Crash of a Beechcraft 65 Queen Air in Elko: 2 killed

Date & Time: Nov 2, 1988 at 1453 LT
Type of aircraft:
Registration:
N9AG
Flight Type:
Survivors:
No
Schedule:
Elko - Farmington
MSN:
LC-51
YOM:
1960
Location:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
884
Captain / Total hours on type:
103.00
Aircraft flight hours:
8945
Circumstances:
Approximately 10 minutes after takeoff, the pilot stated he was returning to land due to a problem. On final the aircraft rolled inverted and descended nose down into a residence. Engine examination revealed a failed supercharger intermediate drive shaft gear resulting in loss of supercharger on the right engine. The aircraft was approximately 300 lbs over max gross weight. The landing gear was down and the flaps were extended approx 20°. The left throttle was found in the full forward (high power) position. The right prop control was in full decrease rpm, high pitch and the right engine magneto switches were off. Witnesses had observed the aircraft descend to below traffic pattern altitude. At approx 200 feet agl a loud engine noise was heard and the slow flying aircraft pitched up, rolled right and descended vertically about 1/2 mile from the airport. The pilot had not declared an emergency or defined his problem. The pilot's last recorded flight in the Beech 65 was in February 1988. There was no record of a check-out or flight training in the aircraft. Both occupants were killed.
Probable cause:
Occurrence #1: loss of engine power (partial) - mech failure/malf
Phase of operation: climb - to cruise
Findings
1. (f) accessory drive assy, drive gear - worn
2. (f) exhaust system, turbocharger - failure, total
----------
Occurrence #2: loss of control - in flight
Phase of operation: approach - vfr pattern - final approach
Findings
3. (f) weather condition - gusts
4. (c) in-flight planning/decision - inadequate - pilot in command
5. (c) airspeed (vmc) - not maintained - pilot in command
6. (f) inadequate training (emergency procedure(s)) - pilot in command
7. (f) lack of recent experience in type of aircraft - pilot in command
8. (f) aircraft weight and balance - exceeded - company/operator management
----------
Occurrence #3: in flight collision with object
Phase of operation: descent - uncontrolled
Findings
9. Object - residence
Final Report:

Crash of an Avro 748-2B-FAA in Cheney: 2 killed

Date & Time: Sep 15, 1988 at 1019 LT
Type of aircraft:
Operator:
Registration:
C-GFFA
Flight Type:
Survivors:
No
Schedule:
Montreal - Ottawa
MSN:
1789
YOM:
1981
Location:
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
A BAe-748 cargo plane was destroyed when it crashed while on approach to Ottawa International Airport, ON (YOW), Canada. Both pilots were killed. The airplane had arrived at Montreal-Dorval International Airport, QC (YUL) following a cargo flight from Dayton, OH, USA. All the cargo was unloaded in Montreal and the aircraft departed at 09:58 for Ottawa on an instrument flight rules (IFR) flight plan. The en route phase of the flight were uneventful. At about 10:19, while the aircraft was in level cruise flight at 3000 feet at approximately 200 knots indicated airspeed (KIAS), the flight data recorder (FDR) recorded a full-up deflection of the left aileron and a full-down deflection of the right aileron, and the aircraft began a roll to the left at a high rate. The right aileron remained at the fully-deflected position for a period of three seconds, and then, over the next seven seconds, the deflection gradually decreased by about five degrees. During the same 10-second period, the left aileron remained nearly fully deflected for the first eight seconds, then the deflection decreased by about five degrees during the next two seconds. By this time, the aircraft had rolled through approximately 460 degrees, and the aircraft nose had dropped 20 to 30 degrees below the horizon. At this point, the ailerons suddenly returned to about the neutral position and remained there for the last three seconds of the flight. The aircraft bank angle remained at approximately 90 degrees of left bank with a maximum vertical g of 4.7 recorded. The aircraft struck the ground at an airspeed of approximately 290 KIAS after a heading change of about 75 degrees left of the cruise heading. At impact, the aircraft bank angle was nearly 90 degrees left and the pitch angle was 41 degrees down. The time from the initial aileron deflection to ground impact was approximately 18 seconds.
Probable cause:
The Board determined that the aileron control system was asymmetrically rigged, making it susceptible to aerodynamic overbalance. The operator did not conduct the required post-maintenance flight tests of the aileron control response. When the ailerons were held at full deflection by aerodynamic forces, following a large control-wheel input by the pilot, the subsequent control reaction by the pilot was inappropriate. Contributing to the accident were the design of the aileron system; ambiguous and incomplete maintenance instructions; a lack of published information for flight crew concerning aileron system performance and possible emergencies; and the presence of factors which may have led to the development of flight crew fatigue.

Crash of a Lockheed L-188A Electra in Lago Agrio: 7 killed

Date & Time: Sep 12, 1988 at 1429 LT
Type of aircraft:
Operator:
Registration:
HC-AZY
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Lago Agrio - Quito
MSN:
1052
YOM:
1959
Country:
Crew on board:
7
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
7
Circumstances:
The engine n°2 was inoperative due to technical problems and the crew decided to takeoff on a positioning flight to Quito with only three engines. Shortly after takeoff from Lago Agrio Airport, while in initial climb, the engine n°1 caught fire and exploded. The crew lost control of the aircraft that banked left and crashed, bursting into flames. All seven occupants were killed.
Probable cause:
Failure and explosion of the engine n°1 at takeoff for unknown reasons.

Crash of a Mitsubishi MU-2B-60 Marquise in Eindhoven: 2 killed

Date & Time: Sep 12, 1988 at 0705 LT
Type of aircraft:
Operator:
Registration:
PH-DRX
Flight Type:
Survivors:
No
Schedule:
Rotterdam - Eindhoven
MSN:
1555
YOM:
1982
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
9050
Captain / Total hours on type:
500.00
Copilot / Total flying hours:
7500
Copilot / Total hours on type:
1200
Circumstances:
The crew was completing a positioning flight from Rotterdam to Eindhoven. On approach to Eindhoven Airport, the visibility was poor due to fog when the aircraft struck tree tops 5,6 km short of runway. On impact, the elevators were torn off. The aircraft then struck other trees and crashed on a embankment located near Best, bursting into flames. Both pilots were killed.
Probable cause:
The crew failed to follow the published procedures, attempted a visual approach in IMC conditions and decided to descend below the MDA without any visual contact with the ground until the aircraft collided with obstacles.

Crash of a Beechcraft 200 Super King Air in Jackson: 1 killed

Date & Time: Sep 11, 1988 at 2157 LT
Registration:
N1283
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Jackson - Redding
MSN:
BB-90
YOM:
1976
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
4400
Captain / Total hours on type:
62.00
Aircraft flight hours:
5677
Circumstances:
The pilot and his two passengers had just arrived at the Jackson-Hole Airport (JAX) approximately 30 minutes prior to the accident. The pilot dropped off his passengers and stepped into operations for a short break. He then returned to the aircraft by himself for a return flight to California. It was a very dark night with a 2,000 feet overcast and no visible horizon. The pilot had departed Redding, CA at 1357 hours and had been on continuous flight duty from that time until the time of the accident. A witness stated the pilot seemed to be tired and hungry. The aircraft was observed making a normal night takeoff. Witnesses stated that as the aircraft turned from crosswind to downwind it appeared that the pilot had trouble controlling the aircraft. After the aircraft made a few extreme up and down maneuvers, it appeared to proceed to the east. The next time the aircraft was observed, it was again climbing and descending rapidly and subsequently impacted the ground in a vertical dive. The pilot, sole on board, was killed.
Probable cause:
Occurrence #1: altitude deviation,uncontrolled
Phase of operation: climb - to cruise
Findings
1. (f) light condition - dark night
2. (c) altitude - uncontrolled - pilot in command
3. (c) planning/decision - poor - pilot in command
4. (f) fatigue (flight schedule) - pilot in command
5. (c) flight controls - improper use of - pilot in command
6. (c) spatial disorientation - pilot in command
----------
Occurrence #2: in flight collision with terrain/water
Phase of operation: descent - uncontrolled
Final Report:

Crash of a Learjet 35A in Morristown: 1 killed

Date & Time: Jul 26, 1988 at 0740 LT
Type of aircraft:
Operator:
Registration:
N442NE
Flight Type:
Survivors:
Yes
Schedule:
Allentown - Morristown
MSN:
35-442
YOM:
1981
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
4810
Captain / Total hours on type:
2100.00
Aircraft flight hours:
4274
Circumstances:
The crew was positioning the aircraft in preparation for a revenue flight and executing a non-directional beacon (NDB) approach to runway 05. The captain reported that the copilot was flying the aircraft. However, the captain stated that he took control of the aircraft during the approach and made some control corrections before returning control of the aircraft to the copilot. Radar data indicated that aircraft control was erratic throughout the approach and that the airspeed and descent rates were high (3,000 fpm sink rate) shortly before the accident. The aircraft struck a fence short of the runway and impacted the ground. The captain said he realized the aircraft was drifting left of course but did not correct it. He said he told the copilot to add power twice during the approach. The copilot's training history indicated difficulty in control, scan of instruments, and with instrument procedures. Company management described the captain as passive and the copilot as aggressive. Supervision of training and operations by management and surveillance of the company by the FAA was considered inadequate by NTSB.
Probable cause:
Occurrence #1: loss of control - in flight
Phase of operation: approach - faf/outer marker to threshold (ifr)
Findings
1. (c) flight controls - improper use of - copilot/second pilot
2. Overconfidence in personal ability - copilot/second pilot
3. (f) inadequate recurrent training - copilot/second pilot
4. (f) inadequate surveillance of operation - faa (organization)
5. (f) airspeed - improper - copilot/second pilot
6. (f) proper descent rate - exceeded - copilot/second pilot
7. (c) supervision - inadequate - pilot in command
8. (f) interpersonal relations - pilot in command
9. Insufficient standards/requirements,airman - company/operator mgmt
----------
Occurrence #2: in flight collision with terrain/water
Phase of operation: approach - faf/outer marker to threshold (ifr)
Final Report:

Crash of a De Havilland DHC-6 Twin Otter 200 in Washington-Dulles: 1 killed

Date & Time: Jul 20, 1988 at 1608 LT
Registration:
N7267
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Washington - Washington
MSN:
195
YOM:
1969
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
12400
Aircraft flight hours:
10513
Circumstances:
This was the first flight after a maintenance inspection. The flaps were left full down after a post-inspection by company mechanics, before the flight. Witnesses stated the flaps were down when the aircraft taxied to takeoff on runway 19L. Witnesses stated the aircraft climbed steeply after it lifted off with a pitch attitude up to 60°. According to witnesses, the aircraft climbed to 200 to 500 feet agl, before it stalled and descended nose down in a left turn. The aircraft crashed about 300 ft left of and 2000 ft down the rwy. Examination of the aircraft revealed the flaps were full down. The scroll type checklist was positioned at the beginning of the takeoff check. The flight manual recommends a 10 degree flap setting for takeoff and prohibits flap full down takeoff. Review of previous DHC-6 accidents involving flap full down resulted in a steep takeoff climb and excessive pitch attitude followed by a stall. The position of the control lock suggests it may have been in the locked position during the takeoff. The pilot, sole on board, was killed.
Probable cause:
The pilot inadvertently misused the flaps, by failing to set the flaps to the proper setting. The flaps were set full down. This caused the aircraft to pitch up steeply after liftoff. Additionally, the flight control lock was probably installed during some portion, if not the entire flight, which prevented flight control operation. The pilot subsequently failed to maintain adequate flying speed and the aircraft stalled. Contributing factors are the pilot's inattention and his failure to adequately use the checklist.
Findings:
Occurrence #1: loss of control - in flight
Phase of operation: takeoff - initial climb
Findings
1. (c) raising of flaps - not performed - pilot in command
2. (f) inattentive - pilot in command
3. (f) checklist - not used - pilot in command
4. (f) procedures/directives - not followed - pilot in command
5. (f) removal of control/gust lock(s) - inadvertent use - pilot in command
----------
Occurrence #2: in flight collision with terrain/water
Phase of operation: descent - uncontrolled
Final Report:

Crash of a De Havilland DHC-6 Twin Otter 200 on Mt Battle Creek: 1 killed

Date & Time: Jul 14, 1988 at 1140 LT
Operator:
Registration:
C-GKBM
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Redmond - John Day
MSN:
417
YOM:
1974
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
The DHC-6 Twin Otter, C-GKBM, was under contract to the U.S. Forest Service. It was to be repositioned to John Day, OR to pick up passengers. At 11:35 PDT, the pilot checked in with John Day Dispatch and transmitted his expected time of arrival would be 12:15 PDT. About 11:40 the aircraft contacted three trees with the right wing at the 5,000-foot level of Battle Creek Mountain. This impact separated the wing into three sections before the aircraft "exited" over the mountain edge. The final impact site was on this ridgeline with the aircraft coming to final rest in a steep canyon to the east. There was a high mountain further east on the flight path that also needed to be crossed before a descent to John Day, Oregon could be commenced. The pilot's medical records indicated the he had been having medical problems, some of which he did not want brought to the attention of the Medical Doctor (MD) designated by the FAA to do flight physicals. In addition, he did not tell his supervisor that he was having medical problems. It was noted that he had complaints of chronic muscular neck pains, back problems, falling asleep, allergy problems, numbness in the top of his feet, feeling tired and run down, and pain in his legs. The flight track showed a gradual descent of about 400 feet per minute. He was off course to the right for about five minutes before impacting with trees. This flight tract strongly supported a very high probability of sleep-induced unconsciousness.
Probable cause:
The most probable cause of this mishap was determined to be the pilot’s acute in-flight incapacitation due to sleep.

Crash of a Piper PA-60 Aerostar (Ted Smith 600) in San Juan: 1 killed

Date & Time: Jun 20, 1988 at 1252 LT
Registration:
N90360
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
San Juan - San Juan
MSN:
60-0212-093
YOM:
1975
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
7391
Captain / Total hours on type:
11.00
Aircraft flight hours:
2958
Circumstances:
As the aircraft was taxiing for takeoff, witnesses noted the left rear baggage door was unlocked and hanging down. A warning was relayed to the pilot via the tower, but by then the aircraft was airborne and the pilot had reported a control problem. During lift-off, the aircraft pitched up sharply and entered an immediate right bank of about 45°. As the gear retracted, the bank angle decreased to about 20°. The aircraft was reported to yaw slightly from side to side and circle to the right while climbing to about 1,000 feet. A witness (in radio contact) asked the pilot about the problem; the pilot replied the controls (ctls) were locked to one side. On advice of others, the pilot tried to control the aircraft with engine power adjustments, but the aircraft lost altitude to about 200 feet agl. Subsequently, while maneuvering, it struck a tree, then hit a utility pole and crashed. During impact the lower fuselage, which housed the flight control linkages, was badly damaged. No preimpact mechanical problem was verified concerning the flight controls, autopilot or trim. A pilot, who had previously flown the aircraft with the baggage door open, said he experienced no adverse control problems. The pilot, sole on board, was killed.
Probable cause:
Occurrence #1: airframe/component/system failure/malfunction
Phase of operation: takeoff - initial climb
Findings
1. (f) aircraft preflight - improper - pilot in command
2. (f) door - open
3. (c) flight control system - undetermined
----------
Occurrence #2: loss of control - in flight
Phase of operation: maneuvering
----------
Occurrence #3: in flight collision with object
Phase of operation: maneuvering
Findings
4. (f) object - tree(s)
5. (f) object - utility pole
----------
Occurrence #4: in flight collision with terrain/water
Phase of operation: descent - uncontrolled
Final Report:

Crash of a Learjet 35A in Teterboro: 4 killed

Date & Time: May 24, 1988 at 0316 LT
Type of aircraft:
Registration:
N500RW
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Teterboro - Morristown
MSN:
35-148
YOM:
1978
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
8910
Captain / Total hours on type:
759.00
Aircraft flight hours:
4735
Circumstances:
Witnesses reported a normal takeoff. Radar indicated the aircraft turned right as cleared and began cruise at 1900 feet, heading northwest at 235 knots. 65 seconds after calling clear of the control zone the aircraft's radar track ended. The aircraft was fragmented by the impact with all flight control surfaces and aircraft extremities found at the impact site. Pitch trim was found in the normal cruise setting with gear, flaps, and spoilers in the retracted position. Examination of the engines indicated operation at impact. Aircraft struck the terrain in approx 80° nose down, wings level attitude and heading opposite to the previous direction of flight. In flight simulator tests, with the aircraft initially in level flight at 1,900 feet and then rolled inverted and the pitch control moved aft, the aircraft attitude was similar to the attitude at impact. There were two unauthorized passengers on board, one was the copilot's wife. The impact point was in a very small region of uncontrolled airspace very near the copilot's and relative's homes. The copilot was new to jet operations. The aircraft departed with several discrepancies uncleared. All four occupants were killed.
Probable cause:
Occurrence #1: in flight collision with terrain/water
Phase of operation: maneuvering
Findings
1. (f) light condition - dark night
2. (c) maneuver - attempted - pilot in command
3. (c) judgment - poor - pilot in command
4. (c) altitude - misjudged - pilot in command
5. (f) lack of total experience in type operation - pilot in command
6. (f) lack of total experience in type operation - copilot/second pilot
7. Operation with known deficiencies in equipment - attempted - company maintenance personnel
Final Report: