Crash of a Cessna 402B in Boise: 2 killed

Date & Time: Nov 16, 1991 at 0256 LT
Type of aircraft:
Registration:
N29517
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Boise - Pocatello
MSN:
402B-0031
YOM:
1970
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
3864
Captain / Total hours on type:
450.00
Aircraft flight hours:
6994
Circumstances:
The pilot announced he had an engine failure during initial climb at 300-400 feet agl after takeoff on a VFR night cargo flight. The tower controller cleared the flight to return to the airport and land on any runway. The aircraft entered a right descending turn, impacted the ground one mile from the airport, and ignited in flames. Evidence indicated the right engine was not operating at impact. The landing gear was down and the right propeller was in the high pitch position. Exam of the right engine revealed blocked fuel injectors, incorrect size fuel injectors, fuel pump out of adjustment, and burned/pitted breaker points in a magneto. Both occupants were killed.
Probable cause:
The loss of power on the right engine during initial climb after takeoff due to inadequate maintenance inspection and adjustment of the engine by company maintenance personnel, and the loss of control by the pilot due to his failure to properly configure the aircraft and perform a proper single engine climb maneuver, and his failure to maintain single engine climb airspeed. A factor relating to the accident was the dark night light conditions.
Final Report:

Crash of a Cessna 340 in Columbus: 5 killed

Date & Time: Nov 12, 1991 at 2030 LT
Type of aircraft:
Registration:
N7672Q
Survivors:
No
Schedule:
Charleston – Columbus
MSN:
340-0184
YOM:
1973
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
2617
Captain / Total hours on type:
969.00
Aircraft flight hours:
2653
Circumstances:
On final approach the pilot reported an engine failure. He said he was putting the landing gear down. The airplane crashed 3 miles from the airport. Examination of the engines revealed no discrepancies. The pilot did not feather the propeller after the engine failure. He had no training in this airplane or any other multi-engine airplane in over 5 years. His last before was in a Cessna 172. It was reported that the pilot did not manage the airplane fuel system in the recommended manner. A witness said the pilot used fuel from the main tanks until they were nearly empty. He ignored forecasts of light icing conditions and during his flight he reported ice accumulation. All five occupants were killed.
Probable cause:
The pilot's improper execution of an emergency procedure, after an engine failure, which resulted in the loss of airplane control. Factors related to the accident were: the pilot's improper management of the fuel system; the pilot's lack of proficiency in emergency procedure; and the flight into known icing conditions.
Final Report:

Crash of a Rockwell Grand Commander 690 in Wichita: 2 killed

Date & Time: Nov 2, 1991 at 1206 LT
Registration:
N799V
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Wichita - Phoenix
MSN:
690-11407
YOM:
1977
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
4900
Captain / Total hours on type:
1078.00
Aircraft flight hours:
3480
Circumstances:
The pilot and his wife departed Wichita, Kansas with a destination of Phoenix, Arizona. Eight minutes after takeoff, while in a climb to 15,000 feet, the passenger contacted departure control and communicated that she thought that her husband might be dead. While departure control was getting a pilot to assist in the situation, the passenger, who was not a pilot attempted to fly the aircraft. A witness reported a rapid series of climbs and descents just before both horizontal stabilizers and the rudder separated from the aircraft. The aircraft then entered a spin terminating with ground impact. The aircraft was consumed by a post-crash fire. Both occupants were killed.
Probable cause:
Incapacitation of the pilot in command, followed by the loss of control and an inflight breakup with a unqualified person on the controls.
Final Report:

Crash of a Cessna 414 Chancellor in Long Beach: 2 killed

Date & Time: Oct 26, 1991 at 0901 LT
Type of aircraft:
Registration:
N3843C
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Long Beach - Scottsdale
MSN:
414-0846
YOM:
1975
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
1510
Captain / Total hours on type:
317.00
Aircraft flight hours:
2711
Circumstances:
The pilot reported that he had lost the left engine during the initial climb phase of a cross-country flight. Ground witnesses observed that the airplane's landing gear was down and the left propeller was feathered as it turned left onto the downwind leg of the traffic pattern. Other witnesses observed the airplane's wings dip before it nosed over into the terrain while turning onto the final approach course. The airplane struck the ground and a fence that separated two residential yards. The wreckage examination disclosed that the left engine's scavenge pump failed. This failure led the pilot to believe that the engine failed. The pilot's improper emergency procedures by failing to retract the landing gear and maintain airspeed precipitated the resulting stall and uncontrolled descent. Both occupants were killed.
Probable cause:
The pilot's improper emergency procedures by not retracting the landing gear when he shut the engine down and his failure to maintain airspeed. The scavenge pump failure, shutting down the engine and the inadvertent stall were factors in the accident.
Final Report:

Crash of a Lockheed P-3A Orion near Florence: 2 killed

Date & Time: Oct 16, 1991 at 1945 LT
Type of aircraft:
Operator:
Registration:
N924AU
Flight Type:
Survivors:
No
Site:
Schedule:
Santa Barbara - Missoula
MSN:
185-5072
YOM:
1964
Flight number:
Tanker 24
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
Air tanker N924AU had been dispatched from its base in Santa Barbara, CA to Missoula, MT to support fire suppression efforts involving a number of large fires in the Northern Region. The flight departed in VFR conditions at 16:05 PDT. While still in the area controlled by the Oakland FAA Air Route Traffic Control Center (ARTCC), the crew requested and received an Instrument Flight Rules (IFR) clearance. They were assigned an altitude of 23,000 feet. The Orion proceeded uneventfully and was handed off to the Approach Controller at Missoula (MSO). MSO Approach did not have, at that time, terminal radar equipment that covered their entire area of responsibility. At first contact with MSO Approach, the Orion was 26 miles southeast of the Missoula International Airport and descending to 12,000 feet. In the course of several exchanges between the Orion and the MSO Approach Controller, it was disclosed and confirmed that the Orion’s flight crew did not have the approach plate (or chart) depicting the published approach procedure for the VOR-DME Bravo (B) approach, which was the approach in use for aircraft arriving from the south. Clearance was nevertheless offered and accepted and the controller provided the information as the Orion crew began to execute the VOR-DME B approach. At this time, the cloud bases at the MSO Airport were at about 7,900 feet and other aircraft making instrument approaches there were descending through 8,000 feet, cancelling their IFR flight plans and making visual approaches to the airport for landing. Since the Orion’s crew was able to monitor these radio communications/transmissions on the same frequency, they were probably counting on doing the same. At this time, there were very strong winds and moderate to severe turbulence reported at altitudes above 8,000 feet that increased with altitude in the MSO area. In addition to turbulence, the Orion crew contended with effects of flying at high altitudes, using oxygen in an unheated and un-pressurized aircraft for more than two hours. At some point in the initial phase of the approach, some confusion as to what heading to fly apparently occurred and the airtanker turned back toward the south, away from MSO. By this time the controller had authorized descent to 8,600 feet on an approximate heading of 200 degrees magnetic. MSO Approach received notification by Salt Lake City ARTCC (Center) that this airtanker was west of the course consistent with the approach procedure and subsequent notification that the airtanker had disappeared off Center’s radar screen. Repeated attempts to contact the Orion crew failed and MSO Approach notified the County Sheriff’s office, the Forest Service, and other agencies that the aircraft was missing and presumed down. Search and rescue attempts were not able to detect an Emergency Locator Transmitter (ELT) signal. The mishap site was located the following day.
Source: https://www.fs.usda.gov/managing-land/fire by Candy S. Rock Fitzpatrick.
Final Report:

Crash of a Convair CV-580 in Belvidere Centre: 2 killed

Date & Time: Sep 18, 1991 at 2150 LT
Type of aircraft:
Operator:
Registration:
C-FICA
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Moncton - Hamilton
MSN:
98
YOM:
1968
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
10400
Captain / Total hours on type:
1200.00
Aircraft flight hours:
39323
Circumstances:
The airplane was cruising in night instrument meteorological conditions when it entered a left turn and exceeded the design airframe limits. The airplane broke up in the descent due to aerodynamic forces and was destroyed. The outboard wing panels had failed downward and center wing section separated from the fuselage. The horizontal stabilizer and elevators had failed down and aft. The captain was found out of the cockpit with no evidence of him being in the seat at impact a human factors study found the aircraft's last minute of flight matched a profile of a pilot experiencing spatial disorientation. Both pilots were killed.
Probable cause:
Failure of the first officer (co-pilot) to maintain control of the aircraft after becoming spatially disoriented, and his exceeding the design stress limits of the aircraft. Factors related to the accident were: the lack of two pilots in the cockpit, darkness, and instrument meteorological conditions (IMC) at flight altitude.
Final Report:

Crash of a Cessna 401 in Jackson

Date & Time: Sep 11, 1991 at 1902 LT
Type of aircraft:
Registration:
N13DT
Flight Type:
Survivors:
Yes
Schedule:
Raleigh - Jackson
MSN:
401-0247
YOM:
1969
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
1681
Captain / Total hours on type:
659.00
Circumstances:
The pilot had cancelled his ifr flight plan, and was proceeding to the airport visually. During his approach, the left engine quit, followed by the right engine. He then realized that he had failed to switch from the auxiliary fuel tanks to the main fuel tanks prior to the approach, and exhausted the auxiliary fuel supply. With insufficient altitude to attempt a restart, he force landed the airplane in a bean field short of the airport. After the airplane came to a stop, the occupants egressed, and the fuselage was consumed in a post-crash fire.
Probable cause:
The pilot's failure to select the main fuel tanks prior to the approach, resulting in fuel starvation and engine stoppage.
Final Report:

Crash of a Piper PA-60 Aerostar (Ted Smith 600) in Ruidoso: 2 killed

Date & Time: Sep 11, 1991 at 1150 LT
Registration:
N4VH
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Ruidoso - Reno
MSN:
60-0055-125
YOM:
1971
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
5600
Circumstances:
While departing on a cross country flight the aircraft was observed to have an abnormally long takeoff roll and to rotate abruptly to a higher than normal nose attitude. Initial climb was followed by settling with a high nose attitude and the aircraft crashed approximately one mile beyond the departure end of the runway. The main cabin door was found in the unlocked position and the lower half was found near the beginning of the wreckage path with impact damage. The top half was found further down the wreckage path and had sustained fire damage. The Aerostar has an observed drag and pitch performance degradation if the cabin door opens during takeoff run. A passenger was seriously injured while two other occupants were killed.
Probable cause:
Loss of control in flight after to the cabin door opened inadvertently during takeoff run.
Final Report:

Crash of an Embraer EMB-120RT Brasília in Eagle Lake: 14 killed

Date & Time: Sep 11, 1991 at 1003 LT
Type of aircraft:
Operator:
Registration:
N33701
Flight Phase:
Survivors:
No
Schedule:
Laredo - Houston
MSN:
120-077
YOM:
1987
Flight number:
CO2574
Crew on board:
3
Crew fatalities:
Pax on board:
11
Pax fatalities:
Other fatalities:
Total fatalities:
14
Captain / Total flying hours:
4243
Captain / Total hours on type:
2468.00
Copilot / Total flying hours:
11543
Copilot / Total hours on type:
1066
Aircraft flight hours:
7229
Aircraft flight cycles:
10009
Circumstances:
The airplane broke up in flight while descending from FL240. The horizontal stabilizer, or top of the T-type tail, had separated from the fuselage before ground impact. Examination revealed that the 47 screw fasteners that would have attached the upper surface of the leading edge assembly for the left side of the horizontal stabilizer were missing. They had been removed the night before during scheduled maintenance. Investigation revealed that there was a lack of compliance with the FAA-approved general maintenance manual procedures by the mechanics, inspectors, and supervisors responsible for assuring the airworthiness of the airplane the night before the accident. In addition, routine surveillance of the continental express maintenance department by the FAA was inadequate and did not detect deficiencies, such as those that led to this accident. All 14 occupants were killed.
Probable cause:
The failure of continental express maintenance and inspection personnel to adhere to proper maintenance and quality assurance procedures for the airplane's horizontal stabilizer deice boots that led to the sudden in-flight loss of the partially secured left horizontal stabilizer leading edge and the immediate severe nose down pitchover and breakup of the airplane. Contributing to the cause of the accident was the failure of continental express management to ensure compliance with the approved maintenance procedures, and the failure of the faa surveillance to detect and verify compliance with approved procedures.
Final Report:

Crash of a Cessna 340A in Brawley

Date & Time: Sep 1, 1991 at 1900 LT
Type of aircraft:
Operator:
Registration:
N4298C
Flight Type:
Survivors:
Yes
Schedule:
San Diego - Brawley
MSN:
340A-0601
YOM:
1978
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
1597
Captain / Total hours on type:
332.00
Circumstances:
Returning to the pilot's home base airport, the pilot indicated that he overflew the uncontrolled field and then entered the traffic pattern for runway 26 which was over 4,400 feet long. The pilot reported that he observed the wind sock was parallel to the runway but failed to initially observe that he was landing with a nearly direct 20 to 25 knot tailwind. The airplane touched down long, overran the runway's departure end, collided with a pole and caught on fire. All three occupants escaped with minor injuries.
Probable cause:
The pilot's selection of the wrong landing runway and his failure to attain the proper touchdown location. Factors which contributed to the accident were related to the pilot's inadequate observations of the weather and the tailwind condition which existed.
Final Report: