Crash of a Piper PA-46-310P Malibu in Ontario

Date & Time: Jun 10, 2010 at 1627 LT
Registration:
N121HJ
Flight Type:
Survivors:
Yes
Schedule:
Santa Monica – Lake Havasu
MSN:
46-8508105
YOM:
1985
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
850
Captain / Total hours on type:
1.00
Copilot / Total flying hours:
5735
Copilot / Total hours on type:
192
Aircraft flight hours:
4803
Circumstances:
The pilot was conducting a cross-country flight with a certified flight instructor (CFI). During the climb-to-cruise phase of the flight, as the airplane was ascending through 16,000 feet mean sea level (msl), the pilot noticed a reduction in manifold pressure. He advanced the throttle and observed an increase of one or two inches of manifold pressure. Shortly thereafter, the pilot heard a loud bang originate from the engine followed by an immediate loss of engine power. The pilot and CFI attempted to troubleshoot the engine anomalies and noted that it seemed to respond with the low boost "on", however it began to run rough whenever the throttle was advanced more than half way. They diverted to a nearby airport and conducted an emergency descent. As the airplane approached the airport, the pilot descended through an overcast cloud layer and attempted to enter the airport traffic pattern. While on final approach to the airport, the pilot thought the airplane was high and extended the landing gear and applied flaps. Shortly thereafter, the airspeed and altitude decreased drastically and the pilot realized he was too low. The pilot applied throttle and noticed no change in engine performance. The airplane subsequently struck a fence and landed hard in an open field just short of the airport, which resulted in structural damage to the fuselage and wings. A postaccident examination of the engine revealed that the induction elbow for cylinders 1-3-5 (right side) was displaced from the throttle and metering assembly where the elbow couples with the throttle and metering assembly by an induction hose and clamp. The clamp was secure to the induction hose, however, the portion of the clamp that should have been installed
beyond the retention bead on the throttle and control assembly was observed on the inboard side of the bead on the induction elbow. Review of the aircraft maintenance logbooks revealed that cylinders 4 and 5 were recently replaced prior to the accident flight due to low compression. The replacement of these cylinders required removal of the induction system to allow for cylinder removal and installation. In addition, a manufacturer service bulletin stated that during the reinstallation of the induction system, one must slide the induction hose and clamp(s) onto one of the tubes to be joined and that the connection joint and both tube beads are to be positioned in the center of the induction hose. The clamps should be installed in a position centered between the tubing bead and end of the induction hose.
Probable cause:
A loss of engine power due to the in-flight separation of the 1-3-5 cylinder induction tube elbow, which was caused by the improper installation of the induction tube elbow by maintenance personnel.
Final Report:

Crash of a Cessna 208B Grand Caravan in Oak Glen: 2 killed

Date & Time: Mar 28, 2006 at 1655 LT
Type of aircraft:
Operator:
Registration:
N208WE
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Thermal - Ontario
MSN:
208B-1171
YOM:
2006
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
2300
Copilot / Total flying hours:
1792
Copilot / Total hours on type:
740
Aircraft flight hours:
52
Circumstances:
The airplane was operated by the manufacturer and was on a sales demonstration itinerary. On the accident flight the airplane was being repositioned following a demonstration and the two pilots included a commercially licensed manufacturer's sales pilot and a private licensed regional sales distributor. One of the two pilots onboard requested, and received, an abbreviated weather briefing prior to departure, the details of which included an airman's meteorological information notice (AIRMET) for occasional moderate rime ice. He then filed an instrument flight rules flight plan for a route passing over mountainous terrain, with a published Minimum En route Altitude (MEA) for the airway that was above the predicted icing level. The flight plan was not activated and the pilots told a TRACON controller who was providing VFR advisories that they intended to continue under visual flight rules through a mountain pass and open their IFR flight plan after reaching the other side of the pass where the MEA was lower. A review of the mode C reported altitudes flown by the pilots and an analysis of the cloud bases and tops revealed that the flight was likely in at least intermittent, if not mostly solid, instrument meteorological conditions as it flew through the pass. As the flight approached the other end of the pass, the controller advised the pilots that the radar showed they were heading into rising terrain. The controller asked, "Do you have the terrain in sight?" One of the pilots responded, "we're maneuvering away from the terrain right now." After that, radar contact was lost. Recorded radar data showed that the airplane made a righthand turn toward rising terrain while continuing to climb to an approximate altitude of 8,800 feet mean sea level (msl). The last minute of radar data showed the airplane at altitudes of 8,000 feet msl, 8,800 feet msl, and 8,600 feet msl. The last radar return was at an altitude of 7,300 feet msl. An aircraft performance study was accomplished using recorded radar data and aerodynamic data provided by Cessna. Based on the radar data and other relevant information, as the aircraft turned toward the rising terrain, the bank angle steadily increased, until a very abrupt change in pitch consistent with a stall occurred, and the airplane departed controlled flight and descended at a very steep nose down attitude into the mountainous terrain. The airplane wreckage was subsequently located at an elevation of 6,073 feet. Nearby ground witnesses first noticed the sound of the airplane, that then suddenly changed to a high pitched increasing rpm. Witnesses then saw the accident airplane coming out of the clouds almost straight nose down. The witnesses described the weather as cold with drizzling rain and reduced visibility due to the clouds. Examination of the wreckage revealed no evidence of mechanical malfunction or failure.
Probable cause:
The pilot's continued flight into instrument meteorological weather conditions and his subsequent failure to maintain an adequate airspeed while maneuvering, that led to a stall/spin.
Final Report:

Crash of a Piper PA-31-350 Navajo Chieftain in Ontario: 1 killed

Date & Time: Sep 15, 1989 at 0652 LT
Operator:
Registration:
N70PE
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Ontario - Santa Barbara
MSN:
31-8052137
YOM:
1980
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
1916
Aircraft flight hours:
3118
Circumstances:
The propeller separated from the right engine during the initial climb. Examination of the wreckage revealed the propeller hub fracture resulted in one of the three propeller blades detaching from the hub. The rest of the propeller hub then separated striking the right front of the fuselage. Oil was spread across the aircraft nose and windshield. The fuselage right side damage increased aerodynamic drag. Witnesses reported the engine cowling was torn. The aircraft entered a right turn and dive. It impacted the ground in a near inverted attitude. Metallurgical examination of the failed prop hub revealed metal fatigue emanating from the threaded hole for the grease fitting. The threads had been deformed by shot peening, resulting in increased stress concentrations at the threads. The pilot, sole on board, was killed.
Probable cause:
Failure of the right propeller hub due to metal fatigue which resulted in catastrophic separation of the propeller. Contributing to the accident was damage done to the aircraft airframe in flight by the separating propeller making the aircraft uncontrollable.
Final Report:

Crash of a Cessna 208 Caravan near Cima: 1 killed

Date & Time: Jan 16, 1987 at 0640 LT
Type of aircraft:
Registration:
N9613F
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Ontario - North Las Vegas
MSN:
208-0106
YOM:
1986
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
2478
Captain / Total hours on type:
91.00
Aircraft flight hours:
126
Circumstances:
While on a day/VFR flight from Ontario, CA to Las Vegas, NV, the aircraft collided with mountainous terrain near the top of a 6,500 feet peak. Radar data showed that approximately 20 minutes before the accident, the aircraft began a gradual descent from about 10,000 feet. No preimpact part failure or malfunction of the aircraft, engine or autopilot was found. The pilot had a rest period on the previous day, but the investigation did not determine whether he had obtained any sleep before a 1700 pst flight. After the 1700 pst flight, he voluntarily flew on a late night flight with another company. That flight was delayed in returning and did not land at Ontario until about 0500 pst the next morning. Approximately 41 min later, the pilot took off on the accident flight.
Probable cause:
Occurrence #1: altitude deviation, uncontrolled
Phase of operation: cruise - normal
Findings
1. (c) altitude - not maintained - pilot in command
2. (c) descent - inadvertent - pilot in command
3. (c) fatigue (lack of sleep) - pilot in command
----------
Occurrence #2: in flight collision with terrain/water
Phase of operation: descent - uncontrolled
Findings
4. (f) terrain condition - mountainous/hilly
Final Report:

Crash of a Rockwell Aero Commander 520 in Clines Corners: 2 killed

Date & Time: Nov 8, 1983 at 2018 LT
Registration:
N4116B
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Bartlesville - Tucumcari - Ontario
MSN:
520-20
YOM:
1952
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
625
Captain / Total hours on type:
95.00
Circumstances:
The non-instrument rated pilot was on ferry flight from Bartlesville, OK to Ontario, CA. An en route stop was made at Tucumcari, NM, where the aircraft was refueled and 14 qts of oil was added to the left engine. The line boy who serviced the aircraft saw no visible oil leaks or spillage around the engine. While on the next leg of the flight, the aircraft crashed near interstate highway 40. Two witnesses that saw the crash stated rain was falling, the wind was blowing very strong and there were low ceilings. Reportedly, a squall line was moving thru the area and there was moderate to severe turbulence. An exam of the wreckage revealed the aircraft had crashed in a steep nose down attitude, with 20° to 30° left bank and at high speed. No preimpact, mechanical failures were found and both engines had evidence that they were operating during impact. The weather briefer said the pilot indicated he would fly around the area of precipitation and remain VFR. Radar info showed the pilot had been following the interstate highway and varying his alt between 7,900 and 6,300 feet msl. Both occupants were killed.
Probable cause:
Occurrence #1: in flight encounter with weather
Phase of operation: cruise - normal
Findings
1. (f) flight into known adverse weather - initiated - pilot in command
2. (f) light condition - dark night
3. (f) weather condition - low ceiling
4. (f) weather condition - high wind
5. (f) weather condition - rain
6. (c) VFR flight into IMC - continued - pilot in command
----------
Occurrence #2: loss of control - in flight
Phase of operation: cruise
Findings
7. (c) aircraft handling - not maintained - pilot in command
8. (c) spatial disorientation - pilot in command
9. (f) lack of total instrument time - pilot in command
----------
Occurrence #3: in flight collision with terrain/water
Phase of operation: descent - uncontrolled
Final Report:

Crash of a Douglas YC-112A-DO in Van Nuys: 3 killed

Date & Time: Feb 8, 1976 at 1044 LT
Type of aircraft:
Registration:
N901MA
Flight Type:
Survivors:
Yes
Schedule:
Burbank - Ontario
MSN:
36326
YOM:
1946
Flight number:
MA901
Crew on board:
5
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
10558
Copilot / Total flying hours:
6600
Aircraft flight hours:
10280
Circumstances:
During acceleration, the flight engineer stated, "Look at that warning light on No. 3." There was no verbal response from any other crewmember. The aircraft was accelerated normally to V1 and V2, was rotated, and was lifted off without difficulty. Shortly after the captain called for gear and flaps up, a loud noise was heard and the flight engineer announced that they had lost the No. 3 engine. The No.. 1 blade of the No. 3 propeller had and the loss of the blade caused an imbalance that caused separation, almost instantly, of the No. 3 engine from the aircraft. The propeller blade penetrated the lower fuselage of the aircraft and penetrated the lower inboard side of the No. 2 engine. As the blade passed through the fuselage, it severed pneumatic, hydraulic, and emergency airbrake lines as well as the electrical wiring for propeller controls and some engine instruments. The first officer informed the captain that the engine had separated. The aircraft continued to climb and began a right turn. An emergency was declared and the crew requested and received clearance for a landing on runway 07. Debris was discovered on the intersection of runways 07/25 and 15/23, but the pilot decided to continue the approach. The aircraft touched down near the end of runway 07. The captain called for flap retraction and for the props to be put in reverse pitch. The engine sounds increased, and the first officer advised the captain that the propellers were not going into reverse and to use the brakes. As the engine sound decreased, the captain replied that nothing was happening. Maximum power was applied and the aircraft again took off, and cleared the blast fence at the end of the runway by approximately 30 feet (9 m). At 10:39:35, the crew advised the Hollywood-Burbank Tower that they had no brakes and that they were proceeding to the Van Nuys Airport (VNY). The crew the saw that the No. 2 oil pressure was low and that there was no BMEP indication. Attempts to feather the No. 2 propeller were not successful, and the No. 2 engine stopped with the propeller blades at a positive, low pitch angle. Van Nuys cleared the flight for landing on runway 16, but the crew replied that they wouldn't make it, and requested runway 34. At 10:43:22, the Van Nuys local controller cleared the flight to land on runway 34L. While approaching the airport, the airplane was losing altitude and airspeed. The crew realized that they would not make it to the runway. The throttles were retarded and a forced landing was attempted on the Woodley Municipal Golf Course, about 1 mile south of the Van Nuys Airport. The aircraft touched down on it's main landing gear and bounced three times. The nose of the aircraft struck a 24-inch-high (61 cm) concrete foundation of a partially constructed building. The aircraft came to rest against a house trailer parked nearby and caught fire about 20 minutes after it came to rest. Three crew members were killed while three other occupants were injured.
Probable cause:
The degraded performance of the aircraft after two engines failed. The dual failure was precipitated by the in-flight failure of the No.1 blade of the No.3 propeller assembly. The failure of the propeller blade resulted from a fatigue crack which originated in the leading edge under the deicer boot. The crack had not been detected during an improperly performed overhaul.
Final Report:

Crash of a De Havilland DHC-6 Twin Otter 200 in Whittier: 12 killed

Date & Time: Jan 9, 1975 at 1607 LT
Operator:
Registration:
N6383
Survivors:
No
Schedule:
Ontario - Los Angeles
MSN:
83
YOM:
1967
Flight number:
GW261
Crew on board:
2
Crew fatalities:
Pax on board:
10
Pax fatalities:
Other fatalities:
Total fatalities:
12
Captain / Total flying hours:
9366
Captain / Total hours on type:
2774.00
Copilot / Total flying hours:
2555
Copilot / Total hours on type:
2065
Aircraft flight hours:
10092
Circumstances:
Golden West Flight 261 departed Ontario, CA at 15:56PST for a VFR flight to Los Angeles. At 16:04 the crew contacted LAX arrival and reported over Rose Hills. The flight was then cleared for the Terminal Control Area (TCA) and no. 2 arrival to runway 24L. At 16:05 the crew were advised that they had traffic 5,5nm in front of them climbing from 1500 to 3000 feet which was a police helicopter on a VFR flight. The arrival controller transmitted another advisory about the helicopter at 16:06, but there was no response. It appeared the Twin Otter had collided in flight at 2200 feet with a Cessna 150 aircraft (N11421). The Twin Otter was flying on a 250deg heading descending 300 feet/min at 146 knots airspeed while the Cessna was flying at 94 kts; the closing speed was 174 kts. The Cessna, operated by CessnAir Aviation had departed from Long Beach on a local training flight at 15:46. Both aircraft crashed. Debris caused some damage to houses and lawns near the crash site.
Probable cause:
The failure of both flight crews to see the other aircraft in sufficient time to initiate evasive action. The Board is unable to determine why each crew failed to see an avoid the other aircraft; however, the Board believes that the ability of both crews to detect the other aircraft in time to avoid a collision was reduced because of the position of the sun, the closure angle of the aircraft, and the necessity for the Twin Otter's fight crew to acquire visual contact with radar-reported traffic directly in front of them.
Final Report:

Crash of a Boeing 720-047B in Ontario: 5 killed

Date & Time: Mar 31, 1971 at 0633 LT
Type of aircraft:
Operator:
Registration:
N3166
Flight Type:
Survivors:
No
Schedule:
Los Angeles - Ontario
MSN:
19439/621
YOM:
1966
Flight number:
WA366
Crew on board:
5
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
19714
Captain / Total hours on type:
3780.00
Copilot / Total flying hours:
15767
Copilot / Total hours on type:
3840
Aircraft flight hours:
11521
Aircraft flight cycles:
7011
Circumstances:
The crew was completing a training flight from Los Angeles to Ontario. The pilot under supervision was supposed to complete an ILS approach with one engine inoperative, to make a missed approach and a go-around procedure. On final to runway 25R, the airplane went out of control and crashed in a field. The airplane was totally destroyed and all five crew members were killed.
Probable cause:
The failure of the aircraft rudder hydraulic actuator support fitting. The failure of the fitting resulted in the inapparent loss of left rudder control which, under the conditions of the flight, precluded the pilots’ ability to maintain directional control during a simulated engine-out missed-approach. The existing weather conditions degraded external visual cues, thereby hampering rapid assessment of aircraft performance by the flight check captain.
Final Report:

Crash of a Lockheed P2V-7LP Neptune in Ontario

Date & Time: Aug 11, 1958
Type of aircraft:
Operator:
Registration:
140434
Flight Phase:
Flight Type:
Survivors:
Yes
MSN:
726-7093
Crew on board:
0
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Lost in a crash landing with VX-6 at Ontario. While taking off for an acceptance check flight at Ontario, a landing gear ski jammed and the aircraft was destroyed while attempting an emergency landing a few minutes later. There were no injuries but the aircraft was destroyed.

Crash of a Lockheed R7V-1 Super Constellation near Taft: 5 killed

Date & Time: May 14, 1958
Operator:
Registration:
131652
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Ontario - Moffett
MSN:
4153
YOM:
1954
Location:
Crew on board:
5
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
5
Circumstances:
En route from Ontario (California) to Moffett AFB, the crew decided to perform five consecutive stalls. Doing so, the airplane lost 3,000 feet and suffered severe vibrations that caused structural damages to skin, stringers and bulkheads in the aft portions of the fuselage. The pilot requested permission to divert to Taft Airport for an emergency landing but shortly later, the airplane disintegrated in the air and crashed in a mountainous area located 7 miles east of Taft. The aircraft was totally destroyed and all five crew members were killed.
Probable cause:
In-flight structural failure of the airframe.