there is seldom another realistic option. On the other hand, pilots who habitually fly

twin

- engine light aircraft seldom, if ever, train for a forced landing, even though there may be a written procedu re for that eventuality.

2.1 1. 2 The pilot’s d ecision to return

The pilot had considerable experience in light twin engine aircraft. He had acquired more than 12,000 hours and more specifically, more than 10,000 hours in the 402C aircraft. Consequentl y, it is possible that the pilot never considered the forced landing option when the aircraft would no longer climb. What seems likely is that under extreme pressure, he maintained the only option that occurred to him

– returning to the airport. That was certainly his expressed intention when he declared to ATC that he would be returning and would accept runway 27 after

notified about the white smoke trailing behind his left engine. At that stage the aircraft was probably still climbing

or at least in leve l flight, and so it was a reasonable decision at the time it was uttered.

Circumstances changed when it was apparent that the aircraft would no longer climb and that might explain why the pilot secured the right engine. If he thought that the failure wa s of the right engine, and not the left that was reported as smoking, he probably knew that unless he feathered the propeller and secured the engine, he had no hope of returning to the airport.

As a result of the decision to accept runway 27 the following tasks, which are standard procedure for any commercial pilot were not accomplished;

 Under no circumstance should you try and return to the runway just departed until a safe altitude has been attained, the situation has been assessed, and the aircraft can make it back safely.

 Always climb to a safe altitude before any actions are taken. If unable to climb, or turn due to obstacles (building, trees, hills/mountains, towers etc.) standard procedures are to select a location straight ahead (free of obstacles, if possible) and land while still under control.

 Under no circumstance should the gear or flaps be extended until it is certain the field can be made.

 Under no circumstance should a turn be made into the engine with a suspected discrepancy

.

The evidence o f the hurried nature of the tasks performed and the inadequate review of critical information between the time of the pilot‟s acceptance of the offer to land on runway 27 and the flight making a turn to attempt the landing on runway 27 indicates that insu fficient time was available to fully or effectively carry out these actions. According to eyewitnesses‟ reports, the aircraft was about 150 to 3 00 feet when it initiated a sharp left turn while trying to intercept runway 27 and extended gear while in the turn. Immediately after gear extension the aircraft could no longer maintain altitude, stalled, became inverted and started a nose dive toward terrain (lake). Consequently, the above necessary steps were performed improperly or not at all and the pilot fai led to recognize that the airplane was heading toward terrain. The evidence indicates that the pilot committed a series of operational errors that led to the accident. The errors, which individually were not causal, interacted in a way that

caused the acc ident

.Air Accident Investigation and Prevention Unit

Final Report C6

- NLH Page 62 Researchers studying decision making in dynamic situations 32 have suggested that experienced persons can quickly make decisions based on cues that they match with those from previous experiences encountered in

similar situations. A referenced text refers to this characteristic as Recognition Primed Decision Making, in which a decision maker‟s rapid assessment of the situation is almost immediately followed by the selection of an

outcome.

It states: Our research has shown that recognitional decisio n making is more likely when the decision maker is experienced, when time pressure is greater, and when conditions are less stable. 33

It is likely therefore that when previously faced with similar situations such as the opportunity to return for a landing after having experienced some sort of failure or problems previously, the pilot who had acquired more than 12,000 hours in total and more specifically more than 10,000 hours in this make and model airplane, accepted the offer and landed without incident. H owever, recognition primed decision making can present risks to the decision maker if the initial assessment of the situation is incorrect, or if the situation changes sufficiently

after the decision has been made but the initial decision is not reconsider ed. In this accident, the latter scenario appears to have been the case; there is no evidence that the pilot reconsidered the initial decision to accept the offer to land on runway 27 versus continuing the climb to a safe altitude and assessing his option s and all subsequent actions were directed to completing the steps necessary to successfully land.

The evidence suggests that either of two reasons could account for the pilot‟s persistence in attempting to land

rather than climb to a safe altitude and as sess his situation. These include the failure to adequately consider the time required to perform the steps needed to climb to a safe altitude, assess his situation, select a suitable runway and return for a landing, considering the report of white smoke t railing behind his engine and the reluctance of decision makers in general to alter a decision once it has been made. By not reconsidering that initial decision, the pilot acted consistently with the findings of human factors research on decision making t hat found that decision makers are reluctant to alter a decision after it has been made. For example: 34

Operators tend to seek (and therefore find) information that confirms the chosen hypothesis and to avoid information or tests whose outcome... could disco nfirm it. This bias produces a sort of “cognitive tunnel vision” in which operators fail to encode or process information that is contradictory to or inconsistent with the initially formulated hypothesis. Such tunneling seems to be enhanced particularly under conditions of high stress and workload.

Thus, in addition to simply being too busy to recognize that he could not properly and safely return to a landing on runway 27 given his altitude , weight and configuration, once the decision to land on runway 27 had been made, the course of action taken was to continue the approach rather than to discontinue it.

2.11.3 Engine failure training and testing in light twin engine aircraft

A glide landing in a twin

- engine aircraft is not generally contemplated exce pt just after take

- off when the landing gear is down and there is runway remaining. All other engine failure procedures are predicated on correctly identifying the failed engine; securing it; climbing away if necessary; and flying a single

- engine approach and landing to a runway. This emphasis is also reflected in the routine recurrent testing of pilot skills.

32 Klein, G., (1993) Naturalistic Decision Making: Implications for Design. Wright

- Patte rson Air Force base, Ohio Crew System Ergonomics Information Analysis Center.

33 Klein, G., (1993) A recognition primed decision (RPD) model of rapid decision making. In Klein, G., A., Orasanu, J., Calderw ood, R., and Zsambok, C.E., (Eds), Decision Making in action: Models and Methods. Norwood, New Jersey, Ablex, p. 146.

34 Wickens, C. D., (1984) Engineering Psychology and Human Performance. Columbus Ohio: Charles E. Merrill, p. 97.Air Accident Investigation and Prevention Unit

Final Report C6

- NLH Page 63 2. 12 The Implications of Performance Category C

An engine failure after take

- off in a twin

- engine Performance Group C aircraft requires immedi ate, prioritized and accurate corrective action from the handling pilot. This is because:

1. Many Group C aircraft will not sustain a single engine climb at maximum take

- off weight unless the landing gear and flaps are retracted. Consequently, there may be a period between leaving the runway and achieving a suitable climb speed and configuration when, if an engine fails completely, the only realistic option is to force land immediately.

2. Some Group C aircraft require the pilot to feather the propeller of a f ailing engine immediately because if the propeller RPM decay below a certain level, it may be impossible to feather the propeller 35

. (S ee Appendix

5.16 )

3. An unexpected and complete engine failure results in one prope ller very rapidly changing its state from thrust to drag. The result is a reduction in forward thrust of significantly more than 50%. The sudden change tends to cause a loss in airspeed whilst the pilot recognizes the failure and takes early corrective a ction.

4. Until the propeller of the failed engine is feathered, a Group C aircraft at or near maximum take

- off weight may be unable to accelerate in level flight or to climb.

5. The single

- engine r ate of climb is highly dependent on airspeed. If, after an un expected engine failure, the airspeed has reduced below the „blue line‟ optimum marked on the Air Speed Indicator (ASI), the aircraft may not climb despite it being properly configured.

Consequently, the handling skills required to successfully overcome a n unexpected failure shortly after take

- off in

a twin

- engine aircraft of Performance Category C are among the most demanding of the skills required by any airplane pilot. He or she must ta ke immediate action to contain the situation and decide rapidly, ba sed on a number of critical factors, whether to force land or to climb away from the point of failure.

2.13 ATC Tower Controller

The Air Traffic Controllers that handled the accident aircraft were all Grade One Air Traffic Control Officers and

were pr operly trained and provided appropriate air traffic services. In addition, the investigation examined the

actions of the ATC Tower controller to determine what role, if any, his actions may have had upon the accident. By the standards of the FAA, CAA and ICAO the pilot and not the controller was in the best position to determine the safety of the acceptance of that offer.

2.14 Survivability

The investigation also assessed survivability issues to determine the extent to which the number of fatal injuri es could have been reduced and the effectiveness of the seatbelt in use. Based on the extent of the damages sustained

the accident was not survivable. The emergency response for this accident was timely and effective. The accident

was not survivable for th e airplane occupants because they were subjected to impact forces that exceeded the

limits of human tolerances.

2.14.1 Aircraft Seating

The analyses of the impact injuries suffered by the fatalities within the aircraft were found to be consistent with

t he cabin damage inflicted by the initial impact with the shallow water of the lake and subsequent secondary

35 See A eronautical I

nformation C ircular 100/2005 Propeller Feathering o n Twin Piston Engined Aircraft Appendix 5.16Air Accident Investigation and Prevention Unit

Final Report C6

- NLH Page 64 cartwheel motion of the aircraft hitting the lake bottom. Most of these impact injuries were chest injuries, injuries to the ankles and leg and feet and there were some head injuries. There is clear evidence that chest injuries were compounded by the separation and collapse of the seats and by the limitations of the passenger seats, where only lap strap was available.

2.15 Situational Awareness 36

Once the decision was made to accept the offer to land on runway 27, the pilot displayed poor situational awareness, with regard to such critical factors as the following;

 His current altitude

 Proximity to terrain

 Flight Path

 Recognition of stall speed

 Ex tension of landing gear while in a turn

 Excessive weight

- Load Factor 37

 Excessive bank angle

 Turning an aircraft into the critical (dead) engine 38

.

Situational awareness refers to a flight

- crew‟s understanding of the status and flight

- path of the aircraft and the accuracy of their prediction about its future status and flight path. Deficiencies in situational a wareness can lead to potential failures involving flight

- path prediction or comprehension and prediction of system parameters as in the

case here inv olving C6

- NLH. The accident indicated that from the beginning of his attempt to land on runway 27, the pilot exhibited a lack of awareness of fundamental parameters of the approach.

2.16 CAD Oversight

CAD / FSI mandate is surveillance of certified AOC as per CASR 2001 Schedule 12. As Acklins Blue Air

Charter Limited was not an AOC holder, no surveillance by CAD/FSI was conducted. C6

- NLH was a private

aircraft owned by an individual . It was registered to Lebocruise Air Limited and operated by Acklins B lue Air

Charter Limited. Ne ither of the above companies was registered with or underwent a certification process by the Bahamas Civil Aviation Department as required by Schedule 12 of the Bahamas Civil Aviation (Safety) Regulations 2001 to be authorized t o c onduct cargo or passenger operations as an authorized Air Operator

Certificate holder.

Several months prior to this accident, the Flight Standards Inspectorate went on a proactive campaign where information was shared with the daily newspaper and med ia outlets. Several articles were written and the department took the message to the airwaves via talk show and media houses warning the general public about the dangers of travelling with unauthorized air carriers. Numerous posters were strategically plac ed at all Fixed Base Operations and the General Aviation Center warning about the dangers of unauthorized air carriers.

36 Situational awareness has been defined as the perception of the elements in the environment within a volume of time and space, the comprehension of their meaning, and the projection of their status in the near future.

37 Load factor

- In aeronautics, the load factor is defined as the ratio of the lift of an aircraft to its weight and represents a global measure

of the str ess . Since the load factor is the ratio of two forces, it is dimensionless. However, its units are traditionally referred to as g , because of the relation between load factor and apparent acceleration of gravity felt on board the aircraft. A load factor o f one, or 1 g, represents conditions in straight and level flight, where the lift is equal to the weight. Load factors greater or less than one (or eve n negative) are the result of maneuvers or wind gusts.

38 Critical engine

– an engine whose failure would mostly affect the performance of an aircraft. In most small twin engine aircraft (unless they have a counter rotating engine) the left engine is considered the critical engine.Air Accident Investigation and Prevention Unit

Final Report C6

- NLH Page 65 The Flight Standards Inspectorate additionally engaged the assistance of the Airport Authority and NAD with meetings and strategic pla nning on ways to curb the incidence of unauthorized air charter operators. List of all authorized air charter operators were distributed to the media and all stake holders at MYNN

. Post accident, the message was again presented to the television media outl ets and print media for their assistance with spreading the message about the dangers of travel with unauthorized air carriers

.

2.1 7 Summary

The experienced and competent pilot was confronted with an unenviable emergency at a critical stage of flight. A number of potentially confusing cues may have led to him misidentifying the partial loss of power from the left engine and secured the right engine. His reaction and insti nct to return to the runway confounded his instinctive reaction to an emergency si tuation, which is much practiced in training and testing.

The t ime for him to make the correct diagnosis and to take the correc tive action was short

. During this time he announced his decision to return to the airport for a landing on runway 27 and initia ted a turn to the left. With the left engine problem persisting and the right engine secured and not producing thrust at this time, the reduced thrust of the left engine was insufficient to maintain lift . In a t ightening turn, with gears extended, the air craft stalled, became inverted which resulted in a steep nose dive into the lake.Air Accident Investigation and Prevention Unit

Final Report C6

- NLH Page 66 3.0 Conclusions

(a) Findings

1. Acklins Blue Air Charter was advertising and operating as a Bahamas air taxi operator without having
underg one the certification process in contravention of Bahamas Civil Aviation (Safety) Regulations

Schedule 12.

2. The airplane was issued a Certificate of Airworthiness on May 19, 2010, by the Bahamas Flight
Standards Inspectorate, and was being operated by Ackl ins Blue Air Charter.

3. The Cessna 402C aircraft is classified in the performance Group C. This requires rapid feathering of the
propeller of a failed engine and the raising of flap and the landing gear in order to achieve maximum
climb performance.

4. The a irplane maintenance records were not located; therefore, no determination could be made whether
the airplane was being maintained in accordance with Bahamas Civil Aviation Regulations.

5. The 12,000 hour pilot and second pilot were not qualified to operate i n Bahamas commercial air taxi
operations.

6. No determination could be made whether the pilot or second pilot had completed required training and
had accomplished a satisfactory recurrent flight check of their flying ability as required by CASR

Schedule 12 and 14 for aircraft operating in commercial air transportation as well as the stipulation by the
insurance policy.

7. Post

- accident weight and balance calculations indicate the airplane was being operated approximately 523
pounds over maximum certificated ta keoff weight (6,850 lb )

8. The pilot was advised by an air traffic controller that white smoke was trailing the left engine during
takeoff; the pilot did not declare an emergency or advise the controller of any engine failure or
mechanical abnormality.

9. T he airplane‟s left engine could not produce rated shaft horsepower during takeoff.

10. Several factors contributing to the degradation of the airplane‟s performance and its inability to maintain
flight include the wind

- milling propeller, the pilot‟s intentional initiation of a steep turn to return to the
departure airport, and his intentional lowering of the landing gear during the turn to return.

11. While turning to return, the airplane stalled, pitched nose down, and impacted in a lake.

12. The search and rescue eff orts were timely and appropriate; however, the lack of accurate information on
the pilot submitted flight plan delayed recovery of all victims.

13. The left propeller was not feathered.Air Accident Investigation and Prevention Unit

Final Report C6

- NLH Page 67 14. The No. 2 cylinder of the left engine failed due to fatigue that originated in the root of the cylinder head
thread that was engaged with the first thread on the barrel

.

15. Post

- accident inspection of the cockpit revealed several switches for the right engine were secured;
however, no determination could be made when the switches were placed / moved in those positions.

16. No evidence of failure of the airplane‟s structures or flight control system contributed to the accident.

17. Existing regulations did not require the aircraft to be fitted with flight recorders. The lack of any recorded
data about the aircraft‟s performance or the flight crew conversations deprived the investigation team of

essential factual information.

18. Current Civil Aviation Department personnel and budget resources may not be sufficient to ensure that
the quality of surveillance for certified as well as u ncertified air carrier operations will improve.

19. Airside access procedures are inadequate at Fixed Base Operators. Access to the secure airside occurring
without any check of individuals to challenge whether they have a legitimate reason for accessing the

secure airside. FBO door to access airside is not secured or locked continuously; persons observed
walking in and out without being challenged.

20. Flight Plan Form s are being accepted and transmitted to ATC with incomplete information. This

information is vi tal for search and rescue purposes.

21. Weather was not a factor in the accident.

22. ATC was not a factor in the accident.

23. Currently flight plans for private flights are only required for international operations.

24. The pilot was aware of discrepancy associated with the manifold pressure reading of the left engine prior

to takeoff. This discrepancy was brought to his attention by a client from the flight immediately preceding the accident flight.

25. The exact center of gravity of the accident airplane could not be calculated accurately as no indication of what seat each passenger occupied in the airplane and no indication of where luggage or equipment were placed on the aircraft could be determined. However, due to the exceedance of weight limits the aircraft

was al ready outside the allowable center of gravity envelope developed by the manufacturer.

26. The pilot had insufficient time to prepare for the approach to runway 27 before beginning the approach.

T he airplane pitched up quickly into a stall, after extension of gear, recovery before ground impact was unlikely once the stall began.

27. Post accident inspection did not reve al any mechanical evidence or problems with the right hand engine.

28. The pilot‟s decision to return to the airfield was reasonable. Once the airc raft began to lose height a return to the airfield became impractical and a forced landing in the direction of flight should have been attempted.Air Accident Investigation and Prevention Unit

Final Report C6

- NLH Page 68 29. The right propeller was never recovered from the lake

.

(b ) Caus al Factors

1. The left engine suffered a me chanical failure of the #2 cylinder, and therefore could not produce rated shaft horsepower . N o indication of total loss of power with the left engine reported.

2. Right Engine electrical and engine control switches were found in the “OFF” position, therefo re the aircraft was incapable of climbing on the power of one engine alone.

3. The excess weight above the maximum weight allowed for takeoff may have been an important factor in the aircraft‟s inability to gain adequate altitude after takeoff.

4. The pilot s ecured the right engine which was mechanically capable of producing power resulting in a total loss of thrust. He then sometime thereafter initiated a steep turn with gear down and the left engine already not developing sufficient shaft horsepower to susta in lift.

5. The pilot attempted to return to the departure airfield but lost control of the aircraft during a turn to the

left.Air Accident Investigation and Prevention Unit

Final Report C6

- NLH Page 69 4.0 Recommendations:

As a result of this investigation

, the AAIPU makes the following recommend ations to t he Department of Civil

Aviation:

1. Evaluate the surveillance programs to ensure that budget and personnel resources are sufficient and used effectively to maintain adequate oversight of the operation and maintenance of both certified and uncertif ied air carriers, irrespective of size.

2. Req uest that t he Government of the Bahamas enact legislation that creates tougher penalties for persons engaging in unauthorized air charters.

3. Request that Civil Aviation Department amend regulations to enforce tha t flight plans be required for all flights, private and commercial, domestic and international and that the AIP be amended to show this requirement.

4. Request the Civil Aviation Department in coordination with Air Traffic Control institute policies and

proc edures where aircraft are not allowed or given permission to turn in any direction after takeoff prior to attaining a minimum of 500 feet as is standard practice in pilot training.

5. Request that the Civil Aviation Department amend its information gathering forms to capture vital information that may be required in the event of lost or unavailable historical information for Bahamas registered aircraft.** 39

6. Request that the Civil Aviation Department in conjunction with NAD require that appropriate and certifi ed weighing devices be installed at all points where aircraft are dispatched so that pilots may have a means to accurately weigh all occupants and cargo that are to be loaded onto aircraft prepared for flight.

7. Request that the Civil Aviation Department en act regulations that make it mandatory that all pilots of private aircraft be required to complete an accurate load and weight and balance document which must be left with an agent at facilities where they depart.

8. Request that the Civil Aviation Departmen t institute policies whereby Aviation Medical Examiners can issue pilots medical certificate immediately upon satisfactory examination as the current policy causes delays in issuing medical certificates. This delay from examination to processing and issua nce results in pilots taking a chance and flying without a medical certificate which invariably renders their pilot licenses invalid.

9. Request that the Civil Aviation Department amend regulations to require all private pilots to have a proficiency check or bi

- annual flight review every 2 years prior to renewal of their private pilot license.

10. Request ATC to review all Flight Plan Form filing procedures to ensure all required information is gathered

as it is vital for search and rescue purposes.

11. Request Air port Authority put in place tighter security measures to properly account for all persons gaining

access to the secure airside. * 40

39 ** Prior to the publication of this report , the Flight Standards Inspectorate instituted corrective action and developed an application form that captures missing information that can establish a baseline of historical aircraft information.

40 * Prior to the publication of this report, corrective actions as a result of recommendation 5

– 9 and 11 above have been addressed by

stakeholders and relevant authorities.Air Accident Investigation and Prevention Unit

Final Report C6

- NLH Page 70 12. Request Airport Authority explore a surveillance program or require all Fixed Base Operators to install surveillance equipment (CCTV) to cover all areas under their control * to properly capture all activities by persons gaining access to the secure airside at all Fixed Base Operators (FBO). *

13. Request Airport Authority to coordinate with all Fixed Base Operators to develop a safet y and security plan and train their personnel with secure airport access procedures. *

14. Request Airport Authority to coordinate with all FBO to install a secure system (door locking system with buzzer) whereby persons do not have unlimited and unimpeded acc ess to the secure airside without the knowledge of representatives of the facility. *

15. Request all FBO‟s to ensure all information is included on flight plan form prior to transmitting it to ATC including all passenger information (item 22 on Flight Plan Fo rm). This information is vital for search and rescue purposes.*Air Accident Investigation and Prevention Unit

Final Report C6

- NLH Page 71 5.0 APPENDICES:

Appendix 5.1 Cylinder Factual Report (NTSB)



## REPORT NOT INCLUDED HERE BUT MAY BE SUPPLIED IF REQUESTEDAir Accident Investigation and Prevention Unit

Final Report C6

- NLH Page 72 Appendix 5.2 Left and Right Engine Factual Report (TCM)



## REPORT NOT INCLUDED HERE BUT MAY BE SUPPLIED IF REQUESTEDAir Accident Investigation and Prevention Unit

Final Report C6

- NLH Page 73 Appendix 5.3 Acklins Blue Companies

Appendix 5.4 Acklins Blue Air Char terAir Accident Investigation and Prevention Unit

Final Report C6

- NLH Page 74 Appendix 5.5 Acklins Blue Air CharterAir Accident Investigation and Prevention Unit

Final Report C6

- NLH Page 75 Appendix 5.6 ATC tower transcript



## REPORT NOT INCLUDED HERE BUT MAY BE SUPPLIED IF REQUESTEDAir Accident Investigation and Prevention Unit

Final Report C6

- NLH Page 76 Appendix 5.7 Flight Plan Form


### FLIGHT PLAN NASSAU TO SAN SALVA DOR

FLIGHT PLAN NASSAU TO TREASURE CAY, ABACO BAHAMASAir Accident Investigation and Prevention Unit

Final Report C6

- NLH Page 77 Appendix 5.8 Fuel Uplift SlipAir Accident Investigation and Prevention Unit

Final Report C6

- NLH Page 78 Appendix 5.9 Alert Issued



# Alert

Alert # SA/A10

- 01312/001/10

- 9

- 10

To : Mrs. Deborah Coleby Director of Operations Nassau Airport Development Comp any

Captain Patrick Rolle

Director Civil Aviation Department

Mr. Milo B. Butler III General Manager Airport Authority

Mr. Joseph Albury Deputy Director

Air Traffic Control

Mr. Alphonzo Bowe Managing Director Executive Flight Support

Mr. Anthony Hinsey Public Relations Manager Odyssey Aviation



## Re: Flight Plan Form Completion and Airside Security and Accountability.
In Accordance with ICAO Annex 13, Ninth Edition, July 2001, Chapter 6 Paragraph 6.8 Safety

recommendations

“ At any stage of the investigation of an accident or incident, the accident or incident investigation authority of the State conducting the investigation shall recommend to the appropriate authorities, including those in other States, any preventive action that it consi ders necessary to be taken promptly to enhance aviation safety. ”

In light of ongoing accident investigations the following Alert is being advanced in an effort to ensure safety, security and enhance search and rescue procedures.

The following findings an d observations have been made and must be addressed by the relevant authority and stakeholders immediately:

1. Pilots or their agents are not completing flight plan forms in its entirety as required by Flight

Plan Form Document. Though provided on the flight plan forms, accepting agents are not
ensuring pilots or those acting on their behalf, list the correct passenger count.Air Accident Investigation and Prevention Unit

Final Report C6

- NLH Page 79 

### 2. Flight Plan Form in use by NAD only requires that items 1 thru 20 be completed in order for
form to be processed.

3. Agents are transmitti ng incomplete flight plan forms to ATC.

4. ATC is accepting, processing and issuing ATC services to pilots based on incomplete flight plan

forms.

5. While conducting investigations at an FBO the investigation team observed individuals who
were given unimpeded a ccess to the secure airside without being challenged, recorded or

documented.

Note: Individuals were allowed to access the secure airside; board an aircraft yet no one at the facility knew who they were or how many people left through their facility or wh at aircraft they boarded.

The following reco mmendations are hereby advanced:

1. Policy and Procedures should be developed, enhanced or enforced by relevant agency to ensure
all information required by Flight Plan Form is captured by said form.

2. In light of th e accident involving C6

- NLH, NAD should amend this form to include items 1 thru
22 as being required prior to processing of form for all general aviation aircraft. This information
would prove to be invaluable as search and rescue procedures can be enhance d as well as

notification of next of kin can be made easier.

3. Training should be developed, initiated or enhanced with the entities responsible for accepting
and dispensing of such information to Air Traffic Control to ensure that all information required

i s captured.

4. All entities involved should develop policy, procedures and institute training to its staff on
methods to reject such Flight Plan Forms if required information are not completed.

5. Airport Authority as the unit with responsibility for security sh ould ensure that all stakeholders
especially in the General Aviation and Fixed Base Operations Area provide an acceptable
security plan that would ensure tighter security measures and more accountability of persons that
grant access to the secure airside.

6. As part of this approved security plan procedures should be in place for the continued monitoring
and surveillance of the ramp used by General Aviation and all Fixed Base Operators (Suggestion
CCTV).

7. Stakeholders should be made to develop policy, procedure s and provide training to its staff on
airside safety and security responsibilities and put stricter airside access criteria in place.

This department requests that all relevant entities institute the above recommendations with immediate

effect in order to enhance safety, security and search and rescue operations.Air Accident Investigation and Prevention Unit

Final Report C6

- NLH Page 80 Appendix 5.10 Engine Failure after Take

- off ChecklistAir Accident Investigation and Prevention Unit

Final Report C6

- NLH Page 81 Appendix 5.11 Crash Aircraft Diagram

Appendix 5.12 Reference Aircraft DiagramAir Accident Investigation and Prevention Unit

Final Report C6

- NLH Page 82 Appendix 5.13 C ASR Regu lation Part X , Regulation 67.

Appendix 5.14 CASR Regulation Part X , Regulation 68Air Accident Investigation and Prevention Unit

Final Report C6

- NLH Page 83 Appendix 5.15 Aerodrome Chart Nassau, BahamasAir Accident Investigation and Prevention Unit

Final Report C6

- NLH Page 84 Appendix 5.16 A eronautical Information Circular 100/2005 Propeller Feathering on Twin Piston Engine AircraftAir Accident Investigation and Prevention Unit

Final Report C6

- NLH Page 85 A ppendix 5.17 Cessna 402C Dual Manifold Pressure Gauge

Manifold vacuum / pressure

- an effect of a piston's movement on the induction stroke and the choked flow through a throttle in the intake manifold of an engine. It is a measure of the amount of restriction of airflow through the engine, and hence of the unused power capacity in the engine

.

The rate of airflow through an internal combustion engine is an important factor determining the amount of power the engine generates. Most gasoline engines are controlled by limit ing that flow with a throttle that

restricts intake airflow

. Manifold vacuum is present in

all naturally

- aspirated engines that use throttles (including carbureted and fuel injected gasoline engines using the otto cycle or the two

- stroke cycle )

.

The mass flow through the engine is determined by the rotation rate of the engine, multiplied by the displacement of the engine, and the den sity of the intake stream in the intake manifold. In most applications the rotation rate is set by the application. The displacement is dependent on the engine geometry, which is generally not adjustable while the engine is in use (although a

handful of mo dels do have this feature, see variable displacement ).

Restricting the input flow reduces the density (and hence pressure) in the intake manifold , reducing the amount of power that is produced. It is also a major source of engine drag, as the engine must pump material

from the low

- pressure intake manifold into the exhaust manifold (at am bient atmospheric pressure).

When the throttle is opened (in a car, the accelerator pedal is depressed), ambient air is free to fill the intake manifold, increasing the pressure (filling the vacuum). A carburetor or fuel injection system adds fuel to the airflow in the correct proportion, providing energy to the engine. When the throttle is opened all the way, t he engine's air induction system is exposed to full atmospheric pressure, and maximum airflow through the engine is achieved. In a "naturally

- aspirated" engine, total engine output is thus determined by the ambient barometric

pressure

. Superchargers and turbochargers can " boost " manifold pressure to above atmospheric pressure.Air Accident Investigation and Prevention Unit

Final Report C6

- NLH Page 86 Appendix 5.18 Alert SA/A10

- 01312/002 /10

- 9

- 10 Historical InformationAir Accident Investigation and Prevention Unit

Final Report C6

- NLH Page 87Air Accident Investigation and Prevention Unit

Final Report C6

- NLH Page 88 Appendix 5.19 CRASH SITE DIAGRAM