Crash of a Douglas C-47B-20-DK in Saint Louis: 1 killed

Date & Time: Jan 9, 1984 at 2232 LT
Operator:
Registration:
C-GSCA
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Saint Louis - Toronto
MSN:
15745/27190
YOM:
1945
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
4000
Captain / Total hours on type:
1350.00
Aircraft flight hours:
17933
Circumstances:
After landing, the pilot-in-command (pic) placed a refueling order to fill the aircraft's two 210 gallons main tanks for a return flight to Toronto, Ontario, Canada. After the cargo was unloaded and the aircraft was refueled, the aircrew aborted the 1st two attempts to takeoff due to slow aircraft performance. Engine run-ups were performed after each abort and reportedly, the engines checked normal. After the 2nd aborted takeoff, the aircrew called the fbo and requested that the refueler be asked what type of fuel was added. The response was '100LL Avgas.' On the 3rd attempt to depart, the aircraft took off, but both engines lost power as the landing gear was retracted. The aircrew selected a highway on which to land. However, the left wing hit a utility pole, then the aircraft went thru a fence and hit a highway embankment. Investigation revealed that Jet-A fuel had been added to the aircraft rather than 100LL fuel. The truck containing Jet-A fuel looked similar to the one with 100LL Avgas, but was properly designated with fuel grade markings. A pilot was killed, the second was seriously injured.
Probable cause:
Occurrence #1: loss of engine power (total) - nonmechanical
Phase of operation: takeoff - initial climb
Findings
1. (c) fluid,fuel - improper
2. (c) maintenance, service of aircraft/equipment - improper - fbo personnel
3. Aircraft performance, two or more engines - inoperative
----------
Occurrence #2: forced landing
Phase of operation: descent - emergency
----------
Occurrence #3: in flight collision with object
Phase of operation: descent - emergency
Findings
4. (f) object - utility pole
----------
Occurrence #4: on ground/water collision with object
Phase of operation: landing
Findings
5. (f) object - fence
----------
Occurrence #5: on ground/water encounter with terrain/water
Phase of operation: landing
Findings
6. (f) terrain condition - dirt bank/rising embankment
Final Report:

Crash of a Learjet 25D in Eagle County

Date & Time: Dec 22, 1983 at 1540 LT
Type of aircraft:
Operator:
Registration:
N300PL
Survivors:
Yes
Schedule:
Saint Louis - Aspen
MSN:
25-247
YOM:
1978
Crew on board:
2
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
8376
Captain / Total hours on type:
735.00
Aircraft flight hours:
2887
Circumstances:
While en route, the aircrew encountered stronger headwinds than expected. They realized there would not be enough fuel reserves for an IFR flight to Aspen, so they elected to divert to Eagle, CO. However, their landing at Eagle was delayed due to a snowplow (with no radio) on the runway. After circling and reentering final approach, the aircrew noted that the snowplow was still on the runway, headed in their direction. They continued their approach and the snowplow cleared the runway. According to the snowplow operator, the aircraft was 100 to 200 feet agl when it crossed the threshold. A FSS specialist noted that the aircraft was still airborne when it passed the 2nd turnoff, approximately 2,300 feet from the threshold. After touching down on the snow covered runway, the pilot deployed the spoilers and immediately applied braking action, but was unable to stop on the remaining runway. The aircraft continued off the end of the runway, went down a 15 feet bank and ran into a small ravine. The runway gradient was 1.4% downhill, elev 6,538 feet. Drag chute was not deployed, 600 lbs fuel remaining. All six occupants were evacuated, among them five were injured, one seriously.
Probable cause:
Occurrence #1: in flight encounter with weather
Phase of operation: cruise - normal
Findings
1. (f) weather condition - unfavorable wind
2. (f) weather condition - high wind
----------
Occurrence #2: overrun
Phase of operation: landing - roll
Findings
3. (c) delayed - pilot in command
4. (f) airport facilities,runway/landing area condition - snow covered
5. Airport snow removal - performed
6. Precautionary landing - continued - pilot in command
7. (c) proper touchdown point - not attained - pilot in command
8. (f) fluid, fuel - low level
9. Go-around - not performed - pilot in command
10. (f) miscellaneous equipment - not used - pilot in command
11. (f) airport facilities,runway/landing area condition - downhill
----------
Occurrence #3: on ground/water encounter with terrain/water
Phase of operation: landing - roll
Findings
12. (f) terrain condition - downhill
13. (f) terrain condition - ditch
Final Report:

Crash of a Cessna 551 Citation II/SP in Mountain View: 3 killed

Date & Time: Nov 18, 1982 at 0930 LT
Type of aircraft:
Operator:
Registration:
N2CA
Flight Phase:
Survivors:
No
Schedule:
Mountain View - Saint Louis
MSN:
551-0024
YOM:
1979
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
3750
Captain / Total hours on type:
1750.00
Aircraft flight hours:
1150
Circumstances:
On November 17, 1982, the pilot called Vichy Flight Service Station (FSS) and filed a request for an instrument flight rules (IFR) clearance for a flight from Mountain View Airport, Mountain View, Missouri, to Lambert - St. Louis International Airport, St. Louis, Missouri, for the following day. The pilot requested the IFR clearance for a 0930 departure. The flight was to be operated under 14 CFR Part 91, and the purpose of the flight was to transport the pilot, who was the president of the company which owned N2CA, and two passengers to St. Louis. Neither passenger was a pilot. Earlier on November 17, the pilot and the company's chief pilot had flown N2CA to Mountain View Airport from St. Louis. The chief pilot said that there were no mechanical deficiencies with the airplane, but that he believed that some of the avionics equipment was slow to warm up and become operationally usable. The Global Navigation System (GNS) 1 / required 4-5 minutes to become operationally usable from the time it was turned on. According to the chief pilot, the attitude director indicator (ADI) on the pilot's side also required more time to become operationally usable than some of the other avionic equipment. He stated that there had been occasions when "we've had to sit for 1- 1 1/2 minutes waiting for the artificial horizon to leave its caged position and go to the normal flight position." He also stated that in the last 10 flying hours, the pilot's heading indicator required more time "than normal to come on line." He said that the pilot had mentioned to him on the previous day that it was taking an increasingly longer time for the flag to disappear before the heading indicator was ready for use in flight. According to the chief pilot, the pilot stated that he (the pilot) occasionally would use the copilot's heading indicator during takeoff until the heading information on the pilot's side was operationally usable. After the flight to Mountain View Airport on November 17, the airplane was refueled with all tanks filled to capacity. A jet-A fuel supply recently had been installed at the airport; the airplane therefore could be "topped off" at Mountain View Airport instead of having to make an extra refueling stop. As a result, the airplane was about 3,400 lbs heavier for flight on the 18th than it had been in past takeoffs from Mountain View Airport. About 0730 2/ c.s.t., November 18, the pilot called a fixed-base operator at Lambert - St. Louis International Airport and inquired about the weather. The operator was neither a pilot nor a weather observer. He told the pilot that the visibility was at least 1 1/2 miles, and the ceiling was "fairly low." The operator called the Lambert - St. Louis Air Traffic Control (ATC) Tower and inquired about ATC delays. He then called the pilot back and relayed information about the ATC situation. There was no record of any other weather briefing. At 0909, the pilot called the Vichy FSS for the IFR clearance. The pilot told the FSS specialist that he would need 15 minutes to get to the airport. He was given the clearance which was valid until 0930. The telephone conversation ended at 0914. The call was placed from the pilot's home. Meanwhile, the chief pilot had conducted a preflight inspection of N2CA, and had taken the airplane out of the hangar. The pilot left his home shortly after 0915 and arrived at the airport between 0920 and 0925. The pilot then loaded the baggage and boarded the two passengers. The chief pilot said that both engines had been started by the time he had driven the tug back to the hangar and started to close the hangar door. The airplane remained on the ramp for I5 to 30 seconds while a person handed some company material to the pilot through the cockpit window. The pilot was in the left cockpit seat, and a male passenger was in the right cockpit seat. The airplane was immediately taxied directly to runway 28, a distance of about 225 feet. The chief pilot said that the airplane was stopped on the runway for 30 to 60 seconds before the takeoff roll started. He said it was exactly 0930 by his watch when the takeoff roll started. He said that, assuming that the generators were turned on as soon as the second engine was started, about 2 minutes elapsed from the time they were turned on to the time the takeoff roll was started. The chief pilot and another pilot at the airport described the takeoff as normal, although the airplane required about three-quarters of the runway before liftoff. The airplane disappeared from sight when it was 20 feet to 50 feet above the runway. The witnesses described the weather as low ceilings, reduced visibility because of fog, but no rain. The runway was damp from 8 previous rainfall. No significant winds were noted. There were no witnesses to the accident. One person, located one-half mile northeast of the accident site, heard a "jet'' fly over his house in a southwesterly direction and shortly afterward heard an explosion. A second person, located one-fifth mile north of the accident site, heard the airplane fly over his house on a southerly heading. He heard a loud explosion and immediately thereafter saw a fire in the woods. He and his sons ran toward the explosion. One son returned to call the sheriff; the call was placed through the operator and was logged at the sheriff's office at 0934. A call was received at a nearby State Police office at 0936. The airplane crashed in a woods about 1.75 miles due north of Mountain View Airport on a heading of 120'in an attitude that was at least 30' nose down and a left bank of 90'. The airplane wreckage was spread over a 400-square-foot area. All three occupants died in the accident.
Probable cause:
The National Transportation Safety Board determines that the probable cause of the accident was the loss of control of the airplane following the takeoff in instrument meteorological conditions as a result of the pilot's use of attitude and heading instruments which had not become operationally usable and/or his partial reliance on the copilot's flight instruments which resulted in an abnormal instrument scan pattern leading to the pilot's disorientation. Contributing to the accident was the pilot's hurried and inadequate preflight procedures.
Final Report:

Crash of a Cessna 421A Golden Eagle I in Richmond: 1 killed

Date & Time: Mar 18, 1982 at 0912 LT
Type of aircraft:
Registration:
N33KC
Flight Type:
Survivors:
Yes
Schedule:
Saint Louis – Richmond
MSN:
421A-0026
YOM:
1967
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
2250
Captain / Total hours on type:
400.00
Aircraft flight hours:
4231
Circumstances:
During a VOR approach to runway 05 when 3 miles away from the airport at minimums ground contact was not made. The pilot stated that she elected to perform a missed approach but before power was applied the copilot raised the flaps. She further stated that she then felt a sinking feeling and put in more power. The aircraft crashed in an open field approximately 2.3 miles southwest of the airport. A pilot was killed while two other occupants were seriously injured.
Probable cause:
Occurrence #1: in flight collision with terrain/water
Phase of operation: approach - FAF/outer marker to threshold (IFR)
Findings
1. (f) weather condition - fog
2. (f) weather condition - below approach/landing minimums
3. (c) in-flight planning/decision - poor - pilot in command
----------
Occurrence #2: in flight collision with terrain/water
Phase of operation: approach - FAF/outer marker to threshold (IFR)
Findings
4. Missed approach - attempted - pilot in command
5. (c) crew/group coordination - inadequate - pilot in command
6. (c) raising of flaps - improper
7. (c) remedial action - inadequate - pilot in command
8. (c) self-induced pressure - pilot in command
Final Report:

Crash of a Boeing 707-131B in San Francisco

Date & Time: Nov 30, 1980
Type of aircraft:
Operator:
Registration:
N797TW
Survivors:
Yes
Schedule:
Saint Louis - San Francisco
MSN:
18760
YOM:
1964
Crew on board:
7
Crew fatalities:
Pax on board:
126
Pax fatalities:
Other fatalities:
Total fatalities:
0
Aircraft flight hours:
49910
Circumstances:
While descending to San Francisco Airport, the nose gear could not be lowered and remained stuck in its wheel well. Following a normal approach, the airplane landed on its main undercarriage then slid on its nose for few hundred yards before coming to rest. All 133 occupants were evacuated safely and the aircraft was damaged beyond repair.

Crash of a Douglas DC-3-313 near Belle Glade

Date & Time: Jul 13, 1979 at 1515 LT
Type of aircraft:
Registration:
N21782
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Saint Louis - Boca Raton
MSN:
2170
YOM:
1939
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
2500
Captain / Total hours on type:
525.00
Circumstances:
En route from Saint Louis to Boca Raton, both engines failed. The crew declared an emergency, reduced his altitude and attempted an emergency landing near Belle Glade. After touchdown, the airplane struck high vegetation then nosed down and crashed. Both pilots escaped with minor injuries while the aircraft was damaged beyond repair.
Probable cause:
Failure of both engines in flight due to fuel exhaustion. The following contributing factors were reported:
- Inadequate preflight preparation,
- Mismanagement of fuel,
- Micalculated fuel consumption,
- Fuel exhaustion,
- Improper alignment/adjustment of the fuel quantity gauge,
- High vegetation,
- Complete failure of both engines,
- Forced landing off airport on land.
Final Report:

Crash of a Carstedt Jet Liner 600F in Saint Louis

Date & Time: Jun 11, 1979 at 2152 LT
Type of aircraft:
Operator:
Registration:
N906MW
Flight Type:
Survivors:
Yes
Schedule:
Kansas City - Saint Louis
MSN:
04449
YOM:
1954
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
4032
Captain / Total hours on type:
651.00
Circumstances:
Upon landing at Saint Louis-Lambert Airport, the undercarriage collapsed. The airplane sank on its belly and slid for several yards before coming to rest. Both pilots escaped uninjured while the aircraft was damaged beyond repair.
Probable cause:
Gear retraction on landing following improper maintenance on part of the maintenance personnel. The following contributing factors were reported:
- Landing gear: normal retraction/extension assembly, improperly installed,
- Chafed,
- Pneumatic line to down port on nlg actuator chafed through.
Final Report:

Crash of a Convair CV-340-38 in Elma

Date & Time: Mar 21, 1978 at 0145 LT
Type of aircraft:
Registration:
N4807C
Survivors:
Yes
Schedule:
Saint Louis - Minneapolis
MSN:
84
YOM:
1953
Location:
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
9000
Captain / Total hours on type:
5500.00
Circumstances:
En route from Saint Louis to Minneapolis, while cruising at an altitude of 6,000 feet, the right engine caught fire. The copilot declared an emergency and was cleared to divert to Elma Airport. Shortly later, the right engine detached. The crew completed an emergency descent but made a forced landing off airport on land. All four occupants evacuated safely while the aircraft was considered as damaged beyond repair.
Probable cause:
Engine failure in flight due to master and connecting rods failure. The following contributing factors were reported:
- Material failure,
- Fire in engine,
- Oil exhaustion - engine lubrication system,
- Separation in flight,
- Complete engine failure,
- Force landing off airport on land,
- Engine separated from aircraft in flight due to fire damage.
Final Report:

Crash of a Lockheed L-188 Electra in Saint Louis: 3 killed

Date & Time: Jul 6, 1977 at 2327 LT
Type of aircraft:
Registration:
N280F
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Saint Louis - Detroit
MSN:
1076
YOM:
1959
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
11540
Captain / Total hours on type:
390.00
Circumstances:
The takeoff procedure was abandoned after the propeller on engine n°2 autofeathered. During the second takeoff, while in initial climb, the airplane entered an uncontrolled descent and crashed in flames by the runway. All three crew members were killed.
Probable cause:
Uncontrolled descent during initial climb due to unwanted thrust reversal on engine n°2. The following contributing factors were reported:
- The pilot-in-command exercised poor judgment,
- Attempted operation with known deficiencies in equipment,
- Failed to follow approved procedures,
- Thrust reversal unwanted,
- Oil exhaustion in propeller system,
- Propeller system: feathering pump - leakage,
- Inadequate maintenance and inspection,
- Deficiency, company maintained equipment, services, regulation,
- Pilot fatigue,
- Oil replaced improperly,
- Pump output o-rings bad.
Final Report:

Crash of a Beechcraft D18S in Detroit

Date & Time: Aug 7, 1974 at 1104 LT
Type of aircraft:
Operator:
Registration:
N35CB
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Detroit - Saint Louis
MSN:
A-206
YOM:
1946
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
9440
Captain / Total hours on type:
3140.00
Circumstances:
During the takeoff roll at Detroit-City-Coleman A. Young Airport, the twin engine airplane went out of control, slid on the ground, overran and came to rest in flames. The pilot escaped with minor injuries while the aircraft was destroyed.
Probable cause:
Inadequate preflight preparation on part of the pilot who apparently raised the landing gear prematurely before rotation. The gear selector was found in up position.
Final Report: