Crash of a De Havilland DHC-2 Beaver in Miners Point: 6 killed

Date & Time: Aug 7, 1994 at 1355 LT
Type of aircraft:
Registration:
N126UA
Flight Phase:
Survivors:
Yes
Schedule:
Kodiak - Karluk Lake
MSN:
1400
YOM:
1959
Crew on board:
1
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
6
Captain / Total flying hours:
1023
Captain / Total hours on type:
139.00
Aircraft flight hours:
22159
Circumstances:
The VFR only part 135 on demand sightseeing flight entered instrument meteorological conditions and collided with terrain. The surviving passenger reported that as the flight progressed, the ceiling and visibility deteriorated. Witnesses in the area reported heavy fog and estimated the ceiling and visibility to be 50 feet and one-fourth of a mile. The company's training program and operations policies and procedures did not address VFR flight in marginal weather conditions. A passenger survived while six other occupants were killed, among them three Dutch and two Swiss citizens.
Probable cause:
The pilot of the VFR only flight intentionally entered instrument meteorological conditions. Factors in the accident were the inadequate procedures/directives by the company/operator management concerning continued VFR flight in marginal weather conditions and the fog.
Final Report:

Crash of a Beechcraft A100 King Air in North Adams: 1 killed

Date & Time: Aug 4, 1994 at 1605 LT
Type of aircraft:
Registration:
N7GA
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
North Adams – White Plains
MSN:
B-119
YOM:
1972
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
10200
Captain / Total hours on type:
106.00
Aircraft flight hours:
10426
Circumstances:
The airplane had undergone routine maintenance for slow acceleration on the right engine. Maintenance records revealed the fuel controls were changed from the right engine to the left engine. The airplane was released back to the pilot for service, and he departed for his home station. Several witnesses saw the airplane after takeoff at a low altitude, and at a slow speed. The airplane turned left, and the left wing struck the ground. Two witnesses saw the airplane pass by them at a low altitude, and wrote, '...at this point we could see the left (port) engine propeller was turning very slowly. You could actually see the individual blades of the propeller turning.' A complete disassembly of both engines, revealed no discrepancies other than impact, and post impact fire damage. Disassembly of the left propeller indicated that the propeller blades were at or near feather at impact. The pilot had a total of 106 flight hours in Beech A100 aircraft, all in the 90 days prior to the accident, and 56 hours in the 30 days prior to the accident.
Probable cause:
The pilot's failure to maintain minimum control speed after an undetermined loss of engine power, which resulted in an inadvertent stall at too low of an altitude to allow recovery.
Final Report:

Crash of a Lockheed P-2V Neptune near Missoula: 2 killed

Date & Time: Jul 29, 1994 at 1600 LT
Type of aircraft:
Operator:
Registration:
N918AP
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Missoula - Missoula
MSN:
726-7186
YOM:
1958
Flight number:
Tanker 04
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
The aircraft departed Missoula on a fire fighting mission under callsign Tanker 04. The crew apparently became fixated on the malfunction of the retardant-release doors and did not realize the tanker was entering a narrow box canyon when it struck the slope of Mt Squaw located about 20 miles northwest of Missoula Airport. The aircraft was destroyed and both pilots were killed.

Crash of a Cessna 414 Chancellor in Taft: 1 killed

Date & Time: Jul 19, 1994 at 1420 LT
Type of aircraft:
Registration:
N414RH
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Taft - Fresno
MSN:
414-0457
YOM:
1974
Location:
Crew on board:
3
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
10000
Aircraft flight hours:
3739
Circumstances:
The emergency medical service (EMS/medevac) flight was dispatched to transport a patient in response to a medical emergency. During arrival to the destination, the pilot contacted the airport unicom for advisories and was advised to land on runway 25. Runway 25 had a 2.2 percent uphill grade and was restricted to landings only. After landing, the airplane was refueled and the patient was put on board. The pilot back-taxied on runway 25 and proceeded to take off uphill with the airplane near its maximum gross weight. According to ground witnesses, there was a tailwind, which they estimated was between 4 and 15 knots. The temperature was about 100 degrees, and the density altitude was about 3,200 feet. After the airplane became airborne, the pilot started an immediate left turn to avoid rising terrain. However, the left tip tank contacted the ground, and the airplane cartwheeled. It came to rest about 711 feet from the departure end of the runway. The flaps and landing gear were found fully extended; the published configuration for takeoff data in the flight manual was for 'wing flaps - up.' The airport had no signs to indicate runway use restrictions; however, the restrictions were published in the airport facility directory.
Probable cause:
The pilot's inadequate preflight planning/preparation and selection of the wrong runway for takeoff. Factors related to the accident were: the uphill slope of the runway, tailwind, high density altitude, and failure of the pilot to correctly configure the flaps for takeoff.
Final Report:

Crash of a Piper PA-46-350P Malibu Mirage in Lancaster

Date & Time: Jul 13, 1994 at 1415 LT
Registration:
N800CE
Flight Phase:
Survivors:
Yes
Schedule:
Lancaster – Des Moines
MSN:
46-22020
YOM:
1989
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3300
Captain / Total hours on type:
2400.00
Circumstances:
The airplane was on takeoff climb, about 400 feet above the ground, when the engine partially and then totally lost power. The pilot did a forced landing in a bean field. The flight occurred following maintenance to check a low manifold pressure condition. According to the pilot, a 'full' engine runup was done before takeoff. He stated: 'the takeoff was smooth, we rotated at an airspeed of slightly more than 80 knots. The climb for the first 350 (feet of altitude), airspeed was routine... I felt a power loss and noticed the manifold pressure dropping. At this point I felt I had enough power to return to the airport... as the turn was being completed, power went out completely.' The post-accident examination of the airplane did not disclose evidence of mechanical malfunction.
Probable cause:
The loss of engine power for undetermined reasons.
Final Report:

Crash of a Piper PA-60-700P Aerostar in White Plains

Date & Time: Jul 12, 1994 at 0916 LT
Registration:
N323CB
Flight Phase:
Survivors:
Yes
Schedule:
White Plains – Elkhart
MSN:
60-8365-007
YOM:
1983
Crew on board:
2
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
1619
Captain / Total hours on type:
1033.00
Aircraft flight hours:
775
Circumstances:
During an aborted takeoff, the airplane overran the 4,451 foot long runway, went down a hill, and struck a fence. According to the pilot, 'during the takeoff roll, the indicated airspeed needle climbed to approximately 60 knots, but then would go no further... My attempts to dislodge it by tapping on the face of the gauge were futile...I pulled back the throttles and applied full brakes...' The pilot reported that based on the existing conditions 'the airplane can accelerate from rest to rotation speed and back to rest in less than 3,500 feet.' The examination of the airplane revealed the pitot tube was internally obstructed with an insect and mud.
Probable cause:
The pilot's delay in aborting the takeoff. A factor was internal obstruction of the pitot tube.
Final Report:

Crash of a Pilatus PC-6/B1-H2 Turbo Porter in Raeford

Date & Time: Jul 9, 1994 at 1015 LT
Operator:
Registration:
N111FX
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Raeford - Raeford
MSN:
701
YOM:
1969
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3000
Captain / Total hours on type:
108.00
Aircraft flight hours:
9960
Circumstances:
The pilot was performing the initial takeoff, when he observed a loss of power, associated with a torque indication of zero. He force landed the aircraft in a wooded area when he could not make an open field. A post accident inspection of the engine revealed that the fuel control unit arm was loose, and the lock wire was not in place. The arm was positioned so that a maximum power demand from the throttle would correspond to an idle power demand at the fuel control. The engine underwent a 100 hour inspection, by company maintenance personnel, 8 days prior to the accident. The inspection checklist called for examining the fuel control linkage for security.
Probable cause:
The improper inspection of the aircraft by company maintenance personnel, which resulted in an unsafetied and disconnected fuel control arm.
Final Report:

Crash of a Douglas DC-9-31 in Charlotte: 37 killed

Date & Time: Jul 2, 1994 at 1843 LT
Type of aircraft:
Operator:
Registration:
N954VJ
Survivors:
Yes
Site:
Schedule:
Columbia - Charlotte
MSN:
47590
YOM:
1973
Flight number:
US1016
Crew on board:
5
Crew fatalities:
Pax on board:
52
Pax fatalities:
Other fatalities:
Total fatalities:
37
Captain / Total flying hours:
8065
Captain / Total hours on type:
1970.00
Copilot / Total flying hours:
12980
Copilot / Total hours on type:
3180
Aircraft flight hours:
53917
Aircraft flight cycles:
63147
Circumstances:
USAir Flight 1016 was a domestic flight from Columbia (CAE) to Charlotte (CLT). The DC-9 departed the gate on schedule at 18:10. The first officer was performing the duties of the flying pilot. The weather information provided to the flightcrew from USAir dispatch indicated that the conditions at Charlotte were similar to those encountered when the crew had departed there approximately one hour earlier. The only noted exception was the report of scattered thunderstorms in the area. Flight 1016 was airborne at 18:23 for the planned 35 minute flight. At 18:27, the captain of flight 1016 made initial contact with the Charlotte Terminal Radar Approach Control (TRACON) controller and advised that the flight was at 12,000 feet mean sea level (msl). The controller replied "USAir ten sixteen ... expect runway one eight right." Shortly afterward the controller issued a clearance to the flightcrew to descend to 10,000 feet. At 18:29, the first officer commented "there's more rain than I thought there was ... it's startin ...pretty good a minute ago ... now it's held up." On their airborne weather radar the crew observed two cells, one located south and the second located east of the airport. The captain said "looks like that's [rain] setting just off the edge of the airport." One minute later, the captain contacted the controller and said "We're showing uh little buildup here it uh looks like it's sitting on the radial, we'd like to go about five degrees to the left to the ..." The controller replied "How far ahead are you looking ten sixteen?" The captain responded "About fifteen miles." The controller then replied "I'm going to turn you before you get there I'm going to turn you at about five miles northbound." The captain acknowledged the transmission, and, at 18:33, the controller directed the crew to turn the aircraft to a heading of three six zero. One minute later the flightcrew was issued a clearance to descend to 6,000 feet, and shortly thereafter contacted the Final Radar West controller. At 18:35 the Final Radar West controller transmitted "USAir ten sixteen ... maintain four thousand runway one eight right.'' The captain acknowledged the radio transmission and then stated to the first officer "approach brief." The first officer responded "visual back up ILS." Following the first officer's response, the controller issued a clearance to flight 1016 to "...turn ten degrees right descend and maintain two thousand three hundred vectors visual approach runway one eight right.'' At 18:36, the Final Radar West controller radioed flight 1016 and said "I'll tell you what USAir ten sixteen they got some rain just south of the field might be a little bit coming off north just expect the ILS now amend your altitude maintain three thousand." At 18:37, the controller instructed flight 1016 to ''turn right heading zero niner zero." At 18:38, the controller said "USAir ten sixteen turn right heading one seven zero four from SOPHE [the outer marker for runway 18R ILS] ... cross SOPHE at or above three thousand cleared ILS one eight right approach." As they were maneuvering the airplane from the base leg of the visual approach to final, both crew members had visual contact with the airport. The captain then contacted Charlotte Tower. The controller said "USAir ten sixteen ... runway one eight right cleared to land following an F-K one hundred short final, previous arrival reported a smooth ride all the way down the final." The pilot of the Fokker 100 in front also reported a "smooth ride". About 18:36, a special weather observation was recorded, which included: ... measured [cloud] ceiling 4,500 feet broken, visibility 6 miles, thunderstorm, light rain shower, haze, the temperature was 88 degrees Fahrenheit, the dewpoint was 67 degrees Fahrenheit, the wind was from 110 degrees at 16 knots .... This information was not broadcast until 1843; thus, the crew of flight 1016 did not receive the new ATIS. At 18:40, the Tower controller said "USAir ten sixteen the wind is showing one zero zero at one nine." This was followed a short time later by the controller saying "USAir ten sixteen wind now one one zero at two one." Then the Tower controller radioed a wind shear warning "windshear alert northeast boundary wind one nine zero at one three.'' On finals the DC-9 entered an area of rainfall and at 18:41:58, the first officer commented "there's, ooh, ten knots right there." This was followed by the captain saying "OK, you're plus twenty [knots] ... take it around, go to the right." A go around was initiated. The Tower controller noticed Flight 1016 going around "USAir ten sixteen understand you're on the go sir, fly runway heading, climb and maintain three thousand." The first officer initially rotated the airplane to the proper 15 degrees nose-up attitude during the missed approach. However, the thrust was set below the standard go-around EPR limit of 1.93, and the pitch attitude was reduced to 5 degrees nose down before the flightcrew recognized the dangerous situation. When the flaps were in transition from 40 to 15 degrees (about a 12-second cycle), the airplane encountered windshear. Although the DC-9 was equipped with an on-board windshear warning system, it did not activate for unknown reasons. The airplane stalled and impacted the ground at 18:42:35. Investigation revealed that the headwind encountered by flight 1016 during the approach between 18:40:40 and 18:42:00 was between 10 and 20 knots. The initial wind component, a headwind, increased from approximately 30 knots at 18:42:00 to 35 knots at 18:42:15. The maximum calculated headwind occurred at 18:42:17, and was calculated at about 39 knots. The airplane struck the ground after transitioning from a headwind of approximately 35 knots, at 18:42:21, to a tailwind of 26 knots (a change of 61 knots), over a 14 second period.
Probable cause:
The board determines that the probable cause of the accident was:
- The flight crew's decision to continue an approach into severe convective activity that was conducive to a microburst,
- The flight crew's failure to recognize a windshear situation in a timely manner,
- The flight crew's failure to establish and maintain the proper airplane attitude and thrust setting necessary to escape the windshear,
- The lack of real-time adverse weather and windshear hazard information dissemination from air traffic control, all of which led to an encounter with and failure to escape from a microburst-induced windshear that was produced by a rapidly developing thunderstorm located at the approach end of runway 18R.
The following contributing factors were reported:
- The lack of air traffic control procedures that would have required the controller to display and issue ASR-9 radar weather information to the pilots of flight 1016,
- The Charlotte tower supervisor's failure to properly advise and ensure that all controllers were aware of and reporting the reduction in visibility and the RVR value information, and the low level windshear alerts that had occurred in multiple quadrants,
- The inadequate remedial actions by USAir to ensure adherence to standard operating procedures,
- The inadequate software logic in the airplane's windshear warning system that did not provide an alert upon entry into the windshear.
Final Report: