Crash of a Cessna 414 Chancellor in Ramona

Date & Time: Mar 16, 1990 at 1440 LT
Type of aircraft:
Registration:
N711AG
Flight Type:
Survivors:
Yes
Schedule:
Carlsbad - Ramona
MSN:
414-0016
YOM:
1969
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
2300
Captain / Total hours on type:
50.00
Circumstances:
The pilot reported that the aircraft landed normally and during the landing roll a loud 'bang' was heard and the right main landing gear collapsed. An investigation was conducted by an FAA airworthiness inspector. During this investigation, it was noted that a washer in the right main landing gear assembly failed. Subsequent investigation, including a review of the aircraft maintenance records, revealed that cessna aircraft service information letter number ME83-37, dated november 23, 1983 had not been complied with. This service letter recommended replacement of the original washers with a new washer, Cessna part number S1450-5H12-063. (Old part number 5045018-2)
Probable cause:
Right main gear scissors assembly becoming disconnected during landing roll, allowing the right run landing gear to collapse; scissor assembly washers not being replaced as recommended in cessna aircraft service bulletin ME83-37.
Final Report:

Crash of a Piper PA-61 Aerostar (Ted Smith 601P) in Lake Butler

Date & Time: Mar 15, 1990 at 2245 LT
Registration:
N7443S
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Jacksonville – Atlanta
MSN:
61-0063-117
YOM:
1970
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
4548
Captain / Total hours on type:
2024.00
Aircraft flight hours:
3234
Circumstances:
Shortly after leveling off at 14,000 feet the left engine quit. The pilot diverted to Tampa, and 34 minutes later the right engine quit. During the subsequent forced landing the airplane collided with the roof of a covered sidewalk and then trees. Teardown of the left engine revealed that the seal between the exhaust flange and turbocharger was not installed; bolt clamp was finger tight. Heat had melted wiring harness and magneto grounding leads insulation; both 'p' leads were grounded. Pilot stated that after losing the left engine he initiated a left tank to right engine crossfeed, and after 20 minutes of single engine flight in this configuration the right engine quit. Flight manual states to land as soon as possible in case of one engine failure. In addition, it warns that when flying on one engine and cross feeding fuel, absolute coordinated flight must be maintained to prevent unporting of the tank's fuel pickup tube when the tank is not full.
Probable cause:
Inflight failure of the left engine which was caused by inadequate maintenance and inspection by company maintenance personnel resulting in heat damaged magneto leads as a result of a missing exhaust flange-to-turbocharger seal. In addition, the inflight power loss of the right engine was caused by the pilot's failure to follow the procedures in the airplane operating handbook and land as soon as possible resulting in fuel starvation of the right engine. Darkness was a related factor.
Final Report:

Crash of a Piper PA-61 Aerostar (Ted Smith 601P) in Bartonville: 2 killed

Date & Time: Mar 10, 1990 at 1228 LT
Operator:
Registration:
N410HC
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Saint Louis – Rochelle
MSN:
61-0367-116
YOM:
1977
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
3312
Circumstances:
Before takeoff, the pilot received a weather briefing and was advised of thunderstorms and heavy rain along the route. The briefing included a warning of a severe thunderstorm watch with hail, wind gusts to 65 knots and a sigmet (31c). The pilot filed an IFR flight plan and took off at 1148 cst. While en route at 15,000 msl, he requested and received clearance to divert 10° left to avoid 'some clouds.' Soon thereafter, the ATC controller noticed the aircraft was about 500 feet high and reminded the pilot to maintain 15,000 feet. The pilot acknowledged, then there was no further communication with the aircraft. Subsequently, an in-flight breakup of the aircraft occurred and the plane crashed. The left outboard wing panel separated from positive overload failure and was found about one mile from the main wreckage. No preimpact fatigue was found. A witness, who saw the aircraft descending out of the clouds, saw a funnel cloud in the area before the accident. Both occupants were killed.
Probable cause:
The pilot allowed the aircraft to exceed its design stress limits after encountering adverse weather. Factors related to the accident were: the pilot's improper evaluation of the weather and the adverse weather conditions.
Final Report:

Crash of a Cessna 208A Cargomaster in Denver: 1 killed

Date & Time: Feb 27, 1990 at 1947 LT
Type of aircraft:
Operator:
Registration:
N820FE
Flight Type:
Survivors:
No
Schedule:
Aspen - Denver
MSN:
208-0043
YOM:
1985
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
3800
Captain / Total hours on type:
70.00
Aircraft flight hours:
3227
Circumstances:
The Cessna 208A was on an IFR flight to haul freight from Aspen to Denver, Colorado. Moderate to heavy icing conditions were forecast for the Denver area. While on an ILS runway 36 approach, the aircraft encountered icing conditions. Subsequently, it entered a steep descent and crashed about 3 miles from the approach end of the runway. No preimpact part failure of the aircraft was found during the investigation. The 1950 mst weather at the airport was in part: 800 feet scattered, 1,000 feet broken, visibility 4 miles with freezing drizzle and snow showers, temp 28°, dew point 25°.
Probable cause:
The accumulation of structural ice and subsequent stalling of the aircraft. The icing condition was a related factor.
Final Report:

Crash of a Cessna T207 Skywagon in Hungry Horse

Date & Time: Feb 21, 1990 at 1928 LT
Operator:
Registration:
N91146
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Kalispell - Great Falls
MSN:
207-0090
YOM:
1969
Flight number:
CPT500
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
1850
Captain / Total hours on type:
27.00
Aircraft flight hours:
10455
Circumstances:
Airspur flight 500, a domestic cargo flight, departed Kalispell, MT, at 1903 mdt with an IFR flight plan to Great Falls, MT. At 1922, the pilot notified Salt Lake ARTCC he was returning to Kalispell due to a rough running engine. Shortly thereafter, the pilot reported the engine had failed completely. The pilot made an emergency forced landing on a mountain ridge at the approximately 5,500 feet level in IFR conditions. Accident location was approximately 18 nm east of Kalispell. Engine disassembly later revealed the #4 connecting rod had failed catastrophically. The pilot escaped with minor injuries.
Probable cause:
Failure of the #4 connecting rod. Factors related to the accident were: the adverse weather conditions and lack of suitable terrain for a forced landing.
Final Report:

Crash of a Piper PA-31-350 Navajo Chieftain in Greeley

Date & Time: Feb 21, 1990 at 0815 LT
Registration:
N3554P
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Greeley - Greeley
MSN:
31-8052052
YOM:
1980
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
2455
Captain / Total hours on type:
139.00
Aircraft flight hours:
22598
Circumstances:
N3554p was on a maintenance test flight after the right wing was repaired. The pilot lost control of the airplane shortly after liftoff and was unable to regain control prior to the ground impact. The a&p mechanic who performed the repairs, re assembled the right wing aileron control cables per the Piper service manual. Post accident examination of the aileron control system revealed the right wing control cables were reversed on the aileron bellcrank, resulting in both ailerons moving the same direction (either up or down) when the control wheel was turned left or right. Both occupants were seriously injured.
Probable cause:
The improper identification of parts in the piper PA-31-350 service manual pertaining to the aileron cables. This discrepancy resulted in the improper installation of the aileron cables on the right aileron bellcrank by a mechanic during the reconstruction of the right wing. The improper connection resulted in a loss of aircraft control by the pilot immediately after takeoff. Also causal to the accident were the inadequate inspection of the flight control system by a second mechanic with inspection authorization, and the inadequate preflight inspection of the flight control system by the pilot prior to takeoff.
Final Report:

Crash of a Piper PA-31-350 Navajo Chieftain in Cold Bay: 1 killed

Date & Time: Feb 17, 1990 at 1335 LT
Operator:
Registration:
N27328
Flight Type:
Survivors:
No
Site:
Schedule:
King Cove - Cold Bay
MSN:
31-7752149
YOM:
1977
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
9487
Captain / Total hours on type:
1000.00
Aircraft flight hours:
12690
Circumstances:
The scheduled flight's departure from King Cove was delayed due to a passing snow squall. A witness at the airport stated that the weather at the airport was good when the flight departed; however, he noted dark clouds in the direction of Cold Bay, the intended destination of the flight. The airplane did not reach its destination. It was found, where it had impacted terrain near the top of a ridgeline at the 1,250 foot level, between King Cove and Cold Bay. About 8 miles west-northwest at Cold Bay, weather reports indicated there were snow showers of unknown intensity in all quadrants. The pilot, sole on board, was killed.
Probable cause:
Continued VFR flight by the pilot into instrument meteorological conditions (IMC), and his failure to maintain adequate altitude (or clearance) from mountainous terrain. The adverse weather and terrain conditions were related factors.
Final Report:

Crash of a Mitsubishi MU-2B-60 Marquise in Putnam: 5 killed

Date & Time: Feb 14, 1990 at 0753 LT
Type of aircraft:
Registration:
N300CW
Flight Phase:
Survivors:
No
Schedule:
Midland - Dallas
MSN:
795
YOM:
1980
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
10327
Captain / Total hours on type:
35.00
Aircraft flight hours:
2600
Circumstances:
Before takeoff, San Angelo AFSS briefer told the pilot computers were down in south Texas for 1.5 hours and no current weather info was available. Current weather info was available at nws at Midland and FSS's at Midland, McAlester and De Ridder, but the pilot didn't call these, nor did the briefer advise him to do so. Pilot didn't update weather in flight. About 38 minutes after takeoff, in area of potential icing, aircraft slowed from 270 to 150 knots ground speed in 4 minutes, then slowed to 100 knots in next 12 seconds. About 33 seconds before reaching 100 knots, pilot requested descent from 15,000 feet to 13,000 feet. At that time, true ground track was approximately 080° with wind aloft about 213° at 43 knots. Before ATC could clear descent, aircraft descended to 14,800 feet, then radar contact was lost after one return at 9,700 feet. Descent rate between last 2 altitudes: 12,750 fpm. No preimpact malfunction was found. IMC existed above 12,500 feet. Freezing level was forecasted at 10,000 feet to 12,000 feet. Aircraft was certified for flight in known icing conditions, but status of anti-ice/deice equipment wasn't determined due to impact/fire damage. Low levels of ethanol were found in tox samples from all occupants; however, there was evidence that the tox samples were unreliable. All five occupants were killed.
Probable cause:
Improper planning/decision by the pilot, which resulted in excessive accumulation of structural icing (on the aircraft's wings, stabilizers, fuselage, and/or engine inlets), and his failure to maintain adequate airspeed and aircraft control. Factors related to the accident were: the pilot's inadequate weather evaluation due to lack of available information at the automated flight service station (AFSS), his failure to obtain additional information from other weather stations (either before takeoff or during the flight), his lack of experience in this make and model of aircraft, and icing conditions at cruise altitude.
Final Report:

Crash of a Beechcraft C90 King Air in Burlington: 2 killed

Date & Time: Feb 13, 1990 at 1830 LT
Type of aircraft:
Operator:
Registration:
N110LT
Survivors:
No
Schedule:
Teterboro - Burlington
MSN:
LJ-729
YOM:
1977
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
13800
Aircraft flight hours:
5976
Circumstances:
The pilot transmitted on unicom that he was on final for runway 24. Following a double fuel starvation power loss the airplane impacted nose low with trees and terrain about 2.6 miles from runway 24. Last fueling occurred on the previous day at Albermarle, NC, the pilot's primary source of fuel, 50 miles from Burlington. The flight proceeded to Burlington, Teterboro, and was returning to Burlington. Total estimated flight time was 4 hours 32 minutes. Fuel burn was calculated to be 361 gallons. Usable fuel was 384 gallons and 24 gallons were recovered from the right center tank. If the fuel transfer pump does not operate 28 gallons will be unusable. That pump was found in the off position. No fuel spillage occurred at the scene. On 2/8/90 the pilot purchased 361 gallons of fuel for N110LT. Lower fuel prices at the favored location were the pilot's reason for fueling there. Examination of engines, propellers, fuel pumps, and other relative components did not reveal any significant discrepancy. Both occupants were killed.
Probable cause:
The double engine power loss due to fuel starvation, the pilot's failure to follow procedures and directives by not engaging the right fuel transfer pump, and the inadvertent stall during the forced landing approach. A factor was the pilot's failure to refuel before adequate fuel reserves were exhausted.
Final Report:

Crash of a Mitsubishi MU-2B-60 Marquise in Rapid City: 1 killed

Date & Time: Feb 9, 1990 at 1114 LT
Type of aircraft:
Registration:
N64MD
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Yuma – Rapid City – Winnipeg
MSN:
747
YOM:
1979
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
5985
Captain / Total hours on type:
291.00
Aircraft flight hours:
4382
Circumstances:
Witnesses reported that shortly after lift-off, the aircraft entered an unusually steep, nose high attitude, while still at low airspeed. One witness (an ATP pilot) reported the aircraft attained an altitude of approximately 75 to 100 feet and appeared to slow down and enter a VMC roll, then it crashed. Impact occurred in an inverted, nose down attitude, left of the runway. An investigation revealed that a coupling shaft (PN 865888-3) had failed in the left engine and the left prop had feathered. A metallurgical examination of the coupling showed evidence of fatigue. One pilot was killed and three other occupants were injured, one seriously.
Probable cause:
Failure of the pilot to maintain adequate airspeed (VMC), which resulted in a loss of aircraft control. A factor related to the accident was: fatigue failure of a coupling shaft in the #1 engine, which resulted in loss of power in that engine.
Final Report: