Crash of an IAI-1124A Westwind I in Oxford

Date & Time: May 1, 1991 at 0920 LT
Type of aircraft:
Registration:
N445BL
Survivors:
Yes
Schedule:
Saint Augustine – Oxford
MSN:
382
YOM:
1982
Crew on board:
2
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
10990
Captain / Total hours on type:
2290.00
Circumstances:
The aircraft completed an instrument approach and landed hard on the runway surface first with the left gear then the right gear. The tires burst and the lower fuselage came into contact with the runway surface. After the nose gear touched down, the right main landing gear collapsed and the pilot lost control of the aircraft. It veered to the left and departed the runway, coming to rest approximately 150 to 200 yards from the point of departure. Initial touch down occurred about 12 feet from the threshold, ten feet left of centerline.
Probable cause:
The failure of the pilot to maintain the proper landing descent rate and the resultant right main landing gear assembly collapse.
Final Report:

Crash of a Piper PA-31-310 Navajo B in Englewood: 1 killed

Date & Time: May 1, 1991 at 0653 LT
Type of aircraft:
Operator:
Registration:
N7407L
Flight Phase:
Survivors:
No
Schedule:
Englewood - Des Moines
MSN:
31-790
YOM:
1972
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
6200
Circumstances:
Shortly after takeoff, while climbing to cruise altitude, the pilot reported the left engine cowl assembly had come off. Witnesses observed the airplane at low altitude and noted that it was 'yawing, sputtering, and rocking back and forth.' They indicated the left engine was not running and that the airplane banked sharply to the right and disappeared behind trees before crashing. An investigation revealed the left propeller had not been feathered. The left engine cowling was found 1.8 miles from the accident site. The three primary (eyebolt) cowl fasteners on the outboard side of the left upper cowl were found unlocked & seven other cowl attaching studs (screws) were missing. The cowling had been removed 16 days before the accident to install an oil/air separator. This was the first flight since that work was performed. The mechanic, who did the work, said he noted several cowl stud fasteners were missing and that he had notified the pilot. The pilot was reported to have replied that he had some fasteners and would take care of the problem. The pilot, sole on board, was killed.
Probable cause:
In-flight separation of the left engine cowl assembly that was not properly latched, and failure of the pilot to maintain minimum control speed, which resulted in his loss of aircraft control. Factors related to the accident were: an inadequate preflight inspection, inadequate markings/alignment indications to assure that the cowl fasteners were locked, and an insufficiently defined procedure in the flight manual for checking the cowl fasteners.
Final Report:

Crash of a Piper PA-46-310P Malibu Mirage in Hollywood

Date & Time: Apr 7, 1991 at 1919 LT
Operator:
Registration:
N9113X
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Las Vegas – Santa Monica
MSN:
46-8608044
YOM:
1986
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
398
Captain / Total hours on type:
45.00
Circumstances:
A Piper PA-46-310P loss engine power and collided with a telephone pole during the forced landing. The pilot contacted the tracon and informed the facility he had a partial power loss. The airplane was about two miles east of the airport at about 3,500 feet msl heading in a southwesterly direction. The tracon instructed the pilot to turn 150° for radar vectors to runway 33. The pilot did not turn to the 150° heading, but continued on a southwesterly course. The airplane flew past the approach ends of two runways. The airplane continued westbound and crashed 2.5 miles west of the airport. The pilot indicated the airplane had 300 pounds (about 50 gallons) of fuel on board at takeoff. The pilot operating handbook for the Piper PA-34-310P is about 16 gallons per hour. The duration of the flight was about one hour. There was no evidence of fuel in the airplane's fuel system or any evidence of fuel spillage from either of the wings after the accident.
Probable cause:
The pilot-in-command's poor preflight planning, inadequate fuel consumption calculations which resulted in a loss of engine power due to fuel exhaustion, and the pilot-in-command's failure to follow air traffic control verbal instructions which would have guided him to a probable safe landing at an airport.
Final Report:

Crash of an Embraer EMB-120RT Brasilía in Brunswick: 23 killed

Date & Time: Apr 5, 1991 at 1451 LT
Type of aircraft:
Operator:
Registration:
N270AS
Survivors:
No
Schedule:
Atlanta - Brunswick
MSN:
120-218
YOM:
1990
Flight number:
EV2311
Crew on board:
3
Crew fatalities:
Pax on board:
20
Pax fatalities:
Other fatalities:
Total fatalities:
23
Captain / Total flying hours:
11724
Captain / Total hours on type:
5720.00
Copilot / Total flying hours:
3925
Copilot / Total hours on type:
2795
Aircraft flight hours:
816
Aircraft flight cycles:
845
Circumstances:
Witnesses reported that the airplane suddenly turned or rolled left until the wings were perpendicular to the ground. The airplane then fell in a nose-down attitude. Examination of the left propeller components indicated a blade angle of about 3°, while the left propeller control unit (pcu) ballscrew position was consistent with a commanded blade angle of 79.2°. Extreme wear on the pcu quill spline teeth, which normally engaged the titanium-nitrided splines of the propeller transfer tube, was found. The titanium-nitrided surface was much harder and rougher than the nitrided surface of the quill. Therefore, the transfer tube splines acted like a file and caused abnormal wear of the gear teeth on the quill. Wear of the quill was not considered during the certification of the propeller system. The aircraft was totally destroyed upon impact and all 23 occupants were killed, among them John Goodwin Tower, Senator of Texas and the astronaut Manley Sonny Carter.
Probable cause:
The loss of control in flight as a result of a malfunction of the left engine propeller control unit which allowed the propeller blade angles to go below the flight idle position. Contributing to the accident was the deficient design of the propeller control unit by hamilton standard and the approval of the design by the federal aviation administration. The design did not correctly evaluate the failure mode that occurred during this flight, which resulted in an uncommanded and uncorrectable movement of the blades of the airplane's left propeller below the flight idle position.
Final Report:

Crash of a Piper PA-61 Aerostar (Ted Smith 601) in Merion: 3 killed

Date & Time: Apr 4, 1991 at 1210 LT
Registration:
N3645D
Survivors:
No
Site:
Schedule:
Williamsport – Philadelphia
MSN:
61-0844-8162153
YOM:
1981
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
1876
Aircraft flight hours:
2739
Circumstances:
Piper Aerostar 601, N3645D, was arriving as Bell 412 (helicopter), N78S, was departing. N3645D reported the aircraft's nose gear indicator light did not illuminate to verify the nose gear was down and locked. Crew of N78S heard the communication and saw N3645D as they crossed beneath N3645D's approach path. They reported N3546D's nose gear appeared to be extended. N3645D flew past the tower and tower personnel also reported the nose gear appeared to be extended. As N3645D was cleared to turn downwind, N78S offered to join for a closer look. Captain of N3645D accepted the offer. During joinup, N78S converged from left rear, then reported they would pass around the right side and look at everything as they went by. They reported that everything looked ok. Moments later, the two aircrafts collided and crashed to the ground. No mechanical reason was found that would have resulted in the accident. None of the pilots had training for flight in close proximity to another aircraft. There were indications the captain of N3645D lacked training in aircraft systems and that his employer (the operator) lacked surveillance by the FAA. The emergency procedure section of the Aerostar flight manual lacked info on emergency gear extension. All three occupants were killed as well as both pilots on board the helicopter. Four other people on the ground were injured, one seriously.
Probable cause:
The poor judgement by the captain of the airplane to permit the inflight inspection after he had determined to the best of his ability that the nose landing gear was fully extended, the poor judgment of the captain of the helicopter to conduct the inspection, and the failure of the flightcrew of the helicopter to maintain safe separation. Contributing to the accident was the incomplete training and checking that the flightcrew of N3645D received from lycoming air service and the faa principal operations inspector assigned to the operator.
Final Report:

Crash of a Beechcraft 60 Duke in Kinston: 3 killed

Date & Time: Apr 1, 1991 at 1326 LT
Type of aircraft:
Registration:
N311MC
Flight Type:
Survivors:
No
Schedule:
Kinston – Stuart
MSN:
P-366
YOM:
1976
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
2345
Captain / Total hours on type:
500.00
Circumstances:
During takeoff from runway 22, the pilot reported that he had a problem, then there was no further communication from the aircraft. Several witnesses saw an object fall from the aircraft and one witness observed that a 'hood' had opened. The aircraft was maneuvered onto final approach to runway 36. A witness said that as the aircraft was lining up on final approach, it entered a steep bank and descended out of his sight. Subsequently, it collided with trees in a 27° descent, crashed and burned. A bag from the nose baggage compartment was found near the departure end of runway 22. No preimpact part failure or system malfunction of the aircraft was found. Before the flight, a ramp person observed the pilot servicing the left engine with oil, but he did not know if the pilot had secured the baggage door. An examination of the recovered door assembly failed to disclose a malfunction of the rear latch assembly. The forward latch assembly area was destroyed by fire. All three occupants were killed.
Probable cause:
The pilot diverted his attention and failed to maintain control of the aircraft, while maneuvering for a precautionary landing. Factors related to the accident were: the unsecured baggage compartment door and the pilot's inadequate preflight.
Final Report:

Crash of a Cessna 421C Golden Eagle III near Cortez: 5 killed

Date & Time: Mar 29, 1991 at 1125 LT
Operator:
Registration:
N3851C
Flight Type:
Survivors:
No
Site:
Schedule:
Tucson - Cortez
MSN:
421C-0119
YOM:
1976
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
530
Captain / Total hours on type:
40.00
Circumstances:
The flight departed without a flight plan or weather brief. En route deteriorating weather was encountered and an IFR flight plan was filed to a revised destination. Clearance was received for a VOR approach and the pilot was advised of 1/2 mile visibility in snow and fog. A missed approach was reported over the unicom frequency. Impact occurred with a heading of about 170° at 7,700 feet msl in mountainous terrain on the 173° radial, 7.3 miles from the VOR. The inbound course to the final approach fix was 170° with an inbound final approach course of 196°. Airport elevation was 5,914 feet msl. The airport was located on the 196° radial, 5.5 miles from the VOR final approach fix. The VOR approach to runway 21 called for a missed approach to be executed at 5.5 DME from the VOR and a minimum descent altitude of 6,600 feet. All five occupants were killed.
Probable cause:
The pilot's improper IFR procedures. Factors were: the existing weather conditions and the pilot's failure to obtain a preflight briefing.
Final Report:

Crash of a Piper PA-46-310P Malibu Mirage in Bronson: 4 killed

Date & Time: Mar 17, 1991 at 1036 LT
Registration:
N9112K
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Saint Petersburg – Bedford
MSN:
46-8608042
YOM:
1986
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
2252
Captain / Total hours on type:
268.00
Aircraft flight hours:
662
Circumstances:
The pilot was on an IFR flight in IMC and received clearance to climb and maintain FL220. During climb, he informed ARTCC, '. . . We're having a problem.' When asked to say again, he began the same reply, then no further radio communication was received from the aircraft. Subsequently an inflight breakup occurred and wreckage was scattered over a wide area. The right outboard wing panel, horizontal stabilizer, elevators, right aileron and parts of the rudder were found at a distance from the main wreckage. These displayed evidence of overstress failure. No preexisting cracks or fatigue was found. Radar and weather data showed deviation from normal flight began at or near moderate convective weather echo (vip 2) as the aircraft was climbing thru 17,300 feet in freezing conditions. At that time, the rate of climb was about 200 feet/min and the ground speed was 150 to 160 knots. At 1032:18, a descent begun. During the next 2 to 3 minutes, the aircraft's altitude, heading and speed deviated. At 1035:17, other primary radar targets appeared, then radar contact was lost. Gross weight of the aircraft was estimated to be 4,311 lbs; max allowable weight was 4,100 lbs. CofG was estimated to be 1.59 inches behind the aft limit. All four occupants were killed.
Probable cause:
The pilot's failure to activate the pitot heat before ascending above the freezing level in instrument meteorological conditions (IMC), followed by his improper response to erroneous airspeed indications that resulted from blockage of the pitot tube by atmospheric icing. Contributing to the accident was: the pilot's lack of currency in flying in IMC.
Final Report:

Crash of a Hawker-Siddeley HS.125-1A-522 on Mt Otay: 10 killed

Date & Time: Mar 16, 1991 at 0143 LT
Type of aircraft:
Registration:
N831LC
Flight Phase:
Survivors:
No
Site:
Schedule:
San Diego – Amarillo – Evansville
MSN:
25095
YOM:
1966
Crew on board:
2
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
10
Captain / Total flying hours:
15000
Captain / Total hours on type:
150.00
Circumstances:
After flying personnel of entertainment group to Lindbergh Field, aircraft was positioned to nearby Brown Field, since late departure was planned after noise curfew was in effect at Lindbergh. Pilot talked with FSS specialist (splst) 3 times before takeoff. He reported he did not have instruction departure procedures from airport. Splst read departure procedures on phone. On last call to FSS, pilot said he planned to depart VFR toward northeast and obtain IFR clearance after airborne (this route was toward mountains.) During call, pilot expressed concern about remaining cleared of TCA and inquired about staying below 3,000 feet. Splst agreed with pilots concerns, but after accident, splst said he thought pilot was referring to 3,000 feet agl, rather than 3,000 feet msl. Pilot had filed to takeoff at midnight, but didn't get airborne until 0141 pst. Since flight was over 1.5 hours late, IFR flight plan had 'clocked out.' As controller was reentering flight plan in computer, aircraft hit rising terrain near top of mountain, about 8 miles northeast of airport at elevation of about 3,300 feet. No deficiencies were found with aircraft or its engines. Copilot had no type rating for this aircraft, tho he reportedly had made 3 takeoffs and landings in Hawker-Siddeley HS.125. All 10 occupants were killed, among them all members of the country music 'Reba McEntire Band'.
Passengers:
Chris Austin,
Kirk Cappello,
Joey Cigainero,
Paul Kaye Evans,
Jim Hammond,
Terry Jackson,
Anthony Saputo,
Michael Thomas.
Probable cause:
Improper planning/decision by the pilot, the pilot's failure to maintain proper altitude and clearance over mountainous terrain, and the copilot's failure to adequately monitor the progress of the flight. Factors related to the accident were: insufficient terrain information provided by the flight service specialist during the preflight briefing after the pilot inquired about a low altitude departure, darkness, mountainous terrain, both pilot's lack of familiarity with the geographical area, and the copilot's lack of familiarity with the aircraft.
Final Report:

Crash of a Douglas DC-8-62F in New York

Date & Time: Mar 12, 1991 at 0906 LT
Type of aircraft:
Operator:
Registration:
N730PL
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
New York - Brussels
MSN:
46161
YOM:
1971
Flight number:
8C102
Crew on board:
3
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
12800
Captain / Total hours on type:
3000.00
Aircraft flight hours:
50145
Circumstances:
Before flight, the flight engineer (f/e) had calculated 'v' speeds and horizontal stabilizer trim setting for takeoff, but neither the captain nor the 1st officer (f/o) had verified them. During rotation for takeoff, the captain noted that the forced needed to pull the yoke aft was greater than normal and that the aircraft would not fly (at that speed). Subsequently, he aborted the attempted takeoff. Realizing the aircraft would not stop on the remaining runway, he elected to steer it to the right to avoid hitting traffic on a highway near the departure end. The aircraft struck ILS equipment; the landing gear collapsed and all 4 engines tore away. Subsequently, the aircraft was destroyed by fire. Investigations revealed the f/e had improperly computed the takeoff data. He had calculated the 'v' speeds and horizontal stabilizer trim setting for 242,000 lbs; however, the actual takeoff wt was 342,000 lbs. Rotation speed (Vr) for this weight was 28 knots above the speed that was used. Investigations revealed shortcomings in the operator's flightcrew training program and questionable scheduling of qualified (but marginally experienced) crew members for the accident flight.
Probable cause:
Improper preflight planning/preparation, in that the flight engineer miscalculated (misjudged) the aircraft's gross weight by 100,000 lbs and provided the captain with improper takeoff speeds; and improper supervision by the captain. Factors related to the accident were: improper trim setting provided to the captain by the flight engineer, inadequate monitoring of the performance data by the first officer, and the company management's inadequate surveillance of the operation.
Final Report: