4 fatalities

2015-02-11: Beechcraft 1900C (YV1674) — Aeropanamericano — Miami-Executive (Kendall-Tamiami), United States of America

Miami-Executive (Kendall-Tamiami), United States of AmericaTakeoff (climb)

On February 11, 2015, a Beechcraft 1900C (registration YV1674) operated by Aeropanamericano was involved in an aviation accident near Miami-Executive (Kendall-Tamiami), United States of America during takeoff. 4 people were killed. Investigators recorded the probable cause as: The left engine propeller's uncommanded travel to the feathered position during takeoff for reasons that could not be determined due to impact damage. This summary draws on records from the Bureau of Aircraft Accidents Archives (B3A).

Sourcesthe Bureau of Aircraft Accidents Archives (B3A)Primary reportUpdated 1781193156Data APIEditorial standards

During a repositioning flight after propeller replacement, the left propeller feathered uncommanded shortly after takeoff. The flight crew shut down the engine but mismanaged trim, leading to a crosscontrolled stall and terrain impact.

Flight and Maintenance Background

The accident flight was a repositioning operation conducted by two airline transport pilots. It was the first flight after an aviation maintenance technician (AMT) had replaced the left engine propeller with an overhauled unit. The AMT performed an engine run, verifying correct power settings and blade angles.

In-Flight Event

Review of flight data recorder (FDR) data showed that about 2 seconds after rotation, the left engine propeller rpm decreased to 60 percent, and the left engine torque increased off-scale (beyond 5,000 ft lbs). This is consistent with the left propeller traveling to the feathered position and the engine torque increasing in an attempt to maintain rpm. Approximately 30 seconds later, the flight crew shut down the left engine and attempted to return to the departure airport.

Postaccident Examination Findings

Postaccident examination of the rudder trim actuator revealed it was at its full-right limit. This position would have been set to counteract left engine drag before its shutdown. Based on evidence, it is likely that the flight crew did not readjust the trim when the drag was alleviated. As a result, the airplane operated in a crosscontrolled attitude for about 50 seconds, with a left bank and full-right rudder trim. Although the airplane should have been able to climb at about 500 ft per minute on one engine, it slowed and descended from 300 ft in the crosscontrolled attitude until it stalled. A stall warning was recorded by the cockpit voice recorder, and the airplane subsequently impacted terrain.

Mechanical Examination

Examination of the wreckage, including teardown of the left engine and propeller, revealed no preimpact mechanical anomalies. Review of the airplane maintenance manual indicated instructions to check the propeller reversing linkage (controlling the beta valve) for proper rigging during propeller installation. A warning in the manual stated that misadjustment of the beta valve can cause unplanned feathering and result in possible hazard and over torque damage. However, beta valve rigging could not be verified postaccident due to impact damage.

Additionally, the ground/flight idle solenoid energizes when weight is off wheels, further opening the beta valve. This could exacerbate an existing misrigged condition as soon as the airplane becomes airborne, which is when the uncommanded feathering occurred.

Checklist Noncompliance

The FDR data were consistent with the flight crew not performing the Before Takeoff (Runup) checklist. One item on that checklist is a low-pitch solenoid test, which would have energized the solenoid and possibly driven the left propeller uncommanded to feather during ground operations rather than in flight. A similar test during the post-maintenance engine run would have had the same results.

Probable cause

The left engine propeller's uncommanded travel to the feathered position during takeoff for reasons that could not be determined due to impact damage. Contributing to the accident was the flight crew's failure to establish a coordinated climb once the left engine was shut down and the left propeller was in the feathered position.