Crash of a Rockwell Shrike Commander 500S near Eagleville: 5 killed

Date & Time: Nov 21, 2001 at 1126 LT
Registration:
N900RA
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Reno - Wenatchee
MSN:
500-3070
YOM:
1970
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
20069
Aircraft flight hours:
8101
Circumstances:
The airplane collided with mountainous terrain during cruise after encountering turbulence and downdrafts associated with mountain wave conditions. According to Federal Aviation Administration (FAA) records, the pilot called the Reno Automated Flight Service Station at 0941 and filed an IFR flight plan, then asked for the winds aloft forecast, which was provided. The pilot did not request any additional weather briefing information for the flight. No other record was found that the pilot obtained additional weather forecast information from any official source associated with the FAA or the National Weather Service. At the time of the pilot's call to the Reno AFSS, several AIRMET weather advisories had been issued hours prior detailing warnings for turbulence and clear icing along the route of flight. The advisories warned of occasional moderate turbulence below 18,000 feet in moderately strong westerly winds especially in the vicinity of mountainous terrain. Clear Air Turbulence (CAT) between 18,000 and 40,000 feet was forecast over the area of the accident site due to jet stream wind shear and mountain wave activity. The pilot departed under visual flight rules (VFR) and picked up his instrument flight rules (IFR) clearance en route and climbed to 14,000 feet. The pilot later asked if he could maintain 12,500 feet. The controller advised him that the minimum IFR altitude on this segment of his route was 14,000 feet, and the pilot cancelled his IFR flight plan. The controller advised the pilot that he had lost radar contact, and instructed the pilot to squawk VFR and the pilot acknowledged the transmission. The last radar target was about 1/2 mile east of Eagle Peak (elevation 9,920 feet) in the Warner Mountains. Rescuers discovered the wreckage near the crest of Eagle Peak on November 23. Investigators found no anomalies with the airframe, engines, or propellers that would have precluded normal operation. The NWS had a full series of AIRMETs current over the proposed route of flight, which included mountain obscuration, turbulence, and icing. Analysis of the weather conditions disclosed a layer between 9,500 and 11,000 feet over the accident site area as having a high likelihood of severe or greater turbulence. A pilot on the same route of flight reported at 1127 that he was in instrument conditions at 11,000 feet, and experiencing light turbulence and light clear icing conditions. He also reported encountering updrafts of 2,000 feet per minute, which was indicative of mountain wave activity. A company pilot was in a second Aero Commander trailing the accident airplane and he reported that at 1147, at a position near the accident site, he encountered a severe downdraft. He applied full climb power, but as the airplane passed over the accident site position, the airplane continued to lose altitude even at maximum power. At 1159, he was able to gain altitude, and return to his assigned cruising altitude of 14,000 feet. The second Aero Commander was turbocharged, the accident airplane was not. Analysis showed that the topography of the area was critical in this case, given that the accident site was at an elevation of 9,240 feet on the eastern slope of Eagle Peak. The accident airplane's flight track was normal along the airway until immediately downwind of the higher terrain. As the flight approached the lee side of the mountain, it came under the influence of the mountain wave and first encountered an updraft and then a downdraft, which increased in amplitude as the flight progressed towards Eagle Peak. Eagle Peak was the tallest point along the Warner Mountain range and the steep slope of this terrain was significant when the mountain wave action was encountered. Such terrain features have been known to enhance the vertical downdrafts and updrafts associated with the most intense mountain wave turbulence.
Probable cause:
The pilot's encounter with forecast mountain wave conditions, moderate or greater turbulence, and icing, with downdrafts that likely exceeded the climb capability of the airplane, which was encountered at an altitude that precluded recovery. Also causal in the accident was the failure of the pilot to obtain an adequate preflight weather briefing which would have included a series of Airmets that were in effect at the time.
Final Report:

Crash of a Cessna 340A in Santa Monica: 2 killed

Date & Time: Nov 13, 2001 at 1836 LT
Type of aircraft:
Registration:
N2RR
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Santa Monica – Van Nuys
MSN:
340A-0643
YOM:
1978
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
6200
Aircraft flight hours:
1036
Circumstances:
During an aborted nighttime takeoff, the airplane continued off the end of the 4,987-foot-long runway, vaulted an embankment, and impacted a guardrail on an airport service road 30 feet below. According to the manufacturer's pilot operating handbook, the takeoff distance required for the ambient conditions was 1,620 feet and the accelerate-stop distance was 2,945 feet. Several witnesses reported observing the airplane traveling along the runway at an unusually high speed, with normal engine sound, and without becoming airborne; followed by an abrupt reduction in engine power and the sound of screeching tires. Skid marks were present on the last 1,000 feet of the runway. In the wreckage, the gust lock/control lock was found engaged in the pilot's control column.
Probable cause:
The pilot's failure to remove the control gust lock prior to takeoff and his failure to abort the takeoff with sufficient runway remaining to stop the airplane on the runway.
Final Report:

Crash of a Piper PA-31T Cheyenne in Graham: 4 killed

Date & Time: Nov 12, 2001 at 2324 LT
Type of aircraft:
Registration:
N6134A
Survivors:
No
Site:
Schedule:
Wharton – Graham
MSN:
31-7804006
YOM:
1978
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
4849
Aircraft flight hours:
3240
Circumstances:
At 2144, the pilot contacted air traffic control and requested visual flight rules (VFR) flight following to his destination. The flight was the final leg of a four-leg trip, which the pilot had begun approximately 1120 that morning. At 2220, the flight began a slow descent toward the destination airport. Radar data confirmed that the airplane executed a steady descent, and flew a straight line course toward Graham. The final radar return occurred 37 minutes later at an altitude of 3,000 feet (radar coverage is not available below 3,000 feet), 8 miles southeast of the Graham Municipal Airport. Two minutes after the final radar return, the pilot reported to air traffic control that the flight was two miles out, and he canceled VFR flight following. No further communications or distress calls were received from the airplane. The pilot did not request or receive updated weather from the air traffic controllers during the flight. According to witnesses who lived near the accident site, they heard an airplane flying low, observed dense fog and heard the sounds of an airplane crashing. According to the nearest weather reporting station, near the time of the accident, the temperature- dew point spread was within 2 degrees, visibilities were reduced to between 3 and 4 miles in fog, and the ceiling was decreasing from 600 feet broken to 400 feet overcast. At the time of the accident, the pilot's duty day exceeded 12 hours. Examination of the airframe revealed no preimpact anomalies and that the gear was extended and the flaps were retracted. Examination of both engines revealed evidence of power at the time of impact.
Probable cause:
The pilot's failure to discontinue the approach after encountering instrument meteorological conditions, which resulted in controlled flight into terrain. Contributing factors were the dark night light condition, low ceiling, and reduced visibility due to fog.
Final Report:

Crash of an Airbus A300-600 in New York: 265 killed

Date & Time: Nov 12, 2001 at 0916 LT
Type of aircraft:
Operator:
Registration:
N14053
Flight Phase:
Survivors:
No
Site:
Schedule:
New York - Santo Domingo
MSN:
420
YOM:
1988
Flight number:
AA587
Crew on board:
9
Crew fatalities:
Pax on board:
251
Pax fatalities:
Other fatalities:
Total fatalities:
265
Captain / Total flying hours:
8050
Captain / Total hours on type:
1723.00
Copilot / Total flying hours:
4403
Copilot / Total hours on type:
1835
Aircraft flight hours:
37550
Aircraft flight cycles:
14934
Circumstances:
On November 12, 2001, about 0916:15 eastern standard time, American Airlines flight 587, an Airbus Industrie A300-605R, N14053, crashed into a residential area of Belle Harbor, New York, shortly after takeoff from John F. Kennedy International Airport, Jamaica, New York. Flight 587 was a regularly scheduled passenger flight to Las Americas International Airport, Santo Domingo, Dominican Republic, with 2 flight crewmembers, 7 flight attendants, and 251 passengers aboard the airplane. The airplane's vertical stabilizer and rudder separated in flight and were found in Jamaica Bay, about 1 mile north of the main wreckage site. The airplane's engines subsequently separated in flight and were found several blocks north and east of the main wreckage site. All 260 people aboard the airplane and 5 people on the ground were killed, and the airplane was destroyed by impact forces and a post crash fire. Flight 587 was operating under the provisions of 14 Code of Federal Regulations Part 121 on an instrument flight rules flight plan. Visual meteorological conditions prevailed at the time of the accident.
Probable cause:
The in-flight separation of the vertical stabilizer as a result of the loads beyond ultimate design that were created by the first officer's unnecessary and excessive rudder pedal inputs. Contributing to these rudder pedal inputs were characteristics of the Airbus A300-600 rudder system design and elements of the American Airlines Advanced Aircraft Maneuvering Program.
Final Report:

Crash of a Beechcraft B200 Super King Air in Chesterfield

Date & Time: Oct 25, 2001 at 1538 LT
Operator:
Registration:
N200RW
Survivors:
Yes
Schedule:
Chesterfield - Osage Beach
MSN:
BB-242
YOM:
1977
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
19213
Captain / Total hours on type:
13242.00
Aircraft flight hours:
11416
Circumstances:
The Beech 200 was substantially damaged during an aborted landing. The winds were gusting in excess of the airplane's maximum demonstrated crosswind component. A witness reported finding landing gear strut pieces on the runway after the Beech 200's landing attempt. The flight then aborted the landing and continued on to its originating airport where the airplane veered off the runway and damaged airport property during its landing.
Probable cause:
The inadequate planning/decision and the exceeded crosswind component by the pilot. The gusts were a contributing factor.
Final Report:

Crash of an Embraer EMB-120RT Brasília in Bethel

Date & Time: Oct 16, 2001 at 2130 LT
Type of aircraft:
Operator:
Registration:
N120AX
Flight Type:
Survivors:
Yes
Schedule:
Anchorage - Bethel
MSN:
120-164
YOM:
1989
Location:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
8526
Captain / Total hours on type:
961.00
Copilot / Total flying hours:
2725
Copilot / Total hours on type:
644
Aircraft flight hours:
26295
Circumstances:
The captain and first officer were conducting a localizer DME back course approach to runway 36 in a twin-engine turboprop airplane during a night cargo flight under IFR conditions. The minimum visibility for the approach was one mile, and the minimum descent altitude (MDA) was 460 feet msl (338 feet agl). Prior to leaving their cruise altitude, the first officer listened to the ATIS information which included an altimeter setting of 29.30 inHg. No other altimeter information was received until the crew reported they were inbound on the approach. At that time, tower personnel told the crew that the visibility was one mile in light snow, the wind was from 040 degrees at 22 knots, and the altimeter setting was 29.22 inHg. The crew did not reset the airplane altimeters from 29.30 to 29.22. At the final approach fix (5 miles from the runway), the captain began a descent to the MDA. Thirty-six seconds before impact, the first officer cautioned the captain about the airplane's high airspeed. Due to strong crosswinds, the captain disconnected the autopilot 22 seconds before impact. He said he pushed the altitude hold feature on the flight director at the MDA. Eighteen seconds before impact, the airplane leveled off about 471 feet indicated altitude, but then descended again 9 seconds later. The descent continued until the airplane collided with the ground, 3.5 miles from the runway. The crew said that neither the airport, or the snow-covered terrain, was observed before impact. The crew reported that the landing lights were off. The airplane was not equipped with a ground proximity warning system.
Probable cause:
The captain's continued descent below the minimum descent altitude which resulted in impact with terrain during an instrument landing approach. Factors contributing to the accident were the flightcrew's failure to reset the altimeters to the correct altimeter setting, and meteorological conditions consisting of snow obscuration that limited visibility, and the ambient night light conditions.
Final Report:

Crash of a Rockwell Grand Commander 690 in Temecula

Date & Time: Oct 13, 2001 at 2220 LT
Registration:
N690JM
Flight Type:
Survivors:
Yes
Schedule:
Flagstaff – Temecula
MSN:
690-11072
YOM:
1973
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
12880
Captain / Total hours on type:
4205.00
Aircraft flight hours:
4844
Circumstances:
The airplane collided with an airport boundary fence during an aborted landing. The pilot made a normal approach following the visual approach slope indicator (VASI) with gear down and full flaps and touched down just past the numbers and began to decelerate. The pilot selected reverse thrust with both engines. As he added power to decelerate, the airplane suddenly veered to the left and off the runway when the right engine did not go into reverse thrust. He deselected reverse thrust and aligned the airplane with the runway. He was approaching the end of the runway at high speed and elected to attempt a takeoff. The airplane went off the end of the runway onto smooth grass. The pilot rotated the airplane, but the airplane collided with an airport boundary fence and came to rest in a field. In a post accident examination, when the power levers were placed in the full reverse position, the left fuel control measured 4°, while the right measured 0°. The left pitch control measured 10°, while the right measured 0°; the controls should have read 0°. A controls engineer determined that during landing, there would be a 10° propeller pitch control (PPC) angle mismatch, which would be about 2.5° of BETA angle. With matched levers, there would be asymmetric reverse thrust with the left engine lower in torque. This would result in the airplane turning towards the left if both propellers had gone into reverse pitch.
Probable cause:
A misrigging of the engine controls that resulted in an asymmetric reverse thrust condition.
Final Report:

Crash of a Cessna 208 Caravan I in Dillingham: 10 killed

Date & Time: Oct 10, 2001 at 0926 LT
Type of aircraft:
Operator:
Registration:
N9530F
Flight Phase:
Survivors:
No
Schedule:
Dillingham – King Salmon
MSN:
208-0088
YOM:
1986
Flight number:
KS350
Crew on board:
1
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
10
Captain / Total flying hours:
3100
Captain / Total hours on type:
869.00
Aircraft flight hours:
10080
Circumstances:
The airplane was parked outside on the ramp the night before the accident and was subjected to rain, snow, and temperatures that dropped below 32 degrees F. Other pilots whose airplanes were also parked outside overnight stated that about 1/4 to 1/2 inch of snow/frost covered a layer of ice on their airplanes the morning of the accident. Because of these conditions, ramp personnel deiced the accident airplane with a heated mixture of glycol and water. The PenAir ramp supervisor who conducted the deicing stated that he believed the upper surface of the wing was clear of ice but that he did not physically touch the wing to check for the presence of ice. Investigators were unable to determine whether the accident pilot visually or physically checked the wing and tail surfaces for contamination after the accident airplane was deiced. However, the airplane's high-wing configuration would have hindered the pilot's ability to see residual clear ice on the surface of the wing after the deicing procedures. Company records indicate that the certificated commercial pilot completed his initial CE-208 flight training 2 months before the accident and had accumulated a total of 74 hours in this make and model of airplane. The airplane, with the pilot and nine passengers onboard, crashed shortly after takeoff from runway 01. A witness observed that the airplane's flight appeared to be normal until the airplane suddenly pitched up, rolled 90 degrees to the left, and yawed to the left. The airplane then descended nose-down until it disappeared from view. Data from the engine monitoring system revealed that the maximum altitude obtained during the accident flight was about 651 feet mean sea level. The airplane crashed in a level attitude. Investigators found no evidence of pre-impact failures in the structure, flight control systems, or instruments. Further, examination of the engine and propeller revealed no pre-impact failures and that the engine was running when the airplane hit the ground.
Probable cause:
An in-flight loss of control resulting from upper surface ice contamination that the pilot-in-command failed to detect during his preflight inspection of the airplane. Contributing to the accident was the lack of a preflight inspection requirement for CE-208 pilots to examine at close range the upper surface of the wing for ice contamination when ground icing conditions exist.
Final Report:

Crash of a Beechcraft C90 King Air in Dallas

Date & Time: Oct 9, 2001 at 1322 LT
Type of aircraft:
Registration:
N690JP
Survivors:
Yes
Schedule:
Taos - Dallas
MSN:
LJ-690
YOM:
1976
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
7000
Captain / Total hours on type:
100.00
Aircraft flight hours:
2356
Circumstances:
The commercial pilot flew the airplane on a cross-country flight of at least 2 hours and 47 minutes before dropping of his passengers, and flew back for 2 hours and 7 minutes without refueling. The pilot reported that as the airplane turned onto final approach, the right engine began to surge. He reduced the power on the right engine and increased power on the left, but the airplane started to roll right so he elected to reduce the power on the left engine and land in an alley. Prior to impacting wires, the pilot retracted the landing gear and brought the condition levers to "cut-off." A witness observed the airplane prior to impact and noted that the "motor wasn't on." The airplane impacted power lines, a tree, a natural gas meter, two residences, and a fence. The fuel tanks were compromised during the impact sequence, and the fire department sprayed the area with fire retardant foam. A test of the water runoff revealed "negative results for petroleum risk." Examination of both engines' fuel lines between their respective firewalls and fuel heaters, and fuel pumps and fuel control units revealed that they were void of fuel.
Probable cause:
The pilot's failure to refuel the airplane, which resulted in fuel exhaustion and subsequent loss of dual engine power while on approach.
Final Report:

Crash of a Cessna 414 Chancellor in Marshfield: 3 killed

Date & Time: Sep 29, 2001 at 1700 LT
Type of aircraft:
Operator:
Registration:
N414NG
Flight Type:
Survivors:
No
Schedule:
Wisconsin Rapids - Poplar Bluff
MSN:
414-0496
YOM:
1974
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Circumstances:
The airplane was destroyed after an attempted landing following a reported partial power loss of the left engine while en route. The flight did not divert to the closest airport located about 27 nautical miles to the southwest while at an altitude of about 15,900 feet. This airport was a controlled field equipped with airport rescue and fire fighting (ARFF), and its longest runway was 9,005 feet. The flight diverted to the departure airport located about 93 nautical miles to the north. This airport was an uncontrolled field not equipped with ARFF, and its longest runway was 5,000 feet. No emergency was declared. The airplane was reported by a witness to be too high and too fast to land on runway 34 at the airport. The winds were from 140 degrees at 6 knots. The wreckage distribution was consistent with an impact resulting from a Vmc (minimum control speed with the critical engine inoperative) roll to the left. The pilot received a checkout from the right seat in the accident airplane by the airplane owner. The checkout was about 20 minutes in duration and did not include any single-engine flight maneuvers or emergency procedures. The owner did not hold a certified flight instructor certificate. The pilot had stopped flying for 12 years and just began giving flight instruction and flying in single-engine airplanes about a year prior to the accident. The pilot's recent multiengine flight experience was limited to a couple of non-revenue flights within the past year while seated in the right seat of a King Air. The King Air was used for commercial charter work which would involve one or two landings per flight. One landing was made on the day prior to the accident. The accident pilot asked the King Air pilot to accompany him along on the accident flight; the King Air pilot declined. A multiengine commercial rated pilot-rated passenger, who the accident pilot knew, was seated in the right front seat. Examination of the airplane's supplemental type certificate (STC) revealed that the airplane had undergone numerous inspections by different maintenance personnel. The left engine's variable absolute pressure controller had safety wire around its control arm, which precluded its normal operation and a pressure relief valve that was not called for in the STC drawings. At the time of issuance, Federal Regulation's did not require STC instructions for continued airworthiness. Reliance on the airplane and engine maintenance manuals would not have provided enough information for continued airworthiness in accordance with the STC and could have yielded a setting exceeding those for which the STC parts were originally certificated to and thus increasing Vmc speed. Examination of the left engine revealed a cylinder head separation on the number six cylinder assembly, which had accumulated an estimated time since installation of 240 hours. Visual inspection of the assembly revealed the presence of some undecipherable characters in its parts numbering. A cylinder head separation from another airplane was also examined. This cylinder assembly accumulated about 270 hours since installation. Both cylinder assembly examinations revealed the presence of additional material on the cylinder barrel threads and fatigue fracture on the cylinder head.
Probable cause:
The pilot's failure to maintain adequate airspeed (Vmc) which resulted in a loss of control. Contributing factors were the improper in-flight planning/decision not to land at a closer airport and the lack of recent experience in multiengine airplanes by the pilot-in-command, the cylinder head separation, the inadequate manufacturing process, and the lack of continued airworthiness instructions relating to the Riley Super-8 STC.
Final Report: