Crash of a Cessna 208B Grand Caravan in Gainesville: 2 killed

Date & Time: Mar 3, 1995 at 1943 LT
Type of aircraft:
Registration:
N227DM
Survivors:
No
Schedule:
Savannah - Gainesville
MSN:
208B-0364
YOM:
1993
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
2005
Captain / Total hours on type:
201.00
Circumstances:
The flight was executing the non-precision NDB runway 04 approach, had reported procedure turn inbound, and was cleared to change to advisory frequency. Witnesses observed the airplane descend out of the base of the overcast clouds in a 10° nose down, 45° left wing down attitude. The airplane impacted terrain about 3/4 mile south-southeast of the airport. Witnesses in the area reported that the weather was ceilings of about 100 feet and visibility of about 500 feet in light rain and fog. The minimum descent altitude for the approach is 465 feet agl. Both pilots were killed.
Probable cause:
The pilots failure to maintain the minimum descent altitude during the approach. The weather and dark night light condition were factors.
Final Report:

Crash of a Cessna 207A Skywagon near Kotzebue: 1 killed

Date & Time: Feb 25, 1995 at 1250 LT
Operator:
Registration:
N6479H
Flight Phase:
Survivors:
No
Site:
Schedule:
Kotzebue - Kivalina
MSN:
207-0539
YOM:
1979
Flight number:
UYA1907
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
1607
Captain / Total hours on type:
333.00
Aircraft flight hours:
8434
Circumstances:
Approximately 10 minutes after departure, the pilot was contacted by a company pilot flying in the opposite direction. During their conversation the pilot stated that he was 'looking for wolves.' Shortly thereafter, the company pilot told the pilot that his radio transmissions were breaking up. The pilot replied that it was probably because he was 'behind a ridge.' The company pilot temporarily went off frequency; however, when he switched back he was unable to contact the pilot. The aircraft was later located on the southwest side of a box canyon about 100 feet below the top of the ridge. The normal course line for the route typically flown by company pilots is 6 miles away. The pilot had no prior experience in mountain flying.
Probable cause:
The pilot's decision to enter a box canyon area at an altitude inadequate to maintain terrain clearance. The pilot's lack of mountain flying experience was a factor in this accident.
Final Report:

Crash of a Douglas DC-8-63CF in Kansas City: 3 killed

Date & Time: Feb 16, 1995 at 2027 LT
Type of aircraft:
Operator:
Registration:
N782AL
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Kansas City - Westover
MSN:
45929
YOM:
1968
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
9741
Captain / Total hours on type:
4483.00
Copilot / Total flying hours:
4460
Copilot / Total hours on type:
218
Aircraft flight hours:
77096
Aircraft flight cycles:
22404
Circumstances:
The airplane crashed immediately after liftoff during a three-engine takeoff. Flightcrew had shortened rest break; rest periods not required for ferry flights. Flight crew fatigue from lack of rest, sleep, and disruption of circadian rhythms. Flightcrew did not have adequate, realistic training in three-engine takeoff techniques or procedures. Flight crew did not adequately understand three-engine takeoff procedures, including significance of vmcg. Flight engineer improperly determined vmcg speed, resulting in value 9 knots too low. During first takeoff attempt, captain applied power to asymmetrical engine too soon, was unable to maintain directional control, and rejected the takeoff. Captain agreed to modify procedure by allowing flight engineer to advance throttle, a deviation of prescribed procedure. FAA oversight of operator was inadequate because the poi and geographic inspectors were unable to effectively monitor domestic crew training and international operations. Existing far part 121 flight time limits & rest requirements that pertained to the flights that the flightcrew flew prior to the ferry flights did not apply to the ferry flights flown under far part 91. Current one-engine inoperative takeoff procedures do not provide adequate rudder availability for correcting directional deviations during the takeoff roll compatible with the achievement of maximum asymmetric thrust at an appropriate speed greater than ground minimum control speed. All three crew members were killed.
Probable cause:
The accident was the consequence of the following factors:
- The loss of directional control by the pilot in command during the takeoff roll, and his decision to continue the takeoff and initiate a rotation below the computed rotation airspeed, resulting in a premature liftoff, further loss of control and collision with the terrain.
- The flightcrew's lack of understanding of the three-engine takeoff procedures, and their decision to modify those procedures.
- The failure of the company to ensure that the flightcrew had adequate experience, training, and rest to conduct the nonroutine flight. Contributing to the accident was the inadequacy of Federal Aviation Administration oversight of air transport international and federal aviation administration flight and duty time regulations that permitted a substantially reduced flightcrew rest period when conducting a non revenue ferry flight under 14 code of federal regulations part 91.
Final Report:

Crash of a Piper PA-46-310P Malibu in Chippewa Falls: 2 killed

Date & Time: Feb 14, 1995 at 2250 LT
Operator:
Registration:
N9YP
Survivors:
Yes
Schedule:
Ithaca - Eau Claire
MSN:
46-08043
YOM:
1986
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
2200
Captain / Total hours on type:
120.00
Aircraft flight hours:
1248
Circumstances:
The single engine airplane departed with two pilots, two passengers, baggage and equipment. At takeoff, the airplane was 955 pounds over the maximum allowable gross weight, and 2 inches beyond the aft c.g. Limit. After 4 hours of flying, the pilot elected to divert to another airport, due to icing conditions. During the descending left turn from base leg to final approach to runway 22, the airplane dropped, struck the ground, and slid 250 feet. The wings were separated from the airplane during the ground slide by two trees. A satisfactory postaccident engine run was completed. The airplane was calculated to be about 600 pounds over the maximum landing weight, and 2 inches beyond the aft c.g. Limit. The air induction lever was in the primary position, and not the required alternate position for icing conditions. The propeller and stall warning heat switches were off. The airplane had been flying in light freezing rain, which the poh stated should be avoided. Severe mixed icing was reported 25 miles northwest of the airport. Winds at the airport were from 150 degrees at 10 knots, gusting to 16 knots. Both pilots were killed and both passengers were seriously injured.
Probable cause:
The pilot's improper decision to depart into known adverse weather conditions, and the subsequent encounter with freezing drizzle, resulting in an inadvertent stall and collision with the terrain during an approach to land. Also causal to the accident was the pilot's failure to adhere to the airplane's weight and balance limitations, resulting in an overweight and out of balance flight condition, and his failure to comply with published procedures for flight into icing conditions.
Final Report:

Crash of a Cessna 414 Chancellor in McGregor

Date & Time: Feb 14, 1995 at 0108 LT
Type of aircraft:
Operator:
Registration:
N4643G
Flight Type:
Survivors:
Yes
Schedule:
Portales - McGregor
MSN:
414-0911
YOM:
1976
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
651
Captain / Total hours on type:
318.00
Aircraft flight hours:
4083
Circumstances:
The pilot was cleared for the VOR runway 17 approach. Field elevation and the minimum descent altitude were 590 and 980 feet respectively. The missed approach point was 10.4 miles outbound from the Waco VOR, which coincided with the runway threshold. The pilot stated that the passenger seated in the right front seat established visual contact with the airport. After confirming that the airport was in sight and the runway environment identified, the pilot continued his descent towards the runway to land on runway 17. The pilot further stated that 'I realized that there would not be adequate runway to safely land, and initiated a right turn to execute a missed approach.' The right wing of the airplane impacted the top of the trees. The FAA inspector at the scene reported that after impacting the trees, the airplane continued through the trees for approximately 400 feet on a track of 344 degrees prior to coming to rest on a heading of 230 degrees.
Probable cause:
The pilot's delayed initiation of the missed approach until well below the minimum descent altitude and beyond the published missed approach point. Factors were the dark night and the low ceiling and visibility.
Final Report:

Crash of a Piper PA-31-350 Navajo Chieftain in Grand Canyon: 8 killed

Date & Time: Feb 13, 1995 at 1536 LT
Operator:
Registration:
N27245
Flight Phase:
Survivors:
Yes
Schedule:
Grand Canyon - Las Vegas
MSN:
31-7752121
YOM:
1977
Flight number:
6G45
Crew on board:
1
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
8
Captain / Total flying hours:
5086
Captain / Total hours on type:
480.00
Aircraft flight hours:
13367
Circumstances:
The charter flight was on a return tour trip after landing at the Grand Canyon National Park Airport. No fueling or maintenance was performed on the airplane while it sat on the ground for three hours. Shortly after takeoff from runway 21, the pilot transmitted that he had a problem and was declaring an emergency. He then stated '...I'm single engine right now....' The airplane was observed to be 100-200 feet above the terrain at the time. It continued flying for about 6 minutes, turning onto a crosswind, downwind, and then a right base leg for runway 21 before colliding with trees about 2.5 miles northeast of the airport. The airport is located in terrain that slopes upward from south to north and west to east. Winds were gusting to 29 knots. The density altitude was 6,870 feet. Examination of the suspect left engine did not reveal any evidence of failures or malfunctions. The investigation revealed deficiencies in the Federal Aviation Administration's oversight of the airline's maintenance program, and in the airline's extension of the time-in-service interval of the engines. The airline's AAIP does not require a maximum rated power check of the engines as required by the engine manufacturer's service instruction. In addition, the TBO of the engines had been extended from 1,800 to 2,400 hours.
Probable cause:
A loss of power on one engine for an undetermined reason(s), and the pilot's improper decision to return to the departure airport for landing which necessitated maneuvering over increasingly higher terrain. Factors in the accident were: the high gusting wind, the high density altitude, the rising terrain, and the reduced single-engine performance capability of the airplane under these conditions.
Final Report:

Crash of a Rockwell Grand Commander 690A in Guthrie: 2 killed

Date & Time: Feb 12, 1995 at 1721 LT
Registration:
N69TM
Flight Type:
Survivors:
No
Schedule:
Wichita - Oklahoma City
MSN:
690-11322
YOM:
1976
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
2870
Circumstances:
The airplane impacted terrain approx 14 miles from the destination during a descent. According to radar data and meteorological information, the airplane descended from 16,700 feet to 3,700 feet agl through clouds and icing conditions. During the descent, the airplane decelerated from 268 kts to 92 kts ground speed. The pilot reported to approach that he 'broke out' of the clouds at 5,400 feet. He subsequently informed approach that he had accumulated 'some clear and rime ice' during the descent. 13 seconds later the pilot made a distress call and stated, 'we're in trouble, we're going down.' The last radar track showed the airplane descending through 3,700 feet at a ground speed of 92 kts. A witness reported he observed that the airplane 'appeared to be doing tricks', and 'then headed straight down in a spin.' An airmet for icing conditions was in effect along the airplane's route of flight. Also, there were several pilot reports of icing encountered in the area of the accident. The pilot did not request a weather briefing prior to, or during the flight.
Probable cause:
The pilot's failure to maintain adequate airspeed due to airframe ice, which resulted in a loss of control. Factors contributing to the accident were the pilot's continued flight into adverse weather, his failure to obtain weather information either before or during the flight, and the icing conditions.
Final Report:

Crash of a Beechcraft B60 Duke near Gatlinburg: 1 killed

Date & Time: Feb 11, 1995 at 1327 LT
Type of aircraft:
Registration:
N6749S
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Knoxville - Knoxville
MSN:
P-519
YOM:
1979
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
1500
Aircraft flight hours:
2488
Circumstances:
The pilot departed Knoxville on a local pleasure flight to the Gatlinburg area. A few minutes into the flight, the pilot requested the ILS approach to Knoxville. About two minutes after the initial request, he requested immediate radar vectors. The controller requested the flight's altitude, but there was no reply from the pilot. The aircraft collided with trees at the 3,500 foot level of rising terrain seven miles southwest of gatlinburg. A hiker reported hearing, the sound of the engines running until the airplane collided with trees. The hiker also stated that clouds obscured the tops of the mountains. Examination of the accident site disclosed that wreckage debris was scattered over an area 650 feet long and 75 feet wide. The wreckage examination failed to disclose a mechanical problem. Sole on board, the pilot was killed.
Probable cause:
The pilot's continued visual flight into instrument weather conditions that resulted in a collision with rising terrain.
Final Report:

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

Date & Time: Feb 9, 1995 at 1821 LT
Operator:
Registration:
N57NW
Flight Type:
Survivors:
No
Site:
Schedule:
Pueblo – Tremonton
MSN:
61-0775-8063388
YOM:
1980
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
4300
Aircraft flight hours:
2100
Circumstances:
The instrument-rated private pilot intended to land at an uncontrolled airport at night. The airport had no instrument approaches. The airplane was flying on an instrument flight rules (IFR) flight plan above an overcast layer of clouds. The pilot informed air traffic control (ATC) that he was going to try to find a 'hole' in the overcast and attempt a visual approach into the uncontrolled airport. The pilot then stated that he could not find a hole; he requested and received an IFR clearance to a larger controlled airport. On his way to the controlled airport, he stated that he found a 'hole' and attempted a visual approach to the uncontrolled airport. He received a cruise clearance from atc for 12,000 feet msl, and then descended at 2,280 feet per minute before impacting mountainous terrain at an elevation of 6,200 feet msl. Instrument meteorological conditions prevailed near the accident site. No distress calls from the airplane were recorded. An examination of the wreckage did not reveal any evidence of preimpact mechanical malfunctions. Both occupants were killed.
Probable cause:
The pilot's attempt to conduct visual flight into instrument meteorological conditions, and his failure to maintain altitude/clearance with the mountainous terrain. Factors were the clouds, and the dark night.
Final Report:

Crash of a Beechcraft E18S in Butte: 1 killed

Date & Time: Jan 26, 1995 at 2230 LT
Type of aircraft:
Operator:
Registration:
N250RP
Flight Type:
Survivors:
No
Schedule:
Seattle - Missoula
MSN:
BA-47
YOM:
1955
Flight number:
MER035
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
14575
Captain / Total hours on type:
2806.00
Aircraft flight hours:
15043
Circumstances:
While performing an ILS approach at night and in IMC, the airplane collided with trees in mountainous terrain prior to the IAF. The MDA prior to the IAF is 10,600 feet. The descent altitude at the outer marker is 7,713 feet. The wreckage was located under the localizer path at an elevation of 7,600 feet. Damage to tree tops along the wreckage distribution path indicates that the airplane travelled through the trees on a level plane until contact with the ground approximately 300 feet into the path. Light snow was falling at the time of the accident and visibility was deteriorating due to fog. During the post crash investigation, there was no evidence found to indicate a mechanical failure or malfunction.
Probable cause:
The pilot's failure to follow the ifr procedure by not maintaining the proper altitude prior to the initial approach fix. Factors to the accident were dark night conditions and a low ceiling.
Final Report: