Crash of a Beechcraft 60 Duke in Cheyenne: 1 killed

Date & Time: Apr 21, 1995 at 1016 LT
Type of aircraft:
Registration:
N711PS
Flight Type:
Survivors:
No
Schedule:
Cheyenne – Colorado Springs
MSN:
P-4
YOM:
1968
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
683
Captain / Total hours on type:
143.00
Aircraft flight hours:
3462
Circumstances:
Shortly after takeoff, the pilot reported he had 'a problem...an overboost situation,' and wanted to return for landing. Instrument meteorological conditions prevailed, so the pilot was cleared for the ILS runway 26 approach. A witness saw the airplane emerge from the low overcast in a wings level descent, then pitch over to a near vertical attitude and impact a shopping center sign. The left turbocharger wastegate was found in the open (low boost) position, and the right turbocharger wastegate was found in the closed (high boost) position. The right turbocharger butterfly valve was severely eroded, the pin was missing, and the valve was free to rotate on the shaft. A hole was burnt through the right engine number 1 cylinder exhaust valve. Both propellers were in the low pitch-high rpm range. Both engines and turbochargers were original equipment and had not been overhauled in 21 years. A toxicology test showed 0.564 mcg/ml of sertraline (antidepressant) in the pilot's blood. Sertraline was not approved for use while flying an aircraft.
Probable cause:
The pilot's failure to maintain aircraft control. Factors were the instrument weather conditions and the excessive workload imposed on the solo pilot attempting to deal with an emergency situation while flying in instrument meteorological conditions.
Final Report:

Crash of a Learjet C-21A in Alexander City: 8 killed

Date & Time: Apr 17, 1995 at 1820 LT
Type of aircraft:
Operator:
Registration:
84-0136
Flight Type:
Survivors:
No
Schedule:
Randolph – Wright-Patterson – Andrews – Randolph
MSN:
35-583
YOM:
1985
Flight number:
Kiowa 71
Crew on board:
2
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
8
Captain / Total flying hours:
1074
Captain / Total hours on type:
877.00
Copilot / Total flying hours:
2242
Copilot / Total hours on type:
547
Circumstances:
The C-21A, a USAF designation of the Learjet 35A was assigned to the 332nd Airlift Flight at Randolph AFB, Texas. The aircraft would depart Randolph AFB as flight Kiowa 71 to Wright-Patterson AFB, Andrews AFB and then back to Randolph. The aircraft was landed at Andrews AFB at 10:57. The crew requested a full load of fuel and told Serv-Air maintenance technicians that they had been unable to transfer fuel from the wing tanks to the fuselage tank. A Serv-Air maintenance technician removed the fuel-control panel from the aircraft and replaced the fuselage-tank transfer/fill switch. The maintenance technician told the crew that replacement of the fuselage-tank switch had not corrected the problem and that he was going to try to correct the problem by replacing the fuel-control relay panel. This was a time consuming job. The crew decided to continue back to Randolph without the repairs. The fuselage fuel tank was full and they had not had trouble earlier in the day getting fuel out of the fuselage tank. The aircraft departed from Andrews AFB at 16:38. The aircraft was in cruise flight at FL390 at 17:53 when the crew began to transfer fuel from the fuselage tank to the wing tanks. The crew did not know that the right standby fuel pump was operating and was preventing fuel from being transferred from the fuselage tank to the right wing. Bearings in the right standby pump were in a deteriorated condition and the pump had required higher-than-normal electrical current for rotation. The higher-than-normal electrical current had caused progressive damage to two contacts in the fuel control relay panel and eventually had caused the contacts to bond together. This caused the pump to run continuously throughout the flight and to prevent fuel transfer from the fuselage tank to the right wing. The aircrew noticed that the left wing-tip tank had become 800 pounds [363 kilograms] heavier than the right wing-tip tank during the transfer, and they attempted to analyse the malfunction and correct the imbalance. A fuel-imbalance during-fuel-transfer malfunction however was not included in the Air Force training syllabus, nor was the procedure contained in the C-21A checklist. At 17:56, the copilot told the Atlanta Air Route Traffic Control Center (Atlanta Center) controller, "Sir, we need to revise our flight plan. We’re having a problem getting some fuel out of one of our wings. Can we get vectors to Maxwell Air Force Base? And we’re going to need to dump fuel for about five minutes." The crew at 18:00 began to dump fuel from the left wing-tip tank. However, they still had an imbalance in the wing tanks themselves of about 200 pounds (91 kilograms). At 18:03 the flight was cleared to descend from FL350. The crew then observed that fuel quantity was decreasing rapidly in the right wing tank, that the left wing tank was full and that the left wing-tip tank had begun to fill with fuel. At 18:07, the copilot told the Atlanta Center controller, "Sir, we’d like to declare an emergency at this time for a fuel problem and, ah, get to Maxwell quick as we can." They were cleared direct to Maxwell AFB and cleared to descend to 17,000 feet, and later to 11,000 feet. At 18:15, the copilot told Atlanta Center, "We need to change the airfield, to get to the closest piece of pavement we can land on." The controller said, "Kiowa 71, we got an airport at 12 o’clock and 12 miles. It’s Alexander City." The crew accepted this and began their emergency descent into Alexander City airport. At 18:16 the copilot took over control since the captain did not have the airfield in sight and the copilot did. The aircraft was northeast of the airport at 8,800 feet and was descending at 5,600 feet per minute with the wing-lift spoilers extended when the copilot told Atlanta Center that they were on a left base for the runway. The crew attempted to fly a visual traffic pattern to runway 18 but were in a poor position to complete the approach and landing. They subsequently elected to enter a left downwind leg for runway 36. As airspeed was reduced, aileron authority diminished and, because of the fuel imbalance, the aircraft became difficult to control. The copilot, flying from the right seat, did not have a good view of the runway and asked the aircraft commander for help in positioning the aircraft on downwind and in beginning the turn toward the runway. The captain wanted to get the gear down but the copilot had difficult controlling the plane already: "Don’t put anything down," the copilot said. "Nothing down, nothing down." The aircraft was at 2,030 feet when the gear-warning horn sounded. The captain said, "Gear down. Gear down." The copilot said, "No. Stand by. Stand by." "Gear down," the captain said. "Gear down, man." "No, not yet, not yet," the copilot said. The copilot then asked the aircraft commander to "push the power up a little bit for me." Power was increased and the gear was extended. The aircraft was at about 1,500 feet and was one mile southwest of the runway at 18:19 when the copilot began a left turn. Approximately halfway through the final turn and one mile due south of runway 36, the aircraft abruptly rolled out, flew through the extended runway centerline and continued in an east, northeasterly direction approximately 800 feet above the ground. The copilot had rolled out of the turn to regain lateral control of the aircraft. At this time the right engine was operating at a reduced thrust setting in an attempt to counteract the effects of the fuel imbalance. The captain, to center the ball in the slip indicator, applied pressure on the left rudder, against pressure that was being applied on the right rudder by the copilot. The captain said, "Step on the rudder. Step on the rudder." The copilot said, "Paul, no. Paul, don’t." The application of left rudder caused the aircraft to roll left rapidly. It rolled inverted entered the trees and struck the ground.
Probable cause:
The investigating officer found that the mechanical malfunction consisted of the right standby [fuel] pump continuing to operate uncommanded after engine start. This malfunction resulted in fuel being pumped into the left wing and prevented fuel from being transferred to the right wing during normal transfer procedures. This condition caused a fuel imbalance. The Air Force, for whatever reason, did not contract for flight-manual updates from Learjet following purchase of the airplane in 1984. The "fuel imbalance during fuel transfer" emergency procedure was included in civilian Learjet flight-manual updates published by subsequent to 1984. As a result, the Air Force training syllabus likewise did not include this emergency procedure. Because the crew did not have checklist or flight-manual guidance on this problem, the crew misanalysed the malfunction. They failed to correct the fuel imbalance as a result, allowed their airspeed to become too slow for the aircraft’s configuration when attempting to land and then made control inputs that caused the aircraft to enter a flight regime from which they could not recover.

Crash of a Douglas C-54G-5-DO Skymaster in Kivalina

Date & Time: Apr 17, 1995 at 1300 LT
Type of aircraft:
Operator:
Registration:
N898AL
Flight Type:
Survivors:
Yes
Schedule:
Galena - Kivalina
MSN:
35986
YOM:
1945
Location:
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3500
Captain / Total hours on type:
2000.00
Circumstances:
The four engine transport category airplane was carrying a load of fuel oil for distribution to the village of kivalina. The pilot reported he flew over the 3,000 feet long by 60 feet wide strip prior to landing, and noted in the center of the runway some gravel was visible through a layer of surrounding snow. He said he could not see any snow banks or deeper snow in the landing area, and available notices to airmen did not mention any snow banks or snow berms on the runway. The pilot said the airplane landed near the threshold and on the centerline, but, the left main landing gear soon encountered a snow berm and the airplane was pulled to the left. The airplane subsequently impacted other snow berms on the left side of the runway and the nose landing gear collapsed. The U.S. Government's supplement for Alaska airports, for the Kivalina Airport, states, in part: unattended. Caution: runway condition not monitored, recommend visual inspection prior to using.
Probable cause:
The pilot's failure to identify a hazardous landing area. Factors in the accident are the presence of snow banks/berms on the runway, and the inadequate snow removal by airport personnel.

Crash of a Piper PA-60P Aerostar (Ted Smith 602P) in Danbury: 1 killed

Date & Time: Apr 12, 1995 at 1327 LT
Registration:
N602PC
Flight Type:
Survivors:
Yes
Schedule:
Washington DC – Danbury
MSN:
62-0861-8165002
YOM:
1981
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
1486
Captain / Total hours on type:
481.00
Aircraft flight hours:
3253
Circumstances:
After making a localizer runway 08 approach, the pilot landed over halfway down the 4,422 feet wet runway. He then decided to abort the landing, added power, and when airborne, retracted the landing gear. He said he asked the right front seat (non-rated) passenger to reset the flaps (to 20°). The pilot saw trees ahead, and realized the airplane was not going to clear the obstacles, though full power was applied. Just before impact, he pulled back on the elevator control to soften the impact, rather than hitting the trees nose first. After the accident, the wing flaps were found in the retracted position. A passenger was killed and three other occupants were seriously injured.
Probable cause:
The pilot's delay in initiating a go-around (aborted landing) and failure to assure that the flaps were properly reset for the go-around. Factors relating to the accident were: the pilot's failure to achieve the proper touchdown point for landing, the wet runway condition, and the proximity of tree(s) to the runway.
Final Report:

Crash of a Beechcraft 65-B80 Queen Air in Great Bend: 1 killed

Date & Time: Apr 12, 1995 at 0843 LT
Type of aircraft:
Registration:
N7057J
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Sioux Falls - Fargo
MSN:
LD-291
YOM:
1966
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
6100
Captain / Total hours on type:
250.00
Aircraft flight hours:
6887
Circumstances:
The airplane was cruising at 6,000 feet where it encountered icing conditions. When cleared to 3,600 feet, the pilot reported that one engine lost all power and the other one was running rough. The airplane continued the descent. After about ten minutes the airplane departed controlled flight, reversing heading and impacting near vertically in the terrain. A post accident examination of the left engine (which was feathered) found an induction duct which had deteriorated and begun to come apart. Foreign object material in the compressor assembly similar in appearance to material from the duct was found. The number five piston had a hole burned through it.
Probable cause:
The pilot/mechanic's inadequate maintenance (inspection) of aircraft and the pilot's failure to maintain airspeed (VMC). Factors were icing conditions, deteriorated induction air ducting, and failure of a piston assembly.
Final Report:

Crash of a Cessna 208B Super Cargomaster in Reno: 1 killed

Date & Time: Mar 22, 1995 at 0812 LT
Type of aircraft:
Operator:
Registration:
N9417B
Flight Type:
Survivors:
No
Schedule:
Sacramento - Reno
MSN:
208B-0065
YOM:
1987
Flight number:
UNF9840
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
4388
Captain / Total hours on type:
200.00
Aircraft flight hours:
4959
Circumstances:
Approaching Reno, the pilot received an instrument clearance to perform a Localizer DME-1, Rwy 16R, approach, which the FAA had previously approved for the operator's use. The localizer centerline passed over a 6,161-foot msl mountain, which was depicted on the chart. The pilot was familiar with the area, having transported cargo from Sacramento to Reno for 5 days each week since December, 1994. IMC existed and light snow showers were present. ATC issued the pilot a series of instructions as he was radar vectored toward the final approach fix (FAF), which had a minimum crossing altitude of 6,700 feet msl. The pilot misstated four of the instructions during clearance readbacks and was corrected by ATC each time. Contact with the pilot was lost following issuance of his landing clearance. The airplane impacted the mountainside at an elevation of about 6,050 feet, while tracking inbound near the centerline of the localizer course, about 2.7 nautical miles before reaching the FAF. The airframe, engine, and avionics equipment were examined. No mechanical malfunctions were found.
Probable cause:
The pilot's failure to comply with published instrument approach procedures by a premature descent below the minimum altitude specified for the approach.
Final Report:

Crash of a Cessna 207A Skywagon in Bethel

Date & Time: Mar 20, 1995 at 1155 LT
Operator:
Registration:
N1719U
Flight Phase:
Survivors:
Yes
Schedule:
Bethel - Kalskag
MSN:
207-0319
YOM:
1976
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
1434
Captain / Total hours on type:
158.00
Aircraft flight hours:
11868
Circumstances:
After receiving a special VFR (SVFR) clearance, the pilot departed the airport with a passenger on a scheduled commuter flight to a remote airport. About 14 miles north of the airport, at 1,000 feet mean sea level (msl), the pilot encountered whiteout conditions and reversed course, descending to about 500 feet msl. The pilot requested a SVFR arrival back to the departure airport and began maneuvering to intercept the inbound course. While in instrument meteorological conditions, the airplane descended and collided with flat, snow covered terrain about 5 mile north of the airport. The pilot was unable to distinguish any terrain features until impact with the ground.
Probable cause:
The pilot's continued VFR flight into imc conditions and a failure to maintain altitude. A factor in the accident was 'whiteout' weather conditions.
Final Report:

Crash of a Piper PA-46-310P Malibu in Cambridge: 1 killed

Date & Time: Mar 15, 1995 at 0512 LT
Operator:
Registration:
N166CP
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Cambridge - Baltimore
MSN:
46-8408024
YOM:
1984
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
9600
Aircraft flight hours:
6089
Circumstances:
The airplane collided with trees shortly after takeoff and came to rest in a church yard. There were no witnesses to the crash; however, several local residents heard the airplane overfly their homes at a low altitude. One resident stated that he heard the airplane collide with the trees. Another resident stated that he heard the engine operating as the airplane flew low overhead. Both residents reported that reduced visibility hampered their ability to find the wreckage. One resident estimated that the visibility was about 50 to 60 feet. The prescribed takeoff minimums for that airport is 300 feet and 1 mile visibility. Examination of the airplane did not disclose evidence of mechanical malfunction. The pilot, sole on board, was killed.
Probable cause:
The commercial/instrument rated pilot's failure to obtain/maintain adequate altitude/clearance during the initial climb after takeoff. Related factors are the pilot's poor planning/decision making, and the fog.
Final Report:

Crash of a Cessna T207A Turbo Stationair 8 in Ketchikan

Date & Time: Mar 10, 1995 at 0745 LT
Registration:
N6478H
Flight Phase:
Survivors:
Yes
Schedule:
Ketchikan - Wrangell
MSN:
207-0538
YOM:
1979
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
1352
Captain / Total hours on type:
750.00
Aircraft flight hours:
16116
Circumstances:
Prior to departing on a scheduled air taxi flight with two passengers, the pilot obtained a weather briefing that included airmets for mountain obscuration, IFR and icing conditions. VFR flight was not recommended. A company flight that departed before the accident flight, returned to the company base due to low ceilings, after the accident flight departed. The flight departed on a VFR flight plan and encountered low ceilings in the area of mountainous terrain. The pilot began maneuvering around the terrain and during a period of obscuration, collided with several trees. The company operations manual specifies that the pilot is responsible for the conduct of the flight; however, procedures are included that detail the dispatch responsibilities, dissemination of weather information, and the director of operations responsibility to monitor and cancel flights if necessary.
Probable cause:
The pilot's continued visual flight rules (VFR) flight into instrument meteorological conditions (IMC). Factors in the accident were fog and low ceilings, and a failure of the operator to follow their procedures specified in the company operations manual.
Final Report:

Crash of a Cessna 421C Golden Eagle III near Taos: 4 killed

Date & Time: Mar 5, 1995 at 1355 LT
Registration:
N421BL
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Oklahoma City - Taos
MSN:
421C-0605
YOM:
1979
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
809
Captain / Total hours on type:
195.00
Circumstances:
The pilot obtained a weather briefing for the IFR flight to Taos, New Mexico, and was advised of forecast conditions for light to moderate rime icing and moderate turbulence at his destination. During descent, about 30 nm east of the Taos VOR, at 15,200 feet, the pilot reported 'light rime icing' and 3 minutes later 'freezing rain.' The airplane was cleared for the VOR DME-B approach to the Taos Airport, and radar services were terminated. The airplane impacted the ground in a steep nose down attitude 7 nm southeast of the VOR and 1 nm right of the inbound approach course. Weather data indicated that the airplane entered clouds about 6 nm east of where 'light rime' was reported and remained in the clouds until it descended below 10,000 feet. Meteorological investigation indicated that the freezing level was about 10,700 feet. Radar data revealed cyclic variations in the airplane's ground speed from 120 to 190 knots, as it crossed the high mountain range east of taos. There was a pirep of severe turbulence on the eastern slope of the mountain range. All four occupants were killed.
Probable cause:
The pilot's decision to continue flight into known adverse weather conditions and the ensuing inadvertent stall due to airframe ice. Factors were the weather conditions.
Final Report: