Crash of a Piper PA-31T Cheyenne II in Norwood

Date & Time: Feb 21, 1994 at 1750 LT
Type of aircraft:
Registration:
N777JM
Survivors:
Yes
Schedule:
Bangor - Norwood
MSN:
31-7820064
YOM:
1978
Crew on board:
2
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
14800
Captain / Total hours on type:
2000.00
Aircraft flight hours:
5466
Circumstances:
The flight crew was advised prior to initiating the approach that visibility at the airport had decreased to 1/8 mile with light rain, fog and obscuration. Published landing visibility minimums for the approach was 1 mile. The 150 feet wide runway had been plowed 100 feet wide, and there were snowbanks up to 3 feet high on both sides. The airplane touched down on the unplowed portion of the runway onto a snowbank, collapsing the landing gear. The flightcrew stated that the approach lights and runway were in sight during the entire approach, and that the second pilot told the pic that he was too far left and needed to correct to the right as the airplane was about to touchdown. The tower controller stated that he lost sight of the airplane as it landed due to fog.
Probable cause:
The pilot's failure to attain alignment with the centerline of the runway, and his failure to execute a missed approach. Factors which contributed to the accident were: the dark night, the pilot's improper decision to initiate the approach in below-minimum weather conditions, the adverse weather, and the snow covered runway.
Final Report:

Crash of a Beechcraft G18S in Fort Lauderdale

Date & Time: Feb 16, 1994 at 0921 LT
Type of aircraft:
Registration:
N49K
Flight Type:
Survivors:
Yes
Schedule:
Fort Lauderdale - Freeport
MSN:
BA-519
YOM:
1960
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
8700
Captain / Total hours on type:
5000.00
Aircraft flight hours:
12099
Circumstances:
The pilot stated the left engine backfired and began to run rough shortly after takeoff. The engine was shut down and the propeller was feathered. He decided to return and land on the departure runway. Witnesses observed the aircraft on the downwind leg at 800 to 1,000 feet with the landing gear extended. As the aircraft turned to base leg it yawed sharply to the left and the left wing dropped. The aircraft descended rapidly. The pilot stated that as he turned from base to final leg at 75 to 100 feet the aircraft was buffeting and beginning to stall. He realized he would not make the runway and crash landed in a vacant lot. Examination of the left engine after the accident revealed no evidence to indicate precrash failure or malfunction of the engine.
Probable cause:
The pilot-in-command's improper approach planning and premature extension of the landing gear, resulting in the flight being unable to maintain sufficient altitude and airspeed to reach the runway. The loss of engine power on one engine was a factor.
Final Report:

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

Date & Time: Feb 10, 1994 at 0713 LT
Operator:
Registration:
N741CA
Flight Type:
Survivors:
Yes
Schedule:
San Antonio - Eagle Pass
MSN:
421C-0899
YOM:
1980
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
5100
Captain / Total hours on type:
400.00
Aircraft flight hours:
2916
Circumstances:
Shortly after takeoff, the pilot reported he had 'a problem' and needed to return immediately. Witnesses observed dark black smoke coming from both engines. The airplane collided with a tree 1/2-mile northeast of the runway threshold. Analysis of fuel samples revealed the presence of approximately 50% jet fuel. The right propeller was found feathered and engine disassembly revealed a hole burned in the right engine number 5 piston. Left engine disassembly revealed piston edges eroded down to the first compression ring. Fuel filler restrictors had been installed in the airplane's fuel tanks, but the fuel truck did not have the restrictive mating nozzle. The fuel truck was owned by the fuel vender and leased to the FBO.
Probable cause:
Improper servicing of the airplane with jet fuel, which resulted in preignition and/or detonation and subsequent failure of pistons in both engines. A factor related to the accident was: the lack of a restrictive mating nozzle on the refueling truck.
Final Report:

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

Date & Time: Jan 26, 1994 at 1515 LT
Registration:
N5468G
Survivors:
Yes
Schedule:
Denver - Columbus
MSN:
421C-0215
YOM:
1976
Crew on board:
1
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
2550
Captain / Total hours on type:
66.00
Aircraft flight hours:
5837
Circumstances:
The part 135 on-demand air taxi flight departed Denver, Colorado, with a destination of Columbus, Nebraska. Weather forecasts were for icing conditions along the entire route of flight. While en route, ATC advised the pilot of reported icing ahead. The pilot was cleared to climb to 19,000 feet to get on top of the clouds. The pilot reported 'some alternator problems,' and requested to divert to North Platte, Nebraska. He then elected to divert to McCook, Nebraska, due to the weather at North Platte. ATC lost communication with the pilot during the diversion. Witnesses reported the airplane circled the McCook Airport twice. According to them, the airplane entered a bank of about 45°, then stalled. Subsequently, it traveled about 190 feet through a stand of trees before coming to rest. Witnesses reported the airplane was covered with ice. One-half inch of mixed ice was found on a piece of windshield. Both alternators had one phase in the stator winding shorted.
Probable cause:
Improper in-flight planning/decision by the pilot, and the accumulation of airframe ice, which resulted in an inadvertent stall. Factors associated with the accident were: partial failure of both alternators, which resulted in a subsequent electrical system failure and an inoperative anti-ice/de-ice system, adverse weather (icing) conditions, and airframe (wing) ice.
Final Report:

Crash of a Cessna 421C Golden Eagle III in Titusville: 3 killed

Date & Time: Jan 21, 1994 at 1445 LT
Registration:
N777BE
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Titusville - Titusville
MSN:
421C-0134
YOM:
1976
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
20000
Circumstances:
Witnesses on the ground reported that the engines sounded normal while the airplane was taxiing to takeoff. After takeoff witnesses reported seeing white smoke trailing the left engine. The airplane was observed to bank to the left with a bank angle of about 90°. The airplane then pitched nose down, descended, and collided with trees and the ground. Examination of the left engine oil separator from the turbocharger assembly revealed that a section of pipe near a flange which is connected to the turbocharger oil outlet failed due to fatigue. There was no other failure or malfunction noted with the left or right engines and propellers. The mixture control arm on the left engine fuel control unit was found in the 'off' position. Additionally, the fuel selectors and magneto switches were also found in the 'off' position. A pilot-rated passenger occupied the left forward seat.
Probable cause:
Failure of the pilot-in-command to maintain vmc resulting in the inflight loss of control. Contributing to the accident was the fatigue failure of a section of pipe adjacent to a flange which connects to the turbocharger oil outlet of the left engine assembly.
Final Report:

Crash of a Cessna 425 Conquest in London

Date & Time: Jan 18, 1994 at 1750 LT
Type of aircraft:
Registration:
N303MC
Flight Type:
Survivors:
Yes
Schedule:
Charleston - Dallas
MSN:
425-0034
YOM:
1980
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
2758
Captain / Total hours on type:
510.00
Aircraft flight hours:
2589
Circumstances:
The pilot stated that the airplane was cruising at an altitude of 18,000 feet 30 minutes after refueling when the left engine lost power. He stated that he was in radio contact with Indianapolis ARTCC so he advised them of the situation and requested a lower altitude. The center cleared the flight to 10,000 feet msl. The pilot stated that his attempt to restart the engine was unsuccessful. Shortly thereafter the pilot reported that the right engine lost power. According to the controller at the center, the pilot was nine miles from the nearest airport and he provided the pilot with radar vectors to the nearest airport, and the weather conditions. The airplane touched down in a wooded area. The faa examined the airplane at the accident site. The engines were removed to Pratt & Whitney for further examination. The examination of the engine and engine accessories did not disclose any pre-existing defects. Fuel samples were removed and tested at the laboratory at Pratt & Whitney. The tests revealed evidence of contaminants.
Probable cause:
Loss of engine power due to fuel contamination.
Final Report:

Crash of a Bae 4101 Jetstream 41 in Columbus: 5 killed

Date & Time: Jan 7, 1994 at 2321 LT
Type of aircraft:
Operator:
Registration:
N304UE
Survivors:
Yes
Site:
Schedule:
Washington DC - Columbus
MSN:
41016
YOM:
1993
Flight number:
UA6291
Crew on board:
3
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
3660
Captain / Total hours on type:
192.00
Copilot / Total flying hours:
2430
Copilot / Total hours on type:
31
Aircraft flight hours:
1069
Aircraft flight cycles:
1000
Circumstances:
The airplane stalled and crashed 1.2 nautical miles east of runway 28L during an ILS approach. The captain initiated the approach at high speed & crossed the FAF at a high speed without first having the airplane properly configured for a stabilized approach. The airspeed was not monitored nor maintained by the flightcrew. The airline had no specified callouts for airspeed deviations during instrument approaches. The captain failed to apply full power & configure the airplane in a timely manner. Both pilots had low flight time and experience in in the airplane and in any EFIS-equipped airplane. Additionally, the captain had low time and experience as a captain. Inadequate consideration was given to the possible consequences of pairing a newly upgraded captain, on a new airplane, with a first officer who had no airline experience in air carrier operations, nor do current FAA regulations address this issue.
Probable cause:
The accident was the consequence of the following factors:
(1) An aerodynamic stall that occurred when the flightcrew allowed the airspeed to decay to stall speed following a very poorly planned and executed approach characterized by an absence
of procedural discipline;
(2) Improper pilot response to the stall warning, including failure to advance the power levers to maximum, and inappropriately raising the flaps;
(3) Flightcrew inexperience in 'glass cockpit' automatic aircraft, aircraft type, and in seat position, a situation exacerbated by a side letter of agreement between the company and its pilots;
(4) The company's failure to provide adequate crew resource management training, and the FAA's failure to require such training;
(5) The company's failure to provide adequate stabilized approach criteria, and the FAA's failure to require such criteria; and
(6) The unavailability of suitable training simulators that precluded fully effective flightcrew training.
Note: Items 1, 2, and 3 were approved by a Board vote of 4-0. Item 5 was adopted 3-1, with the dissenting Member believing the item was a contributory cause. The Board was divided 2-2 on items 4 and 6, two Members believing them causal and two Members, contributory.
Final Report:

Crash of a Beechcraft C90 King Air near Okeechobee: 10 killed

Date & Time: Jan 5, 1994 at 1829 LT
Type of aircraft:
Registration:
N230TW
Flight Type:
Survivors:
No
Schedule:
Kissimmee - Miami
MSN:
LJ-445
YOM:
1969
Crew on board:
1
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
10
Captain / Total flying hours:
12000
Captain / Total hours on type:
130.00
Aircraft flight hours:
7072
Circumstances:
The pilot (or pilot-rated passenger) reported an 'indication' problem and said they intended to land at Okeechobee, but couldn't find the airport. They then reported engine trouble and said that they would try to land on a road. They circled the area and approached a dirt road with landing lights on. A car was proceeding on the road in the opposite direction. The plane began to climb, and it entered a left turn. It then rolled into a steep right bank, descended nose down, crashed and was consumed by fire. An exam revealed indications that both engines were operating at high rpm. A teardown revealed a right engine fuel control bearing had failed, which would have allowed improper movement of the fuel control drive shaft. The plane was last inspected on 11/25/92 and was 13 hours over a required 150 hour inspection. A service bulletin for maintenance of the fuel control bearings had not been complied with. The owner/pilot had not completed formal ground school instruction on the airplane systems and operation. The plane had 9 seats; 10 occupants were aboard.
Probable cause:
The pilot's improper remedial action concerning a right engine power anomaly, and his failure to maintain adequate airspeed during go-around from an aborted precautionary landing, which resulted in a loss of aircraft control and an uncontrolled descent. Factors related to the accident were: failure of the owner/operator/pilot to assure proper maintenance inspection of the aircraft, failure to comply with a service bulletin concerning the engine fuel controls, subsequent bearing failure in the right engine fuel control, and the pilot's lack of familiarity with this make and model of aircraft.
Final Report:

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

Date & Time: Jan 1, 1994 at 1420 LT
Registration:
N243KW
Flight Type:
Survivors:
No
Schedule:
Naples - Destin
MSN:
46-8508089
YOM:
1985
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
4000
Captain / Total hours on type:
1262.00
Aircraft flight hours:
1262
Circumstances:
The pilot was executing an ASR approach to runway 32 and 9 seconds after the approach controller advised the pilot that the flight was over the missed approach point, the pilot advised the controller that the airport was in sight and he would be circling to land. The controller acknowledged this and witnesses observed the airplane flying northwesterly west of runway 32 about 150-200 feet above ground level. They then observed the airplane enter a left bank between 60-80 degrees and the airplane pitched nose down and collided with trees then a fence and the ground. There was a small post crash fire which was extinguished by the fire department. Examination of the airframe revealed no evidence of preimpact failure or malfunction of the flight controls. The engine was removed and placed on a test bench and after replacement of several components which were impact damaged, the engine started and operated normally. The passenger was seated in the furthest aft right seat and the lap belt attach point on the right side of this seat failed due to overload.
Probable cause:
Airspeed not maintained, inadvertent stall/mush, and altitude inadequate for recovery from the inflight loss of control by the pilot-in-command while circling for landing.
Final Report:

Crash of a Rockwell Aero Commander 500A in White Mills: 2 killed

Date & Time: Dec 16, 1993 at 1515 LT
Operator:
Registration:
N9379R
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Honesdale - Honesdale
MSN:
500-897-6
YOM:
1960
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
585
Circumstances:
The airplane was observed by witnesses in a rolling maneuver, followed by the separation of the left wing and collision with trees. Witnesses stated that the pilot had performed acrobatics in this airplane on other occasions. The airplane flight manual prohibits intentional acrobatics. No evidence of corrosion or fatigue in the wing spar or support structures was observed.
Probable cause:
The fracture and separation of the airplane wing, and the subsequent loss of control and collision with trees, as a result of the pilot's repeated performance of acrobatic maneuvers, which exceeded the design limits of the airplane.
Final Report: