Crash of a Socata TBM-700 in Denver: 1 killed

Date & Time: Mar 26, 2001 at 0719 LT
Type of aircraft:
Registration:
N300WC
Flight Phase:
Survivors:
No
Schedule:
Denver – Santa Monica
MSN:
82
YOM:
1993
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
1024
Captain / Total hours on type:
136.00
Aircraft flight hours:
5139
Circumstances:
The airplane was fueled to capacity and placed in a heated hangar about one hour before departure. The instrument rated pilot obtained a weather briefing, filed an IFR flight plan, and obtained an IFR clearance. Low ceiling, reduced visibility, and ice fog prevented control tower personnel from observing the takeoff. Radar (NTAP) and on-board GPS data indicated the airplane began drifting to the left of runway centerline almost immediately after takeoff. The airplane made a climbing left turn, achieving a maximum altitude of 7,072 feet and completing 217 degrees of turn, before beginning a descending left turn. The airplane impacted terrain on airport property. Autopsy/toxicology protocols were unremarkable. There was no evidence of preimpact failure/malfunction of the airframe, powerplant, propeller, or flight controls. The autopilot and servos, pitot-static system, and flight instruments were tested and all functioned satisfactorily. The pilot's shoulder harness was found attached to the seatbelt, but the male end of the seatbelt buckle was broken.
Probable cause:
The pilot's spatial disorientation, which led to his failure to maintain aircraft control. A contributing factor was the pilot's decision to intentionally fly into known adverse weather that consisted of low ceilings, obscuration, and ice fog.
Final Report:

Crash of a Douglas C-47A-80-DL in Donalsonville

Date & Time: Mar 15, 2001 at 2130 LT
Registration:
N842MB
Flight Type:
Survivors:
Yes
Schedule:
Panama City – Albany
MSN:
19741
YOM:
1943
Flight number:
HKN041
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
6000
Captain / Total hours on type:
700.00
Circumstances:
The DC-3 experienced an in-flight engine fire, and made a forced landing at nearby airport, following the separation of the right engine assembly from the airframe. According to the pilot, during cruise flight, at 5000 feet, he heard a loud "bang" and saw a reflection of fire on his left engine nacelle. Fire damage was found on the trailing edge of the right wing and on the landing gear assembly. The engine examination also showed that No. 12 cylinder had separated from the main case. Evidence of oil from the No. 12 cylinder was found across engine and exhaust systems. Further examination revealed Nos. 7, 8 and 9 cylinders also failed and separated, and the engine seized and separated from the airframe.
Probable cause:
The failure and separation of No.12 cylinder from the engine case that resulted in an in-flight oil fed fire; and the subsequent separation of the right engine from airframe.
Final Report:

Crash of a Short C-23B Sherpa in Unadilla: 21 killed

Date & Time: Mar 3, 2001 at 0955 LT
Type of aircraft:
Operator:
Registration:
93-1336
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Hurlburt Field - Oceana
MSN:
3420
YOM:
1985
Flight number:
PAT528
Crew on board:
3
Crew fatalities:
Pax on board:
18
Pax fatalities:
Other fatalities:
Total fatalities:
21
Circumstances:
The Sherpa departed Hurlburt Field AFB, Florida, on flight PAT528 to Oceana NAS, Virginia, carrying 18 passengers and a crew of three. While in cruising altitude over Georgia, the crew encountered poor weather conditions with thunderstorm activity, heavy rain falls, severe turbulences, windshear conditions and wind gusting up to 72 knots. The aircraft became unstable, lost 100 feet in three seconds then adopted a nose up attitude. Within the next 12 seconds, the aircraft suffered a positive aerodynamic acceleration then entered an uncontrolled descent, partially disintegrated in the air and eventually crashed in an open field. All 21 occupants were killed.
Crew (171st Aviation Regiment Lakeland):
CW4 Johnny W. Duce,
CW2 Erik P. Larson,
S/Sgt Robert F. Ward Jr.
Passengers (213rd Red Horse Flight, Virginia Beach):
M/Sgt James Beninati,
S/Sgt Paul J. Blancato,
T/Sgt Ernest Blawas,
S/Sgt Andrew H. Bridges,
M/Sgt Eric G. Bulman,
S/Sgt Paul E. Cramer,
T/Sgt Michael E. East,
S/Sgt Ronald L. Elkin,
S/Sgt James P. Ferguson,
S/Sgt Randy V. Johnson,
SRA Mathrew K. Kidd,
M/Sgt Michael E. Lane,
T/Sgt Edwin B. Richardson,
T/Sgt Dean J. Shelby,
S/Sgt John L. Sincavage,
S/Sgt Gregory T. Skurupey,
S/Sgt Richard L. Summerell,
Maj Frederick V. Watkins III.
Probable cause:
The Collateral Investigation Board found the preponderance of the evidence concluded that the aircraft accident was due to crew error. The board found other factors present but not contributing directly to this aircraft accident. These factors may have influenced the crew's decision making process and aircraft performance. This is normally the case in most aircraft human factor accidents. The board did find the preponderance of the evidence directed the board toward the crew's failure to properly load the aircraft. In particular, the crew's failure to properly manage the weight and balance of the aircraft resulted in an 'out-of-CG' condition that exceeded the aircraft design limits, rendering the aircraft unstable and leading to a violent departure from controlled flight. Once the aircraft departed controlled flight, the rapid onset of significant G-force shifts rendered the crew and passengers incapacitated and unconscious and led to a structural break-up of the aircraft in flight. This ultimately resulted in the aircraft impacting the ground, killing all on board.

Crash of a Cessna 500 Citation I in Sault Sainte Marie

Date & Time: Feb 26, 2001 at 1030 LT
Type of aircraft:
Operator:
Registration:
N234UM
Flight Type:
Survivors:
Yes
Schedule:
Detroit – Sault Sainte Marie
MSN:
500-0105
YOM:
1973
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
2770
Captain / Total hours on type:
1410.00
Copilot / Total flying hours:
3142
Copilot / Total hours on type:
300
Aircraft flight hours:
8329
Circumstances:
The captain said that he flew the VOR approach to runway 32. At 2,500 feet, the captain said that they were out of the clouds and initiated a visual straight-in approach. After aligning the airplane with the runway, the captain said he noticed that there was contamination on the runway, "maybe compacted snow or maybe ice with fresh snow over it." The captain briefed that they would perform a go-around if by midfield they were not decelerating adequately. The captain said that they touched down within the first third of the runway. Close to midfield the airplane fishtailed. Past midfield, the captain called a go-around. The first officer said that the captain added power and he retracted the airbrakes. The first officer exclaimed, "There is not enough runway! I braced myself as the aircraft went into the snow." The first officer said that at about 2 miles out from the runway, the unicom called and said that braking action was nil. A Notice to Airman, in effect at the time of the accident for the airport stated, "icy runway, nil braking."
Probable cause:
The pilot exceeding the available runway distance during landing and the pilot's delay in executing a go-around. Factors relating to the accident were, the pilots improper in-flight planning/decision, the pilot disregarding the NOTAMS for the airport, the pilot failing to properly consider the warning given by the Unicom operator regarding the icy runway and nil braking action, the icy runway, and the drop-off/descending embankment.
Final Report:

Crash of a Piper PA-46-350P Malibu Mirage in Mac Gillivray: 1 killed

Date & Time: Feb 20, 2001 at 1900 LT
Registration:
N9176Z
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Mac Gillivray – Santa Ana
MSN:
46-22059
YOM:
1989
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
12000
Aircraft flight hours:
4194
Circumstances:
The accident occurred during a dark night departure from a private unlighted airstrip. The pilot had landed, assisted by the headlights of a car, on the landing strip/road about 1830. After dropping off a passenger, he departed about 1900. The departure direction was towards a sparsely populated area of rolling hills. Local area residents reported hearing a plane depart, followed by a loss of engine sound, and an impact in a grape vineyard. Examination of the wreckage revealed that the airplane impacted the ground in a nose down attitude. According to maintenance records, the last recorded annual inspection occurred 12 months and about 299.5 flight hours prior to the accident. Approximately 5 months before the accident, the FAA Certified Repair Station (CRS) that performed the maintenance on the airplane had given the pilot/owner a 15-item list of "grounding discrepancies." The discrepancies were: Cracked nose cowling; fraying seat belts; LH mag switch broken; LH window cracked; LH windshield crazed; stall warning inoperative; turbine inlet temperature inoperative; door latch safety inoperative; several hydraulic components leaking; main gear trunion pins worn; several cracks in wing lower skins; fuel leaks; loose rivets on RH flap; wing spar bolts loose; and elevator trim cable frayed. According to the CRS manager, the only item that had been repaired prior to the accident was the cracked nose cowling. However, an engine log entry indicated the TIT gage had also been replaced. Additionally, several witnesses reported that the pilot had been flying the airplane with an inoperative landing gear retract system for about 4 months. During post accident examination of the wreckage, investigators were able to verify that many of the listed discrepancies still existed; however, none of these discrepancies could be directly linked to the accident.
Probable cause:
The pilot/owner/operator's failure to maintain control of the airplane during the takeoff initial climb resulting in an in-flight collision with terrain. Contributing to the accident was the dark night light condition.
Final Report:

Crash of a Cessna 421A Golden Eagle in Talladega: 5 killed

Date & Time: Feb 13, 2001 at 1840 LT
Type of aircraft:
Registration:
N5AY
Survivors:
No
Schedule:
Hamilton – Talladega
MSN:
421A-0133
YOM:
1968
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
2000
Captain / Total hours on type:
29.00
Aircraft flight hours:
4887
Circumstances:
The pilot and passengers were on a instrument flight returning home. When they were within range of the destination airport, the controller cleared the flight for an instrument approach. Moment later the pilot canceled his instrument flight plan and told the controller that he was below the weather. Low clouds, reduced visibility and fog existed at the destination airport at the time of the accident. The airplane collided with a river bank as the pilot maneuvered for the visual approach. The post-crash examination of the airplane failed to disclose a mechanical problem.
Probable cause:
The pilot continued visual flight into instrument weather conditions that resulted in the inflight collision with a river bank. Factors were reduced visibility and dark night.
Final Report:

Crash of a Swearingen SA227AT Merlin IVC in Beaver Island: 2 killed

Date & Time: Feb 8, 2001 at 1920 LT
Registration:
N318DH
Survivors:
Yes
Schedule:
Chicago – Beaver Island
MSN:
AT-469
YOM:
1982
Crew on board:
2
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
6500
Captain / Total hours on type:
250.00
Copilot / Total flying hours:
800
Aircraft flight hours:
7207
Circumstances:
The airplane was on an on-demand air-taxi flight operating under 14 CFR Part 135 and was destroyed when it impacted trees and terrain while circling to land during a non-precision instrument approach at night. The airplane came to rest 1.74 nautical miles and 226 degrees magnetic from the intended airport. A weather briefing was obtained and instrument meteorological conditions were present along the route of flight at the time of the briefing. Weather conditions for the two reporting stations closest to the destination were obtained by the airplane prior to executing the approach. The weather reports listed ceilings and visibilities as 400 to 500 feet overcast and 5 to 7 statute miles. The airport elevation is 669 feet and the minimum descent altitude for the approach was listed as 1,240 feet. There was no weather reporting station at the destination airport at the time of the accident. According to the operators General Operations Manual, the pilot was responsible for the dispatch of the airplane including flight planning, and confirming departure, en-route, arrival and terminal operations compliance. The manual also states, "For airports without weather reporting, the area forecast and reports from airports in the vicinity must indicate that the weather conditions will be VFR [visual flight rules] at the ETA so as to allow the aircraft to terminate the IFR operations and land under VFR. (Note: a visual approach is not approved without weather reporting)." For 14 CFR Part 135 instrument flight operations conducted at an airport, federal regulations require weather observations at that airport. Furthermore, the regulations state that, for 14 CFR Part 135 operations, an instrument approach cannot be initiated unless approved weather information is available at the airport where the instrument approach is located, and the weather information indicates that the weather conditions are at or above the authorized minimums for the approach procedure. The commercial pilot held a type rating for the accident airplane. The right seat occupant was a commercial pilot employed by the operator and did not hold an appropriate type rating for the accident airplane. The pitch trim selector switch was found set to the co-pilot side. The regulations state that 14 CFR Part 135 operators cannot use the services of any person as an airman unless that person is appropriately qualified for the operation for which the person is to be used. The circling approach was made over primarily unlit land and water. An FAA publication states that during night operations, "Distance may be deceptive at night due to limited lighting conditions. A lack of intervening Page 2 of 17 CHI01FA083 references on the ground and the inability of the pilot to compare the size and location of different ground objects cause this. This also applies to the estimation of altitude and speed. Consequently, more dependence must be placed on flight instruments, particularly the altimeter and the airspeed indicator." No anomalies were found with respect to the airframe, engines, or systems that could be associated with a pre-impact condition.
Probable cause:
The flightcrew not maintaining altitude/clearance during the circling instrument approach. Factors were the pilot in command initiating the flight without proper weather reporting facilities at the destination, the flightcrew not flying to an alternate destination, the flightcrew not following company and FAA procedures/directives, the lack of certification of the second pilot, the operator not following company and FAA procedures/directives, and the dark night and the low ceiling.
Final Report:

Crash of a Douglas DC-6B in Donlin Creek

Date & Time: Jan 31, 2001 at 1315 LT
Type of aircraft:
Operator:
Registration:
N4390F
Flight Type:
Survivors:
Yes
Schedule:
Fairbanks – Donlin Creek
MSN:
44898
YOM:
1956
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
29500
Captain / Total hours on type:
8100.00
Aircraft flight hours:
37052
Circumstances:
The certificated airline transport captain related that the purpose of the flight was to deliver about 4,800 gallons of fuel oil to the remote mining site. He said that the 5,400 feet long by 100 feet wide airstrip was situated within hilly, snow-covered terrain. He added that the airstrip has a 7 percent uphill grade. Flat light conditions existed at the airstrip, and light snow showers were present, with visibility reported at 2 miles. The captain stated that during final approach, as the airplane passed over the airstrip threshold, flat light conditions made it very difficult to discern where the airstrip surface was. He said that the initial touchdown was "firm", but was thought to be within acceptable tolerances. Just after touchdown, the left wing broke free from the airplane at the wing to fuselage attach point. The airplane veered to the left, and off the left side of the runway. The captain said that the airplane's computed landing weight was 92,260 pounds.
Probable cause:
The flight crew's misjudged flare while landing. Factors associated with the accident were flat light conditions, snow-covered terrain, and an uphill runway grade.
Final Report:

Crash of a Cessna 402C II in Martha's Vineyard

Date & Time: Jan 30, 2001 at 1835 LT
Type of aircraft:
Operator:
Registration:
N6837Y
Flight Type:
Survivors:
Yes
Schedule:
Providence – Martha’s Vineyard
MSN:
402C-0467
YOM:
1981
Flight number:
9K415
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
1668
Captain / Total hours on type:
348.00
Aircraft flight hours:
19131
Circumstances:
The pilot departed on a scheduled flight conducted under night instrument meteorological conditions. Arriving in the area of the destination airport, the weather was reported as, winds from 220 degrees at 18 knots, gusts to 25 knots; 1/2 statute miles of visibility and haze; vertical visibility of 100 feet. The pilot was vectored and cleared for the ILS 24 approach. As the airplane crossed the glideslope, the pilot observed that the "ride" became increasingly bumpy and turbulent, with a strong wind component from the right. The approach lights came into view as the airplane neared the runway, but soon disappeared due to the low visibility. The pilot executed a missed approach, and as full power was applied, the airplane began to move laterally to the left. During the missed approach, a "thunk" was heard on the left side of the fuselage, and the airplane descended into the trees. The airplane came to rest in a wooded area about 1/4 mile from the Runway 24 threshold, about 1,000 feet to the left of the extended centerline. Review of the approach plate for the ILS 24 approach revealed that the glide slope altitude at the final approach fix for the non-precision approach, which was located about 4 miles from the approach end of the runway, was 1,407 feet. The glide slope altitude at the middle marker, which was located about 0.6 miles from the approach end of the runway, was 299 feet. Review of radar data revealed that the airplane intercepted the glideslope about 4 miles from the threshold of runway 24. In the following 2 minutes, 30 seconds, the airplane deviated below and returned to the glideslope centerline approximately 4 times, with a maximum deviation of 2-dots below the glideslope centerline. About 1-mile from the runway, the airplane began a trend downward from the glideslope centerline, descending below the 2- dot low deviation line of the glideslope to an altitude of about 300 feet, when the last radar hit was recorded. During the approach, the airplane's ground speed varied between 50 and 125 knots. According to the Aeronautical Information Manual chapter on Navigation Aids, Instrument Landing System (ILS), it stated that "Make every effort to remain on the indicated glide path." It also cautioned the pilot to, "Avoid flying below the glide path to assure obstacle/terrain clearance is maintained."
Probable cause:
The pilot's failure to maintain a stabilized approach with an adequate vertical and lateral track. Also causal was his failure to maintain obstacle clearance.
Final Report:

Crash of a Beechcraft 200 Super King Air in Byers: 10 killed

Date & Time: Jan 27, 2001 at 1737 LT
Operator:
Registration:
N81PF
Flight Phase:
Survivors:
No
Schedule:
Jefferson - Stillwater
MSN:
BB-158
YOM:
1976
Location:
Crew on board:
2
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
10
Captain / Total flying hours:
5117
Captain / Total hours on type:
767.00
Copilot / Total flying hours:
1828
Copilot / Total hours on type:
1218
Aircraft flight hours:
8737
Circumstances:
On January 27, 2001, about 1737 mountain standard time, a Raytheon (Beechcraft) Super King Air 200, N81PF, owned by North Bay Charter, LLC, and operated by Jet Express Services, crashed into rolling terrain near Strasburg, Colorado. The flight was operating on an instrument flight rules (IFR) flight plan under 14 Code of Federal Regulations (CFR) Part 91. The flight departed about 1718 from Jefferson County Airport (BJC), Broomfield, Colorado, with two pilots and eight passengers aboard. The pilot who occupied the left seat in the cockpit was solely responsible for the flight. The pilot who occupied the right seat in the cockpit, referred to in this report as the "second pilot," was not a required flight crewmember. N81PF was one of three airplanes transporting members of the Oklahoma State University (OSU) basketball team and associated team personnel to Stillwater Regional Airport (SWO), Stillwater, Oklahoma, after a game at the University of Colorado at Boulder that afternoon. All 10 occupants aboard N81PF were killed, and the airplane was destroyed by impact forces and a post crash fire. Instrument meteorological conditions (IMC) prevailed at the time of the accident.
Probable cause:
The pilot’s spatial disorientation resulting from his failure to maintain positive manual control of the airplane with the available flight instrumentation. Contributing to the cause of the accident was the loss of a.c. electrical power during instrument meteorological conditions.
Final Report: