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Crash of a Cessna 525C CitationJet CJ4 off Cleveland: 6 killed

Date & Time: Dec 29, 2016 at 2257 LT
Type of aircraft:
Operator:
Registration:
N614SB
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Cleveland – Columbus
MSN:
525C-0072
YOM:
2012
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
6
Captain / Total flying hours:
1205
Captain / Total hours on type:
56.00
Aircraft flight hours:
861
Circumstances:
The airplane entered a right turn shortly after takeoff and proceeded out over a large lake. Dark night visual conditions prevailed at the airport; however, the airplane entered instrument conditions shortly after takeoff. The airplane climb rate exceeded 6,000 fpm during the initial climb and it subsequently continued through the assigned altitude of 2,000 ft mean sea level. The flight director provided alerts before the airplane reached the assigned altitude and again after it had passed through it. The bank angle increased to about 62 degrees and the pitch attitude decreased to about 15 degrees nose down, as the airplane continued through the assigned heading. The bank angle ultimately decreased to about 25 degrees. During the subsequent descent, the airspeed and descent rate reached about 300 knots and 6,000 fpm, respectively. The enhanced ground proximity warning system (EGPWS) provided both "bank angle" and "sink rate" alerts to the pilot, followed by seven "pull up" warnings. A postaccident examination of the recovered wreckage did not reveal any anomalies consistent with a preimpact failure or malfunction. It is likely that the pilot attempted to engage the autopilot after takeoff as he had been trained. However, based on the flight profile, the autopilot was not engaged. This implied that the pilot failed to confirm autopilot engagement via an indication on the primary flight display (PFD). The PFD annunciation was the only indication of autopilot engagement. Inadequate flight instrument scanning during this time of elevated workload resulted in the pilot allowing the airplane to climb through the assigned altitude, to develop an overly steep bank angle, to continue through the assigned heading, and to ultimately enter a rapid descent without effective corrective action. A belief that the autopilot was engaged may have contributed to his lack of attention. It is also possible that differences between the avionics panel layout on the accident airplane and the airplane he previously flew resulted in mode confusion and contributed to his failure to engage the autopilot. The lack of proximal feedback on the flight guidance panel might have contributed to his failure to notice that the autopilot was not engaged.The pilot likely experienced some level of spatial disorientation due to the dark night lighting conditions, the lack of visual references over the lake, and the encounter with instrument meteorological conditions. It is possible that once the pilot became disoriented, the negative learning transfer due to the differences between the attitude indicator display on the accident airplane and the airplane previously flown by the pilot may have hindered his ability to properly apply corrective control inputs. Available information indicated that the pilot had been awake for nearly 17 hours at the time of the accident. As a result, the pilot was likely fatigued which hindered his ability to manage the high workload environment, maintain an effective instrument scan, provide prompt and accurate control inputs, and to respond to multiple bank angle and descent rate warnings.
Probable cause:
Controlled flight into terrain due to pilot spatial disorientation. Contributing to the accident was pilot fatigue, mode confusion related to the status of the autopilot, and negative learning transfer due to flight guidance panel and attitude indicator differences from the pilot's previous flight experience.
Final Report:

Ground accident of a Douglas DC-9-51 in Minneapolis

Date & Time: May 10, 2005 at 1936 LT
Type of aircraft:
Operator:
Registration:
N763NC
Flight Phase:
Survivors:
Yes
Schedule:
Columbus - Minneapolis
MSN:
47716/822
YOM:
1976
Flight number:
NW1495
Crew on board:
5
Crew fatalities:
Pax on board:
94
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
10811
Captain / Total hours on type:
6709.00
Copilot / Total flying hours:
3985
Copilot / Total hours on type:
3985
Aircraft flight hours:
67268
Aircraft flight cycles:
66998
Circumstances:
The DC-9 was taxiing to the gate area when it collided with a company A319 that was being pushed back from the gate. Prior to arriving at the destination airport, the DC-9 experienced a loss of hydraulic fluid from a fractured rudder shutoff valve located in the DC-9's right side hydraulic system. The left side hydraulic system had normal hydraulic pressure and quantity throughout the flight. The flightcrew elected to continue to the scheduled destination and declared an emergency while on approach to the destination airport. After landing, the emergency was negated by the flight crew and the airplane taxied to the gate. Flight data recorder information indicates the left engine, which provides power for the left hydraulic system, was shut down during taxi. The captain stated he did not remember shutting the left engine down, and that if he had, it would have been after clearing all runways. The first officer stated that he was unaware that the left engine was shut down. Upon arrival at the gate with the left engine shut down and no hydraulic pressure from the left system and a failure of the right hydraulic system, the airplane experienced a loss of steering and a loss of brakes. The flightcrew requested company maintenance to chock the airplane since they were unable to use brakes to stop the airplane. The crew said they were going to keep the "...engines running in case we have to use reversers..." The airplane began to roll forward and the captain applied reverse thrust but the reversers did not deploy. The airplane impacted the A319 with a speed of approximately 15.65 miles per hour to 16.34 miles per hour. Evacuation of the DC-9 was completed approximately 5:22 minutes after the collision and evacuation of the A319 occurred approximately 13:08 minutes after the collision. Examination of the left hydraulic system revealed no anomalies and examination of the right hydraulic system revealed a fractured rudder shutoff valve that displayed features consistent with fatigue. Following the accident, the airplane manufacturer issued a service letter pertaining to the replacement of the rudder shutoff valve based upon reliability information that was reported to them. The number of reports was greater than that of the Federal Aviation Administration's Service Difficulty Reports database, and less than the operators records.
Probable cause:
The Captain's decision to shutdown the left engine during taxi with no hydraulic pressure on the right side hydraulic system to effectively operate the brakes, steering, or thrust reversers. A factor was the fatigue fracture of the rudder shutoff valve which resulted in the loss of right side hydraulic pressure.
Final Report:

Crash of a Piper PA-60P Aerostar (Ted Smith 600P) in Columbus: 1 killed

Date & Time: Jul 18, 2002 at 0345 LT
Operator:
Registration:
N158GA
Flight Type:
Survivors:
No
Schedule:
Cleveland - Columbus
MSN:
60-0608-7961195
YOM:
1979
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
2378
Captain / Total hours on type:
51.00
Aircraft flight hours:
6288
Circumstances:
The airplane was destroyed by impact forces and fire after it impacted the intersection of runway 23 and 32 while attempting a missed-approach. The pilot's crew day started at 1300 and the 14 hour duty limit was 0300 the following morning. The second leg of the flight was delayed 1 hour and 36 minutes due to a freight delay. The operator reported the pilot exceeded his 14 hour crew day by 45 minutes as a result of the freight delay. The flight was cleared for the runway 23 ILS instrument approach. A witness, who was monitoring the Unicom radio frequency, reported that he heard clicking sounds on the Unicom frequency (to bring up the runway light intensity), but the pilot did not make any radio transmissions. The witness reported the ground fog was very thick. Two witnesses reported they heard the airplane's engines. They then heard the engines go to "full power," and then they heard the airplane impact the ground. They saw an initial flash, but could not see the airplane on fire from 2,500 feet away. FAR 135.213 requires that, "Weather observations made and furnished to pilots to conduct IFR operations at an airport must be made at the airport where those IFR operations are conducted." The destination did not have authorized weather reporting, and the operator's Operating Specifications did not list an alternate weather reporting source. At 0253, the observed weather 20 miles to the north, indicated the following: winds 190 at 4 knots, 1/4 statute mile visibility, fog, indefinite ceilings 100 feet, temperature 22 degrees C, dew point 22 degrees C, altimeter 30.00. From the initial point of impact (POI), the wreckage path continued for about 210 feet on a heading of about 180 degrees. The outboard section of the left wing outboard of the nacelle was found on runway 32, about 85 feet from the POI. Separated, unburned, portions of the left aileron and left flap were also found on the runway. The remaining pieces of the left wing were located with the main wreckage. The right wing was located with the main wreckage and the entire span of the right wing from the wing root to the wingtip exhibited continuity. The inspection of the airplane revealed no preexisting anomalies.
Probable cause:
The pilot's failure to maintain control of the airplane during a missed approach. Additional factors included the operator's inadequate oversight, the pilot's improper in-flight decision, conditions conducive to pilot fatigue, fog, and night.
Final Report:

Crash of a Cessna 421B Golden Eagle II in Columbus

Date & Time: Aug 6, 1998 at 0450 LT
Registration:
N5MJ
Flight Phase:
Survivors:
Yes
Schedule:
Columbus - Detroit
MSN:
421B-0925
YOM:
1975
Crew on board:
2
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
2145
Captain / Total hours on type:
594.00
Aircraft flight hours:
6925
Circumstances:
Upon reaching an altitude of 400 agl after takeoff, the left side door on the nose baggage door opened. The pilot-in- command initiated a left turn to return to the airport. During the turn the stall horn sounded. The airplane then descended and impacted the terrain. Investigation revealed that both pilots did a portion of the aircraft preflight inspection. Both pilots were qualified to act as PIC for the flight and this flight would typically have been a single pilot operation. However, the company who hired the operator to transport their employees requested two pilots. The operator did not have any written procedures regarding the division of duties for a two pilot operation on this type of aircraft.
Probable cause:
The pilot-in-commands failure to maintain airspeed and the subsequent stall/mush. Factors associated with the accident were the open baggage door and the inadequate aircraft preflight.
Final Report:

Crash of a Convair CV-240D in Akron

Date & Time: Nov 28, 1991 at 1434 LT
Type of aircraft:
Operator:
Registration:
N450GA
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Akron - Columbus
MSN:
52-83
YOM:
1954
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Aircraft flight hours:
18528
Circumstances:
Shortly after departure the airplane was seen climbing to an altitude of about 200 feet agl. Witnesses saw smoke coming from one of the engines and heard a 'popping noise.' The pilot executed a forced landing in a field. The airplane struck electrical wires and fence then burst into flames. The airplane had refueled just prior to take off, and the fuel receipt showed that 300 gallons of jet (A) fuel was put into the tanks. The normal fuel used in the airplane was 100LL.
Probable cause:
The use of an improper grade of fuel, which was approved by the captain and resulted in a loss of engine power during climbout and an in flight collision with terrain.
Final Report:

Crash of a Boeing 737-3B7 in Los Angeles: 22 killed

Date & Time: Feb 1, 1991 at 1807 LT
Type of aircraft:
Operator:
Registration:
N388US
Survivors:
Yes
Schedule:
Columbus - Los Angeles
MSN:
23310
YOM:
1985
Flight number:
US1493
Crew on board:
6
Crew fatalities:
Pax on board:
83
Pax fatalities:
Other fatalities:
Total fatalities:
22
Captain / Total flying hours:
16300
Captain / Total hours on type:
4300.00
Copilot / Total flying hours:
4316
Copilot / Total hours on type:
982
Circumstances:
SKW5569, N683AV, had been cleared to runway 24L, at intersection 45, to position and hold. The local controller, because of her preoccupation with another airplane, forgot she had placed SKW5569 on the runway and subsequently cleared US1493, N388US, for landing. After the collision, the two airplanes slid off the runway into an unoccupied fire station. The tower operating procedures did not require flight progress strips to be processed through the local ground control position. Because this strip was not present, the local controller misidentified an airplane and issued a landing clearance. The technical appraisal program for air traffic controllers is not being fully utilized because of a lack of understanding by supervisors and the unavailability of appraisal histories.
Probable cause:
The failure of the los angeles air traffic facility management to implement procedures that provided redundancy comparable to the requirements contained in the national operational position standards and the failure of the faa air traffic service to provide adequate policy direction and oversight to its air traffic control facility managers. These failures created an environment in the Los Angeles air traffic control tower that ultimately led to the failure of the local controller 2 (lc2) to maintain an awareness of the traffic situation, culminating in the inappropriate clearances and the subsequent collision of the usair and skywest aircraft. Contributing to the cause of the accident was the failure of the faa to provide effective quality assurance of the atc system.
Final Report:

Crash of a Piper PA-31-310 Navajo in Springfield: 1 killed

Date & Time: Jan 3, 1989 at 0812 LT
Type of aircraft:
Operator:
Registration:
N9034Y
Flight Type:
Survivors:
No
Site:
Schedule:
Indianapolis - Columbus
MSN:
31-47
YOM:
1967
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
1041
Captain / Total hours on type:
57.00
Aircraft flight hours:
5906
Circumstances:
The pilot was making a contract cargo flight under far 91 rules and had experienced icing enroute. When just past Dayton, he indicated that he 'had a little fuel problem' and needed to get into OSU without delays. A short time later he indicated that he needed to go to the nearest airport. He was vectored toward SGH for landing. He then indicated that he had lost an engine and a short time later indicated that he had lost the other engine. The aircraft crashed in a residential area. There was no fire and only residual fuel was found in the airplane. The company president indicated that he did not encourage his pilots to carry 'excess fuel'. It was reported that this pilot, along with others, had been 'chewed out' for carrying 'excess fuel'. The operation should have been conducted under far 135 rules since the company had retained operational control of the operation. The pilot, sole on board, was killed.
Probable cause:
Fuel exhaustion precipitated by the inadequate fuel consumption calculations performed by the pilot, pressure from the company president to not carry excess fuel and improper in-flight planning/decisions by the pilot by not refueling enroute before fuel was exhausted. Contributing to the accident was the inadequate surveillance and certification of the operator by the FAA.
Occurrence #1: loss of engine power (total) - nonmechanical
Phase of operation: descent
Findings
1. (c) fuel consumption calculations - inadequate - pilot in command
2. (c) company-induced pressure - company/operator management
3. (c) inadequate surveillance of operation - faa (organization)
4. (c) fluid, fuel - exhaustion
5. (c) aircraft preflight - inadequate - pilot in command
6. (c) inadequate certification/approval - faa (organization)
7. (c) refueling - not performed - pilot in command
8. (c) in-flight planning/decision - inadequate - pilot in command
----------
Occurrence #2: forced landing
Phase of operation: descent - emergency
----------
Occurrence #3: in flight collision with terrain/water
Phase of operation: descent - uncontrolled
Final Report:

Crash of a Beechcraft H18 in Pittsburgh

Date & Time: Nov 12, 1986 at 1100 LT
Type of aircraft:
Operator:
Registration:
N925J
Flight Type:
Survivors:
Yes
Schedule:
Columbus - Pittsburgh
MSN:
BA-642
YOM:
1963
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
8030
Captain / Total hours on type:
115.00
Aircraft flight hours:
10537
Circumstances:
The aircraft suffered a right landing gear leg breakage due to a fracture in the area where the fork assembly separated during landing roll. The pilot, sole on board, was uninjured.
Probable cause:
Occurrence #1: main gear collapsed
Phase of operation: landing - roll
Findings
1. (c) landing gear, main gear - assembly
2. Landing gear, main gear - fatigue
3. (c) landing gear, main gear - previous damage
Final Report:

Crash of a Beechcraft H18 in Louisville

Date & Time: Feb 11, 1986 at 2052 LT
Type of aircraft:
Operator:
Registration:
N148PA
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Louisville - Columbus
MSN:
BA-645
YOM:
1963
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
1663
Captain / Total hours on type:
203.00
Aircraft flight hours:
6405
Circumstances:
The aircraft collided with the ground after stalling during takeoff. Witnesses reported that the aircraft pitched up in two increments, climbed sharply to about 200 feet agl, stalled dropped the right wing and descended, impacting the ground in a flat attitude.
Probable cause:
Occurrence #1: loss of control - in flight
Phase of operation: takeoff - initial climb
Findings
1. (c) proper climb rate - not maintained - pilot in command
2. (c) stall - not corrected - pilot in command
----------
Occurrence #2: in flight collision with terrain/water
Phase of operation: descent - uncontrolled
Final Report:

Crash of a Rockwell Grand Commander 680F in Chesapeake: 1 killed

Date & Time: Jul 27, 1985 at 1145 LT
Registration:
N100HA
Flight Phase:
Survivors:
No
Schedule:
Chesapeake - Columbus
MSN:
680-1184-96
YOM:
1962
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Aircraft flight hours:
3484
Circumstances:
As near as can be determined, this was the pilot's second flight since obtaining his multi engine rating and third flight since obtaining his commercial pilot certificate from a designated p.e. The aircraft was observed to depart Lawrence County Airpark and upon reaching a point over the runway end, an engine started making a popping sound. The pilot radioed on unicom that he was having trouble with the aircraft. The aircraft climbed to an estimated 500 feet and a left turn away from the Ohio River and toward the hills was started. Witnesses observed aircraft porpoise in flight and said that at least once it sounded as if both engines quit momentarily then restarted. Then aircraft rolled into left bank and struck trees on ridgetop. The pilot, sole on board, was killed.
Probable cause:
Occurrence #1: loss of engine power (partial) - nonmechanical
Phase of operation: takeoff - initial climb
Findings
1. (f) engine assembly, other - erratic
2. (c) throttle/power control - inadequate - pilot in command
3. (f) self-induced pressure - pilot in command
4. (f) inadequate certification/approval, airman - faa(organization)
5. (c) emergency procedure - not used - pilot in command
6. (f) excessive workload (task overload) - pilot in command
7. (f) insuff standards/requirements, operation/operator - company/operator mgmt
8. (c) airspeed (vmc) - not maintained - pilot in command
9. (c) lack of total experience - pilot in command
10. (c) lack of familiarity with aircraft - pilot in command
11. (f) inadequate training - pilot in command
12. (c) pressure - pilot in command
13. (c) lack of total experience - pilot in command
----------
Occurrence #2: in flight collision with object
Phase of operation: maneuvering
Findings
14. (f) terrain condition - mountainous/hilly
15. (c) propeller feathering - not identified - pilot in command
16. (f) object - tree(s)
17. (c) judgment - poor - pilot in command
Final Report: