Crash of a Rockwell Grand Commander 690B in Springfield: 1 killed

Date & Time: Oct 8, 1994 at 1031 LT
Registration:
N27MT
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Springfield - Olathe
MSN:
690-11533
YOM:
1979
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
2750
Captain / Total hours on type:
3.00
Circumstances:
After taking off on an IFR flight, the airplane was observed to climb into a low overcast. The pilot contacted departure control and reported climbing through 2,200 feet for an assigned altitude of 5,000 feet msl. Shortly thereafter, radar and radio contact were lost, and the airplane crashed in a steep dive. During an investigation, no preimpact part failure or malfunction was found, though the airplane was extensively damaged during impact. The pilot's logbook indicated that he had flown three instrument approaches on 3/3/94 and that he had flown 3.1 hours in actual instrument conditions since that date.
Probable cause:
Failure of the pilot to maintain control of the airplane, due to spatial disorientation. A factor related to the accident was: the pilot's lack of recent instrument experience.
Final Report:

Crash of a Rockwell Grand Commander 690B in the Pacific Ocean: 9 killed

Date & Time: Oct 2, 1994 at 1315 LT
Operator:
Registration:
VH-SVQ
Flight Phase:
Survivors:
No
Schedule:
Sydney - Williamtown - Lord Howe Island
MSN:
690-11380
YOM:
1977
Flight number:
CD111
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
9
Captain / Total flying hours:
2915
Captain / Total hours on type:
60.00
Aircraft flight hours:
6014
Circumstances:
At 1018 hours EST, on Sunday 2 October 1994, the pilot submitted a flight plan by telephone to the Melbourne Regional Briefing Office of the Civil Aviation Authority. The flight plan indicated that Aero Commander 690 aircraft VH-SVQ would be conducting a regular public transport service, flight CD 111, from Sydney (Kingsford-Smith) Airport to Lord Howe Island with an intermediate landing at Williamtown. The flight was planned to operate in accordance with instrument flight rules with a nominated departure time from Sydney of 1100 hours. The aircraft was crewed by one pilot. The aircraft departed Sydney at 1117, carrying baggage that had been off-loaded from another company service which was to operate direct from Sydney to Lord Howe Island that day. The flight to Williamtown apparently proceeded normally and the aircraft arrived at about 1140. The company had no ground-based representatives at Williamtown but the pilot was observed by other persons in the terminal building to converse with passengers before proceeding to the aircraft. No other person saw the pilot and the passengers board the aircraft. At 1206 the pilot informed Sydney Flight Service that the aircraft was taxiing at Williamtown for Lord Howe Island and that he intended climbing to flight level (FL) 210. Departure was subsequently reported as 1208 when the pilot reported tracking 060 on climb to FL230 which was the original planned cruising level. The pilot reported passing 20,000 feet on climb to FL210 at 1229 and shortly afterwards asked if VH-IBF, a company aircraft flown by the chief pilot and operating from Sydney direct to Lord Howe Island, had departed. The pilot was advised that it had departed. The radar trace showed that the climb was discontinued at 20,400 ft at 1231:22. Three seconds later the aircraft commenced descent. The last recorded radar trace for SVQ was at 19,800 ft at 1232:54. The pilot of SVQ did not report at the position ‘Shark’ at 1232 as scheduled in his flight plan, and at 1235 he notified that the aircraft had commenced a descent to FL130. At 1238, the pilot of SVQ asked Sydney Flight Service if IBF was listening on high frequency and was advised that the aircraft was not due on frequency for another 30 minutes. He requested that the pilot of IBF call him on the company VHF frequency and reported that the aircraft had just passed ‘Shark’ and he would shortly provide an estimate for the next position, ‘Shrimp’. At 1245, he provided an estimate for ‘Shrimp’ of 1310 and stated that the aircraft was maintaining FL160. No explanation of the amended level was given by the pilot or sought by Sydney Flight Service. The chief pilot subsequently stated that he contacted SVQ on company frequency at about 1240 and that the pilot of that aircraft reported a severe vibration which he thought was caused by airframe or propeller icing. He also confirmed that he had turned the propeller heat on. The chief pilot recalled that he asked the pilot of SVQ if the cockpit indication showed that the propeller heat was working normally, to which he replied ‘yes its working’. During this period, the chief pilot and the pilot of SVQ had also discussed crew rostering. Prior to contact with the chief pilot, the pilot of SVQ contacted the pilot of VH-SVV, another company aircraft which was operating a flight from Coffs Harbour to Lord Howe Island. At 1316, after SVQ had not reported at the ‘Shrimp’ position, Sydney Flight Service commenced communications checks but was unable to establish communications with SVQ directly or through any other aircraft. At 1325 an uncertainty phase was declared and the Melbourne Rescue Coordination Centre was subsequently notified at 1331. At 1401 the duty officer at the Melbourne Rescue Coordination Centre contacted the Lord Howe Island aerodrome terminal and left a message for the pilot of IBF to telephone the Centre. After the arrival of IBF at Lord Howe Island, the company managing director, who was also on board the aircraft, called the Melbourne Search and Rescue Centre at 1410 to inquire about SVQ. Arrangements were made by the company and Civil Aviation Authority search and rescue to organise search aircraft and a distress phase was declared at 1411. Subsequently, the crews of IBF and SVV reported hearing a radio transmission from the pilot of SVQ, stating that he had ‘lost it’. Attempts at the time by the chief pilot to contact SVQ were unsuccessful.
Probable cause:
The factors that directly related to the loss of the aircraft could not be determined.
Final Report:

Crash of a Rockwell Grand Commander 690 off Sydney: 1 killed

Date & Time: Jan 14, 1994 at 0114 LT
Registration:
VH-BSS
Flight Type:
Survivors:
No
Schedule:
Canberra - Sydney
MSN:
690-11044
YOM:
1972
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
1800
Captain / Total hours on type:
50.00
Aircraft flight hours:
7975
Circumstances:
On 14 January 1994 at 0114, Aero Commander 690 aircraft VH-BSS struck the sea while being radar vectored to intercept the Instrument Landing System approach to runway 34 at Sydney (Kingsford-Smith) Airport, NSW. The last recorded position of the aircraft was about 10 miles to the south-east of the airport. At the time of the accident the aircraft was being operated as a cargo charter flight from Canberra to Sydney in accordance with the Instrument Flight Rules. The body of the pilot who was the sole occupant of the aircraft was never recovered. Although wreckage identified as part of the aircraft was located on the seabed shortly after the accident, salvage action was not initially undertaken. This decision was taken after consideration of the known circumstances of the occurrence and of the costs of salvage versus the potential safety benefit that might be gained from examination of the wreckage. About 18 months after the accident, the wing and tail sections of the aircraft were recovered from the sea by fishermen. As a result, a detailed examination of that wreckage was carried out to assess the validity of the Bureau’s original analysis that the airworthiness of the aircraft was unlikely to have been a factor in this accident. No evidence was found of any defect which may have affected the normal operation of the aircraft. The aircraft descended below the altitude it had been cleared to by air traffic control. From the evidence available it was determined that the circumstances of this accident were consistent with controlled flight into the sea.
Probable cause:
Findings
1. The pilot held a valid pilot licence, endorsed for Aero Commander 690 aircraft.
2. The pilot held a valid multi-engine command instrument rating.
3. There was no evidence found to indicate that the performance of the pilot was adversely affected by any physiological or psychological condition.
4. The aircraft was airworthy for the intended flight, despite the existence of minor anomalies in maintenance and serviceability of aircraft systems.
5. The aircraft carried fuel sufficient for the flight.
6. The weight and balance of the aircraft were estimated to have been within the normal limits.
7. Recorded radio communications relevant to the operation of the aircraft were normal.
8. Relevant ground-based aids to navigation were serviceable.
9. At the time of impact the aircraft was capable of normal flight.
10. The aircraft was fitted with an altitude alerting system.
11. The aircraft was not fitted with a ground proximity warning system.
12. The aircraft was equipped with a transponder which provided aircraft altitude information to be displayed on Air Traffic Control radar equipment.
3.2 Significant factors
1. The pilot was relatively inexperienced in single-pilot Instrument Flight Rules operations on the type of aircraft being flown.
2. The aircraft was being descended over the sea in dark-night conditions.
3. The workload of the pilot was significantly increased by his adoption of a steep descent profile at high speed, during a phase of flight which required multiple tasks to be completed in a limited time prior to landing. Radio communications with another company aircraft during that critical phase of flight added to that workload.
4. The pilot probably lost awareness of the vertical position of the aircraft as a result of distraction by other tasks.
5. The aircraft was inadvertently descended below the altitude authorized by Air Traffic Control.
6. The secondary surveillance radar system in operation at the time provided an aircraft altitude readout which was only updated on every sixth sweep of the radar display.
7. The approach controller did not notice a gross change of aircraft altitude shortly after a normal radio communication with the pilot.
Final Report:

Crash of a Rockwell Grand Commander 690A in Lansing: 2 killed

Date & Time: Sep 27, 1993 at 1123 LT
Registration:
N242TC
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Lansing - Battle Creek
MSN:
690-11219
YOM:
1974
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
8790
Aircraft flight hours:
4373
Circumstances:
The airplane departed in IMC conditions on an IFR flight plan. Shortly after takeoff the pilot told the departure controller he had '...a problem.' The airplane's flight path was a series of left hand turns while performing descents and ascents. Reports of engine sounds varied from high rpm to low rpm. Many witnesses reported the airplane descending out of, and climbing into, clouds. The airplane was observed in a 45° angle descent, right wing low, as it collided with trees and the ground. The on-scene investigation found an intermittent electric gyro system inverter, a broken filament on the inverter power 'out' light bulb, electrically powered gyro's rotors did not have rotational damage, and a vacuum powered attitude indicator rotor with rotational damage. The pilot's toxicology report stated 45 mg/dl of ethanol detected in his muscle tissue.
Probable cause:
The pilot-in-command not maintaining aircraft control during the intermittent operation of the electrically operated attitude gyro. Factor's associated with this accident are an fluctuating (intermittent) electrical system inverter and the pilot-in-command not performing remedial action by using the vacuum powered attitude gyro and other flight instruments once the airplane was making a series of climbs, descents, and heading changes.
Final Report:

Crash of a Rockwell Grand Commander 690 in Camacho

Date & Time: Aug 9, 1993
Registration:
CP-1016
Survivors:
Yes
Schedule:
La Paz - Camacho
MSN:
690-11053
YOM:
1973
Location:
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
After landing, the single engine aircraft deviated to the right, causing the right main gear to struck a ditch and to be torn off. The aircraft came to rest on its belly and was damaged beyond repair. All seven occupants escaped with minor injuries.

Crash of a Rockwell Grand Commander 690A in Norfolk: 4 killed

Date & Time: Jul 30, 1993 at 1700 LT
Registration:
N707BP
Survivors:
No
Schedule:
Mountain Home - Norfolk
MSN:
690-11326
YOM:
1976
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
17770
Captain / Total hours on type:
414.00
Circumstances:
The Rockwell 690A, N707BP, was flying a straight-in entry to a downwind leg for runway 19 at the non-controlled airport. The only radio call heard from the Rockwell was a request for an airport advisory when it was about 20 miles southeast. The Piper PA-28R, N33056, had departed from runway 19. No radio calls were heard from the Piper. Witnesses observed the Rockwell heading north and the Piper heading east moments before the collision. The witnesses stated the Piper pitched up and banked steeply moments before the collision. The collision occurred approximately 2 miles east-southeast of the airport. On-scene investigation showed that the Piper's left main landing gear tire had made an imprint on the bottom of the Rockwell's outboard left wing. Paint color from the Rockwell had transferred to the Piper's left wing skin. All six people in both aircraft were killed.
Probable cause:
The failure of the pilots of the Rockwell 690A, N707BP, and the Piper PA28R, N33056, to see and avoid each other. A factor which contributed to the accident was the failure of both pilot's to follow recommended communication procedures contained in the airman's information manual for operating at an airport without an operating control tower.
Final Report:

Crash of a Rockwell Grand Commander 69A0 in Sepahua: 1 killed

Date & Time: May 17, 1993
Registration:
N28AD
Flight Type:
Survivors:
Yes
Schedule:
Puerto Bermudez - Sepahua
MSN:
690-11291
YOM:
1976
Location:
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
On final approach to the Sepahua Airstrip, the captain noticed a thin layer of mist over the runway and decided to make a low pass to assess the situation. While passing over the runway at low height, he lost control of the airplane that rolled to the right then overturned and eventually crashed in a river located near the runway end. One pilot was injured and the second was killed.
Probable cause:
The exact cause of the loss of control could not be established. Nevertheless, it is possible that the captain remembered at the last moment the presence of a radio antenna located about 40 metres from his position and maybe lost control of the airplane after initiating an evasive maneuver.

Crash of a Rockwell Grand Commander 690 in Herlong: 2 killed

Date & Time: Dec 31, 1992 at 1536 LT
Operator:
Registration:
N300CP
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Reno - Susanville
MSN:
690-11374
YOM:
1977
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
6984
Captain / Total hours on type:
782.00
Aircraft flight hours:
4052
Circumstances:
The pilot and flight nurse were en route to pick up a medical patient. The airplane experienced an in-flight breakup while flying by the leeward side of the sierra nevada mountains in the general area where standing lenticular clouds had been observed. No evidence was found that the pilot obtained a weather briefing from flight service or the duat vendors prior to departure. Pilots flying in the general area had reported airspeed variances from plus 60 to minus 40 knots. An in-flight weather advisory for occasional moderate turbulence was in effect. About one hour after the accident the weather service issued a sigmet for severe turbulence. Cause: an inadvertent encounter with severe turbulence which exceeded the design strength of the airplane's structure. Both occupants were killed.

Crash of a Rockwell Grand Commander 690B in Konawa: 1 killed

Date & Time: Jun 25, 1992 at 0833 LT
Registration:
N690JC
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Norman - Fort Lauderdale
MSN:
690-11479
YOM:
1978
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
8857
Captain / Total hours on type:
98.00
Aircraft flight hours:
3355
Circumstances:
As the airplane was deviating around low intensity weather returns, and passing through 20,500 feet during climb out, it departed controlled flight and entered a right spiral. Descent rates exceeded 16,600 fpm during the descent from 18,300 feet to 3,900 feet and then slowed. Witnesses stated they saw the airplane descend from the clouds in a right flap spin. The empennage had separated from the airplane in pieces. Pieces of the wreckage were found up to 1.5 mile from the primary impact point. Both wings remained attached. The right engine was flamed out, and the propeller was feathered at impact. No mechanical reason for the flameout could be determined. At no time did the pilot indicate he was having difficulties. The NTSB weather study indicated that moderate turbulence was present in the area. The pilot's toxicology tests found 0.151 ug/ml of chlorpheniramine in the blood; normal therapeutic concentration is 0.01 to 0.04. Effects of overdosage include sedation, diminished mental alertness, and cardiovascular collapse to stimulation. The pilot, sole on board, was killed.
Probable cause:
The pilot's failure to maintain control of the airplane which resulted in an inadvertent spiral and subsequent rapid descent. The design stress limits of the airframe were exceeded resulting in an overload failure of the empennage. Factors related to the accident were: turbulence and the pilot's physical impairment due to drugs.
Final Report:

Crash of a Rockwell Grand Commander 690A in Taos: 1 killed

Date & Time: Mar 29, 1992 at 1900 LT
Registration:
N111FL
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Taos - Tulsa
MSN:
690-11163
YOM:
1974
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
2200
Captain / Total hours on type:
120.00
Aircraft flight hours:
3404
Circumstances:
The airplane impacted slightly rising terrain in a 15° left bank, slight nose up attitude while descending shortly after takeoff in dark night IMC. There were rain and snow showers in the area and it was devoid of visible ground reference lights. The difference between the takeoff heading and the impact heading was 75° and the airplane had traveled 3,987 feet from the departure end of the runway at initial impact. The wreckage subsequently traveled an additional 837 feet through the brush. The pilot stated that the takeoff was normal in all aspects and all of the airplane systems were operating normally. He stated that the last thing he remembered was passing through 8,500 feet with a rate of climb of 1,500 feet per minute. The airport elevation was 7,091 feet. He did not recall the radio altimeter alert or the warning light activating. No evidence of pre-impact failure or malfunction was found during the investigation. Rescue of the occupants were delayed due to the weather, darkness, and spurious elt signals masked by the wreckage.
Probable cause:
The pilot in command's failure to maintain the climb after departing the runway environment. Factors were the weather conditions and the dark night.
Final Report: