Crash of a Cessna 421B Golden Eagle II in Jefferson City: 4 killed

Date & Time: May 27, 1999 at 1826 LT
Registration:
N34TM
Survivors:
No
Schedule:
Poplar Bluff – Jefferson City
MSN:
421B-0965
YOM:
1975
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
1850
Captain / Total hours on type:
850.00
Aircraft flight hours:
5530
Circumstances:
The airplane impacted the ground in a nose low, inverted attitude. The pilot reported, 'Jeff Tower, N34TM, I've just lost power on the right engine, eh, left engine.' The airplane's altitude was approximately 200 to 400 feet when the airplane's wings wobbled back and forth. The airplane's wings banked approximately 90 degrees to the left, and then the airplane nosed over and impacted the ground. White smoke was seen coming from the belly of the airplane for 1 to 2 seconds about 20 seconds prior to it impacting the ground. The terrain was a flat, hard packed field used for growing grass sod. Both the left and right propellers were found 12 to 18 inches under the hard packed soil. Rotational paint transfer patterns from the propeller blades onto the hard packed soil were evident. The left and right propeller blades exhibited chordwise scratching and leading edge polishing. The #2 cylinder piston was broken and the piston pin was still attached to the piston rod. The NTSB Materials Laboratory examination revealed the fracture face of the #2 exhaust valve stem was consistent with a bending fatigue separation. Both #2 and #6 exhaust valve guides showed heavy wear that ovalized the bores. The annual inspection conducted on March 15, 1999, indicated the compression on the left engine was 80/64, 50, 67, 70, 69, and 62.
Probable cause:
The pilot failed to maintain control of the airplane. A factor was the partial loss of power due to the exhaust valve fatigue failure.
Final Report:

Crash of a Beechcraft C18S Expeditor in Waldron: 1 killed

Date & Time: May 23, 1999 at 1915 LT
Type of aircraft:
Registration:
N9729H
Survivors:
No
Schedule:
Beaumont – Springdale
MSN:
8205
YOM:
1945
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
6860
Captain / Total hours on type:
860.00
Aircraft flight hours:
4400
Circumstances:
During a cross-country flight, the pilot of the twin-engine airplane reported to air traffic control that he has 'lost an engine.' A witness observed the right engine hanging from its lower mounts as the airplane turned right and headed towards the nearest airport. The airplane impacted trees approximately 1 mile short of the runway threshold. Examination of the right engine propeller revealed that one of its blades was separated about mid-span. The separated tip section of the blade was not recovered. Metallurgical examination of the fracture surface revealed that the blade failed as a result of a fatigue crack that originated from corrosion pits on the camber surface (face) of the blade. The failed blade was examined approximately 6 hours prior to the accident in accordance with an airworthiness directive (AD 81-13-06 R2) that called for inspections of the blade for corrosion and fatigue. However, the inspections called out in the AD were only applicable to the blade fillet and shank regions, well inboard of the fracture location on the failed blade. Overhaul of the propeller in accordance with the propeller manufacturer's manual includes grinding of each blade to 'remove all visual evidence of corrosion.' According to the airplane's owner, the propellers had not been overhauled in the eight years that he had owned the aircraft. The maintenance records were destroyed in the accident, which precluded determination of the date and time of the last propeller overhaul. The accident airplane was being operated under Title 14 CFR Part 91, and therefore, the propellers were not required to be overhauled at specified intervals.
Probable cause:
The separation of a propeller blade in cruise flight as a result of fatigue cracking emanating from surface corrosion pitting.
Final Report:

Crash of a Beechcraft B90 King Air off Dillingham: 1 killed

Date & Time: May 22, 1999 at 1930 LT
Type of aircraft:
Operator:
Registration:
N301DK
Survivors:
No
Schedule:
Dillingham - Dillingham
MSN:
LJ-372
YOM:
1968
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
2000
Circumstances:
Following the 12th sport parachute jump of the day, which occurred after sunset, ground witnesses observed the airplane descend into the ocean in a left wing low, nose down attitude. They did not hear the engines sputtering or popping, or see the airplane make any erratic movements during its descent. Skydivers indicated that the two previous flights had been conducted at altitudes of at least 18,000 feet, and the accident flight and subsequent jump were made at 20,000 feet. During this final jump flight, one of the skydivers stated he had a hard time breathing and felt nauseous. The skydivers also noted that the pilot was unable to maintain a steady course and did not respond well to minor course corrections. No supplemental oxygen was found onboard the airplane during the recovery or subsequent inspection phases of the investigation. No skydiver observed the pilot using supplemental oxygen. The airplane manufacturer noted that the pressurization system would have been rendered inoperable due to a non-sealed cockpit door. Hypoxia is defined as a physiological condition where a person is bereft of needed oxygen. Judgment is poor and reaction time delayed. Total incapacitation coupled with a loss of consciousness can occur with little or no warning. The airframe, engines, and propellers were examined with no preexisting impact anomalies found.
Probable cause:
The pilot's incapacitation due to the effects of hypoxia from repeated flights to altitudes above 18,000 feet msl without supplemental oxygen.
Final Report:

Crash of a Cessna 414 Chancellor in Orland

Date & Time: May 21, 1999 at 1725 LT
Type of aircraft:
Registration:
N8153Q
Flight Type:
Survivors:
Yes
Schedule:
San Jose – Redding
MSN:
414-0053
YOM:
1970
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
12000
Captain / Total hours on type:
480.00
Aircraft flight hours:
4471
Circumstances:
The pilot refueled the auxiliary tanks of the airplane at a different airport 1 month prior to the accident, and had not flown on the auxiliary tanks since that time. He was repositioning the airplane back to home base after a series of revenue flights when the accident occurred. About 20 minutes after takeoff he positioned the left and right engines to their respective auxiliary fuel tanks, and then returned to the mains 30 minutes later. The right engine began to surge and subsequently stopped running. Turning on the fuel boost pump restarted the engine. Five minutes later the engine quit and he secured it after unsuccessful restart attempts. Then the left engine began to surge and was developing only partial power. He diverted to an alternate airport with decaying altitude and power in the remaining engine. Crossing the airport, he saw he was too high to land with a tailwind so he circled to land into the wind. On the base leg he made the decision to land straight ahead in a field due to power lines in his path, rapidly decaying altitude, and power. During the landing roll, the airplane collided with a ditch. The left and right main fuel filters contained a foreign substance, which upon laboratory examination, was found to be a polyacrylamide. This is a manmade synthetic polymer that is used as an agricultural soil amendment that aids in reducing soil erosion. Distribution of the polymer is typically not done by aircraft. Inspection of the fueling facility revealed that the employees who do refueling did not have any formal or on-the-job training. There was no record that the delivery system filters had been examined or changed. The maintenance to the truck, delivery system, and storage facility are done by the employees on an as needed, time permitted basis. The fuel truck was found to be improperly labeled, and the fuel nozzle was lying in a compartment amid dirt, gravel, and other contaminates with no caps or covers for protection.
Probable cause:
A loss of engine power in both engines due to fuel contamination, which resulted from the fueling facilities improper quality control procedures.
Final Report:

Crash of a Cessna T303 Crusader in San Diego

Date & Time: May 7, 1999 at 2230 LT
Type of aircraft:
Registration:
N3303S
Flight Type:
Survivors:
Yes
Schedule:
Houston – San Diego
MSN:
303-00018
YOM:
1981
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
25000
Captain / Total hours on type:
200.00
Aircraft flight hours:
1832
Circumstances:
The airplane departed Houston, Texas, for a VFR flight to San Diego, California. The pilot in the left seat said that they originally planned to purchase fuel at Gila Bend, Arizona, but were told that the fueling was closed. The left seat pilot said they elected to land at a private airstrip and made arrangements to have an individual drive to Casa Grande airport to purchase fuel for them. The left seat pilot said they were worried about adequate runway length, so they elected to only purchase 65 gallons of fuel for the remainder of the flight to San Diego. En route to San Diego, the right seat pilot obtained weather for the destination from FSS and was advised of 1,000-foot overcast ceiling. The right seat pilot then requested and received an instrument clearance. The TRACON controller advised the pilot of the accident airplane that he would have to keep speed up due to jet traffic or be given delay vectors for traffic spacing. The pilot told ATC that they were fuel critical and later said they had about 45 minutes to 1 hour of fuel. The right seat pilot was cleared for the localizer runway 27 approach. Approximately 18 minutes later, the pilot elected to do a missed approach because he was too high to land and moments later told San Diego radar that he was fuel critical and only had about 5 minutes of fuel left. San Diego radar began to give the pilot vectors to the closest airport and told the pilot not to descend any further. The right seat pilot replied that they were a glider and later told San Diego police that they had run out of fuel. There were no discrepancies noted with either the airframe or the engines during the postaccident aircraft examination.
Probable cause:
The pilot-in-command's inaccurate fuel consumption calculations that resulted in fuel exhaustion and the subsequent ditching.
Final Report:

Crash of a Cessna 402C in Goldsby: 1 killed

Date & Time: Apr 27, 1999 at 0916 LT
Type of aircraft:
Registration:
N819BW
Flight Type:
Survivors:
No
Schedule:
Dallas - Oklahoma City
MSN:
402C-0423
YOM:
1980
Flight number:
TXT818
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
1754
Aircraft flight hours:
20457
Circumstances:
The twin-engine airplane impacted the ground in an uncontrolled descent following the inflight separation of the right wing during a normal descent. The airplane had accumulated a total time of 20,457 hours and had been flown 52 hours since the most recent annual inspection, which was performed by the current operator 3 weeks prior to the accident. Available maintenance records indicated that since 1988, maintenance personnel had made numerous repairs to the right wing, including repairing skin cracks, working rivets, wing stub spar straps, and the right main landing gear. Metallurgical examination revealed that the right wing's front spar failed due to fatigue that started at an area of mechanical damage and rough machining marks. The presence of primer covering the mechanical damage strongly suggests that the damage was produced during the manufacturing process. It could not be determined whether the mechanical damage or the machining, acting alone, could have caused the fatigue cracking to initiate. Fatigue cracking found on the rear spar and the forward auxiliary spar is most likely secondary fatigue due to load shedding as the crack grew in the front spar.
Probable cause:
The fatigue failure of the right wing spar as a result of inadequate quality control during manufacture of the spar. A factor was the inadequate inspection of the right wing by maintenance personnel, which failed to detect the crack.
Final Report:

Crash of a Piper PA-61 Aerostar (Ted Smith 601) in Ruidoso: 2 killed

Date & Time: Apr 23, 1999 at 1023 LT
Registration:
N48MD
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Ruidoso – North Las Vegas
MSN:
61-0492-201
YOM:
1978
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
3681
Captain / Total hours on type:
597.00
Aircraft flight hours:
4526
Circumstances:
The pilot departed on runway 06 with zero degrees of flaps. A witness said that she noticed that the airplane appeared to wobble and shudder, and immediately went into a steep right bank turn right after takeoff. The airplane then went into the clouds which were 200 to 400 feet agl. Radar data indicated that the airplane made several 90 degree turns prior to impacting the mountainous terrain 2.55 nm from the departure end of the runway. The pilot normally used 20 degrees of flaps for takeoff. A test pilot said that the airplane handles significantly different during takeoff if zero degrees of flaps are used verses 20 degrees of flaps. The upper cabin's entry door was found, with the locking handle and locking pins, in the closed position. No preimpact engine or airframe anomalies, which might have affected the airplane's performance, were identified.
Probable cause:
The pilot's failure to maintain aircraft control for undetermined reason. A factor was the low ceiling IMC weather condition.
Final Report:

Crash of a Cessna 402B in Fort Lauderdale

Date & Time: Apr 20, 1999 at 1910 LT
Type of aircraft:
Registration:
N744MA
Flight Type:
Survivors:
Yes
Schedule:
Fort Myers – Fort Lauderdale
MSN:
402B-0592
YOM:
1974
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
2600
Captain / Total hours on type:
500.00
Aircraft flight hours:
2675
Circumstances:
While on approach to land the left engine surged and lost power. The pilot switched the left engine fuel selector to another fuel tank and the engine restarted. A short time later the left engine surged and lost power again. The pilot switched the left engine fuel selector to the right main fuel tank and the engine again restarted. A short time later the left engine quit again and he shutdown the engine and feathered the propeller. A short time later the right engine surged and lost power. He shut down the right engine and feathered the propeller. He then made a forced landing in a field and during landing rollout the aircraft's left wing collided with a tree. A fire erupted in the left wing area. Post crash examination showed the right main fuel tank was empty. The right auxiliary fuel tank contained 2.5 gallons. The left main fuel tank contained one half gallon of fuel and the left auxiliary tank was ruptured. The pilot operating handbook stated that the main fuel tanks had one gallon unusable fuel and the auxiliary fuel tanks had one half gallon of unusable fuel.
Probable cause:
A loss of engine power due to fuel exhaustion and the pilot in command's failure to ensure that the aircraft had adequate fuel to complete the flight.
Final Report:

Crash of a Beechcraft Beechjet 400A in Beckley

Date & Time: Apr 17, 1999 at 1451 LT
Type of aircraft:
Operator:
Registration:
N400VG
Survivors:
Yes
Schedule:
West Palm Beach – Beckley
MSN:
RK-113
YOM:
1996
Crew on board:
2
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
4719
Captain / Total hours on type:
107.00
Copilot / Total flying hours:
6250
Copilot / Total hours on type:
148
Aircraft flight hours:
1215
Circumstances:
The airplane touched down about 1/3 beyond the approach end of Runway 28, a 5,000 footlong, asphalt runway. The PIC stated, 'as usual,' he applied 'light' braking and attempted to actuated the airplane's thrust reverser (TR) system; however, the TR handles could not be moved beyond the 'Deploy-Reverse-Idle' position. After the PIC cycled the levers two or three times, he began to apply maximum braking. A passenger in the airplane stated he looked out of the cockpit window, saw the end of the runway, and the airplane seemed like it was still moving 'pretty fast.' As the airplane approached the end of the runway, he could see smoke, which he believed was coming from the airplane's tires. He then sensed the airplane was falling. The co-pilot stated he had no memory at all of the accident flight. Review of the CVR revealed the co-pilot said that the airplane was 'Vref plus about twenty,' when the airplane was 100 feet over the runway threshold. The PIC could not recall the airplane's touchdown speed, however, he stated that it seemed like the airplane was still traveling 50 to 60 knots when it departed the end of the runway. A pair of parallel tire marks were observed 3,200 feet beyond the approach end of the runway. The tire marks extended past the end of the runway and onto a 106 foot-long grass area. The airplane came to rest on a plateau about 90 feet below the runway elevation. Examination of the airplane, including the optional TR system did not reveal any pre-impact malfunctions. The airplane's estimated landing distance was calculated to be about 3,100 feet. The PIC reported about 4,700 hours of total flight experience, of which, 107 hours were in make and model. The PIC stated he had never performed a landing in the accident airplane without using the TR system. Winds reported at the time of the accident were from 290 degrees at 15 knots, with 21 knot gusts.
Probable cause:
The pilot-in-command misjudged his altitude and airspeed which resulted in an overrun. Contributing to the accident were the pilot's lack of total flight experience in make and model, the pilot's reliance on the airplane's optional thrust reverser system and his inability to engage the airplane's thrust reverser system for undetermined reasons.
Final Report:

Crash of a Piper PA-31-310 Navajo off Monterey

Date & Time: Apr 14, 1999 at 1800 LT
Type of aircraft:
Registration:
N141CM
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Honolulu – Long Beach
MSN:
31-234
YOM:
1968
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
427
Captain / Total hours on type:
42.00
Aircraft flight hours:
4882
Circumstances:
The pilot reported that about 150 miles southwest of Monterey, the right engine made unusual noises, began to run rough, and exhibited high cylinder head temperature at the limits of the gauge. He advised Oakland Center of his position and situation, but did not declare an emergency. The pilot attempted to open the right engine cowl flap; however, it malfunctioned. He then increased fuel flow to the right engine in order to cool it and eventually had to reduce power on that side to keep it running. To compensate for the power loss in the right engine, he had to add power to the left engine. The combination of remedial actions increased the fuel consumption beyond his planned fuel burn rate. The flight attitude required by the asymmetric power also induced a periodic unporting condition in the outboard fuel tank pickups. The pilot said he was forced to switch to the inboard tanks until that supply was exhausted and then attempted to feed from the outboard tanks. The pilot said he was unsuccessful in maintaining consistent engine power output and was forced to ditch 20 miles short of the coastline. The pilot's VFR flight plan indicated that the total time en route would be 13 hours 10 minutes and total fuel onboard was 14 hours. The lapsed time from departure until the aircraft ditching was approximately 13 hours 12 minutes.
Probable cause:
An undetermined system malfunction in the right engine, which led to an increase in fuel usage beyond the pilot's planned fuel consumption rate and eventual fuel supply exhaustion.
Final Report: