Crash of a Swearingen SA227AT Expediter in Waukesha

Date & Time: Nov 15, 2022 at 1500 LT
Operator:
Registration:
N247DH
Flight Type:
Survivors:
Yes
Schedule:
New Orleans – Waukesha
MSN:
AT-626B
YOM:
1985
Flight number:
AMF7141
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
2848
Captain / Total hours on type:
1316.00
Copilot / Total flying hours:
1320
Copilot / Total hours on type:
537
Aircraft flight hours:
29256
Circumstances:
The flight crew reported that while on an instrument landing system (ILS) approach with the autopilot system engaged in approach mode, they noticed that the airplane flight director indicated a climbing right turn but the airplane was still tracking the localizer and glideslope. The airplane’s ice protection was on, and no visible ice had accumulated. They reported that they disconnected the autopilot, and the airplane suddenly rolled to the right. They attempted to regain control by increasing engine power and applying counteractive control inputs, but the airplane impacted the ground in a near-wings-level attitude. Examination of the airplane’s primary flight control system and engines after the accident did not reveal any defects. The rudder trim was neutral, and the pitch trim was airplane nose up. Aileron trim could not be determined. Examination of the airplane’s autopilot components revealed deficiencies in the yaw damper system that rendered it inoperative; however, on the accident airplane the yaw damper system was an optional component and was not necessary for airplane operation. Testing of the remaining autopilot components revealed some deficiencies that could have degraded performance but would not have resulted in a complete failure of the automatic flight control system. A performance study based on ADS-B data showed that the airplane intercepted the localizer and glideslope for the ILS approach and was descending in a level attitude. While maintaining the ILS approach guidance, the airplane slowed below the 130 knots (kts) airspeed that the crew stated was the desired approach speed. The airspeed continued to slow to about 102 kts when the ADS-B data indicated that the airplane rolled slightly to the right, likely corresponding to the flight crew’s description of events after they disconnected the autopilot. The airplane continued to slow below 100 kts and the airplane was at a bank angle of 27° right wing down. Subsequently, the descent rate increased to over 4,000 ft/min and airspeed increased while ground speed remained between 80 and 90 kts. The airplane rolled sharply to the left. The sudden roll and loss of altitude after reaching a low airspeed was consistent with an aerodynamic stall. Based on the available evidence, the airplane entered an inadvertent aerodynamic stall due to exceedance of the critical angle of attack after the flight crew allowed the airspeed to decay during the instrument approach. Although an unknown anomaly in the flight director system could have resulted in the crew becoming fixated on an errant flight director indication at the expense of airspeed control, the postaccident component examination was not able to explain the errant flight director indication that the flight crew described.
Probable cause:
The flight crew’s failure to maintain adequate airspeed and their exceedance of the airplane’s critical angle of attack during the instrument approach, which resulted in an aerodynamic stall. Contributing to the accident was an undetermined anomaly in the airplane flight director system which resulted in the flight crew likely becoming fixated on the anomaly at the expense of airspeed control.
Final Report:

Crash of a Raytheon 390 Premier I in Atlanta: 2 killed

Date & Time: Dec 17, 2013 at 1924 LT
Type of aircraft:
Operator:
Registration:
N50PM
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Atlanta - New Orleans
MSN:
RB-80
YOM:
2003
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
7200
Captain / Total hours on type:
1030.00
Aircraft flight hours:
713
Circumstances:
The pilot and passenger departed on a night personal flight. A review of the cockpit voice recorder (CVR) transcript revealed that, immediately after departure, the passenger asked the pilot if he had turned on the heat. The pilot subsequently informed the tower air traffic controller that he needed to return to the airport. The controller then cleared the airplane to land and asked the pilot if he needed assistance. The pilot replied "negative" and did not declare an emergency. The pilot acknowledged to the passenger that it was hot in the cabin. The CVR recorded the enhanced ground proximity warning system (EGPWS) issue 11 warnings, including obstacle, terrain, and stall warnings; these warnings occurred while the airplane was on the downwind leg for the airport. The airplane subsequently impacted trees and terrain and was consumed by postimpact fire. Postaccident examination of the airplane revealed no malfunctions or anomalies that would have precluded normal operation. During the attempted return to the airport, possibly to resolve a cabin heat problem, the pilot was operating in a high workload environment due to, in part, his maneuvering visually at low altitude in the traffic pattern at night, acquiring inbound traffic, and being distracted by the reported high cabin temperature and multiple EGPWS alerts. The passenger was seated in the right front seat and in the immediate vicinity of the flight controls, but no evidence was found indicating that she was operating the flight controls during the flight. Although the pilot had a history of coronary artery disease, the autopsy found no evidence of a recent cardiac event, and an analysis of the CVR data revealed that the pilot was awake, speaking, and not complaining of chest pain or shortness of breath; therefore, it is unlikely that the pilot's cardiac condition contributed to the accident. Toxicological testing detected several prescription medications in the pilot's blood, lung, and liver, including one to treat his heart disease; however, it is unlikely that any of these medications resulted in impairment. Although the testing revealed that the pilot had used marijuana at some time before the accident, insufficient evidence existed to determine whether the pilot was impaired by its use at the time of the accident. Toxicology testing also detected methylone in the pilot's blood. Methylone is a stimulant similar to cocaine and Ecstasy, and its effects can include relaxation, euphoria, and excited calm, and it can cause acute changes in cognitive performance and impair information processing. Given the level of methylone (0.34 ug/ml) detected in the pilot's blood, it is likely that the pilot was impaired at the time of the accident. The pilot's drug impairment likely contributed to his failure to maintain control of the airplane.
Probable cause:
The pilot's failure to maintain airplane control while maneuvering the airplane in the traffic pattern at night. Contributing to the accident was the pilot's impairment from the use of illicit drugs.
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 Beechcraft 100 King Air in Houston

Date & Time: Sep 16, 1989 at 0855 LT
Type of aircraft:
Operator:
Registration:
N204AJ
Flight Type:
Survivors:
Yes
Schedule:
New Orleans - Houston
MSN:
B-10
YOM:
1970
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
2787
Captain / Total hours on type:
48.00
Aircraft flight hours:
7351
Circumstances:
The airplane was on a positioning flight and had two passengers along for the ride. The airplane was on base leg when the left engine sputtered. The pilot turned on the secondary boost pump and the engine operated normally until both engines flamed out. During the forced landing in a residential area, the airplane hit a powerline, trees, a house, a fireplug, a tree and a van, then another house. There was no smell of fuel in the entire area, and no usable fuel in the fuel system. All three occupants were seriously injured.
Probable cause:
The inadequate preflight planning preparation & the improper inflight planning/decision by the pic when he failed to refuel the aircraft which resulted in a total loss of power in both engines.
Final Report:

Crash of a Partenavia P.68C Victor off New Orleans

Date & Time: Sep 11, 1987 at 0629 LT
Type of aircraft:
Registration:
N1352W
Survivors:
Yes
Schedule:
Hammond - New Orleans
MSN:
232
YOM:
1982
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
15164
Captain / Total hours on type:
30.00
Aircraft flight hours:
913
Circumstances:
The pilot began an ILS runway 18R approach at night to the Lakefront Airport. He reported that after the aircraft broke out of the clouds at 1,700 feet, he transitioned to a visual approach. He stated that as he continued, the approach seemed normal, except the VASI lights seemed too far down the runway. He remembered that just before impact, the VASI was providing a red over red indication, but he did not worry as he perceived the aircraft was over the end of the runway and he was about to flare. At about that time, the aircraft impacted with water, well short of the runway. As the aircraft sank, the pilot escaped thru a hole in the windshield. Subsequently, he was found by passing fishermen. The pilot believed he had gotten a false perception of the runway location due to reflection of lights off of calm lake water.
Probable cause:
Occurrence #1: undershoot
Phase of operation: approach - vfr pattern - final approach
Findings
1. (f) light condition - dark night
2. (f) terrain condition - water, glassy
3. (c) in-flight planning/decision - improper - pilot in command
4. (c) unsafe/hazardous condition warning - disregarded - pilot in command
5. (c) distance - misjudged - pilot in command
6. (f) visual/aural perception - pilot in command
7. (c) altitude - misjudged - pilot in command
----------
Occurrence #2: in flight collision with terrain/water
Phase of operation: approach - vfr pattern - final approach
Findings
8. Terrain condition - water
Final Report:

Crash of a Cessna 441 Conquest in Dallas: 4 killed

Date & Time: Oct 1, 1985 at 1328 LT
Type of aircraft:
Registration:
N400BG
Survivors:
No
Schedule:
New Orleans - Dallas
MSN:
441-0069
YOM:
1978
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
7000
Captain / Total hours on type:
2200.00
Aircraft flight hours:
2227
Circumstances:
A student pilot in a Cessna 152, N5522L, had departed Redbird Airport at Dallas. He was practicing solo maneuvers in a privately designated practice area that overlapped the extended inbound course to runway 31L and 31R at Love Field. At the same time, a Cessna 441, N400BG, was being vectored for a back course ILS to rwy 31R. DFW approach control cleared N400BG to continue descending to 3,000 feet and fly heading 290°. While N400BG was descending thru approximately 3,600 feet, about 14 miles southeast of Love Field, the two aircraft collided. The Cessna 152 pilot was maneuvering at or near the edge of the practice area when the collision occurred. An investigation revealed the Cessna 152 had just completed an approximately 180° turn toward an easterly heading. Both aircraft were demolished in a quartering head-on collision. Radar info from both aircraft was displayed on the controller's scope. The Cessna 152 was depicted as a 1200 beacon code; however, it was not equipped with a mode C (altitude reporting) transponder. The controller did not provide a traffic advisory for the Cessna 441 pilot; but, in this situation, an advisory was not mandatory. All five pilot on both aircraft were killed.
Probable cause:
Occurrence #1: midair collision
Phase of operation: descent
Findings
1. (f) in-flight planning/decision - improper - pilot of other aircraft
2. (f) monitoring - inadequate - atc personnel(dep/apch)
3. (c) visual lookout - inadequate - pilot in command
4. (c) visual lookout - inadequate - pilot of other aircraft
Final Report:

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

Date & Time: May 30, 1983 at 1004 LT
Registration:
N52AC
Flight Type:
Survivors:
No
Schedule:
Diamondhead – New Orleans
MSN:
61-0019
YOM:
1969
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Aircraft flight hours:
2809
Circumstances:
Witnesses reported that when the aircraft was stabilized on final approach, it pitched up slightly and yawed, then rolled left to an inverted attitude and crashed in a canal. Several witnesses stated that the left prop was windmilling. One stated the left prop had stopped. Two others said smoke was trailing from the aircraft. One witness stated that after the aircraft passed over his car, a fine mist of oil fell on his windshield. When the aircraft was recovered from the canal, the left prop was found in the feathered position while the right prop was near its low pitch stops. The left prop dome was found depleted of air pressure and no oil was found in the left engine case. Also, an oil film was found on the bottom of the left eng, left flap and left stabilizer. A further exam revealed that an oil interconnect line, Piper pn: 920024-811, had failed inside its fireproof covering. The hose was 8 years old, its recommended replacement interval was 5 years. It had been installed with a small bend radius. Also, the left engine had evidence of heat and wear due to lack of oil.
Probable cause:
Occurrence #1: loss of engine power(partial) - mech failure/malf
Phase of operation: approach - VFR pattern - final approach
Findings
1. (f) lubricating system,oil hose - deteriorated
2. (f) maintenance,inspection - inadequate - other maintenance personnel
3. (f) lubricating system,oil hose - life expired
4. (f) maintenance,replacement - not performed - other maintenance personnel
5. (f) lubricating system,oil hose - failure,total
6. (f) fluid,oil - loss,total
----------
Occurrence #2: loss of control - in flight
Phase of operation: approach
Findings
7. (c) airspeed(vmc) - not maintained - pilot in command
----------
Occurrence #3: in flight collision with terrain/water
Phase of operation: descent - uncontrolled
Final Report:

Crash of a Mitsubishi MU-2-40 Solitaire off New Orleans: 7 killed

Date & Time: Feb 23, 1980 at 1118 LT
Type of aircraft:
Operator:
Registration:
N962MA
Survivors:
No
Schedule:
Chicago - New Orleans
MSN:
401
YOM:
1979
Crew on board:
1
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
7
Captain / Total flying hours:
10000
Captain / Total hours on type:
2500.00
Circumstances:
The approach to New Orleans-Lakefront Airport was completed in limited visibility due to low ceiling and foggy conditions. The twin engine airplane struck the water surface and crashed into Lake Pontchartrain. The wreckage was found about 400 yards to the left of the localizer and all seven occupants were killed.
Probable cause:
Controlled collision with water on final approach due to improper IFR operation. The following contributing factors were reported:
- Low ceiling,
- Fog,
- Visibility 1/4 mile or less,
- Weather conditions below minimums.
Final Report:

Crash of a Rockwell Sabreliner 40 off New Orleans: 3 killed

Date & Time: Nov 7, 1977 at 1820 LT
Type of aircraft:
Registration:
N77AP
Flight Phase:
Survivors:
Yes
Schedule:
New Orleans - Fort Lauderdale
MSN:
282-37
YOM:
1965
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
6612
Captain / Total hours on type:
243.00
Circumstances:
Shortly after takeoff from New Orleans-Lakefront Airport runway 35, while climbing by night to a height of 300 feet, the airplane entered a left turn then struck the water surface and crashed into Lake Pontchartrain. A pilot was seriously injured while three other occupants were killed.
Probable cause:
Controlled collision with water during initial climb after the crew failed to maintain a positive rate of climb. The following contributing factors were reported:
- Instruments misread or failed to read,
- Failed to use the checklist.
Final Report:

Crash of a Beechcraft A60 Duke off New Orleans: 3 killed

Date & Time: Jul 18, 1973 at 2145 LT
Type of aircraft:
Operator:
Registration:
N7658D
Flight Type:
Survivors:
No
Schedule:
Yakima – Tulsa – New Orleans
MSN:
P-158
YOM:
1971
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Circumstances:
The airplane was completing a flight from Yakima, Washington, to New Orleans with an intermediate stop in Tulsa, OK. On final approach by night, the pilot lost control of the airplane that crashed into Lake Pontchartrain few hundred yards short of runway. Few debris were found floating on water and a day later, it was confirmed that all three occupants have been killed.
Probable cause:
Loss of control on a night approach after the pilot suffered a spatial disorientation. The following factors were reported:
- Pilot fatigue,
- Surrounding area sparsely limited,
- No approach light.
Final Report: