Crash of a Learjet 25 in Ithaca: 2 killed

Date & Time: Aug 24, 2001 at 0542 LT
Type of aircraft:
Operator:
Registration:
N153TW
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Ithaca – Jackson
MSN:
25-053
YOM:
1970
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
4826
Captain / Total hours on type:
760.00
Copilot / Total flying hours:
3634
Copilot / Total hours on type:
377
Aircraft flight hours:
12486
Circumstances:
While departing from the airport, with the second-in-command (SIC) at the controls, the airplane impacted a fence, and subsequently the ground about 1,000 feet beyond the departure end of the runway. A witness on the ramp area south of the runway, stated that he heard the engines spool up; however, due to the fog, he could only see the strobe lights on the airplane. He then observed the airplane rotate about 3,500 feet from the departure end of the runway and begin to climb at a steep angle, before losing sight of it when it was about 150 feet above ground level. The weather reported, at 0550 was, calm winds; 1/2 statute miles of visibility, fog; overcast cloud layer at 100 feet; temperature and dew point of 17 degrees Celsius. Excerpts of the cockpit voice recorder (CVR) transcript revealed that the flightcrew discussed the prevailing visibility at the airport on numerous occasions, and indicated that it appeared to be less than one mile. Examination of the wreckage revealed no anomalies with the airframe or engines. According to the FAA Instrument Flying Handbook, "Flying in instrument meteorological conditions (IMC) can result in sensations that are misleading to the body's sensory system...A rapid acceleration, such as experienced during takeoff, stimulates the otolith organs in the same way as tilting the head backwards. This action creates the somatogravic illusion of being in a nose-up attitude, especially in situations without good visual references. The disoriented pilot may push the aircraft into a nose-low or dive attitude."
Probable cause:
The pilot's failure to maintain a proper climb rate while taking off at night, which was a result of spatial disorientation. Factors in the accident were the low visibility and cloud conditions, and the dark night.
Final Report:

Crash of a Learjet 25D in Salina

Date & Time: Jun 12, 2001 at 1300 LT
Type of aircraft:
Operator:
Registration:
N333CG
Flight Type:
Survivors:
Yes
Schedule:
Newton - Salina
MSN:
25-262
YOM:
1978
Location:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
19000
Captain / Total hours on type:
1500.00
Copilot / Total flying hours:
5168
Copilot / Total hours on type:
470
Aircraft flight hours:
8419
Circumstances:
During a test flight, the airplane encountered an elevator system oscillation while in a high speed dive outside the normal operating envelope. The 17 second oscillation was recorded on the cockpit voice recorder and had an average frequency of 28 Hz. The aft elevator sector clevis (p/n 2331510-32) fractured due to reverse bending fatigue caused by vibration, resulting in a complete loss of elevator control. The flight crew reported that pitch control was established by using horizontal stabilizer pitch trim. The flightcrew stated that during final approach to runway 17 (13,337 feet by 200 feet, dry/asphalt) the aircraft's nose began to drop and that the flying pilot was unable to raise the nose using a combination of horizontal stabilizer trim and engine power. The aircraft landed short of the runway, striking an airport perimeter fence and a berm. The surface winds were from the south at 23 knots, gusting to 32 knots.
Probable cause:
The PIC's delayed remedial action during the elevator system oscillation, resulting in the failure of the aft elevator sector clevis due to reverse bending fatigue caused by vibration, and subsequent loss of elevator control. Factors contributing to the accident were high and gusting winds, the crosswind, the airport perimeter fence, and the berm.
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 Learjet 25B in Northolt

Date & Time: Aug 13, 1996 at 0957 LT
Type of aircraft:
Operator:
Registration:
EC-CKR
Survivors:
Yes
Schedule:
Palma de Mallorca - Northolt
MSN:
25-184
YOM:
1974
Flight number:
MAQ123
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
5200
Captain / Total hours on type:
1900.00
Copilot / Total flying hours:
5340
Copilot / Total hours on type:
1700
Aircraft flight hours:
4396
Circumstances:
Learjet 25B EC-CKR arrived near Northolt following a flight from Palma de Mallorca. Due to the presence of priority traffic which was due to depart Northolt at that time, the flight was extended down wind to a distance of 10 nm before the crew received vectors and descent instructions for the final approach to runway 25. At 3.5nm short of the runway the pilot was asked to confirm that his landing gear was down and locked as is normal procedure at Northolt. After some rephrasing of this question, the landing gear was confirmed down, however during this exchange the aircraft was seen to deviate above the glidepath. At 2.5 nm, landing clearance was confirmed and the aircraft was advised of the surface wind and the fact that there was a 4 kt tailwind. The aircraft was also advised that it was above the glide path. At the decision altitude which was at approximately half a mile from the runway the aircraft was still above the glidepath although seen to be correcting to it. On arrival at the runway the aircraft was observed to land some distance beyond the normal touchdown point. Towards the end of the landing roll it veered to the right and then swerved to the left and overran the end of the runway. It collided with three lighting stanchions and continued in a south-westerly direction towards the airfield boundary which is marked by a high chain-link fence. After bursting through the boundary fence the aircraft ran onto the A40 trunk road and was almost immediately in collision with a Ford Transit van on the east bound carriageway, and seriously injuring its driver. The aircraft came to rest in the left hand lane of the road with the van embedded in the right side of the fuselage immediately forward of the right wing.
Probable cause:
The following causal factors were identified:
(1) The commander landed the aircraft at a speed of 158 (+/- 10 kt) and at a point on the runway such that there was approximately 3,125 feet (952 metres) of landing run remaining;
(2) The commander did not deploy the spoilers after touchdown;
(3) The first officer did not observe that the spoilers had not been deployed after touchdown;
(4) At a speed of 158 (+/- 10 kt) with spoilers retracted and given the aircraft weight and atmospheric conditions prevailing, there was insufficient landing distance remaining from the point of touchdown within which to bring the aircraft to a standstill;
(5) The commander allowed himself to become overloaded during the approach and landing. The safeguards derived from a two crew operation were diminished by the first officer’s lack of involvement with the final approach.
Final Report:

Crash of a Learjet 25C in Ribeirão Preto: 2 killed

Date & Time: Jun 4, 1996 at 1320 LT
Type of aircraft:
Registration:
PT-KBC
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
São Paulo – Uberaba – Ribeirão Preto
MSN:
25-165
YOM:
1974
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
3500
Captain / Total hours on type:
250.00
Copilot / Total flying hours:
2000
Copilot / Total hours on type:
420
Circumstances:
The crew departed São Paulo on a training flight to Ribeirão Preto with an intermediate stop in Uberaba. On approach to Ribeirão Preto-Leite Lopes Airport, the instructor decided to reduce power on the left engine to simulate a failure and to complete a touch-and-go manoeuvre. After touchdown, the left engine power lever remained in the idle position so the captain took over control and attempted to take off as he judged it impossible to stop on the remaining runway. The aircraft took off but landed back about 92 metres past the runway end. Out of control, it collided with a truck and a tree and came to rest, bursting into flames. A man in the truck as well as one pilot were killed while three other pilots were injured. The aircraft was destroyed.
Probable cause:
The following findings were reported:
- There are indications of the presence of psychological variables that may have influenced the instructor's decision to perform the touch-and-go manoeuvre.
- There was inadequate supervision, at the technical and operational level, by the aircraft operating company, due to the lack of training, inadequate instruction and absence of flight simulator training.
- There was an error made by the pilots due to the inadequate use of the crew resources in the cockpit intended for the operation of the aircraft, due to an ineffective fulfillment of the tasks assigned to each of the crew and the non-observance of the operational rules.
- Even though the crew was qualified for the type of flight, there was inadequate planning regarding the absence of a takeoff and landing briefing.
- There was an error made by the copilot, when the delay in reducing the power levers, as soon as the locking of the left engine lever was established during the dash on the ground, with an inadequate assessment of the situation in this regard.
- There was the participation of the training process received, due to quantitative and qualitative deficiency, which did not attribute to pilots the full technical conditions to be developed in the activity, regarding the lack of simulator training, lack of a company training program that included CRM and local flights, among others.
- There are indications that the difficulties reported by the pilots in relation to the throttle were caused by the rupture of fibers in the cable that transfers its control to the FCU. This cable slides inside a corrugated cover and can be jammed if any fiber in the cable breaks.
Final Report:

Crash of a Learjet 25D in São Paulo: 9 killed

Date & Time: Mar 2, 1996 at 2316 LT
Type of aircraft:
Registration:
PT-LSD
Survivors:
No
Site:
Schedule:
Brasília – São Paulo
MSN:
25-243
YOM:
1978
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
9
Captain / Total flying hours:
2500
Captain / Total hours on type:
220.00
Copilot / Total flying hours:
330
Copilot / Total hours on type:
57
Aircraft flight hours:
6123
Circumstances:
The twin engine aircraft was completing a charter flight from Brasília to São Paulo, carrying seven members of the pop music group 'Mamonas Assassinas' and two pilots. On approach in limited visibility due to the night, absence of ground lights and clouds, the crew initiated a go-around as his position was erroneous (too high and the glide and excessive speed). The captain initiated a turn to the left when shortly later, at an altitude of 3,280 feet, the aircraft struck trees and crashed in a dense wooded area located about 11 km from the airport. The aircraft was destroyed by impact forces and all nine occupants were killed.
Probable cause:
The following findings were reported:
- The crew was tired due to a long duty period of 16 hours and 30 minutes without rest time,
- The captain showed excess of self-confidence,
- Physical fatigue worsened the level of situational stress of the crew,
- Lack of crew training programme,
- Poor crew coordination,
- Poor approach and landing planning,
- Lack of visibility, lack of ground lights (environment) and low clouds,
- The crew failed to follow the missed approach procedures,
- The copilot was inexperienced,
- Instead of a right turn to 092° and continue to 6,000 feet, the captain initiated a left turn, causing the aircraft to struck obstacles.
Final Report:

Crash of a Learjet 25D in Washington DC: 12 killed

Date & Time: Jun 18, 1994 at 0625 LT
Type of aircraft:
Operator:
Registration:
XA-BBA
Survivors:
No
Schedule:
Mexico City – New Orleans – Washington DC
MSN:
25-223
YOM:
1977
Crew on board:
2
Crew fatalities:
Pax on board:
10
Pax fatalities:
Other fatalities:
Total fatalities:
12
Captain / Total flying hours:
1706
Captain / Total hours on type:
1314.00
Copilot / Total flying hours:
852
Copilot / Total hours on type:
426
Aircraft flight hours:
6118
Aircraft flight cycles:
5663
Circumstances:
The airplane crashed 0.8 nm south of the threshold of the runway during an ILS approach in instrument meteorological conditions. The captain was not authorized to attempt the approach and was relatively inexperienced for an approach under the weather conditions. The captain failed to adhere to acceptable standards of airmanship during two unstabilized approaches. After the unsuccessful ils approach to runway 01R, the captain should have held for improvements in the weather, requested the runway 19L ILS, or proceeded to his alternate. An operating gpws aboard the airplane would have provided continuous warning to the crew for the last 64 seconds of flight and might have prevented the accident. All 10 passengers were Mexican citizens flying to Washington DC to assist a game of the World Football Championship.
Probable cause:
Poor decision making, poor airmanship, and relative inexperience of the captain in initiating and continuing an unstabilized instrument approach that led to a descent below the authorized altitude without visual contact with the runway environment. Contributing to the cause of the accident was the lack of a GPWS on the airplane.
Final Report:

Crash of a Learjet 25D on Mt Rowe: 7 killed

Date & Time: Sep 5, 1993 at 1715 LT
Type of aircraft:
Registration:
N999BH
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Houston - Santa Fe
MSN:
25-318
YOM:
1980
Crew on board:
2
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
7
Captain / Total flying hours:
17000
Captain / Total hours on type:
4000.00
Aircraft flight hours:
4973
Circumstances:
While descending to his destination the pilot in command (pic) canceled his IFR clearance and declined VFR flight following. Witnesses observed the aircraft maneuvering at low altitude in the area where the accident occurred, approximately 25 miles from the destination airport. The aircraft impacted rising terrain at 7,300 feet msl. Toxicological testing revealed that the pic and two passengers had cocaine and alcohol in tissue samples. At an unknown time the pic left the cockpit. Based on cockpit voice recorder analysis, he was called back to the cockpit approximately 11 minutes prior to the accident by the copilot. The copilot had no previous Lear experience. Toxicological test results indicated that the pic 'used cocaine in the very recent past, probably while in-flight' and concluded that he 'was impaired by multiple drug use of cocaine and alcohol.' The investigation did not reveal any structural or system failure or malfunction. All seven occupants were killed.
Probable cause:
Physical impairment of the pilot in command from alcohol and drugs. A factor was the first officer's lack of experience in the Learjet.
Final Report:

Crash of a Learjet 25D in Tijuana

Date & Time: Sep 2, 1993
Type of aircraft:
Operator:
Registration:
XA-NOG
Survivors:
Yes
Schedule:
Mexico City – Tijuana
MSN:
25-349
YOM:
1981
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The approach to Tijuana-General Abelardo L. Rodríguez Airport was completed in poor weather conditions with clouds down to 180 metres. On short final, the captain realized his position was not correct and made several correction but inefficiently. The aircraft landed hard, right main gear first. On impact, both tires on the right main gear burst. The aircraft went out of control, veered to right and came to rest. All six occupants escaped uninjured while the aircraft was damaged beyond repair.
Probable cause:
The crew completed a landing procedure following an unstabilized approach and failed to initiate a go-around.