Crash of a Rockwell CT-39G Sabreliner in Glenview: 3 killed

Date & Time: Mar 3, 1991 at 1140 LT
Type of aircraft:
Operator:
Registration:
160057
Flight Type:
Survivors:
No
Site:
Schedule:
Glenview - Glenview
MSN:
306-108
YOM:
1975
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
3
Circumstances:
The crew (one instructor and two pilots under training) was completing a local training at Glenview Airport. On approach to runway 27, the instructor decided to initiate a go-around procedure then started an approach to runway 35. He cancelled his IFR flight plan when control was lost. The airplane crashed onto several houses located near the airport. All three crew members were killed while there were no casualties on ground.

Crash of a Boeing 737-291 in Colorado Springs: 25 killed

Date & Time: Mar 3, 1991 at 0944 LT
Type of aircraft:
Operator:
Registration:
N999UA
Survivors:
No
Schedule:
Peoria – Moline – Denver – Colorado Springs
MSN:
22742
YOM:
1982
Flight number:
UA585
Crew on board:
5
Crew fatalities:
Pax on board:
20
Pax fatalities:
Other fatalities:
Total fatalities:
25
Captain / Total flying hours:
9902
Captain / Total hours on type:
1732.00
Copilot / Total flying hours:
3903
Copilot / Total hours on type:
1077
Aircraft flight hours:
26050
Aircraft flight cycles:
19734
Circumstances:
On March 3, 1991, a United Airlines Boeing 737, registration number N999UA, operating as flight 585, was on a scheduled passenger flight from Denver, Colorado, to Colorado Springs, Colorado. Visual meteorological conditions prevailed at the time, and the flight was on an instrument flight rules flight plan. Numerous witnesses reported that shortly after completing its turn onto the final approach course to runway 35 at Colorado Springs Municipal Airport, about 0944 mountain standard time, the airplane rolled steadily to the right and pitched nose down until it reached a nearly vertical attitude before hitting the ground in an area known as Widefield Park. The airplane was destroyed, and the 2 flight crewmembers, 3 flight attendants, and 20 passengers aboard were fatally injured.
Probable cause:
A loss of control of the airplane resulting from the movement of the rudder surface to its blowdown limit. The rudder surface most likely deflected in a direction opposite to that commanded by the pilots as a result of a jam of the main rudder power control unit servo valve secondary slide to the servo valve housing offset from its neutral position and overtravel of the primary slide.
Final Report:

Crash of a Piper PA-60 Aerostar (Ted Smith 600) in Fort Chaffee: 1 killed

Date & Time: Mar 1, 1991 at 1655 LT
Registration:
N7488S
Flight Type:
Survivors:
No
Schedule:
Fort Smith – Vicksburg
MSN:
60-0045-100
YOM:
1970
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
1800
Captain / Total hours on type:
500.00
Circumstances:
The pilot of the multi-engine aircraft reported that his right engine was losing oil as he was climbing to cruise altitude. He secured the engine, feathered the propeller, and maneuvered to return to the airport. The pilot trimmed the aircraft for single engine operation and extended the main landing gear. During the approach, the operating left engine would not develop full power and the pilot reported to atc that he could not make the airport. The aircraft continued its emergency descent, impacted trees, and descended uncontrolled through a densely wooded area. A fuel tank ruptured during the uncontrolled descent through the trees and a fire/explosion occurred. The aircraft continued to burn after ground impact. Both engines were disassembled and numerous mechanical anomalies were found. They had been recently overhauled. This was the first flight of the aircraft since the engine overhauls. The pilot/owner was en route to sell the aircraft when the accident occurred. The pilot, sole on board, was killed.
Probable cause:
The pilot's operation of the aircraft with known deficiencies in equipment. Factors were the improper overhaul of the engines by other maintenance personnel resulting in oil loss, deteriorated engine performance, and unsuitable terrain.
Final Report:

Crash of an IAI 1123 Westwind in Avon Park

Date & Time: Feb 23, 1991
Type of aircraft:
Registration:
XA-POJ
Flight Type:
Survivors:
Yes
MSN:
161
YOM:
1973
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Upon touchdown at Avon Park Airport, tyre(s) burst. The crew lost control of the airplane that veered off runway, lost its undercarriage and came to rest. Both pilots escaped uninjured and the aircraft was damaged beyond repair.

Crash of a Mitsubishi MU-2B-60 Marquise in Tulsa: 3 killed

Date & Time: Feb 22, 1991 at 1519 LT
Type of aircraft:
Registration:
N274MA
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Tulsa - Tulsa
MSN:
786
YOM:
1980
Location:
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
4910
Captain / Total hours on type:
445.00
Aircraft flight hours:
6094
Circumstances:
Airplane was departing on a required maintenance test flight following replacement of both engines. Witnesses stated that the takeoff roll and initial climb appeared normal, but that at about 500 feet agl, the airplane entered a right bank which continued until the wings were vertical and the nose fell through. Airplane impacted in an inverted steep nose down attitude. Examination of wreckage revealed that the right engine had been secured and feathered. Subsequent investigation did not reveal any evidence of pre-impact failure or malfunction of either engine or any of the airframe systems. Engine mounting/rigging continuity could not be established due to impact damage. The pilot was a principal in the operator's organization and not one of the regular line pilots. Evidence indicated that the gear was up and that the left spoiler was deployed at impact. Emerg procedure taught in transition training is to use rudder trim as soon as possible after engine failure to preclude deployment of spoilers. Rudder trim found in neutral position. All three occupants were killed.
Probable cause:
The shutdown of one engine for undetermined reasons, and the pilot's failure to maintain VMCA during a critical phase of flight. A factor in the accident was the pilot's improper emergency procedure.
Final Report:

Crash of a Douglas DC-9-15RC in Cleveland: 2 killed

Date & Time: Feb 17, 1991 at 0019 LT
Type of aircraft:
Operator:
Registration:
N565PC
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Buffalo - Cleveland - Indianapolis
MSN:
47240
YOM:
1968
Flight number:
RYN590
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
10505
Captain / Total hours on type:
505.00
Copilot / Total flying hours:
3820
Copilot / Total hours on type:
510
Aircraft flight hours:
47574
Circumstances:
The flight had flown through weather conducive to airframe ice about 40 minutes prior to the accident during descent into Cleveland. During the 35-minute turnaround at Cleveland the crew did not exit the airplane to conduct an exterior preflight inspection to verify that the wings were free of ice contamination. It was snowing while they were on the ground. The airplane stalled and rolled into the ground immediately after takeoff. There was no operator requirement for the preflight. The flight had not been given training regarding the effects of wing contamination on the airplane. The FAA and the manufacturer have been aware for several years of the propensity of the DC-9 series 10 to the loss of control caused by wing contamination, but neither of them took positive action to include related information in the approved airplane flight manual. Both pilots were killed.
Probable cause:
The failure of the flightcrew to detect and remove ice contamination on the airplane's wings, which was largely a result of a lack of appropriate response by the federal aviation administration, Douglas aircraft company, and ryan international airlines to the known critical effect that a minute amount of contamination has on the stall characteristics of the DC-9 series 10 airplane. The ice contamination led to wing stall and loss of control during the attempted takeoff.
Final Report:

Crash of a Learjet 35A in Aspen: 3 killed

Date & Time: Feb 13, 1991 at 1741 LT
Type of aircraft:
Operator:
Registration:
N535PC
Survivors:
No
Schedule:
Las Vegas - Aspen
MSN:
35-291
YOM:
1980
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
10530
Captain / Total hours on type:
3700.00
Circumstances:
The flight crew reported to the tower controller that they were over the airport and requested a right downwind circling approach to runway 15. The tower controller and other witnesses observed the airplane in a steep right bank on base leg. The airplane overshot the extended runway centerline. The tower controller observed the airplane entering a steeper right bank to correct back to the runway centerline. The controller stated that he observed the airplane "flutter" and then crash right-wing first, about one mile north of the runway threshold. Other witnesses reported a variety of indications consistent with a loss of control. The last recorded transmission was "Oh no you're (stall…)." The ( ) indicates that the word was questionable text. Both engines were producing about 1,700 pounds of thrust (2,561 pounds available). A snow squall had just passed over the airport and was obscuring mountains to the east. The terrain was snow covered. The accident occurred about eight minutes before official sunset. The approach procedure is not authorized at night or for category D airplanes. Minimums for the approach were three miles visibility with an MDA of 10,840 feet. Airport elevation is 7,815 feet. Both pilots were rated in the airplane. It could not be determined which pilot was at the controls at the time of the accident.
Probable cause:
The flight crew's failure to maintain airspeed and control of the airplane while maneuvering to land. Contributing factors were the flight crew's execution of an unstabilized approach and the surrounding snow-covered mountainous terrain.
Final Report:

Crash of a Piper PA-31-350 Navajo Chieftain in Munford: 4 killed

Date & Time: Feb 7, 1991 at 0830 LT
Operator:
Registration:
N27818
Survivors:
No
Schedule:
Macon - Anniston
MSN:
31-7952001
YOM:
1979
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
3000
Circumstances:
During an updated 0528 est weather briefing, the pilot was advised of flight precautions for IFR weather conditions in the Georgia and Alabama areas. At 0841 est he departed Macon, GA on an IFR flight plan to Anniston, AL. At 0821 cst, approximately 22 miles southeast from the Anniston Airport, the pilot contacted Atlanta center and cancelled his IFR flight plan. He was advised that the minimum safe altitude in his area was 2,900 feet msl. Two minutes later he contacted Anniston radio and requested local weather conditions. He was given the latest reported (0756 cst) weather as ceiling 1,500 broken, 3,100 overcast, 5 miles with fog. The Anniston airport field elevation is 526 feet. The aircraft subsequently impacted a mountain top 10 miles southwest of the airport at an elevation of approximately 2,300 feet. The 0850 cst Anniston weather was 800 feet overcast, 4 miles in fog. All four occupants were killed.
Probable cause:
The pilot attempting visual flight in instrument meteorological conditions below the minimum safe altitude for terrain clearance. Contributing factors were the low ceiling and mountainous terrain.
Final Report:

Crash of a Swearingen SA227AC Metro III in Los Angeles: 12 killed

Date & Time: Feb 1, 1991 at 1807 LT
Type of aircraft:
Operator:
Registration:
N683AV
Flight Phase:
Survivors:
No
Schedule:
Los Angeles - Palmdale
MSN:
AC-683
YOM:
1987
Flight number:
OO5569
Crew on board:
2
Crew fatalities:
Pax on board:
10
Pax fatalities:
Other fatalities:
Total fatalities:
12
Captain / Total flying hours:
8808
Captain / Total hours on type:
2107.00
Copilot / Total flying hours:
8000
Copilot / Total hours on type:
1363
Circumstances:
SKW5569, N683AV, had been cleared to runway 24L, at intersection 45, to position and hold. The local controller, because of her preoccupation with another airplane, forgot she had placed SKW5569 on the runway and subsequently cleared US1493, N388US, for landing. After the collision, the two airplanes slid off the runway into an unoccupied fire station. The tower operating procedures did not require flight progress strips to be processed through the local ground control position. Because this strip was not present, the local controller misidentified an airplane and issued a landing clearance. The technical appraisal program for air traffic controllers is not being fully utilized because of a lack of understanding by supervisors and the unavailability of appraisal histories.
Probable cause:
The failure of the los angeles air traffic facility management to implement procedures that provided redundancy comparable to the requirements contained in the national operational position standards and the failure of the faa air traffic service to provide adequate policy direction and oversight to its air traffic control facility managers. These failures created an environment in the Los Angeles air traffic control tower that ultimately led to the failure of the local controller 2 (lc2) to maintain an awareness of the traffic situation, culminating in the inappropriate clearances and the subsequent collision of the usair and skywest aircraft. Contributing to the cause of the accident was the failure of the faa to provide effective quality assurance of the atc system.
Final Report:

Crash of a Boeing 737-3B7 in Los Angeles: 22 killed

Date & Time: Feb 1, 1991 at 1807 LT
Type of aircraft:
Operator:
Registration:
N388US
Survivors:
Yes
Schedule:
Columbus - Los Angeles
MSN:
23310
YOM:
1985
Flight number:
US1493
Crew on board:
6
Crew fatalities:
Pax on board:
83
Pax fatalities:
Other fatalities:
Total fatalities:
22
Captain / Total flying hours:
16300
Captain / Total hours on type:
4300.00
Copilot / Total flying hours:
4316
Copilot / Total hours on type:
982
Circumstances:
SKW5569, N683AV, had been cleared to runway 24L, at intersection 45, to position and hold. The local controller, because of her preoccupation with another airplane, forgot she had placed SKW5569 on the runway and subsequently cleared US1493, N388US, for landing. After the collision, the two airplanes slid off the runway into an unoccupied fire station. The tower operating procedures did not require flight progress strips to be processed through the local ground control position. Because this strip was not present, the local controller misidentified an airplane and issued a landing clearance. The technical appraisal program for air traffic controllers is not being fully utilized because of a lack of understanding by supervisors and the unavailability of appraisal histories.
Probable cause:
The failure of the los angeles air traffic facility management to implement procedures that provided redundancy comparable to the requirements contained in the national operational position standards and the failure of the faa air traffic service to provide adequate policy direction and oversight to its air traffic control facility managers. These failures created an environment in the Los Angeles air traffic control tower that ultimately led to the failure of the local controller 2 (lc2) to maintain an awareness of the traffic situation, culminating in the inappropriate clearances and the subsequent collision of the usair and skywest aircraft. Contributing to the cause of the accident was the failure of the faa to provide effective quality assurance of the atc system.
Final Report: