Crash of a Boeing 747-136 in New York

Date & Time: Dec 20, 1995 at 1136 LT
Type of aircraft:
Operator:
Registration:
N605FF
Flight Phase:
Survivors:
Yes
Schedule:
New York - Miami
MSN:
20271
YOM:
1971
Flight number:
FF041
Crew on board:
17
Crew fatalities:
Pax on board:
451
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
16455
Captain / Total hours on type:
2905.00
Copilot / Total flying hours:
17734
Copilot / Total hours on type:
4804
Aircraft flight hours:
90456
Aircraft flight cycles:
17726
Circumstances:
The captain initiated a takeoff on runway 04L, which was covered with patches of ice and snow. The wind was from 330 degrees at 11 knots. Before receiving an 80-knot call from the 1st officer, the airplane began to veer to the left. Subsequently, it went off the left side of the runway and collided with signs and an electric transformer. Investigation revealed evidence that the captain had overcontrolled the nosewheel steering through the tiller, then applied insufficient or untimely right rudder inputs to effect a recovery. The captain abandoned an attempt to reject the takeoff, at least temporarily, by restoring forward thrust before the airplane departed the runway. The current Boeing 747 operating procedures provide inadequate guidance to flightcrews regarding the potential for loss of directional control at low speeds on slippery runways with the use of the tiller. Current Boeing 747 flight manual guidance was inadequate about when a pilot should reject a takeoff following some indication of a lack of directional control response. Improvements in the slippery runway handling fidelity of flight simulators used for Boeing 747 pilot training were considered to be both needed and feasible.
Probable cause:
The captain's failure to reject the takeoff in a timely manner when excessive nosewheel steering tiller inputs resulted in a loss of directional control on a slippery runway. Inadequate Boeing 747 slippery runway operating procedures developed by Tower Air, Inc., and the Boeing Commercial Airplane Group and the inadequate fidelity of B-747 flight training simulators for slippery runway operations contributed to the cause of this accident. The captain's reapplication of forward thrust before the airplane departed the left side of the runway contributed to the severity of the runway excursion and damage to the airplane.
Final Report:

Crash of a Beechcraft B200 Super King Air in Ingleside

Date & Time: Dec 18, 1995 at 1730 LT
Registration:
N231RL
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Ingleside - Cartagena
MSN:
BB-868
YOM:
1981
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
2000
Circumstances:
On December 18, 1995, at 1730 central standard time, a Beech B200, N231RL, was substantially damaged, during takeoff near Ingleside, Texas. The commercial pilot and his passenger were not injured. The airplane was owned by R.A. Beeler Leasing Company, of Carrizo Springs, Texas, and operated by Western Airways Inc., of Houston, Texas. The airplane was stolen from the West Houston Airport at 1600. Visual meteorological conditions prevailed and no flight plan was filed. According to U.S. Customs officials, the operator's chief mechanic reported the aircraft stolen as soon as the airplane was broken into by the two occupants. A U.S. Customs airplane was vectored to intercept the stolen airplane. The owner of the airplane reported there was approximately 800 pounds of fuel aboard at the time the airplane was stolen. The airplane was intercepted as it was landing at the T.P. McCampbell Airport, near Ingleside, Texas. The Customs aircraft landed and blocked the single 4,996 foot runway. While attempting to takeoff to evade law enforcement personnel, the airplane impacted a fence, crossed a ditch, and came to rest in a swamp. The two occupants of the airplane jumped out and ran. The pilot's son was captured, but the pilot was not apprehended. The following items were found in the airplane: bolt cutters, 2 masks, loaded weapons, the pilot's wallet, and charts and maps indicating that the planned destination of the flight was near Cartagena, Colombia. The nose landing gear collapsed, the left wing sustained structural damage, and the pressure bulkhead was punctured.
Probable cause:
The pilot's improper decision, while evading law enforcement personnel during an illegal/unauthorized operation.
Final Report:

Crash of a Beechcraft G18S in Nome

Date & Time: Dec 18, 1995 at 1316 LT
Type of aircraft:
Operator:
Registration:
N340K
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Nome - Gambell
MSN:
BA-605
YOM:
1962
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
8500
Captain / Total hours on type:
450.00
Aircraft flight hours:
6886
Circumstances:
The pilot was attempting to transport by-pass mail from Nome to Gambell, Alaska. The pilot stated that the takeoff run was normal until he rotated the nose of the airplane to lift off. The pilot said the airplane pitched up and he had to apply full forward control yoke pressure while he adjusted the pitch trim to nose down. The airplane rolled to the left and the pilot used the rudders to level the wings prior to impact. The information provided by the company, the FAA, and the post office, indicate that the airplane weighed 10,114 pounds at the time of the takeoff. The certificated maximum gross weight was 10,100 pounds. A weight and balance calculation, based upon information obtained from the company and the placarded limits on the airplane, showed a center of gravity of 121.9 inches. The center of gravity limits shown in the airplane manual are 113 to 120.5 inches. The wreckage examination showed that the elevator trim indicator was indicating full nose up trim.
Probable cause:
The pilot exceeding the weight and balance limitations of the airplane and improperly utilizing the airplane's elevator trim by selecting full nose up trim.
Final Report:

Crash of a Swearingen SA226AT Merlin IV in Detroit

Date & Time: Dec 15, 1995 at 0423 LT
Registration:
N31AT
Flight Type:
Survivors:
Yes
Schedule:
Flint - Louisville
MSN:
AT-057
YOM:
1977
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
9550
Captain / Total hours on type:
3977.00
Aircraft flight hours:
6965
Circumstances:
The pilot reported that shortly after takeoff, the airplane's left engine started to surge. The airplane also began experiencing intermittent electrical surges which caused the instrument panel lights, cabin lights, and radios to go off and on. The pilot diverted to an alternate airport to land. He did not secure the left engine before landing because it was still developing some usable power. He placed the gear select handle in the down position and observed three green gear-down-and-locked lights. Prior to touchdown, both power levers were positioned to flight idle and no gear warning horn sounded. The airplane landed gear up. Postaccident examination revealed no abnormalities with the landing gear or electrical system. The landing gear emergency extension functioned properly. The landing gear indicating system showed a safe gear indication when the gear was extended during examination. Substantial damage to the gear doors was observed, but no damage to the landing gear was observed.
Probable cause:
The pilot's failure to extend the landing gear. A factor in the accident was the pilot's diverted attention.
Final Report:

Crash of a Cessna 340A on Mt Spokane: 1 killed

Date & Time: Dec 13, 1995 at 1816 LT
Type of aircraft:
Registration:
N5GM
Flight Phase:
Survivors:
No
Site:
Schedule:
Spokane – Sandpoint
MSN:
340A-0317
YOM:
1977
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
3500
Captain / Total hours on type:
132.00
Circumstances:
The pilot's departure plans were changed, when, instead of flying direct to his originally planned destination, he was asked to pick up a passenger at another airport prior to returning home. He departed for his alternative destination in dark night conditions, leveled off at his cruise altitude and impacted the side of a mountain in level flight about 25 miles from his departure point. Air Traffic Control vectored another aircraft to the vicinity after communications and radar contact were lost. The crew of that aircraft stated that instrument meteorological conditions prevailed at the time in the vicinity of the crash site.
Probable cause:
The pilot's failure to maintain terrain clearance in mountainous terrain. Factors contributing to the accident were: dark night conditions, mountainous terrain, and instrument meteorological conditions.
Final Report:

Crash of a Cessna 340A in La Verne: 1 killed

Date & Time: Dec 7, 1995 at 0624 LT
Type of aircraft:
Registration:
N37324
Flight Type:
Survivors:
No
Schedule:
Big Bear Lake - La Verne
MSN:
340A-0348
YOM:
1977
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
5282
Captain / Total hours on type:
653.00
Circumstances:
The pilot departed his home base in VFR conditions without filing a flight plan and did not request or receive a preflight or en route weather briefing from the FAA. While en route, he contacted Southern California TRACON (SOCAL) and requested an ILS runway 26 approach to the destination airport. SOCAL cleared the pilot for the approach and to change to an advisory frequency. There was no current weather report available at the airport because the tower was closed, but another pilot who was on the same frequency stated that the airport weather was 'zero zero.' (An automated weather observation system at the airport recorded 'zero zero' conditions near the time of the accident.) Ground witnesses heard the airplane as the pilot began a missed approach. However, the airplane collided with trees and a snack bar building about 1/4 mile northwest of the departure end of the runway. Impact occurred as the airplane was in a right turn through a heading of 345 degrees, which was the opposite direction of turn for the missed approach procedure. Toxicology test of the pilot's blood showed 1.518 mcg/ml Fenfluramine and 0.678 mcg/ml Phentermine; these are appetite suppressant drugs that are chemically related to amphetamines and have a high incidence of abuse. Neither of these drugs was approved by the FAA for use while flying aircraft. The amount of Fenfluramine in the pilot's blood was above a normal level for control of appetite.
Probable cause:
The pilot's impairment of judgment and performance due to drugs, his resultant improper planning/decision, his failure to follow proper IFR procedures, and his failure to maintain proper altitude during a missed approach. Factors relating to the accident were: the pilot's inadequate weather evaluation, and the adverse weather condition (below landing minimums).
Final Report:

Crash of a Cessna 402A in Avon Park: 2 killed

Date & Time: Dec 5, 1995 at 0632 LT
Type of aircraft:
Registration:
N402RL
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Avon Park – Moss Town – Port-au-Prince
MSN:
402A-0051
YOM:
1969
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
2700
Captain / Total hours on type:
104.00
Aircraft flight hours:
11512
Circumstances:
After takeoff at dawn on a foggy morning, the airplane collided with electrical transmission wires about one mile from the end of the runway, on an extended line about 50 degrees left of the extended runway centerline. The left wing tip fuel tank (left main) was partially severed from the airplane, breaching the tank. Additionally, the top of the vertical stabilizer and rudder were severed, and a portion of the windscreen was separated. A suggestion was made by the operator that the autopilot trim may have been improperly set, precipitating a nose pitch down upon engagement of the autopilot during the climb. The airplane continued to fly for about 20 minutes, then impacted in a steep right wing down attitude into a densely wooded area that was surrounded by open terrain. The ensuing fire precluded any determination of engine malfunction, systems' discrepancies, or wire strike damage to the left propeller. No determination of pilot incapacitation was possible because of the post impact fire. Based upon the ground witness statement, the left engine was probably inoperative following the wire strike. The impact attitude was inconsistent with a decreasing speed loss of control with the left engine inoperative. However, the flight control trim settings, left main fuel tank selected, and throttle quadrant settings all may have been indicative of pilot incapacitation that precluded proper emergency procedure response. Additionally, the airplane impacted into a densely wooded area surrounded by flatter terrain absent of tall obstacles.
Probable cause:
The failure of the pilot to maintain the proper climb rate and direction of flight following takeoff, resulting in a collision with obstacles. The reason for the loss of control and subsequent unusual attitude ground impact was not determined.
Final Report:

Crash of a Beechcraft D18S in Fort Collins

Date & Time: Nov 30, 1995 at 1330 LT
Type of aircraft:
Operator:
Registration:
N8603A
Flight Type:
Survivors:
Yes
Schedule:
Fort Collins - Fort Collins
MSN:
A-557
YOM:
1951
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
7000
Captain / Total hours on type:
800.00
Circumstances:
The pilot-owner/operator, who was seated in the right seat, said the left seat pilot made the approach to runway 15. The wind was reported as being from the southwest at 20 knots with no reference to gusts. He said the pilot aligned the airplane 40 feet left of runway centerline and failed to flare. The airplane contacted the runway, bounced back into the air with the right wing high, and began drifting to the left. The right seat pilot took control, first trying to lower the wing then attempting to abort the landing. The airplane struck the ground and cartwheeled. The left seat pilot said he was 'receiving training' from the pilot-owner and was 'not at the controls' at the time of the accident.
Probable cause:
The second pilot's failure to compensate for wind conditions and his improper recovery from a bounced landing, and the pilot-in-command's inadequate supervision of the flight. Factors were the second pilot's lack of landing experience in the airplane make/model, and the gusty crosswind conditions.
Final Report:

Crash of a Cessna 414 Chancellor in Marlinton: 1 killed

Date & Time: Nov 28, 1995 at 0940 LT
Type of aircraft:
Operator:
Registration:
N28901
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Sutton - Lynchburg
MSN:
414-0353
YOM:
1972
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
4850
Aircraft flight hours:
3378
Circumstances:
The pilot took off from an uncontrolled airport. He attempted to obtain an IFR clearance and reported that he was VFR at 3,500 feet. While air traffic control personnel were locating the flight plan and coordinating the IFR clearance, they lost radio contact with the pilot. The pilot continued to fly towards his destination, transiting rising mountainous terrain which was partially obscured by clouds. Wreckage was located about 28 nautical miles from the departure airport, at the 4,050-foot level. There was no evidence of mechanical failure or malfunction. According to FAR Part 91.3, the pilot had the ultimate authority for the operation of the airplane, and in the case of an in-flight emergency, had the authority to deviate from flight rules "to the extent required to meet that emergency." According to the AIM, an emergency could be either "a distress or an urgency condition." An urgency condition would exist "the moment the pilot becomes doubtful about position... weather, or any other condition that could adversely affect flight safety." Under FAR Part 91.3, the pilot would have been authorized to climb the airplane under IFR conditions, even if he were to enter controlled airspace.
Probable cause:
The pilot's continued VFR flight into obscured, rising mountainous terrain, and his failure to climb the airplane as conditions worsened. Factors included the rising terrain and the weather obscuration.
Final Report:

Crash of a Beechcraft 65-B80 Queen Air near O. H. Ivie Lake: 1 killed

Date & Time: Oct 26, 1995 at 0950 LT
Type of aircraft:
Operator:
Registration:
N9NP
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Waco - San Angelo
MSN:
LD-428
YOM:
1970
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
2502
Captain / Total hours on type:
593.00
Aircraft flight hours:
8127
Circumstances:
Witnesses observed the airplane contact the water while buzzing a lake, 'emerge from a cloud of water,' and enter a climb trailing white vapor. As the airplane approached the lake shore, the right propeller 'quit turning,' then the airplane entered a steep right bank and impacted the ground. The right propeller lever was found in the feather position. Propeller teardowns revealed signatures indicating the right propeller was feathered and the left propeller was operating in the low pitch range at impact. Disassembly of the engines revealed no evidence of any pre-impact mechanical anomalies, and, in the opinion of the manufacturer, 'both engines appeared capable of producing power prior to impact.' Toxicological tests showed 178.000 mg/dl (0.178%) ethanol in vitreous fluid, 90.000 mg/dl (0.09%) ethanol in blood, 114.000 mg/dl (0.114%) ethanol in brain fluid, 3.000 mg/dl acetaldehyde in brain fluid, 22.000 mg/dl acetaldehyde in blood, and 4.000 mg/dl 2-propanol in brain fluid. The levels of ethanol found indicate ingestion of alcohol, and the levels of acetaldehyde and 2-propanol (metabolites of ethanol) detected support ingestion of alcohol.
Probable cause:
The pilot's impairment of judgment and performance due to alcohol which resulted in his improper decision to shutdown an engine, and his failure to maintain adequate airspeed for single-engine flight.
Final Report: