“Inadvertent Dual Engine Shutdown” — Critical Error Leads to Fatal Crash

The Hawker Beechcraft Premier IA was descending toward South Bend, Indiana, when the airplane suddenly lost all engine power.

At first, the air traffic controller heard what sounded like an ordinary emergency transmission.

Then the pilot said the words no controller wants to hear:

The aircraft was about 18 miles southwest of South Bend Regional Airport, descending through approximately 6,700 feet.

Both engines had stopped.

There had been no mechanical failure.

No fuel exhaustion.

No catastrophic engine malfunction.

The engines had been shut down from inside the cockpit.

The person who moved the controls was not the captain.

It was a pilot-rated passenger who had been allowed to manipulate the aircraft controls during the descent.

Instead, he moved both throttles beyond the flight-idle stops into the fuel-cutoff position.

Both engines shut down.

The pilot immediately realized what had happened.

But the accident was only beginning.

The aircraft would eventually reach South Bend, but the crew could not fully restore the airplane's electrical and hydraulic systems. The main landing gear failed to extend normally. The aircraft bounced during the first landing attempt, went around, and eventually crashed into a residential neighborhood.

Two of the four people aboard died.

The NTSB investigation concluded that the dual-engine shutdown itself was caused by the captain's decision to let an unqualified pilot-rated passenger manipulate the controls. The captain's inadequate response to the emergency then contributed to the fatal loss of control. (Accidents App)

The Flight to South Bend

The aircraft was a Hawker Beechcraft 390 Premier IA, registration N26DK.

On March 17, 2013, it departed Tulsa, Oklahoma, on a business flight bound for South Bend.

There were four people aboard.

The flight initially proceeded normally.

The weather was visual.

The aircraft climbed and cruised at approximately 11,000 feet.

Nothing suggested that the flight would become an emergency.

As the aircraft approached South Bend, the controller began clearing it lower.

At approximately 16:13 local time, the airplane was cleared to descend to 3,000 feet.

The captain was flying the aircraft.

The second person in the cockpit was a pilot-rated passenger.

He had substantial flight experience in piston-engine aircraft, but he had no experience operating a Premier IA turbine business jet.

That distinction would become critical.

The Decision to Let the Passenger Fly

This was not simply a passenger being shown how a control worked while the airplane was safely parked.

The captain remained responsible for the airplane.

The passenger had no training or experience in the Premier's systems.

The captain told him to reduce engine power to maintain the desired airspeed.

The instruction sounded simple.

But the engine controls on the Premier were not something an inexperienced person should manipulate casually.

The throttles contained flight-idle stops.

Moving the levers beyond those stops commanded the engines toward fuel cutoff.

The passenger moved them too far.

Both engines began spooling down.

The cockpit voice recorder captured the sound of the engines winding down.

The captain immediately recognized the problem.

He told the passenger that he had gone behind the stops and that they had lost power. (Accidents App)

The ATC Emergency

The pilot contacted South Bend Approach.

He reported a complete engine failure.

The controller immediately began working to get the airplane toward South Bend.

The captain reported that the airplane had no power and was barely controllable.

ATC provided vectors.

The airport was ahead.

The emergency appeared survivable.

A business jet with a substantial amount of altitude and an airport directly ahead still has options.

But those options depend on the pilot restoring enough aircraft systems to configure the airplane for landing.

The captain attempted to restart the engines.

At least one engine eventually restarted.

The investigation determined that the left engine was operating at impact.

That meant the airplane was no longer completely powerless.

But another problem had developed.

The Generator Problem

The Premier's systems were designed so that when an engine was restarted, its generator could be reset to restore electrical power to the essential bus.

The NTSB found that this procedure was not properly completed.

The aircraft therefore continued operating on the standby electrical bus.

That had serious consequences.

The normal landing-gear extension system was affected.

The pilot needed to use the alternate landing-gear extension procedure.

But the alternate extension handle was only partially extended.

As a result, only the nose gear extended.

The airplane was approaching South Bend with one engine operating and an abnormal landing-gear configuration.

The captain had already been through an engine shutdown emergency.

Now he had to manage an airplane with degraded electrical and hydraulic capability and an incomplete landing-gear extension.

The First Approach

The controller continued providing assistance.

The tower controller observed the configuration and advised the approach controller.

The aircraft touched down with only the nose gear extended.

It bounced.

The pilot attempted to go around.

The aircraft climbed again.

The controller continued assisting.

But the airplane was no longer in a stable configuration.

The captain was trying to fly a single-engine jet while dealing with abnormal systems, an improperly configured landing gear and an emergency that had already consumed a significant amount of his attention.

The Go-Around

A go-around is demanding even during normal operations.

During an emergency, it can become much more difficult.

The airplane must accelerate.

The pilot must establish the correct pitch attitude.

The aircraft must climb.

The landing gear must be configured.

The engines must produce the required thrust.

And the pilot must maintain directional control.

The Premier was operating with only one engine.

The NTSB determined that the aircraft was capable of completing a successful single-engine landing if the landing gear had been fully extended using the appropriate alternate procedure. (ABC57)

But that did not happen.

The aircraft entered a climbing right turn.

Then it began descending in a nose-down attitude.

The Final Seconds

The Premier descended toward a residential neighborhood south of the airport.

It struck a street and then a house.

The impact destroyed the aircraft.

Two of the four occupants died.

The other two survived.

The crash also caused extensive property damage.

The emergency that had begun with two engine shutdowns had now become a loss-of-control accident.

But the NTSB investigation showed that the engines themselves were not the root cause.

The engines had been shut down by the cockpit crew.

Why the Mistake Was So Dangerous

The phrase "pilot-rated passenger" can create a misleading impression.

A person may hold a pilot certificate and still be completely unqualified to manipulate the controls of a particular aircraft.

Aircraft differ enormously.

A pilot accustomed to a piston twin may understand basic throttle movement but not the specific detents, protections, systems or emergency procedures of a turbine-powered business jet.

The passenger in N26DK had no experience in the Premier.

That did not mean he was poorly trained as a pilot.

It meant he was not qualified to operate that aircraft's systems without proper training.

The captain nevertheless gave him access to the controls.

That created an unnecessary hazard during a critical phase of flight.

The Human-Factors Chain

The accident is a textbook example of an error chain.

The second was the instruction to reduce power.

The third was the passenger moving the throttles beyond the flight-idle stops.

The fifth involved the incomplete restoration of electrical power.

The sixth involved the failure to fully extend the alternate landing gear.

The eighth was the loss of control during the subsequent go-around.

No single action explains the entire accident.

The chain does.

NTSB Probable Cause

“The private pilot's inadequate response to the dual engine shutdown during cruise descent, including failure to follow procedures, which resulted in loss of aircraft control during a single-engine go-around.”

The Board also identified:

as a contributing cause of the accident. (ABC57)

That distinction is important.

The passenger's mistake caused the engines to shut down.

But the captain remained responsible for managing the emergency.

Accident Facts

The NTSB investigation used cockpit voice recorder information, ATC data, aircraft-system evidence and wreckage examination to reconstruct the sequence. (Accidents App)

The Broader Safety Lesson

The South Bend accident demonstrates why aircraft controls are not appropriate teaching tools for an unqualified passenger during a critical phase of flight.

There was no reason the passenger needed to control the engine throttles while the aircraft was descending toward its destination.

The captain could have handled the power adjustment himself.

That simple decision would have eliminated the first link in the accident chain.

The accident also shows that a successful engine restart does not automatically mean the emergency is over.

Electrical, hydraulic and landing-gear systems must also be restored.

The lesson is therefore straightforward:

In aviation, unnecessary complexity is a safety hazard.

When an emergency begins, the pilot should reduce variables, follow the checklist and retain control of every critical aircraft function.

Sources

• Original ATC recording