Crash of a Piper PA-31-325 Navajo C/R in Palm Beach: 2 killed

Date & Time: Jun 24, 1994 at 0905 LT
Type of aircraft:
Registration:
N27872
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Palm Beach - Palm Beach
MSN:
31-7912031
YOM:
1979
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
1000
Captain / Total hours on type:
3.00
Circumstances:
The airplane was observed to rotate about 3,217 feet down the 3,746-feet runway. One or both engines were heard running rough. The airplane climbed to about 300 feet agl, banked left, pitched nose down and impacted the ground. During the investigation, the left engine operated to full rated rpm after replacement of the damaged ignition harness, adjustment of the turbocharger density controller, and adjustment of the magneto-to-engine timing. The right engine also operated normally after replacement of the magneto, ignition harness, and engine-driven fuel pump. The density controller required adjustment to obtain full rated rpm. The #3 cylinder fuel injector nozzle was also partially blocked by contaminant. The right engine magneto contact assemblies operationally checked ok. The capacitors were heat damaged. Right engine magneto-to-engine timing and internal timing of the magneto were not determined. Pilot's toxicological results were positive for butalbital (1.768 ug/ml blood, 0.553 ug/ml urine), and also positive for acetaminophen and salicylate (aspirin) in urine. Butalbital is a prescription medication (barbiturate) not approved for flying. Both occupants were killed.
Probable cause:
The pilot's impairment of judgment and performance due to drugs, his failure to abort the takeoff after experiencing reduced takeoff performance, and his failure to maintain minimum control speed. Factors in the accident were: a partial loss of engine power due to improper magneto-to-engine timing, and a partially blocked fuel nozzle.
Final Report:

Crash of a De Havilland DHC-3 Otter off Taku Lodge: 7 killed

Date & Time: Jun 23, 1994 at 2015 LT
Type of aircraft:
Operator:
Registration:
N13GA
Flight Phase:
Survivors:
Yes
Schedule:
Taku Lodge - Juneau
MSN:
179
YOM:
1956
Crew on board:
1
Crew fatalities:
Pax on board:
10
Pax fatalities:
Other fatalities:
Total fatalities:
7
Captain / Total flying hours:
12000
Captain / Total hours on type:
400.00
Aircraft flight hours:
7672
Circumstances:
Five aircraft departed a lodge, one behind the other. Fog and drizzle were encountered, and the pilot of the first aircraft radioed to the pilots of the other aircraft to cross the river to the east shoreline. A passenger in the fourth aircraft (N13GA) stated that when the aircraft was over the middle of the river, she could not see either shore due to fog. The pilot of N13GA (a floatplane) stated that he encountered deteriorating weather and started a descent, intending to make a precautionary landing. He began to level, expecting conditions to improve. Subsequently, the floatplane hit the surface of 'glassy water' and crashed. Seven passengers were killed and four other occupants were seriously injured. The aircraft was destroyed.
Probable cause:
VFR flight by the pilot into instrument meteorological conditions (IMC), and his failure to maintain altitude (clearance) above the surface of the river. Factors related to the accident were: the adverse weather conditions, and the surface condition of the river (glassy water).
Final Report:

Crash of a Learjet 25D in Washington DC: 12 killed

Date & Time: Jun 18, 1994 at 0625 LT
Type of aircraft:
Operator:
Registration:
XA-BBA
Survivors:
No
Schedule:
Mexico City – New Orleans – Washington DC
MSN:
25-223
YOM:
1977
Crew on board:
2
Crew fatalities:
Pax on board:
10
Pax fatalities:
Other fatalities:
Total fatalities:
12
Captain / Total flying hours:
1706
Captain / Total hours on type:
1314.00
Copilot / Total flying hours:
852
Copilot / Total hours on type:
426
Aircraft flight hours:
6118
Aircraft flight cycles:
5663
Circumstances:
The airplane crashed 0.8 nm south of the threshold of the runway during an ILS approach in instrument meteorological conditions. The captain was not authorized to attempt the approach and was relatively inexperienced for an approach under the weather conditions. The captain failed to adhere to acceptable standards of airmanship during two unstabilized approaches. After the unsuccessful ils approach to runway 01R, the captain should have held for improvements in the weather, requested the runway 19L ILS, or proceeded to his alternate. An operating gpws aboard the airplane would have provided continuous warning to the crew for the last 64 seconds of flight and might have prevented the accident. All 10 passengers were Mexican citizens flying to Washington DC to assist a game of the World Football Championship.
Probable cause:
Poor decision making, poor airmanship, and relative inexperience of the captain in initiating and continuing an unstabilized instrument approach that led to a descent below the authorized altitude without visual contact with the runway environment. Contributing to the cause of the accident was the lack of a GPWS on the airplane.
Final Report:

Crash of a Cessna 421C Golden Eagle III in Carlsbad: 2 killed

Date & Time: Jun 15, 1994 at 1434 LT
Registration:
N421AG
Flight Phase:
Survivors:
Yes
Schedule:
Carlsbad - Las Vegas
MSN:
421C-0843
YOM:
1980
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
3340
Captain / Total hours on type:
1240.00
Aircraft flight hours:
2943
Circumstances:
About 2 minutes after takeoff, the pilot declared an emergency, stating that he had lost an engine and needed to return to the airport. The airplane descended into rough, brush-covered terrain and then struck a large dirt berm, about 1-1/2 miles northeast of the departure airport. Examination of the engines did not reveal any obvious mechanical malfunction. The fuel was correct. Combustion chamber signatures indicated that the engines were operated at a lean or mild detonation condition. The flaps were extended about 30 degrees and the landing gear was retracted. The surviving passenger could not recall any dramatic engine problems, only that the airplane could not maintain altitude. The pilot and front seat passenger were not wearing shoulder harnesses.
Probable cause:
A loss of engine power for undetermined reasons. The pilot's failure to raise the flaps and maintain altitude were factors in the accident.
Final Report:

Crash of a Cessna T207A Skywagon in Banning: 2 killed

Date & Time: Jun 9, 1994 at 1630 LT
Registration:
N6383H
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Burbank - San Diego
MSN:
207-0504
YOM:
1979
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
5032
Captain / Total hours on type:
1160.00
Circumstances:
The PA-28, N4512Z, was westbound in level flight about 1,000 feet agl, about 2 miles north of an airport at which an intermediate stop was planned. The Cessna T207A, N6383H, was maneuvering in left turns while conducting aerial photography, and had just initiated a turn toward the east. The left wings of each aircraft were struck by the other airplane. Witnesses indicated that about 2 seconds before impact, the PA-28 attempted to avoid a collision by beginning a climbing right turn. Each aircraft continued past the other and then both spiraled to the ground. The weather conditions were clear, visibility 3 miles in haze. Neither airplane was in radar or voice contact with any FAA facility. All three occupants in both aircraft were killed.
Probable cause:
The failure of both pilots to see and avoid each other. The haze was a factor.
Final Report:

Crash of a BAe 125-3A in Waukegan

Date & Time: May 30, 1994 at 1842 LT
Type of aircraft:
Registration:
N900CD
Flight Type:
Survivors:
Yes
Schedule:
Wheeling - Waukegan
MSN:
25111
YOM:
1966
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
10000
Captain / Total hours on type:
950.00
Circumstances:
The corporate jet's sink rate increased during short final approach. The copilot applied elevator back pressure and nose up trim. The sink rate continued to increase. The captain observed the copilot's efforts and began applying back pressure on his control yoke. Through combined efforts of both pilots they were able to increase the pitch enough that the airplane touched down on the main gear first. However, the touchdown was hard. The on-scene investigation revealed that a trip manifest container was lodged between the copilot's control yoke column and seat frame. The pilots stated the container is required to be carried in the cockpit during lights. Both pilots said there is no designated space in the cockpit to retain the container.
Probable cause:
The pilot-in-command disregarding the location of the flight manifest container in the cockpit. Factor's associated with the accident were a jammed control column and inadequate procedures for the use and storage of the flight manifest container on the part of company management.
Final Report:

Crash of a Rockwell Aero Commander 500A near Livermore: 4 killed

Date & Time: May 19, 1994 at 1754 LT
Registration:
N601MK
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Hayward - Hayward
MSN:
500-1073-47
YOM:
1961
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
23700
Circumstances:
The aircraft had not flown for 2 years. Before flight, a mechanic saw evidence of fuel leaking at drain holes in the left wing root, just aft of the main cabin door. He brought this to the attention of the pilotrated passenger, who shortly thereafter, departed in the aircraft with the pilot (pic), the aircraft owner and a passenger/mechanic. About 14 minutes after takeoff, radar data showed the aircraft transitioning from a climb to a descent, while in a 180°turn. Also, witnesses saw smoke/flames trailing from the aircraft. Subsequently, the aircraft impacted trees and power lines, then it crashed in a small flat field in hilly terrain. Post-crash examination revealed melted aluminum spatters on the leading edge and underside of the left horizontal stabilizer. Also, 'focalized' fire damage was noted on the cabin behind the drain holes in the left wing root. Tetrahydrocannabinol carboxylic acid (marijuana) was detected in the pilot-rated passenger's blood (0.004 ug/ml) and urine (0.010 ug/ml).
Probable cause:
A fuel system leak, inadequate preflight by the pilot (pic), and by the non-flying pilot/passenger intentionally allowing operation of the aircraft with a known deficiency (fuel leak). A factor related to the accident was: the lack of suitable terrain for a forced landing.
Final Report:

Crash of a Cessna 340 near Elko: 2 killed

Date & Time: May 18, 1994 at 1551 LT
Type of aircraft:
Operator:
Registration:
N5158J
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Las Vegas – Elko
MSN:
340-0548
YOM:
1975
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
2864
Captain / Total hours on type:
2.00
Aircraft flight hours:
1769
Circumstances:
The non-instrument rated pilot obtained an abbreviated weather briefing for a flight from Las Vegas to Elko, Nevada. He was advised of mountain obscuration, icing and turbulence, and was told that VFR flight was not recommended. A VFR flight plan was filed and activated. The airplane departed Las Vegas at 1414 pdt. The last radio communications with the plane was at 1545 pdt, about 14 miles south of Elko. Several local residents reported a thunderstorm was passing through the area at that time. The airplane was located the next morning about 10 miles southwest of Elko Airport near Grindstone Peak at about 6,000 feet msl. An exam of the airframe and engine at the accident site did not disclose any mechanical problems. During a toxicology test, 4.8 mg/kg of diphenhydramine (an antihistamine) was detected in the pilot's liver tissue. Both occupants were killed.
Probable cause:
The pilot's continued flight into instrument meteorological conditions (IMC), and his failure to maintain altitude (or clearance) from mountainous terrain. Factors related to the accident were: the adverse weather conditions, high (mountainous/hilly) terrain, and the pilot's lack of instrument experience.
Final Report:

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

Date & Time: Apr 27, 1994 at 2256 LT
Operator:
Registration:
N990RA
Survivors:
Yes
Schedule:
Atlantic City - Stratford
MSN:
31-7405417
YOM:
1974
Crew on board:
1
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
8
Captain / Total flying hours:
3500
Captain / Total hours on type:
527.00
Circumstances:
The captain had ILS glideslope data available during the approach but did not fly the ILS glideslope. The partial obscuration of the airport environment, due to ground fog, contributed to the captain's failure to recognize that the airplane was high on both his approach and landing. The destruction of the airplane and the resulting occupant injuries were a direct result of the collision with the blast fence. FAA interaction and communication with local communities, although persistent, were unsuccessful in gaining support for runway safety area improvements and for the installation of approach lighting for runway 6. The passenger seats had been improperly assembled using unapproved parts, and seat belts had been installed incorrectly.
Probable cause:
The failure of the captain to use the available ILS glideslope, his failure to execute a go-around when conditions were not suitable for landing, and his failure to land the airplane at a point
sufficient to allow for a safe stopping distance; the fatalities were caused by the presence of the non frangible blast fence and the absence of a safety area at the end of the runway.
Final Report:

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

Date & Time: Apr 7, 1994 at 0810 LT
Operator:
Registration:
N64LB
Flight Type:
Survivors:
No
Schedule:
Augusta - Elizabethton
MSN:
31-7852127
YOM:
1978
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
7800
Aircraft flight hours:
2910
Circumstances:
The ATP and his passenger were en route to pick up a patient for transport to a VA hospital. The destination airport was uncontrolled, and VFR only. The pilot cancelled with ATC and reported the field in sight. The airport was reporting VFR conditions, but rising, mountainous terrain existed to the northeast, and local authorities reported that the top third of the mountain was obscured in clouds during the morning of the accident. After cancelling IFR, no subsequent radio calls were received from the flight, and the flight did not arrive at its destination. The wreckage was found several hours later near the crest of holston mountain, 1/2 mile east of the Holston mountain VOR. An examination of the wreckage indicated the aircraft impacted upsloping, wooded terrain, while at a climb angle of 8°. Disintegration of the wreckage was indicative of a high speed impact. No evidence of mechanical malfunction or failure was found during the examination of the wreckage. Both occupants were killed.
Probable cause:
The pilot's attempted VFR flight into imc conditions, and his failure to maintain a proper altitude over mountainous terrain. Factors were the clouds and obscuration at the accident site.
Final Report: