Crash of a Rockwell Sabreliner 75A in Iron Wood: 2 killed

Date & Time: Aug 14, 2000 at 1822 LT
Type of aircraft:
Operator:
Registration:
N85DW
Survivors:
Yes
Schedule:
Brainerd – Flint
MSN:
380-27
YOM:
1975
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
13037
Captain / Total hours on type:
2560.00
Aircraft flight hours:
7185
Circumstances:
The airplane impacted heavily wooded terrain after experiencing a dual engine failure due to a reported lightning strike. The pilot received a weather brief that included information concerning a Convective Sigmet and a Severe Weather Watch. The weather briefer informed the pilot that a route to the southeast would keep the flight out of the heavy weather, and that, "... you'll get clobbered if you go due east." After departure, the pilot requested a turn to the northeast to stay clear of weather. While in the climb, the flight was advised of a Weather Watch that covered the area of their flight. The CVR revealed that Continuous Ignition was not selected prior to encountering turbulence. About 23 minutes after takeoff, the airplane was climbing at about 30,800 feet msl when the pilot reported a dual engine failure due to a lightning strike. The CVR indicated one engine quit and the second quit about two seconds later. The copilot established a 170 kts descent airspeed for "best glide." The airplane was vectored near a level 5 thunderstorm during the emergency descent. Two air starts were attempted when the airplane's altitude was outside of the air start envelope. Two more air starts were attempted within the air start envelope but were unsuccessful. The minimum airspeed for an air restart is 160 kts and the maximum speed for air start is 358 kts. The CVR indicated that the pilots did not call for the airplane's checklist, and no challenge and response checklists were used during the emergency descent. The CVR indicated the pilots did not discuss load shedding any of the electrical components on the airplane. The CVR indicated the hydraulic system cycled twice during the emergency descent and the landing gear was lowered using the hydraulic system during descent. During the descent the pilots reported they had lost use of their navigation equipment. The airplane impacted the terrain located about 166 nautical miles from the departure airport on a bearing of 083 degrees. No preexisting engines or airframe anomalies were found.
Probable cause:
The pilot's improper in-flight decision, the pilot's continued flight into known adverse weather, the pilot's failure to turn on the continuous ignition in turbulence, and the pilot's failure to follow the procedures for an airstart. Factors included the thunderstorms, the lightning strike, and the woods.
Final Report:

Crash of a Piper PA-46-350P Malibu Mirage in Augusta: 3 killed

Date & Time: Aug 4, 2000 at 0745 LT
Registration:
N198PM
Flight Phase:
Survivors:
No
Schedule:
Augusta – Atlantic City
MSN:
46-36133
YOM:
1998
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
6000
Captain / Total hours on type:
80.00
Aircraft flight hours:
451
Circumstances:
Witness's reported that the airplane took off from runway 05, which has an up slope of 1.2 degrees. The airplane was observed at approximately 10 feet above ground level, in a nose high attitude traveling parallel to the ground and not climbing. The airplane narrowly cleared a 6- foot fence off the departure end of runway 05. Shortly thereafter, the airplane impacted a utility pole, the roof of a bus stop, which was followed by a brick wall. At the time of the accident runway 23, which has a 1.2-degree down slope and has a clear-cut area on the departure end, was available for use. The basic empty weight for this airplane is 3,097 pounds; the useful load is 1,201.7 pounds. The actual load at the time of the accident was in excess of the useful load. There is no record of the pilot completing a weight and balance computation prior to take-off. The toxicology examinations were negative for carbon monoxide, cyanide, drugs and alcohol. The toxicology examination revealed that 1175(mg/dl) glucose was detected in the urine. Examination of the airplane and subsystems failed to disclose any mechanical or component failures.
Probable cause:
Improper preflight planning/preparation by the pilot, which resulted in taking off with the airplane exceeding the weight and balance limitations. Factors to the accident were the improper loading of the airplane, taking off from a short, up sloping runway and the pilot's elevated glucose level.
Final Report:

Crash of a Piper PA-46-310P Malibu in Thury-en-Valois: 6 killed

Date & Time: Jun 3, 2000 at 1846 LT
Operator:
Registration:
D-EEII
Flight Phase:
Survivors:
No
Schedule:
Jersey - Allendorf
MSN:
46-08036
YOM:
1986
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
6
Circumstances:
The single engine airplane, owned by a German company based in Allendorf, departed Jersey Island on a flight to Allendorf-Eder Airport. While in cruising altitude over the east part of Paris in poor weather conditions, the aircraft entered an uncontrolled descent and crashed in a colza field located in Thury-en-Valois. The aircraft was totally destroyed by impact forces but did not catch fire. All six occupants were killed. At the time of the accident, the airplane was flying in very poor weather conditions with thunderstorm activity.

Crash of a Cessna 414 Chancellor near Monarch: 3 killed

Date & Time: May 31, 2000 at 1728 LT
Type of aircraft:
Operator:
Registration:
N5113G
Flight Phase:
Survivors:
No
Site:
Schedule:
Great Falls - Billings
MSN:
414-0952
YOM:
1977
Location:
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
8000
Aircraft flight hours:
7406
Circumstances:
During climbout, the airplane encountered an area of freezing rain resulting in rapid airframe ice accretion and loss of climb capability. The pilot informed ATC that he was unable to maintain altitude and requested and received clearance back to Great Falls, the departure airport. ATC radar showed that the airplane then began a right turn over mountainous terrain extending up to 8,309 feet prior to loss of radar contact (lower and relatively flat terrain, down to less than 5,000 feet, was located to the left of the aircraft's track.) During the last minute of radar contact, the aircraft was in a right turn at a descent rate of about 400 feet per minute; the aircraft passed less than 1/2 mile from the 8,309-foot mountain summit just prior to loss of radar contact, at an altitude of 8,400 to 8,500 feet. The aircraft crashed on the southwest flank of the 8,309-foot mountain about 1/2 mile south of the last recorded radar position. Wreckage and impact signatures at the crash site were indicative of an inverted, steep-angle, relatively low-speed, downhill impact with the terrain. The investigation revealed no evidence of any aircraft mechanical problems.
Probable cause:
The failure of the pilot-in-command to ensure adequate airspeed for flight during a forced descent due to airframe icing, resulting in a stall. Factors included: freezing rain conditions, airframe icing, an improper decision by the pilot-in-command to turn toward mountainous terrain (where a turn toward lower and level terrain was a viable option), mountainous terrain, and insufficient altitude available for stall recovery.
Final Report:

Crash of a Rockwell Sabreliner 65 in Molokai: 6 killed

Date & Time: May 10, 2000 at 2031 LT
Type of aircraft:
Registration:
N241H
Survivors:
No
Schedule:
Papeete – Christmas Island – Kahului – Molokai
MSN:
465-5
YOM:
1979
Location:
Crew on board:
2
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
6
Captain / Total flying hours:
12775
Captain / Total hours on type:
1370.00
Copilot / Total flying hours:
1725
Aircraft flight hours:
7934
Circumstances:
The airplane collided with mountainous terrain after the flight crew terminated the instrument approach and proceeded visually at night. The flight crew failed to brief or review the instrument approach procedure prior to takeoff and exhibited various cognitive task deficiencies during the approach. These cognitive task deficiencies included selection of the wrong frequency for pilot controlled lighting, concluding that the airport was obscured by clouds despite weather information to the contrary, stating inaccurate information regarding instrument approach headings and descent altitudes, and descending below appropriate altitudes during the approach. This resulted in the crew's lack of awareness regarding terrain in the approach path. Pilots approaching a runway over a dark featureless terrain may experience an illusion that the airplane is at a higher altitude that it actually is. In response to this illusion, referred to as the featureless terrain illusion or black hole phenomenon, a pilot may fly a lower than normal approach potentially compromising terrain clearance requirements. The dark visual scene on the approach path and the absence of a visual glideslope indicator were conducive to producing a false perception that the airplane was at a higher altitude. A ground proximity warning device may have alerted the crew prior to impact. However, the amount of advanced warning that may have been provided by such a device was not determined. Although the flight crew's performance was consistent with fatigue-related impairment, based on available information, the Safety Board staff was unable to determine to what extent the cognitive task deficiencies exhibited by the flight crew were attributable to fatigue and decreased alertness.
Probable cause:
Inadequate crew coordination led to the captain's decision to discontinue the instrument approach procedure and initiate a maneuvering descent solely by visual references at night in an area of mountainous terrain. The crew failed to review the instrument approach procedure and the copilot failed to provide accurate information regarding terrain clearance and let down procedures during the instrument approach.
Final Report:

Crash of a Cessna 402B near Mojotoro: 4 killed

Date & Time: Feb 23, 2000 at 0925 LT
Type of aircraft:
Operator:
Registration:
LV-MEW
Survivors:
No
Site:
Schedule:
Orán – Salta
MSN:
402B-1310
YOM:
1977
Location:
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
890
Captain / Total hours on type:
83.00
Copilot / Total flying hours:
680
Copilot / Total hours on type:
70
Circumstances:
The twin engine aircraft departed Orán Airport at 0845LT on an executive flight to Salta, carrying two passengers and two pilots. At 0910LT, while flying under VFR mode, the crew reported his position over Moxat at an altitude of 8,000 feet. At 0923LT, he informed ATC about his position 15NM northeast of Salta Airport and was instructed to contact Salta Tower. Shortly later, the aircraft struck the slope of a mountain (Finca el Desmonde) located near Mojotoro. The aircraft disintegrated on impact and all four occupants were killed.
Probable cause:
Controlled flight into terrain after the crew decided to continue the descent under VFR mode in IMC conditions. It was reported that both pilots have the qualifications for IFR flight but were never trained to fly in such conditions.
Final Report:

Crash of a Mitsubishi MU-300 Diamond IA in Dallas

Date & Time: Jan 27, 2000 at 1015 LT
Type of aircraft:
Registration:
N900WJ
Survivors:
Yes
Schedule:
Austin - Dallas
MSN:
A028SA
YOM:
1982
Crew on board:
2
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
5960
Captain / Total hours on type:
770.00
Aircraft flight hours:
5266
Circumstances:
Freezing rain, mist, and ice pellets were forecast for the destination airport with temperatures 34 to 32 degrees F. During the daylight IMC descent and vectors for the approach, the airplane began to accumulate moderate clear ice, and a master warning light illumination in the cockpit indicated that the horizontal stabilizer heat had failed. The airplane was configured at 120 knots and 10 degrees flaps in accordance with the flight manual abnormal procedures checklist; however, the crew did not activate the horizontal stabilizer deice backup system. The aircraft touched down 1,500 ft down the runway, which was contaminated with slush, and did not have any braking action or antiskid for 3,000 ft on the 7,753-ft runway. Therefore, 3,253 ft of runway remained for stopping the aircraft, which was 192 feet short of the 3,445 ft required for a dry runway landing. Upon observing a down hill embankment and support poles beyond the runway, the captain forced the airplane to depart the right side of the runway to avoid the poles. After the airplane started down the embankment, the nose landing gear collapsed, and the airplane came to a stop.
Probable cause:
The diminished effectiveness of the anti-skid brake system due to the slush contaminated runway. Factors were the freezing rain encountered during the approach, coupled with a failure of the horizontal stabilizer heat.
Final Report:

Crash of a Beechcraft C90 King Air in Güdül: 4 killed

Date & Time: Jan 24, 2000
Type of aircraft:
Operator:
Registration:
TC-DBZ
Flight Phase:
Survivors:
No
Schedule:
Ankara - Istanbul
MSN:
LJ-703
YOM:
1977
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
4
Circumstances:
The twin engine airplane departed Ankara-Esenboğa Airport on a flight to Istanbul with three passengers and one pilot on board, among the operator's President. Few minutes after takeoff, while flying in poor weather conditions due to snow falls, the aircraft went out of control and crashed in a field located in Güdül, about 65 km west of Ankara-Esenboğa Airport. All four occupants were killed.

Crash of a Beechcraft C90 King Air in Somerset: 4 killed

Date & Time: Jan 18, 2000 at 1202 LT
Type of aircraft:
Registration:
N74CC
Survivors:
No
Schedule:
Philadelphia - Columbus - Somerset
MSN:
LJ-620
YOM:
1974
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
19320
Captain / Total hours on type:
1270.00
Aircraft flight hours:
9118
Circumstances:
The pilot requested and received clearance to execute the SDF approach, and was instructed to maintain 4,000 feet until established on the approach. Radar data revealed the airplane was never established on the approach, and started to descend before reaching the IAF. The airplane passed the IAF at 2,900 feet, and continued in a descending left hand turn into unprotected airspace. The airplane disappeared from radar at 1,900 feet, as it completed 180 degrees of turn. The turn did not match any of the four instrument approaches to the airport. The airplane struck a guy wire on a lighted communications antenna 3.3 MN southeast of the airport on a heading of 360 degrees. No evidence of a mechanical failure or malfunction of the airplane or its systems was found. A flight check by the FAA confirmed no navigation signal was received for the approach, which had been turned off and listed as out of service for over 4 years. In addition, the pilot did not report the lack of a navigation signal to ATC or execute a missed approach. Interviews disclosed the ATC controller failed to verify the approach was in service before issuing the approach clearance.
Probable cause:
The failure of the pilot to follow his approach clearance, and subsequent descent into unprotected airspace which resulted in a collision with the guy wire. Factors were the failure of the air traffic controller to verify the approach he cleared the pilot to conduct was in service, and the clouds which restricted the visibility of the communications antenna.
Final Report:

Ground fire of an IAI-1124A Westwind II in Milwaukee

Date & Time: Dec 26, 1999 at 0715 LT
Type of aircraft:
Registration:
N422BC
Flight Phase:
Survivors:
Yes
Schedule:
Milwaukee - Waukesha
MSN:
302
YOM:
1980
Crew on board:
2
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
14363
Captain / Total hours on type:
2024.00
Aircraft flight hours:
7975
Circumstances:
During the activation of the crew oxygen system a fire erupted which consumed the entire pressure vessel. Representatives from the National Aeronautics and Space Administration's (NASA) Johnson Space Center (JSC), White Sands Testing Facility (WSTF), Las Cruces, New Mexico, examined the retained oxygen system components. Examination of these components revealed that the fire's initiation location was the first stage pressure reducer located in the oxygen regulator assembly.
Probable cause:
The failure of the first stage pressure reducer in the oxygen regulator assembly.
Final Report: