Crash of a Rockwell Grand Commander 690A in Taos: 1 killed

Date & Time: Mar 29, 1992 at 1900 LT
Registration:
N111FL
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Taos - Tulsa
MSN:
690-11163
YOM:
1974
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
2200
Captain / Total hours on type:
120.00
Aircraft flight hours:
3404
Circumstances:
The airplane impacted slightly rising terrain in a 15° left bank, slight nose up attitude while descending shortly after takeoff in dark night IMC. There were rain and snow showers in the area and it was devoid of visible ground reference lights. The difference between the takeoff heading and the impact heading was 75° and the airplane had traveled 3,987 feet from the departure end of the runway at initial impact. The wreckage subsequently traveled an additional 837 feet through the brush. The pilot stated that the takeoff was normal in all aspects and all of the airplane systems were operating normally. He stated that the last thing he remembered was passing through 8,500 feet with a rate of climb of 1,500 feet per minute. The airport elevation was 7,091 feet. He did not recall the radio altimeter alert or the warning light activating. No evidence of pre-impact failure or malfunction was found during the investigation. Rescue of the occupants were delayed due to the weather, darkness, and spurious elt signals masked by the wreckage.
Probable cause:
The pilot in command's failure to maintain the climb after departing the runway environment. Factors were the weather conditions and the dark night.
Final Report:

Crash of a Fokker F28 Fellowship 4000 in New York: 27 killed

Date & Time: Mar 22, 1992 at 2135 LT
Type of aircraft:
Operator:
Registration:
N485US
Flight Phase:
Survivors:
Yes
Schedule:
Jacksonville – New York – Cleveland
MSN:
11235
YOM:
1986
Flight number:
US405
Crew on board:
4
Crew fatalities:
Pax on board:
47
Pax fatalities:
Other fatalities:
Total fatalities:
27
Captain / Total flying hours:
9820
Captain / Total hours on type:
2200.00
Copilot / Total flying hours:
4507
Copilot / Total hours on type:
29
Aircraft flight hours:
12462
Aircraft flight cycles:
16280
Circumstances:
USAir flight 405 was scheduled to depart Jacksonville, FL (JAX) at 16:35 but was given a ground delay because of poor weather in the New-York-LaGuardia (LGA) area and was further delayed in order to remove the baggage of a passenger who chose to deplane. The Fokker F-28 jet departed Jacksonville at 17:15 and was cleared into the LaGuardia area without significant additional delays. The first officer accomplished an ILS approach to LaGuardia's runway 04 to minimums and initiated braking on the landing roll. Ramp congestion delayed taxiing to the parking gate. The airplane was parked at Gate 1 at approximately 19:49, 1 hour and 6 minutes behind schedule. After the airplane was parked at Gate 1, the line mechanic who met the flight was advised by the captain that the aircraft was "good to go." The captain left the cockpit and the first officer prepared for the next leg to Cleveland , OH (CLE) that had originally been scheduled to depart at 19:20. Snow was falling as the F-28 was prepared for departure. The airplane was de-iced with Type I fluid with a 50/50 water/glycol mixture, using two trucks. After the de-icing, about 20:26, one of the trucks experienced mechanical problems and was immobilized behind the airplane, resulting in a pushback delay of about 20 minutes. The captain then requested a second de-icing of the airplane. The airplane was pushed away from the gate to facilitate de-icing by one de-icing truck. The second de-icing was completed at approximately 21:00. At 21:05:37, the first officer contacted the LaGuardia ground controller and requested taxi clearance. The airplane was cleared to taxi to runway 13. At 21:07:12, the flightcrew switched to the LaGuardia ground sequence controller, which they continued to monitor until changing to the tower frequency at 21:25:42. The before-takeoff checklist was completed during the taxi. Engine anti-ice was selected for both engines during taxi. The captain announced that the flaps would remain up during taxi, and he placed an empty coffee cup on the flap handle as a reminder. The captain announced they would use US Air's contaminated runway procedures that included the use of 18 degrees flaps. They would use a reduced V1 speed of 110 knots. The first officer used the ice (wing) inspection light to examine the right wing a couple of times. He did not see any contamination on the wing or on the black strip and therefore did not consider a third de-icing. Flight 405 was cleared into the takeoff and hold position on runway 13 at 21:33:50. The airplane was cleared for takeoff at 21:34:51. The takeoff was initiated and the first officer made a callout of 80 knots, and, at 21:35:25, made a V1 callout. At 21:35:26, the first officer made a VR callout. Approximately 2.2 seconds after the VR callout, the nose landing gear left the ground. Approximately 4.8 seconds later, the sound of stick shaker began. Six stall warnings sounded. The airplane began rolling to the left. As the captain leveled the wings, they headed toward the blackness over the water. The crew used right rudder to maneuver the airplane back toward the ground and avoid the water. They continued to try to hold the nose up to impact in a flat attitude. The airplane came to rest partially inverted at the edge of Flushing Bay, and parts of the fuselage and cockpit were submerged in water. After the airplane came to rest, several small residual fires broke out on the water and on the wreckage debris.
Probable cause:
The failure of the airline industry and the Federal Aviation Administration to provide flight crews with procedures, requirements, and criteria compatible with departure delays in conditions conducive to airframe icing and the decision by the flight crew to take off without positive assurance that the airplane's wings were free of ice accumulation after 35 minutes of exposure to precipitation following de-icing. The ice contamination on the wings resulted in an aerodynamic stall and loss of control after lift-off. Contributing to the cause of the accident were the inappropriate procedures used by, and inadequate coordination between, the flight crew that led to a takeoff rotation at a lower than prescribed air speed.
Final Report:

Crash of a BAe 3101 Jetstream 31 in Knoxville: 2 killed

Date & Time: Mar 12, 1992 at 0013 LT
Type of aircraft:
Operator:
Registration:
N165PC
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Knoxville - Knoxville
MSN:
683
YOM:
1985
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
4929
Captain / Total hours on type:
4400.00
Aircraft flight hours:
10607
Circumstances:
After a series of instrument procedures, the flight returned to Knoxville and landed. On the next takeoff, the first officer dropped the airplane's checklist and the check airman elected to continue the flight without using the checklist. On the next visual approach, the check airman and first officer attempted a landing without lowering the landing gear. The airplane touched down and both propeller assemblies struck the concrete runway surface. The pilot reported the gearup touchdown to the control tower and elected to go around. During the climbout the check airman lowered the landing gear, established a teardrop pattern for the opposite runway and feathered the right propeller. Crash fire rescue (cfr) equipment was alerted and was in position for the second landing attempt. While on short final, the check airman called for max power, a reduction in the flap setting, and initiated a single engine go-around below 200 feet. There is no operational procedure for a single engine go-around below 200 feet. The airplane climbed briefly and crashed inverted about 7,500 feet from the approach end of the runway. Both pilots were killed.
Probable cause:
The pilot's failure to use the airplane checklist which resulted in a gear up landing; and the pilot's failure to maintain flying speed which resulted in an uncontrolled collision with the ground.
Final Report:

Crash of a NAMC YS-11A-205 in Wilmington

Date & Time: Mar 6, 1992
Type of aircraft:
Operator:
Registration:
N918AX
Flight Type:
Survivors:
Yes
Schedule:
Wilmington - Wilmington
MSN:
2112
YOM:
1969
Location:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The crew departed Wilmington-Air park (Clinton County Airport) on a local training flight. On final approach to runway 22, the crew forgot to lower the undercarriage and the aircraft landed on its belly. It slid for few dozen yards and came to rest on the main runway. All three occupants escaped uninjured while the aircraft was damaged beyond repair.
Probable cause:
It was determined that the crew was focused on a flapless landing configuration and failed to follow the approach checklist and forgot to lower the landing gear.

Crash of a Cessna 414 Chancellor in MBS-Tri City: 3 killed

Date & Time: Mar 5, 1992 at 1504 LT
Type of aircraft:
Registration:
N69662
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
MBS-Tri-City - Chicago
MSN:
414-0621
YOM:
1975
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
2057
Captain / Total hours on type:
184.00
Aircraft flight hours:
4106
Circumstances:
While loading a patient & his personal gear in the aircraft for an air ambulance flight, the aircraft tipped onto its tail. As a result, the tail bumper was forced upward into the belly of the empennage. The pilot refused the offer to have a mechanic look at the damage, and remarked 'this has happened before.' after takeoff, the pilot radioed to the tower that he had a jammed elevator, and was coming around to land. While maneuvering on a base leg, control was lost & the airplane was observed to crash with one wing perpendicular to the ground. Another airplane was in the takeoff position on the runway. The airplane was configured with a hospital litter/stretcher and oxygen bottle on the right side of the cabin. There was no record for the approval for, or installation of, the stretcher. In addition, there was no weight & balance record for the airplane with the stretcher installation. All three occupants were killed.
Probable cause:
The pilot's poor judgement in attempting flight after the airplane's fuselage was damaged during a loading operation. Factors which contributed to the accident were: the operator's failure to provide proper weight and balance data for the airplane, the pilot's failure to supervise the loading operation, and his failure to accept the services of a mechanic to inspect the damage.
Final Report:

Crash of a Mitsubishi MU-2B-60 Marquise near New Castle: 6 killed

Date & Time: Mar 5, 1992 at 1002 LT
Type of aircraft:
Registration:
N303CA
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Fort Worth – Rifle
MSN:
1518
YOM:
1981
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
6
Captain / Total flying hours:
1265
Captain / Total hours on type:
154.00
Circumstances:
The airplane impacted mountainous terrain approximately 10.5 dme from the airport while executing a LOC/DME instrument approach. The airplane was configured for landing. The elevator trim jackscrew was approximately 18° nose up. The altitude preselect, coupled to the sperry autopilot system, was set at 9,500 feet. Minimum descent altitude until reaching the final approach fix is 9,500 feet. Final approach fix is located at 9.3 dme. Twenty four prescription and nonprescription drugs were found aboard the airplane. The pilot's toxicology report disclosed 0.206 (ug/ml, ug/g) chlorpheniramine, an antihistamine, in his liver fluid. According to an FAA flight surgeon, this would equate to approximately .034 ug/ml in blood. Therapeutic dosage is .01 to .04 ug/ml. The drug is contraindicated for flying due to its capability of producing drowsiness. Chlorpheniramine is an ingredient found in comtrex, one of the drugs found aboard the airplane. All six occupants were killed.
Probable cause:
An inadvertent stall during an instrument approach with the autopilot engaged. A factor was: the pilot's physical impairment from a prescription drug.
Final Report:

Crash of a Douglas DC-6BF in Selawik

Date & Time: Mar 3, 1992 at 1820 LT
Type of aircraft:
Operator:
Registration:
N151
Flight Type:
Survivors:
Yes
Schedule:
Fairbanks-Selawik
MSN:
45174
YOM:
1957
Location:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
6800
Captain / Total hours on type:
5600.00
Aircraft flight hours:
33232
Circumstances:
The heavily loaded fuel tanker landed with an approximate 3 knot tailwind, overran the departure end of the runway, and came to a stop on a frozen river. The last two thirds of the 3,150 feet long gravel runway was covered with ice. The crew stated that the propellers either failed to go into reverse, or were slow in reversing, to assist in stopping. Examination revealed that all propeller blades were in the reversed position. Outside air temperature was minus 30 to minus 35° F. The airplane performance chart used to calculate the landing distance was for 'concrete runways'. Stopping distance was not predicated on the use of reverse propeller thrust. Post accident calculations, using the same chart, found the estimated landing distance needed for the accident flight to be 100 to 200 feet more than the length of the runway.
Probable cause:
The pilot's inadequate pre flight planning and disregarding the aircraft performance data. Contributing factors were the extreme outside air temperatures, the icy runway, and the tailwind.
Final Report:

Crash of a Helio H-550A Stallion in Salome

Date & Time: Mar 1, 1992 at 1500 LT
Type of aircraft:
Registration:
N550HZ
Flight Phase:
Flight Type:
Survivors:
Yes
Site:
Schedule:
Prescott - Prescott
MSN:
007
YOM:
1972
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
1725
Captain / Total hours on type:
72.00
Circumstances:
The certificated airline transport pilot and a passenger were conducting a low level flight over mountainous terrain. The surface wind conditions were reported to be from the south at or above 20 knots. The pilot reported that he approached the mountain peak in a southerly direction and climbed the airplane to an altitude of 150 feet above the ground to clear the mountain. The airplane encountered downdraft conditions on the lee side of the mountain. The pilot failed to immediately correct for this condition and the airplane collided with the upsloping mountainous terrain when the pilot was executing a 180° turn.
Probable cause:
The pilot's inadequate in-flight planning, improper altitude, and delaying the required remedial action to prevent the collision with the mountain. Contributing to the accident was the unfavorable wind and downdraft conditions.
Final Report:

Crash of a Beechcraft H18 in Morganton: 1 killed

Date & Time: Feb 26, 1992 at 0826 LT
Type of aircraft:
Operator:
Registration:
N347G
Flight Type:
Survivors:
No
Schedule:
Charlotte - Morganton
MSN:
BA-654
YOM:
1963
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
10000
Captain / Total hours on type:
3000.00
Aircraft flight hours:
13506
Circumstances:
The commercial pilot was on a part 135 cargo flight. Since the destination airport had no weather reporting facility, company policy and far 135 required a VFR descent and landing from the MVA. The pilot requested and received clearance for a localizer approach to the airport, although a nearby airport was reporting 400' broken/3 miles with fog. The pilot reported to ATC that he had missed his first approach, and requested a second approach to the same airport. After executing the missed approach, the aircraft impacted mountainous terrain while aligned with the extended centerline of the localizer. Cap personnel reported that the accident site was obscured in clouds at the time of the accident. The investigation revealed that the aircraft descended about 1,500 feet below a minimum altitude on the first approach attempt. Mode c altitude data was lost during the missed approach. Four years earlier, this pilot descended below glidepath on an ILS approach and crashed into trees with weather below approach minimums. The pilot, sole on board, was killed.
Probable cause:
The failure of the pilot to follow far and company procedures, and his failure to maintain proper altitude during the approach. Factors were the mountainous terrain conditions, and the foggy, low ceiling weather conditions existing at the time of the accident.
Final Report:

Crash of a Piper PA-31T-620 Cheyenne II near Big Bear Lake: 7 killed

Date & Time: Feb 16, 1992 at 1635 LT
Type of aircraft:
Registration:
N60AW
Survivors:
No
Site:
Schedule:
San Diego - Big Bear
MSN:
31-8020051
YOM:
1980
Crew on board:
2
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
7
Captain / Total flying hours:
15000
Circumstances:
The pilots had entered into an agreement with the 5 pax to fly them to a ski resort. The airplane owner stated that the pic, who was the company pilot, did not have permission to use the airplane, nor did the owner know the pax. The airport at the ski resort is located in mountainous terrain at 6,750 feet msl. There is no instrument approach. There is no record of any weather briefings. The airplane collided with terrain (Mt Clark) at about 6,580 feet msl approximately 7.5 miles southwest of the destination airport. Weather for the area was: mountains locally obscured 3,000 to 5,000 feet scattered to broken with tops to 9,000, and widely scattered visibilities below 3 miles with snow and rain showers. Examination of the wreckage and impact site revealed the aircraft collided with the brush and snow covered 45° slope in a level left turn. All seven occupants were killed.
Probable cause:
The pilot's poor judgement in continuing visual flight into instrument meteorological conditions, in mountainous terrain obscured by clouds. Factors in the accident were: the pilot's failure to obtain a preflight weather briefing, the weather conditions, and the high mountainous terrain.
Final Report: