Crash of a Cessna 421C Golden Eagle III in Mesquite: 8 killed

Date & Time: Sep 2, 1995 at 0838 LT
Operator:
Registration:
N6234G
Survivors:
No
Schedule:
North Las Vegas - Yellowstone
MSN:
421C-0265
YOM:
1977
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
8
Captain / Total flying hours:
18628
Captain / Total hours on type:
86.00
Aircraft flight hours:
5461
Circumstances:
After climbing to 18,400 feet msl, the pilot reported a turbocharger problem and reversed course. He said he 'may lose the left engine' and that he was unable to maintain altitude. He diverted to an alternate airport. During a right turn onto final approach, the airplane was observed to cross (overshoot) the extended centerline of the runway. It continued in a right turn back toward the centerline, and then entered a left turn to intercept the inbound course. The turn steepened, and then the airplane entered a spin and crashed 1/2 mile short of the runway. A warped flange and evidence of exhaust gas leakage were found on the Inconel exhaust system Wye collector, at the wastegate outlet of the left engine. Neither propeller was in a feather position. There was evidence that the left engine was providing low power during impact. A note on the pilot's clipboard indicated that the (left engine) fuel flow and cylinder head temperature went to zero, and the manifold pressure dropped to 10 inches. The note also indicated that the pilot switched the 'boost pump' to high, the fuel flow went to 260 psi, and manifold pressure increased to 18.5 inches. Calculations showed that the airplane's gross weight (GW) and center-of-gravity (CG) were 7,645 pounds and 158.32 inches. The maximum allowable GW and CG were 7,450 pounds and 158 inches. During impact, the flaps were fully extended. The 'Engine Inoperative Landing' procedure stated, 'Wing Flaps - DOWN when landing is assured.' Most of the pilot's flight time in the Cessna 421 was before 1985; no record was found of recurrent training in the airplane since 1984. Annual and turbocharger inspections were made at 78 and 120 flight hours, respectively, before the accident, but no logbook entries were made concerning maintenance or replacement parts for the exhaust system. All eight occupants were killed.
Probable cause:
Failure of the pilot to maintain adequate airspeed, while maneuvering on approach, which resulted in an inadvertent stall/spin and uncontrolled collision with terrain. Factors relating to the accident were: the pilot allowed the aircraft weight and balance limitations to be exceeded; the pilot's lack of recurrent training in the make and model of airplane; inadequate maintenance/inspection of the engine exhaust systems; a warped and leaking exhaust system flange on the left engine, which resulted in a loss of power in that engine; and the pilot's improper use of the flaps.
Final Report:

Crash of a Short SC.7 Skyvan 3 Variant 200 near Farewell: 1 killed

Date & Time: Sep 1, 1995 at 1200 LT
Type of aircraft:
Operator:
Registration:
N30GA
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Farewell - Anchorage
MSN:
1839
YOM:
1968
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
11389
Captain / Total hours on type:
2200.00
Aircraft flight hours:
15798
Circumstances:
The pilot had departed a remote airstrip on the return portion of a cargo flight. An instrument flight plan was on file with the ARTCC. After departure, the pilot attempted to contact ARTCC to open his flight plan but communications were not established. The airplane struck mountainous terrain about 6 miles south of the departure airport. Radar data showed that after departure, the airplane climbed westbound and then turned southbound toward higher terrain. It circled southwest of the airport and turned eastbound while climbing to 5,300 feet msl. The airplane then turned southbound again toward the accident site. The last recorded radar data was at 5,200 feet msl. The airplane struck a ridgeline about 4,800 feet msl. Airmets were in effect for IFR conditions, low ceilings, mountain obscurations, rain, fog, and icing in clouds and in precipitation. A witness reported that when the airplane arrived at the airport, the airframe had a coating of ice. When the airplane departed, snow was falling at the airport.
Probable cause:
The pilot's continued vfr flight into instrument meteorological conditions. The weather was a factor.
Final Report:

Crash of a Cessna T207A Skywagon in San Diego

Date & Time: Aug 23, 1995 at 1318 LT
Operator:
Registration:
N91004
Flight Type:
Survivors:
Yes
Schedule:
Wendover - San Diego
MSN:
207-0004
YOM:
1969
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
900
Aircraft flight hours:
2085
Circumstances:
The local controller instructed the pilot to go-around because of inadequate spacing in the traffic pattern. While executing the go-around, the engine lost power and the airplane crashed on a bridge after colliding with the guard railing about 1 mile from the airport. The wreckage examination showed that the fuel line between the engine driven pump and the fuel control servo was empty. The left main tank leaked for about 5 minutes; the right main fuel tank was not compromised and contained between 5 and 10 gallons of fuel. Both auxiliary fuel tanks were empty. The fuel selector valve was found selected between the right main fuel tank and the off position. There were no other engine or airframe anomalies found.
Probable cause:
The pilot's improper fuel management and improper use of the fuel selector valve.
Final Report:

Crash of a Rockwell Aero Commander 560F in Miami: 1 killed

Date & Time: Aug 22, 1995 at 1123 LT
Registration:
N4630W
Flight Type:
Survivors:
No
Schedule:
Miami - Miami
MSN:
560-1068-24
YOM:
1961
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
The non-certificated pilot took a multiengine airplane without the owner's permission and attempted to fly around the traffic pattern. On base leg to final, the airplane was observed to stall, enter a nose down descent, and crash. The non-certificated pilot was apparently unaware that the static system ports had been taped over for avionics work.
Probable cause:
Failure of the non-certificated pilot (unqualified person) to maintain sufficient airspeed, which resulted in a stall and a collision with the ground. Factors relating to the accident were: the non-certificated pilot's unauthorized use of an airplane that had static ports taped for maintenance, and his failure to properly preflight the airplane (and ensure the static ports were clear).
Final Report:

Crash of an Embraer EMB-120RT Brasília in Carrollton: 8 killed

Date & Time: Aug 21, 1995 at 1253 LT
Type of aircraft:
Operator:
Registration:
N256AS
Survivors:
Yes
Schedule:
Atlanta - Gulfport
MSN:
120-122
YOM:
1989
Flight number:
EV529
Crew on board:
3
Crew fatalities:
Pax on board:
26
Pax fatalities:
Other fatalities:
Total fatalities:
8
Captain / Total flying hours:
9876
Captain / Total hours on type:
7374.00
Copilot / Total flying hours:
1193
Copilot / Total hours on type:
363
Aircraft flight hours:
17151
Aircraft flight cycles:
18171
Circumstances:
Atlantic Southeast Airline Flight 529 was climbing through 18,000 feet, when a blade from the left propeller separated. This resulted in distortion of the left engine nacelle, excessive drag, loss of wing lift, and reduced directional control. The degraded performance resulted in a forced landing. While landing, the airplane passed through trees, impacted the ground, and was further damaged by post impact fire. An exam of the left propeller revealed the blade had failed due to a fatigue crack that originated from multiple corrosion pits in the taper bore surface of the blade spar. The crack had propagated toward the outside of the blade and around both sides of the taper bore. Due to 2 previous blade failures (separations), a borescope inspection procedure had been developed by Hamilton Standard to inspect returned blades (that had rejectable ultrasonic indications) for evidence of cracks, pits and corrosion. The accident blade was one of 490 rejected blades that had been sent to Hamilton Standard for further evaluation and possible repair. Maintenance technicians, who inspected the blade, lacked proper NDI familiarization training and specific equipment to identify the corrosion that resulted in fatigue. The captain and seven passengers were killed.
Probable cause:
The in-flight fatigue fracture and separation of a propeller blade resulting in distortion of the left engine nacelle, causing excessive drag, loss of wing lift, and reduced directional control of
the airplane. The fracture was caused by a fatigue crack from multiple corrosion pits that were not discovered by Hamilton Standard because of inadequate and ineffective corporate inspection and repair techniques, training, documentation, and communications. Contributing to the accident was Hamilton Standard's and FAA's failure to require recurrent on-wing ultrasonic inspections of the affected propellers. Contributing to the severity of the accident was the overcast cloud ceiling at the accident site.
Final Report:

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

Date & Time: Aug 20, 1995 at 0028 LT
Registration:
N41GA
Flight Type:
Survivors:
No
Schedule:
Myrtle Beach – Rock Hill
MSN:
61-0465-183
YOM:
1978
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
638
Captain / Total hours on type:
458.00
Aircraft flight hours:
2561
Circumstances:
As the flight approached the airport, radar data showed that it went into a shallow descending left turn away from the airport. Radar data was lost at about 650 feet agl with the ground speed about 100 knots. Witnesses observed the aircraft flying on a southerly heading and enter a spin or spiral from which it crashed nose first into the ground. Post-crash examination of the aircraft structure, flight controls, and engines showed no precrash failure or malfunction. Post-mortem examination of the pilot showed he had suffered a heart attack. The pilot had a history of heart disease, a previous heart attack, and heart bypass surgery. He held a special issuance faa medical certificate, due to his history of heart disease.
Probable cause:
The pilot's in-flight loss of aircraft control, due to incapacitation by a heart attack.
Final Report:

Crash of a Piper PA-31-350 Navajo Chieftain in Ardoch: 2 killed

Date & Time: Aug 18, 1995 at 1642 LT
Registration:
N85115
Flight Phase:
Survivors:
No
Schedule:
Thief River Falls - Minot
MSN:
31-7405182
YOM:
1974
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
40000
Captain / Total hours on type:
3000.00
Aircraft flight hours:
8814
Circumstances:
After deplaning passengers at Thief River Falls after an air taxi flight, the pilot was reportedly anxious to return to his base in Minot to prepare for another trip the following day, and left for the return trip within a few minutes after his arrival at Thief River Falls. There was no record of a weather briefing. Observations of Doppler radar by the University of North Dakota, and a Safety Board meteorological study, show that the airplane had penetrated a thunderstorm when control was lost. The airplane had encountered the center of a microburst, and was located directly under the downdraft.
Probable cause:
The pilot-in-command's continuing flight into adverse weather. Factors were the pilot-in-command's failure to obtain a weather observation and the adverse weather.
Final Report:

Crash of a Cessna 421C Golden Eagle III off Middleton Island: 4 killed

Date & Time: Jul 29, 1995 at 1150 LT
Registration:
N800DD
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Juneau - King Salmon
MSN:
421C-0469
YOM:
1978
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
2000
Aircraft flight hours:
4912
Circumstances:
The flight departed Juneau, Alaska on a VFR flight to King Salmon, Alaska. When the flight was 50 miles southwest of the Yakutat VOR, the pilot requested an IFR clearance. He was cleared direct to Middleton Island VOR, then direct to King Salmon VOR. When the flight was 20 miles northwest of Middleton Island, the pilot contacted ARTCC and indicated his right engine had come apart. The pilot attempted to fly to and land at Middleton Island, Alaska. During the flight, the airplane consistently lost altitude. He flew past the island and was southeast of the island, when radar contact was lost. The airplane was not recovered. Flight crew of rescue aircraft stated they saw bubbles, an oil slick, and airplane debris in the ocean approximately 3 miles south of the Middleton Island Airport. The 1126 adt weather at the airport was in part: 600 feet broken, visibility 5 miles, wind from 117° at 17 gusting 25 knots.
Probable cause:
Mechanical loss of engine power for undetermined reason(s), and subsequent in-flight collision with water (or ditching at sea).
Final Report:

Crash of a Douglas C-47A-75-DL in Independence: 1 killed

Date & Time: Jul 19, 1995 at 1050 LT
Registration:
N54NA
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Elmira - Kansas City
MSN:
19475
YOM:
1944
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
12534
Captain / Total hours on type:
2865.00
Aircraft flight hours:
16700
Circumstances:
The new owner/co-pilot of the 50-year-old airplane and another pilot, who was typed rated in the airplane, departed on a 1,700 mile ferry flight. After the first 250 mile leg, the airplane was landed at another airport with a right engine problem. The owner replaced the right engine and continued the ferry flight. Twenty minutes into the second flight, the replacement right engine lost power. The owner stated that they applied maximum power to the left engine, were unable to feather the right propeller, and performed a forced landing to a field. However, the airplane collided with trees before reaching the field, then burned after impact. Investigation revealed that during the past 5 years, the airplane had neither flown nor had an annual inspection, except for 3 recent maintenance flights, totaling 1.5 Hours. The right propeller blades had chordwise scratches. The left propeller blades had no chordwise scratches. Examination of the wreckage revealed three propeller strikes in the ground, near the right engine ground scar, and no propeller strikes in the ground, near the left engine ground scar. The right engine mixture was locked in the auto-cruise position, while the left was locked in the emergency position. Airplane charts listed the single-engine rate of climb with a feathered propeller to be 350 feet per minute, and 10 feet per minute with a windmilling propeller.
Probable cause:
The loss of engine power for undetermined reasons, and the pilot's shutdown of the wrong engine, which resulted in a forced landing and collision with trees.
Final Report:

Crash of a Piper PA-31-310 Navajo in Valdez: 4 killed

Date & Time: Jun 25, 1995 at 1557 LT
Type of aircraft:
Operator:
Registration:
N62851
Flight Type:
Survivors:
No
Schedule:
Homer - Valdez
MSN:
31-7612085
YOM:
1976
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
4800
Circumstances:
The pilot received an instrument approach clearance to a non tower airport surrounded by mountainous terrain. Weather conditions on the ground were VFR, and the pilot descended through an overcast. The approach environment was not serviced by any atc radar facility. The pilot declared a missed approach to the appropriate faa flight service station, and was advised to contact ARTCC. ARTCC never received a radio transmission from the pilot. The airplane wreckage was located approximately 6 miles beyond the airport, slightly to the north of the extended runway centerline. Missed approach procedures were for an immediate climb, and then a climbing right turn to reverse direction away from the airport. The missed approach segment began 5.2 DME miles prior to the airport. Minimum descent altitude (MDA) for the approach was 4,320 feet msl (4,200 feet above the runway elevation); impact with mountainous terrain occurred at about the same altitude. All four occupants were killed.
Probable cause:
The pilot's failure to follow the published ifr (missed approach) procedure and assure adequate altitude/clearance from mountainous terrain.
Final Report: