Crash of a Swearingen SA227AC Metro III in San Antonio

Date & Time: Aug 16, 1999 at 1733 LT
Type of aircraft:
Operator:
Registration:
N2671V
Flight Type:
Survivors:
Yes
Schedule:
San Antonio - San Antonio
MSN:
AC-437
YOM:
1981
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3400
Captain / Total hours on type:
490.00
Aircraft flight hours:
19317
Circumstances:
The airplane landed wheels up after the instructor pilot failed to lower the landing gear. The instructor told the student to execute 'a no flap landing due to a simulated hydraulic pump failure.' The student established the airplane on the approach and called for the 'Emergency Gear Extension Checklist.' The instructor delayed extending the gear in accordance with the operator's flight standards manual, which stated that the landing gear should not be extended until the landing was assured. Later in the approach, when the gear warning horn stopped sounding, due to the student's movement of the power levers forward, the instructor removed his hand from the gear handle without extending the gear. The instructor stated that 'because [the student] had already called for the [Emergency Gear Extension] checklist once before, in a split second thought process, [he] mistakenly thought it had been completed.' Following the accident, the landing gear system was tested and found to operate normally. Review of the maintenance records revealed no uncorrected discrepancies. At the time of the accident, the instructor pilot was completing a 9-hour work day, and did not have a lunch break.
Probable cause:
The instructor pilot's failure to complete the Emergency Gear Extension Checklist, resulting in the inadvertent wheels-up landing. A factor was the instructor pilot's fatigued condition.
Final Report:

Crash of a Lockheed L-1329-25 JetStar II in Austin

Date & Time: Nov 27, 1998 at 1405 LT
Type of aircraft:
Operator:
Registration:
N787WB
Survivors:
Yes
Schedule:
Houston - Austin
MSN:
5210
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
8350
Captain / Total hours on type:
750.00
Aircraft flight hours:
5938
Circumstances:
During the landing roll, the nose gear settled onto the runway, and the aircraft veered hard to the right. Application of the left brake had no effect. The airplane skidded, exited the runway, struck a runway marker, and collapsed the nose landing gear. The steering actuator had failed, the hydraulic fluid was lost from the steering actuator, and the fuselage received structural damage. The steering actuator assembly, p/n 1501-4, had accumulated 5,938.0 hours since new and had not been repaired or overhauled. Examination of the nose gear steering actuator cylinder by the metallurgist revealed that the cylinder fracture was the result of fatigue cracking initiated by an abrupt machining transition from the 45 degree thread ring chamfer to the straight wall of the cylinder. The engineering drawings appear to depict the radius at the fatigue origin as a continuation of the 0.03 inch to 0.06 inch radius adjacent to the fracture. However, the drawing is not clear on the specific intent of the transition between the nearby radius and the internal threads for the nut.
Probable cause:
The steering actuator fatigue failure resulting from inadequate procedure documentation for the manufacturing process.
Final Report:

Crash of a Cessna 421C Golden Eagle III in Eagle Pass

Date & Time: Oct 18, 1998 at 0600 LT
Operator:
Registration:
N19MH
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Eagle Pass - San Antonio
MSN:
421C-1008
YOM:
1980
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
2095
Captain / Total hours on type:
120.00
Aircraft flight hours:
4071
Circumstances:
During takeoff climb, the twin-engine airplane encountered a strong downdraft and impacted trees and terrain. The pilot reported that while taxiing to the runway, he scanned the sky with the monochrome weather radar, which was set at the 40-mile range. 'No weather was shown behind the runway and a cell was shown 15 miles from the runway.' The takeoff roll was 'uneventful,' and the airplane was rotated at 95 knots. Climb out was accomplished at 110 knots, the engines were at maximum power, the propellers at maximum RPM, and the manifold pressure was indicating maximum. A 10-degree turn towards the Cotulla VOR was being made when at 1,500 feet msl, a sharp descent was felt with the VSI indicating an 800 ft/min rate of descent. The wings were leveled and the airspeed was slowed to 85 knots. 'The rate of descent slowed to 400 ft/min and then finally to 300 ft/min until impact...' The airplane was destroyed by fire that erupted on impact. A review of doppler weather radar images showed thunderstorms in the vicinity of the airport.
Probable cause:
A downdraft, which exceeded the aircraft's climb performance. A factor was the thunderstorms in the vicinity of the airport.
Final Report:

Crash of a Dassault Falcon 20C in El Paso

Date & Time: Aug 28, 1998 at 0650 LT
Type of aircraft:
Operator:
Registration:
N126R
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Addison - El Paso - Memphis
MSN:
126
YOM:
1968
Flight number:
RLT126
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3700
Captain / Total hours on type:
1850.00
Copilot / Total flying hours:
3636
Copilot / Total hours on type:
124
Aircraft flight hours:
16602
Circumstances:
The airplane was dispatched as a cargo flight to pick up a load of 118 boxes of automotive seatbelts. After refueling and loading the cargo on board, the flight crew taxied to runway 22 for a no-flap takeoff, which called for a V1 speed of 141 knots. The first officer was the flying pilot for this leg of the flight. The crew reported that the initial takeoff roll from the 11,009 foot runway was normal. At approximately 120 knots, the flight crew reported hearing a loud bang followed by a vibration. The captain called for the first officer to abort the takeoff. The captain later stated that he believed he saw the #2 engine "roll back." The flight crew reported that the brakes were not effective in slowing the airplane. A witness stated that the airplane was going west on the runway at a high rate of speed when it "went up to two feet, then came back down." Another witness stated that he saw the airplane "exit off the end of the runway" and after about "seventy-five to one hundred feet, the front wheels lifted off the ground about ten feet." The airplane overran the departure end of the runway, went through the airport's chain link perimeter fence, across a 4-lane highway, collided with 3 vehicles on the roadway, and went through a second chain link fence, before coming to rest. The airplane came to rest on its belly, 2,010 feet from the departure threshold of runway 22. The investigation revealed that the flight crew was provided an inaccurate weight for the cargo, and the airplane was found to be 942 pounds over the maximum takeoff weight at the time of the accident. The density altitude was calculated to be 5,614 feet at the time of the accident. Both crewmembers were current and properly certified; however, the captain had upgraded to his present position two months prior to the accident, and the first officer had accumulated a total of 123.8 hours in the Falcon 20 at the time of the accident. Both engines were operated in a test cell and performed within limits. About 90% of the right outboard main landing gear tire's retread was found on the runway approximately 7,200 feet from where the aircraft had commenced its takeoff roll. The operator stated that since the aircraft was over maximum gross weight, the long taxi to the runway could have resulted in the brakes and tires heating more than normal.
Probable cause:
The captain's decision to abort the takeoff at an airspeed above V1, which resulted in a runway overrun. Contributing factors were: the loading of an excessive amount of cargo by the shipper which resulted in an over gross weight airplane, the high density altitude, the separation of tire retread on takeoff roll, and the flight crew's lack of experience in the accident make and model aircraft.
Final Report:

Crash of a Beechcraft E18S in Del Rio

Date & Time: Apr 8, 1998 at 1905 LT
Type of aircraft:
Registration:
N2083C
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Del Rio - San Antonio
MSN:
BA-446
YOM:
1959
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
6800
Captain / Total hours on type:
55.00
Circumstances:
The pilot lost control of the airplane following the loss of engine power from the right engine during takeoff. The pilot stated that the engine power loss was not sudden, but rather a slow continued reduction of power. The pilot further stated that the loss of power occurred after he placed the landing gear selector in the retract position. He added that his airspeed at the time of the power loss was between Vmc (86 mph) and Vy (120 mph). The airplane started to roll towards the right (dead) engine as the pilot reduced the power on the left engine. The outboard portion of the right wing impacted the ground short of a taxiway. Examination of the wreckage revealed that the right engine propeller was in the feather position and the left engine was torn from the airframe. The reason for the loss of engine power was not determined.
Probable cause:
A loss of engine power on the right engine for undetermined reasons, and the pilot's failure to maintain control of the airplane.
Final Report:

Crash of an Embraer ERJ-145 in Beaumont

Date & Time: Feb 11, 1998 at 1216 LT
Type of aircraft:
Operator:
Registration:
N14931
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Beaumont - Beaumont
MSN:
145-013
YOM:
1997
Flight number:
CO910
Crew on board:
4
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
10800
Captain / Total hours on type:
800.00
Copilot / Total flying hours:
1932
Copilot / Total hours on type:
15
Aircraft flight hours:
1844
Aircraft flight cycles:
1472
Circumstances:
The pilot-in-command (PIC) was administering a proficiency check flight to the first officer (FO) in a regional jet. One of the required check items was the loss of an engine at "V1" speed. While on takeoff roll with the FO at the controls, the PIC retarded the left engine throttle to idle when "V1" speed was attained. The FO called, "check max thrust," and then called, "positive rate gear up." As the PIC reached for the gear lever, he noticed the airplane roll to the left at a rate which he felt was "excessive and dangerous." He then reached for the flight controls and felt the left rudder "go all the way to the floor." As the PIC took control of the airplane, he applied full right rudder and right aileron. The airplane began recovering from the bank and impacted the ground. Flight recorder data revealed that the time interval between the throttle retarded to idle and ground impact was about 8 seconds. The data showed that the airplane became airborne about 2 seconds after the throttle was retarded, and that the airplane had rolled to a 71 degree left bank within 6 seconds from the throttle reduction. Ground scars and wreckage distribution revealed that the left wing had contacted the ground first and then the right wing prior to the airplane coming to rest. The FO had a total of 15 hours in the type aircraft in the last 90 days. Examinations of the airframe, engines, and flight control system did not reveal any anomalies that could have contributed to the accident. Company flight training policy stated that all check airmen should be ready to take control of the airplane while practicing these types of training maneuvers.
Probable cause:
The first officer's improper use of the rudder when given a simulated engine failure on takeoff and the pilot-in-command's delayed remedial action which resulted in a loss of control. A factor was the first officer's lack of experience in the regional jet airplane.
Final Report:

Crash of a Learjet 25B in Houston: 2 killed

Date & Time: Jan 13, 1998 at 0810 LT
Type of aircraft:
Registration:
N627WS
Flight Type:
Survivors:
No
Schedule:
Houston - Fargo
MSN:
25-170
YOM:
1974
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
8777
Captain / Total hours on type:
2512.00
Aircraft flight hours:
8943
Circumstances:
The flight crew was positioning the airplane in preparation for a revenue flight when it crashed 2 nautical miles (nm) short of the runway during a second instrument landing system approach in instrument meteorological conditions. Except for the final 48 seconds of the 25- minute flight, the captain was the flying pilot, and the first officer was the nonflying pilot. When the airplane was about 0.5 nm inside the outer marker on the first approach, the compass warning flag on the captain's course deviation indicator appeared, indicating that the heading display was unreliable. The airplane deviated from the localizer centerline to the left but continued to descend. After about 1 minute, during which time the airplane's track continued to diverge from the localizer centerline, the flight crew executed a missed approach. The flight crew then unsuccessfully attempted to clear the compass flag by resetting circuit breakers. The captain directed the first officer to request a second approach. Contrary to company crew coordination procedures, the flight crew did not conduct an approach briefing or make altitude callouts for either approach. Although accurate heading information was available to the captain on his radio magnetic indicator, he experienced difficulty tracking the localizer course as the airplane proceeded past the outer marker on the second approach. The captain transferred control to the first officer when the airplane was 1.9 nm inside the outer marker. The airplane then began to deviate below the glideslope. The descent continued through the published decision height of 200 feet above ground level, and the airplane struck 80-foot-tall trees. Post accident testing revealed that the first officer's instruments were displaying a false full fly-down glideslope indication because of a failed amplifier in the navigation receiver. The glideslope deficiency was discovered 2 months before the accident by another flight crew. An FAA repair station attempted to resolve the problem and misdiagnosed it as "sticking" needles in the cockpit instruments. The operator was immediately advised of the problem. The operator's minimum equipment list for the airplane required that the problem be repaired within 10 days, but the operator improperly deferred maintenance on it for 60 days and allowed the unairworthy airplane to be flown by the accident flight crew. The airplane was not equipped with, nor was it required to be equipped with, a ground proximity warning system, which would have sounded 40 seconds before impact.
Probable cause:
The flight crew's continued descent of the airplane below the glideslope and through the published decision height without visual contact with the runway environment. Also, when the captain encountered difficulty tracking the localizer course, his improper decision to continue the approach by transferring control to the first officer instead of executing a missed approach contributed to the cause.
In addition, the following were factors to the accident:
(1) American Corporate Aviation's failure to provide an airworthy airplane to the flight crew following maintenance, resulting in a false glideslope indication to the first officer;
(2) the flight crew's failure to follow company crew coordination procedures, which called for approach briefings and altitude callouts; and
(3) the lack of an FAA requirement for a ground proximity warning system on the airplane.
Final Report:

Crash of a Rockwell Aero Commander 500B in Ennis: 2 killed

Date & Time: Jan 10, 1998 at 1427 LT
Registration:
N556BW
Flight Type:
Survivors:
Yes
Schedule:
Lancaster - Laredo
MSN:
500-1625-215
YOM:
1966
Location:
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
1550
Aircraft flight hours:
8081
Circumstances:
After departing on an IFR flight in VFR conditions, the flight had been cleared to climb from 3,000 to 4,000 feet, when the right engine lost power. The pilots diverted toward an uncontrolled airport, secured the right engine, & cancelled their IFR clearance. They made an approach to land on runway 15, then attempted a single engine go-around. During the go-around, the airplane yawed/rolled to the right in what the passenger believed was a VMC roll. It then struck power lines & crashed in a right wing low attitude. Investigation revealed that both pilots held multi-engine ratings. The owner said the pilot (PIC) had flown the airplane for a short time on 12/21/98; however, no other record was found to verify that either the pilot or copilot had flight experience in this make/model of airplane. Examination of the wreckage revealed evidence that the flaps were retracted, the landing gear was in transit, the left propeller was operating with power, & the right propeller was feathered. The airplane had a history of fuel flow fluctuations in the right engine. The diaphragm (P/N 364446) in the right engine distributor valve assembly was found ruptured. It was an old style diaphragm, which was colored black. Bendix Service Bulletin RS-76, issued 11/15/80, called for replacement of the black diaphragm with a red fluorosilicone diaphragm (P/N 245088) at overhaul. The engine was overhauled in June 1992. During maintenance in December 1997, both fuel system injectors & nozzles were tested; however, the distributor valve assembles were not tested. Calculations showed the airplane was loaded 116.3 lbs over the maximum allowable gross weight & 1.3 inches forward of the allowable CG range.
Probable cause:
failure of the flight crew to maintain minimum control speed (VMC) during go-around from a single-engine approach, which resulted in loss of control and collision with power lines and the ground. Related factors were: a ruptured diaphragm in the distributor valve (flow divider) of the right engine's fuel injector system, which resulted in loss of power in the right engine; inadequate maintenance; a failure to comply with Bendix Service Bulletin RS-76; the airplane's excessive gross weight and forward center-of-gravity (CG); and both pilots' lack of experience in this make and model of airplane.
Final Report:

Crash of a Beechcraft G18S in Crosbyton

Date & Time: Oct 6, 1997 at 1830 LT
Type of aircraft:
Registration:
N9312Y
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Lubbock - Dallas
MSN:
BA-550
YOM:
1960
Flight number:
MXP1061
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3222
Captain / Total hours on type:
1328.00
Aircraft flight hours:
17974
Circumstances:
While in cruise flight at 9,000 feet MSL, the left engine began to 'run rough and lose power.' The pilot said he interpreted the problem as carburetor icing and applied carburetor heat. With the engine still running rough, the left propeller was feathered and the left engine shut down. Restart attempts were not successful. Unable to maintain altitude, the pilot requested to land at a nearby airport. After descending through IMC weather, the pilot realized that he would not make it to the airport, and executed a forced landing to rough/uneven terrain. Examination of the engines revealed that the alternate air doors were missing on the right and left engine. The hinges for the doors were attached to both carburetors and showed no evidence of distortion or impact damage. The doors were not found at the wreckage site. A missing alternate air door would allow ambient air to enter the carburetor, rendering the carburetor heating system ineffective. According to carburetor icing probability charts, the reported temperature and dew point values would be favorable to the formation of induction system icing.
Probable cause:
Inadequate maintenance which resulted in diminished carburetor heat effectiveness due to missing alternate air doors. Contributing were conducive carburetor icing weather conditions, low ceilings during the emergency descent, and the lack of suitable terrain for the forced landing.
Final Report:

Crash of a Beechcraft A90 King Air in Alice: 4 killed

Date & Time: Aug 12, 1997 at 1153 LT
Type of aircraft:
Registration:
N41VC
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Alice - Alice
MSN:
LJ-242
YOM:
1967
Location:
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
17710
Aircraft flight hours:
7250
Circumstances:
The flight was part of a pre-buy inspection of the airplane. Witnesses reported the airplane did not climb more than 200 feet above ground level (agl) after takeoff. The airplane entered a shallow left turn and completed about 210 degrees of heading change before it impacted a flat field near the approach end of runway 26. Witnesses reported that the landing gear were retracted and that the engines sounded like they running at high power, but the airplane did not accelerate or climb normally. The airspeed was slow and 'mushy.' The engines' gas generator sections exhibited strong rotational scoring. The engines' power sections exhibited light rotational signatures. The left and right propellers exhibited minimal leading edge damage. Both propellers exhibited high blade angles. The secondary low pitch stops (SLPS) had been installed on the aircraft four days prior to the accident. A ground check, but no flight check, had been conducted. The SLPS sensors were found in the full aft position on the mounting bracket, not in the normal mid-range position. The SLPS control box installed on the aircraft was an updated box and was incompatible with the existing wiring.
Probable cause:
Loss of control due to the pilot's improper in-flight decision. A factor was the improper installation of the secondary low pitch stop system by the mechanic.
Final Report: