Pilot error caused a fatal aircraft crash in June 2019 at Addison Airport that killed 10 people, according to a report released Tuesday by the National Transportation Safety Board.
The failure of a pilot to control the plane following the loss of thrust in one of two engines just seconds after takeoff led to the fatal crash, the NTSB reported.
The Beechcraft King Air 350 rolled upside down and crashed into an airport hangar seconds after liftoff, killing the pilot, co-pilot and all eight passengers.
It was the worst aviation disaster in Dallas-Fort Worth in three decades.
On a cockpit voice recorder, pilot Howard Cassady, 71, of Fort Worth, can be heard talking with another, unidentified person about the engine on the left side of the plane, according to the transcript.
The recording also reveals that, at 9:10 a.m., about six seconds after liftoff, the pilot uttered the phrase “What in the world?”
Then the co-pilot, Matthew Palmer, 28, also of Fort Worth, responded, “You just lost your left engine,” according to the transcript. Another six seconds later, the co-pilot can be heard saying “Holy ----” and two seconds after that there is a sound of impact and the recording stops.
Passengers killed in the crash included Brian and Ornella Ellard, whose family owned a business that bought the plane earlier in 2019; their children Alice and Dylan Maritato; Steve and Gina Thelen; and John and Mary Titus.
Cassady had 16,450 hours of flight experience, according to NTSB records.
Palmer and his wife had just celebrated their one-year wedding anniversary, according to Palmer’s wife’s Facebook page. Palmer was a ranch and arena hand at the Fort Worth Stock Show & Rodeo.
Palmer had 2,357 hours of overall flight experience — including 225 hours as pilot, and 615 hours as co-pilot, of a turboprop aircraft.
Investigators analyzed video from multiple cameras on and off the airport property, the flight track broadcast by the airplane as well as known flight performance data and characteristics of the plane to recreate the accident flight path and determine the plane’s position, speed, altitude and roll angles.
The left engine lost almost all thrust several seconds after takeoff and the pilot responded with left rudder input, the opposite action of what the emergency called for, according to the NTSB report. Seconds later, the pilot applied right rudder but by that point the plane was rolling inverted, and there was insufficient altitude for recovery.
Investigators determined that had the pilot applied right rudder input, the airplane would have been controllable, according to the report released on Tuesday.
The audio from the recorder indicated that the pilots did not call for any of the checklists that would typically be used before takeoff, and they did not discuss what they would do in case of loss of engine thrust on takeoff or any other emergency procedure, the report stated.
The pilots’ failure to follow checklists and adhere to the airplane manufacturer’s emergency procedure were factors in the fatal accident, according to the NTSB report.
A detailed examination of the left engine and its control systems found no condition that would have prevented normal operation, the report says. The NTSB noted that there was a known risk of an unintentional movement of an engine power lever if its friction lock was adjusted incorrectly. Friction lock settings are one of the items in a pre-takeoff checklist the pilot failed to use, the NTSB said.
Investigators were unable to determine if the friction lock settings played a role in the loss of thrust on the left engine. The cause for loss of engine thrust could not be determined, according to the report.
In 2020, family members of two people killed in the crash filed a wrongful death lawsuit against the aircraft’s operators, EE Operations LLC, EE Realty, Inc. and S&H Aircraft LLC. The suit was filed in Dallas County. The status of the lawsuit was not available on Tuesday.
The flight on the privately owned airplane was bound for St. Petersburg, Florida.
This report contains information from the Fort Worth Star-Telegram archives.