Crash of a Douglas DC-9-33RC at Carswell AFB: 2 killed

Date & Time: Mar 18, 1989 at 0216 LT
Type of aircraft:
Operator:
Registration:
N931F
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Carswell - Tinker
MSN:
47192
YOM:
1968
Flight number:
EV417
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
7238
Captain / Total hours on type:
1938.00
Copilot / Total flying hours:
10863
Copilot / Total hours on type:
1213
Aircraft flight hours:
41931
Aircraft flight cycles:
40808
Circumstances:
The DC-9 arrived at Carswell AFB at 01:12 CST after a flight from Kelly AFB. The aircraft was off-loaded and re-loaded with cargo by USAF personnel. The engines were then started at 02:04. The crew received taxi instructions for runway 17 and took off from this runway at 02:09. At (or immediately after) rotation, the main cargo door opened. An emergency was declared and the crew climbed to 2500 feet msl before entering a right turn. When about 5nm north of the airport the captain began a shallow turn to the right (for base leg). The aircraft crossed the extended centreline and the captain tightened the turn to establish their position relative to the runway threshold. In doing so, the air load on the door probably caused it to rapidly move to its full open over the top position. A sudden opening of the door would also have produced an unexpected change in the yawing and rolling moments. The captain, possibly partially disoriented, may not have sensed the increasing roll and nose tuck and thus failed to correct a changing attitude until a critical bank angle and loss of altitude had occurred. The DC-9 struck the ground in an inverted, nose down, left wing low attitude and disintegrated. It appeared that the first officer, when closing the main cargo door, didn't hold the door control valve 'T' handle in the closed position long enough for the latching hooks to move into place over the door sill spools. External latched and locked indicators were applied incorrectly, so the first officer thought the door was latched properly when the handle was pointed more toward the 'locked' than the 'unlocked' chevron. It also appeared that one of the two open door warning light switches was malfunctioning. Because of their wiring, this malfunction made the entire door warning system ineffective.
Probable cause:
The loss of control of the airplane for undetermined reasons following the in-flight opening of the improperly latched cargo door. Contributing to the accident were inadequate procedures used by Evergreen Airlines and approved by the FAA for pre-flight verification of external cargo door lock pin manual control handle, and the failure of McDonnell Douglas to provide flight crew guidance and emergency procedures for an in-flight opening of the cargo door. Also contributing to the accident was the failure of the FAA to mandate modification to the door-open warning system for DC-9 cargo-configured airplanes, given the previously known occurrences of in-flight door openings.
Final Report:

Crash of a Cessna 421B Golden Eagle II in San Antonio

Date & Time: Mar 3, 1989 at 0245 LT
Registration:
N5999M
Survivors:
Yes
Schedule:
Memphis - San Antonio
MSN:
421B-0242
YOM:
1972
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
732
Captain / Total hours on type:
34.00
Aircraft flight hours:
2897
Circumstances:
The airplane had made one approach, followed by a missed approach during a dark night with low ceilings and low visibility. During the next approach the airplane was high on the glide slope and touched down fast and long. The airplane hit the terrain 300 feet past the end of the runway, hit a second time 115 feet further down, then flew into the ils localizer. Part of the left wing burned. There were no indications of an attempted go-around.
Probable cause:
The failure of the pilot to follow the proper procedures/directives by not following the glideslope which resulted in not being able to attain the proper touchdown point.
Final Report:

Crash of a Boeing KC-135A-BN Stratotanker at Dyess AFB: 19 killed

Date & Time: Jan 31, 1989 at 1210 LT
Type of aircraft:
Operator:
Registration:
63-7990
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Dyess - Hickham
MSN:
18607
YOM:
1963
Location:
Crew on board:
7
Crew fatalities:
Pax on board:
12
Pax fatalities:
Other fatalities:
Total fatalities:
19
Circumstances:
Shortly after liftoff from runway 16 at Dyess AFB, while climbing to a height of about 60-100 feet, the aircraft banked right, causing the right wing to struck the ground. Out of control, the aircraft crashed in a huge explosion and was totally destroyed by impact forces and a post crash fire. All 19 occupants were killed, among them army officer and family members including spouses and children.
Probable cause:
It is believed that vapor was coming out from an engine, maybe due to a technical problem on the water injection system.

Crash of a Douglas C-47A-70-DL in Laredo

Date & Time: Jan 18, 1989 at 2043 LT
Operator:
Registration:
XB-DYP
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Laredo - Torreón
MSN:
19239
YOM:
1943
Location:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
8000
Captain / Total hours on type:
3800.00
Circumstances:
The pilot stated that during takeoff from runway 35L, the copilot on the flight controls reduced left propeller and right engine power at an altitude of less than 100 feet agl. He attempted to restore takeoff power while applying forward pressure on the control yoke, but lost control of the aircraft and impacted the terrain adjacent to the departure runway. He further stated that the cargo may have shifted to the rear of the aircraft during takeoff. The aircraft was destroyed and both pilots were seriously injured.
Probable cause:
The pic's disregard for the security of the cargo that permitted its shift during the takeoff roll. This resulted in an aft cg situation and a subsequent stall and loss of aircraft control. A contributing factor in the accident was the mismanagement of the engine power by the crew and the lack of experience of the copilot.
Occurrence #1: cargo shift
Phase of operation: takeoff - initial climb
Findings
1. (f) security of cargo - disregarded - pilot in command
2. (f) procedure inadequate - pilot in command
3. (c) aircraft weight and balance - exceeded
----------
Occurrence #2: loss of control - in flight
Phase of operation: takeoff - initial climb
Findings
4. (f) throttle/power control - reduced - copilot/second pilot
5. (f) lack of total experience in type of aircraft - copilot/second pilot
6. (f) propeller - reduced - copilot/second pilot
7. (c) airspeed (vs) - not maintained - pilot in command
8. Stall/mush - inadvertent - pilot in command
----------
Occurrence #3: in flight collision with terrain/water
Phase of operation: descent - uncontrolled
Findings
9. Terrain condition - grass
Final Report:

Crash of a Piper PA-61 Aerostar (Ted Smith 601) in Houston: 1 killed

Date & Time: Nov 2, 1988 at 0302 LT
Registration:
N60819
Flight Type:
Survivors:
No
Schedule:
Baton Rouge – Conroe
MSN:
61-0759-8062149
YOM:
1980
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
2887
Captain / Total hours on type:
190.00
Aircraft flight hours:
3202
Circumstances:
The aircraft collided with power lines and trees while on final approach. The reported weather immediately following the accident was an indefinite ceiling zero, sky obscured, and visibility 1/16 of a mile in fog. No preimpact failures or malfunctions of the aircraft were found. The pilot had diverted from his intended destination due to fog. The pilot, sole on board, was killed.
Probable cause:
Pilot's decision to fly the approach visually with outside reference to the lights and inadvertently descending below the decision height off the proper glide path.
Occurrence #1: in flight collision with object
Phase of operation: approach - faf/outer marker to threshold (ifr)
Findings
1. (f) weather condition - fog
2. (f) weather condition - obscuration
3. (c) in-flight planning/decision - poor - pilot in command
4. (c) decision height - below - pilot in command
5. (c) proper glidepath - not maintained - pilot in command
6. (f) object - wire, transmission
7. (f) object - tree(s)
Final Report:

Crash of a Piper PA-31-310 Navajo in Edinburg

Date & Time: Oct 16, 1988 at 1635 LT
Type of aircraft:
Registration:
N91BB
Flight Phase:
Survivors:
Yes
Schedule:
McAllen - Houston
MSN:
31-141
YOM:
1968
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
2925
Captain / Total hours on type:
195.00
Aircraft flight hours:
6373
Circumstances:
Aircraft experienced a double engine failure. Pilot stated that immediately after the left engine failed, in climb to cruise, the aircraft rolled left, the stall warning activated, and the aircraft entered a left spiral. The right engine failed during the two-turn spiral. Pilot's attempts to restart the engines were unsuccessful. Pilot subsequently made a successful gear up emergency landing on a road, however, the aircraft was destroyed by post-crash fire. Investigation revealed that both engine fuel systems were contaminated with water and dissolved solids. Aircraft had just been refueled at a foreign airport. All seven occupants were uninjured.
Probable cause:
Occurrence #1: loss of engine power (total) - nonmechanical
Phase of operation: climb - to cruise
Findings
1. 1 engine
2. (c) fluid, fuel - contamination
3. (c) fluid, fuel - water
4. (c) maintenance, service of aircraft/equipment - improper - fbo personnel
----------
Occurrence #2: loss of control - in flight
Phase of operation: climb - to cruise
Findings
5. (c) airspeed (vmc) - not maintained - pilot in command
6. Spiral - uncontrolled
----------
Occurrence #3: loss of engine power (total) - nonmechanical
Phase of operation: descent - uncontrolled
Findings
7. All engines
8. (c) fluid, fuel - contamination
9. (c) fluid, fuel - water
----------
Occurrence #4: forced landing
Phase of operation: descent - emergency
----------
Occurrence #5: in flight collision with terrain/water
Phase of operation: landing - roll
Findings
10. Wheels up landing - performed - pilot in command
Final Report:

Crash of a Douglas A-20G Havoc in San Benito: 1 killed

Date & Time: Oct 8, 1988 at 1415 LT
Operator:
Registration:
N67921
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Harlingen - Harlingen
MSN:
21857
YOM:
1943
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
26100
Circumstances:
The 70 years old pilot was flying a Douglas A-20 in a flight of 3 aircraft at an airshow (Confederate Air Force 'Airshow 88'). Afterflying on a southerly heading, the flight entered a procedure turn which involved a 90° left turn to the east followed by a 270° right turn back northbound. While maneuvering, the A-20 entered a right descending turn and subsequently crashed on level terrain in a relatively wings level descent. The main wreckage came to rest about 225 feet from the initial impact point. According to a pathological report, the pilot had severe coronary arteriosclerosis and suffered a heart attack.
Probable cause:
Incapacitation of the pilot while flying an aircraft due to loss of consciousness from a cardiac rhythm disturbance.
Findings:
Occurrence #1: loss of control - in flight
Phase of operation: maneuvering
Findings
1. Aircraft control - not maintained
2. (c) incapacitation (cardiovascular) - pilot in command
----------
Occurrence #2: in flight collision with terrain/water
Phase of operation: descent - uncontrolled
Final Report:

Crash of a Boeing 727-232 in Dallas: 14 killed

Date & Time: Aug 31, 1988 at 0901 LT
Type of aircraft:
Operator:
Registration:
N473DA
Flight Phase:
Survivors:
Yes
Schedule:
Jackson - Dallas - Salt Lake City
MSN:
20750
YOM:
1973
Flight number:
DL1141
Crew on board:
7
Crew fatalities:
Pax on board:
101
Pax fatalities:
Other fatalities:
Total fatalities:
14
Captain / Total flying hours:
17000
Captain / Total hours on type:
7000.00
Copilot / Total flying hours:
6500
Copilot / Total hours on type:
4000
Aircraft flight hours:
43023
Circumstances:
Flight DL1141 (Jackson - Dallas - Salt Lake City) left Gate 15 at 08:30 and was instructed to taxi to runway 18L. When first in line for takeoff (at 08:59) the flight was cleared for takeoff. The takeoff was uneventful until the airplane reached the rotation phase (at 154 knots, 6017 feet down the runway). As the main gear wheels left the ground, the airplane began to roll violently, causing the right wingtip to contact the runway (1033 feet after lift-off), followed by compressor surges. The plane continued and struck the ILS localizer antenna array 1000 feet past the end of runway 18L. After impacting the antenna installation, the airplane remained airborne for an additional 400 feet, then struck the ground, traversed a ground depression and slid sideways until it came to rest near the airport perimeter fence, 3200 feet from the runway end. Parts of the aircraft had separated in the slide and a fire had erupted in the right wing area, quickly engulfing the rear, right side of the airplane after it came to rest. Twelve passengers and two crew members were killed. The aircraft was destroyed.
Probable cause:
The board determines that the accident was caused mainly by the captain and first officer's inadequate cockpit discipline which resulted in the flight crew's attempt to takeoff without the wing flaps and slats properly configured; and the failure of the takeoff configuration warning system to alert the crew that the airplane was not properly configured for the takeoff. Contributing to the accident was Delta's slow implementation of necessary modifications to its operating procedures, manuals, checklists, training and crew checking programs which were necessitated by significant changes in the airline following rapid growth and merger. Also contributing to the accident was the lack of sufficiently aggressive action by the FAA to have known deficiencies corrected by Delta and the lack of sufficient accountability within the FAA's air carrier inspection process.
Findings:
Occurrence #1: loss of control - in flight
Phase of operation: takeoff - initial climb
Findings
1. (c) preflight planning/preparation - improper - pilot in command
2. (c) overconfidence in personal ability - pilot in command
3. (c) procedures/directives - not followed - copilot/second pilot
4. (c) procedures/directives - not followed - pilot in command
5. (f) procedure inadequate - company/operator management
6. (f) insufficient standards/requirements, operation/operator - FAA (organization)
7. (f) inadequate method of compliance determination record keeping - FAA (organization)
8. (c) lowering of flaps - not performed
9. (c) lowering of slats - not performed
10. (c) safety system (other) - inoperative
----------
Occurrence #2: in flight collision with terrain/water
Phase of operation: descent - uncontrolled
Final Report:

Crash of a Cessna 340 in Georgetown: 2 killed

Date & Time: Jun 6, 1988 at 2000 LT
Type of aircraft:
Operator:
Registration:
N7828Q
Flight Phase:
Flight Type:
Survivors:
No
MSN:
340-0241
YOM:
1973
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
1005
Aircraft flight hours:
1175
Circumstances:
The pilot in the right seat had hired the pilot in the left seat to ferry the airplane to Germany, then to Turkey. A four tank ferry fuel system was installed but a weight and balance check was not made. During the tkof, the aircraft would not climb. Afterward the airplane was computed to have been overweight and the cg was aft of the rear limit. The left wing hit trees and the right wing hit two fences. After colliding with the terrain, the airplane burned. Both occupants were killed.
Probable cause:
Occurrence #1: in flight collision with object
Phase of operation: takeoff - initial climb
Findings
1. (c) preflight planning/preparation - inadequate - pilot in command
2. (c) aircraft weight and balance - exceeded - pilot in command
3. (c) lift-off - premature - pilot in command
4. (c) airspeed - inadequate - pilot in command
5. (f) object - tree(s)
6. (f) object - fence
----------
Occurrence #2: in flight collision with terrain/water
Phase of operation: takeoff - initial climb
Final Report:

Crash of a Douglas DC-10-30 in Dallas

Date & Time: May 21, 1988 at 1612 LT
Type of aircraft:
Operator:
Registration:
N136AA
Flight Phase:
Survivors:
Yes
Schedule:
Dallas - Frankfurt
MSN:
47846
YOM:
1972
Flight number:
AA070
Crew on board:
14
Crew fatalities:
Pax on board:
240
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
15660
Captain / Total hours on type:
2025.00
Aircraft flight hours:
61322
Aircraft flight cycles:
12864
Circumstances:
A rejected takeoff was attempted when the slat disagree light illuminated and the takeoff warning horn sounded at 166 knots (V1). The pilot aborted the takeoff, but the aircraft accelerated to 178 knots ground speed before it began to decelerate. The deceleration was normal until 130 knots where an unexpected rapid decay in the deceleration occurred. The aircraft ran off the end of the runway at 95 knots, the nose gear collapsed, and the aircraft came to a stop 1,100 feet beyond the end of the runway. Eight of the ten brake sets failed. Post-accident exam of the brakes revealed that excessive brake wear occurred during the rejected takeoff. Testing showed that dc-10 worn brakes have a much greater wear rate during an rto. The faa does not require worn brake testing. Douglas did not use brake wear data from rto certification tests to set more conservative brake wear replacement limits. New brakes were used for those tests. All 254 occupants were evacuated, among them eight were injured, two seriously. The aircraft was damaged beyond repair.
Probable cause:
Occurrence #1: airframe/component/system failure/malfunction
Phase of operation: takeoff
Findings
1. (f) flt control syst, wing slat system - false indication
----------
Occurrence #2: airframe/component/system failure/malfunction
Phase of operation: takeoff - aborted
Findings
2. Aborted takeoff - attempted
3. Airspeed (v1) - exceeded
4. (c) landing gear, normal brake system - inadequate
5. (c) acft/equip, inadequate aircraft component - manufacturer
6. (c) inadequate substantiation process - manufacturer
7. (c) inadequate certification/approval, aircraft - faa (organization)
8. Landing gear, normal brake system - worn
9. (c) landing gear, normal brake system - failure, total
----------
Occurrence #3: overrun
Phase of operation: takeoff - aborted
Findings
10. Terrain condition - soft
11. Object - approach light/navaid
----------
Occurrence #4: nose gear collapsed
Phase of operation: takeoff - aborted
Final Report: