Atlantic City

The aircraft crashed after it overran the end of runway 11 during a rejected takeoff at Laurence G. Hanscom Field (BED), Bedford, Massachusetts. The airplane rolled through the paved overrun area and across a grassy area, collided with approach lights and a localizer antenna, passed through the airport’s perimeter fence, and came to a stop in a ravine. The two pilots, a flight attendant, and four passengers died. The airplane was destroyed by impact forces and a postcrash fire. The corporate flight, which was destined for Atlantic City International Airport, Atlantic City, New Jersey, was conducted under the provisions of 14 Code of Federal Regulations (CFR) Part 91. An instrument flight rules flight plan was filed. Night visual meteorological conditions prevailed at the time of the accident. During the engine start process, the flight crew neglected to disengage the airplane’s gust lock system, which locks the elevator, ailerons, and rudder while the airplane is parked to protect them against wind gust loads. Further, before initiating takeoff, the pilots neglected to perform a flight control check that would have alerted them of the locked flight controls. A review of data from the airplane’s quick access recorder revealed that the pilots had neglected to perform complete flight control checks before 98% of their previous 175 takeoffs in the airplane, indicating that this oversight was habitual and not an anomaly. A mechanical interlock between the gust lock handle and the throttle levers restricts the movement of the throttle levers when the gust lock handle is in the ON position. According to Gulfstream, the interlock mechanism was intended to limit throttle lever movement to a throttle lever angle (TLA) of no greater than 6° during operation with the gust lock on. However, postaccident testing on nine in-service G-IV airplanes found that, with the gust lock handle in the ON position, the forward throttle lever movement that could be achieved on the G-IV was 3 to 4 times greater than the intended TLA of 6°. During takeoff, the pilot-in-command (PIC) manually advanced the throttle levers, but the engine pressure ratio (EPR) did not reach the expected level due to the throttles contacting the gust lock/throttle lever interlock. The PIC did not immediately reject the takeoff; instead, he engaged the autothrottle, and the throttle levers moved slightly forward, which allowed the engines to attain an EPR value that approached (but never reached) the target setting. As the takeoff roll continued, the second-in-command made the standard takeoff speed callouts as the airplane successively reached 80 knots, the takeoff safety speed, and the rotation speed. When the PIC attempted to rotate the airplane, he discovered that he could not move the control yoke and began calling out “(steer) lock is on.” At this point, the PIC clearly understood that the controls were locked but still did not immediately initiate a rejected takeoff. If the flight crew had initiated a rejected takeoff at the time of the PIC’s first “lock is on” comment or at any time up until about 11 seconds after this comment, the airplane could have been stopped on the paved surface. However, the flight crew delayed applying brakes for about 10 seconds and further delayed reducing power by 4 seconds; therefore, the rejected takeoff was not initiated until the accident was unavoidable. Among the victims was Lewis Katz, co-owner of the 'Philadelphia Inquirer'.

On July 31, 2008, about 0945 central daylight time, East Coast Jets flight 81, a BAe 125-800A airplane, registered N818MV, crashed while attempting to go around after landing on runway 30 at Owatonna Degner Regional Airport, Owatonna, Minnesota. The two pilots and six passengers were killed, and the airplane was destroyed by impact forces. The nonscheduled, domestic passenger flight was operating under the provisions of 14 Code of Federal Regulations Part 135. An instrument flight rules flight plan had been filed and activated; however, it was canceled before the landing. Visual meteorological conditions prevailed at the time of the accident.

The first officer was flying the Area Navigation, Global Positioning System, approach to runway 22. During the approach, the airplane was initially fast as the first officer had increased engine power to compensate for wind conditions. Descending below the minimum descent altitude (MDA), the first officer momentarily deployed the speed brakes, but stowed them about 200 feet above ground level (agl), and reduced the engine power to flight idle. The airplane became low and slow, and developed an excessive sink rate. The airplane subsequently landed hard on runway 22, which drove the right main landing gear into the right wing, resulting in substantial damage to the right wing spar. The first officer reported intermittent airspeed fluctuations between his airspeed indicator and the captain's airspeed indicator; however, a subsequent check of the pitot-static system did not reveal any anomalies that would have precluded normal operation of the airspeed indicators. About the time of the accident, the recorded wind was from 190 degrees at 11 knots, gusting to 24 knots; and the captain believed that the airplane had encountered windshear near the MDA, with the flaps fully extended. Review of air traffic control data revealed that no windshear advisories were contained in the automated terminal information system broadcasts. Although the local controller provided windshear advisories to prior landing aircraft, he did not provide one to the accident aircraft. Review of the airplane flight manual (AFM) revealed that deploying the speed brakes below 500 feet agl, with the flaps in any position other than the retracted position, was prohibited.

The airplane was loaded to within a few hundred pounds of its maximum gross takeoff weight, and departed from an airport located in a valley, surrounded by rising terrain. Although visual conditions prevailed at the accident airport, fog was present in the adjacent valleys. During the initial climb after takeoff, the right engine lost partial power due to a failure of the number one cylinder exhaust valve. The pilot secured the right engine; however, he was unable to maintain a climb with only the left engine producing power. The airplane was manufactured in 1964. Review of weight and performance data published at the time of manufacture, revealed that the airplane should have been able to climb about 400 feet-per-minute with a single engine producing power. No current weight and balance data was recovered, and due to impact and fire damage, the preimpact power output of the left engine could not be determined. Both engines were last overhauled slightly more than 12 years prior to the accident, and flown about 310 hours during that time. For the make and model engine, the manufacturer recommended overhaul at 1,200 hours of operation, or during the twelfth year.

The crew briefed the Instrument Landing System approach, including the missed approach procedures. Weather at the time included a 100-foot broken cloud layer, and at the airport, 2 miles visibility. The approach was flown over water, and at the accident location, there was dense fog. Two smaller airplanes had successfully completed the approach prior to the accident airplane. The captain flew the approach and the first officer made 100-foot callouts during the final descent, until 200 feet above the decision height. At that point, the captain asked the first officer if he saw anything. The first officer reported "ground contact," then noted "decision height." The captain immediately reported "I got the lights" which the first officer confirmed. The captain reduced the power to flight idle. Approximately 4 seconds later, the captain attempted to increase power. However, the engines did not have time to respond before the airplane descended into the water and impacted a series of approach light stanchions, commencing about 2,000 feet from the runway. Neither crew member continued to call out altitudes after seeing the approach lights, and the captain descended the airplane below the decision height before having the requisite descent criteria. The absence of ground references could have been conducive to a featureless terrain illusion in which the captain would have believed that the airplane was at a higher altitude than it actually was. There were
no mechanical anomalies which would have precluded normal airplane operation.

Witness's reported that the airplane took off from runway 05, which has an up slope of 1.2 degrees. The airplane was observed at approximately 10 feet above ground level, in a nose high attitude traveling parallel to the ground and not climbing. The airplane narrowly cleared a 6- foot fence off the departure end of runway 05. Shortly thereafter, the airplane impacted a utility pole, the roof of a bus stop, which was followed by a brick wall. At the time of the accident runway 23, which has a 1.2-degree down slope and has a clear-cut area on the departure end, was available for use. The basic empty weight for this airplane is 3,097 pounds; the useful load is 1,201.7 pounds. The actual load at the time of the accident was in excess of the useful load. There is no record of the pilot completing a weight and balance computation prior to take-off. The toxicology examinations were negative for carbon monoxide, cyanide, drugs and alcohol. The toxicology examination revealed that 1175(mg/dl) glucose was detected in the urine. Examination of the airplane and subsystems failed to disclose any mechanical or component failures.

On May 21, 2000, about 1128 eastern daylight time (EDT), a British Aerospace Jetstream 3101, N16EJ, operated by East Coast Aviation Services (doing business as Executive Airlines) crashed
about 11 miles south of Wilkes-Barre/Scranton International Airport (AVP), Wilkes-Barre, Pennsylvania. The airplane was destroyed by impact and a post crash fire, and 17 passengers and two flight crewmembers were killed. The flight was being conducted under 14 Code of Federal Regulations (CFR) Part 135 as an on-demand charter flight for Caesar’s Palace Casino in Atlantic City, New Jersey. An instrument flight rules (IFR) flight plan had been filed for the flight from Atlantic City International Airport (ACY) to AVP. The captain checked in for duty about 0800 at Republic Airport (FRG) in Farmingdale, New York, on the day of the accident. The airplane was originally scheduled to depart FRG at 0900 for ACY and to remain in ACY until 1900, when it was scheduled to return to FRG. While the pilots were conducting preflight inspections, they received a telephone call from Executive Airlines’ owner and chief executive officer (CEO) advising them that they had been assigned an additional flight from ACY to AVP with a return flight to ACY later in the day, instead of the scheduled break in ACY. Fuel records at FRG indicated that 90 gallons of fuel were added to the accident airplane’s tanks before departure to ACY. According to Federal Aviation Administration (FAA) air traffic control (ATC) records, the flight departed at 0921 (with 12 passengers on board) and arrived in ACY at 0949. According to passenger statements, the captain was the pilot flying from FRG to ACY. After arrival in ACY, the flight crew checked the weather for AVP and filed an IFR flight plan. Fuel facility records at ACY indicated that no additional fuel was added. The accident flight to AVP, which departed ACY about 1030, had been chartered by Caesar’s Palace. According to ATC records, the flight to AVP was never cleared to fly above 5,000 feet mean sea level (msl). According to ATC transcripts, the pilots first contacted AVP approach controllers at 1057 and were vectored for an instrument landing system (ILS) approach to runway 4. The flight was cleared for approach at 1102:07, and the approach controller advised the pilots that they were 5 nautical miles (nm) from Crystal Lake, which is the initial approach fix (IAF) for the ILS approach to runway 4. The pilots were told to maintain 4,000 feet until established on the localizer. At 1104:16, the approach controller advised that a “previous landing…aircraft picked up the airport at minimums [decision altitude].” The pilots were instructed to contact the AVP local (tower) controller at 1105:09, which they did 3 seconds later. The airplane then descended to about 2,200 feet, flew level at 2,200 feet for about 20 seconds, and began to climb again about 2.2 nm from the runway threshold when a missed approach was executed (see the Airplane Performance section for more information). At 1107:26 the captain reported executing the missed approach but provided no explanation to air traffic controllers. The tower controller informed the North Radar approach controllers of the missed approach and then instructed the accident flight crew to fly runway heading, climb to 4,000 feet, and contact approach control on frequency 124.5 (the procedure published on the approach chart). The pilots reestablished contact with the approach controllers at 1108:04 as they climbed through 3,500 feet to 4,000 feet and requested another ILS approach to runway 4. The flight was vectored for another ILS approach, and at 1110:07 the approach controller advised the pilots of traffic 2 nm miles away at 5,000 feet. The captain responded that they were in the clouds. At 1014:38, the controller directed the pilots to reduce speed to follow a Cessna 172 on approach to the airport, and the captain responded, “ok we’re slowing.” The flight was cleared for a second approach at 1120:45 and advised to maintain 4,000 feet until the airplane was established on the localizer. At 1123:49 the captain transmitted, “for uh one six echo juliet we’d like to declare an emergency.” At 1123:53, the approach controller asked the nature of the problem, and the captain responded, “engine failure.” The approach controller acknowledged the information, informed the pilots that the airplane appeared to be south of the localizer (off course to the right), and asked if they wanted a vector back to the localizer course. The flight crew accepted, and at 1124:10 the controller directed a left turn to heading 010, which the captain acknowledged. At 1124:33, the controller asked for verification that the airplane was turning left. The captain responded, “we’re trying six echo juliet.” At 1124:38, the controller asked if a right turn would be better. The captain asked the controller to “stand by.” At 1125:07, the controller advised the pilots that the minimum vectoring altitude (MVA) in the area was 3,300 feet. At 1125:12, the captain transmitted, “standby for six echo juliet tell them we lost both engines for six echo juliet.” At that time, ATC radar data indicated that the airplane was descending through 3,000 feet. The controller immediately issued the weather conditions in the vicinity of the airport and informed the flight crew about the location of nearby highways. At 1126:17, the captain asked, “how’s the altitude look for where we’re at.” The controller responded that he was not showing an altitude readout from the airplane and issued the visibility (2.5 miles) and altimeter setting. At 1126:43, the captain transmitted, “just give us a vector back to the airport please.” The controller cleared the accident flight to fly heading 340, advised the flight crew that radar contact was lost, and asked the pilots to verify their altitude. The captain responded that they were “level at 2,000.” At 1126:54, the controller again advised the flight crew of the 3,300-foot MVA and suggested a 330° heading to bring the airplane back to the localizer. At 1127:14 the controller asked, “do you have any engines,” and the captain responded that they appeared to have gotten back “the left engine now.” At 1127:23, the controller informed the pilots that he saw them on radar at 2,000 feet and that there was a ridgeline between them and the airport. The captain responded, “that’s us” and “we’re at 2,000 feet over the trees.” The controller instructed the pilots to fly a 360° heading and advised them of high antennas about 2 nm west of their position. At 1127:46, the captain transmitted, “we’re losing both engines.” Two seconds later the controller advised that the Pennsylvania Turnpike was right below the airplane and instructed the flight crew to “let me know if you can get your engines back.” There was no further radio contact with the accident airplane. The ATC supervisor initiated emergency notification procedures. A Pennsylvania State Police helicopter located the wreckage about 1236, and emergency rescue units arrived at the accident site about 1306. The accident occurred in daylight instrument meteorological conditions (IMC). The location of the accident was 41° 9 minutes, 23 seconds north latitude, 75° 45 minutes, 53 seconds west longitude, about 11 miles south of the airport at an elevation of 1,755 feet msl.

While descending from 5,000 feet to 3,000 feet, the pilot informed ATC that the left engine had failed and the engine cowling was open. The crew said that after feathering the left propeller, and with the right engine at full power, they could not arrest a 300-500 fpm rate of descent. The crew informed ATC that they would be landing in the water. All the occupants exited the airplane from the left front pilot's emergency door. The victims were in the water for approximately 30 minutes before being rescued. One of the passengers was in cardiac arrest when he was retrieved from the water. Examination of the left engine revealed that the #2 cylinder had separated from the engine in flight as a result of high stress fatigue cracking of the cylinder hold down studs and the #3 main bearing thru-studs. The fatigue in the studs occurred as a result of the cylinder fastener preload forces either initially inadequate or lost during service. Maintenance records indicated that the thru-stud was replaced 80 service hours prior to the accident. Examination of the cylinder hold down studs and the #3 main bearing thru-studs revealed that they were improperly torqued, resulting in low initial preload on the fasteners. Incorrect installation of the oversize thru-studs, per existing service information, could have also been a factor in the improper torquing of the studs. The locations of the fatigue origins and the edge worn into the deck indicate that the upper studs were probably the first to fail, allowing the cylinder to rock on the lower rear corner of the cylinder flange.

The captain had ILS glideslope data available during the approach but did not fly the ILS glideslope. The partial obscuration of the airport environment, due to ground fog, contributed to the captain's failure to recognize that the airplane was high on both his approach and landing. The destruction of the airplane and the resulting occupant injuries were a direct result of the collision with the blast fence. FAA interaction and communication with local communities, although persistent, were unsuccessful in gaining support for runway safety area improvements and for the installation of approach lighting for runway 6. The passenger seats had been improperly assembled using unapproved parts, and seat belts had been installed incorrectly.

The pilot was approaching Atlantic City Airport by night and poor weather conditions when the twin engine aircraft struck the ground and crashed few miles short of runway. The aircraft was destroyed and the pilot, sole on board, was killed.