Crash of a Beechcraft 200 Super King Air in Pensacola: 3 killed

Date & Time: Apr 10, 1989 at 1300 LT
Registration:
N30PC
Flight Phase:
Survivors:
No
Schedule:
Pensacola - Atlanta
MSN:
BB-702
YOM:
1980
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
14200
Captain / Total hours on type:
3000.00
Aircraft flight hours:
6351
Circumstances:
The aircraft was routinely flown to Pensacola to pickup a gulf power executive for a flight to Atlanta. The pax had 4 bags, 2 placed in the aft baggage area by the ground crew, the other 2 carried onboard by the pax. After takeoff the CVR recorded the pax stating that there was a fire. The fire in the aft cabin area was confirmed by the 1st officer. An emergency was declared to the personnel ATCT. Subsequently, the aircraft was seen descending out of the overcast streaming dark smoke behind it. The aircraft impacted an apartment complex and a post crash fire destroyed it. No evidence of a lightning strike, aircraft system malfunction, or incendiary device was found during the investigation. Forensic chemical tests showed traces of hydrochloric and sulphuric acid on pax articles but none on the cabin interior. Metallurgical exam of broken fuel line showed overload failure and post heat distress. The interior of the cockpit windows were severely sooted. The flight crew did not don available oxygen masks.
Probable cause:
An in flight cabin fire of undetermined origin, and smoke (toxic condition) in the crew compartment, which resulted in physical impairment of the flight crew.
Final Report:

Crash of a Piper PA-61 Aerostar (Ted Smith 601) in Santa Ana: 5 killed

Date & Time: Mar 31, 1989 at 0835 LT
Operator:
Registration:
C-GWPS
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Santa Ana – Pocatello – Camrose
MSN:
61-0522-219
YOM:
1978
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
1490
Captain / Total hours on type:
243.00
Aircraft flight hours:
1908
Circumstances:
Several mechanic witnesses at the airport said the right engine backfired and trailed black smoke during the takeoff ground roll. Reportedly, the takeoff roll was about 80% longer than normal. Witnesses said the aircraft staggered off the ground, was slow and never got above 100 feet agl. The pilot reported to the tower that the flight had to come back to the runway. Shortly thereafter, witnesses saw the aircraft enter a steep left turn, apparently stall, then crash into some tennis courts. An investigation revealed evidence that the right engine had lost power. A modification kit for the fuel injector reference air lines was incorrectly installed and allowed an unfiltered air source. Spectral analysis of residue (from the right engine turbocharger compressor) revealed that it had the same composition as the alternate air door seal. Traces of the material were found in the fuel injector reference air line. All five occupants were killed.
Probable cause:
Failure of the pilot to attain adequate airspeed before maneuvering (turning) back toward the airport, which resulted in a loss of aircraft control. A factor related to the accident was: improper maintenance/installation of a fuel injector reference air line, which allowed contamination of the injectors and loss of power in the right engine.
Final Report:

Crash of a Cessna 421A Golden Eagle I in Brownsville: 1 killed

Date & Time: Mar 28, 1989 at 1834 LT
Type of aircraft:
Registration:
N4595L
Flight Type:
Survivors:
No
Schedule:
Brownsville - Brownsville
MSN:
421A-0195
YOM:
1968
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
1215
Captain / Total hours on type:
1.00
Circumstances:
The newly hired corporate pilot starved the right engine of fuel on the multi-engine airplane while on a local area self checkout in the airplane. He did not feather the right propeller. At the time of the non-mechanical loss of power, the airplane was in low level (600 feet agl) cruise. The pilot lowered the flaps to 45° and extended the landing gear to the down and locked position. The airplane's airspeed decreased below vmc and the airplane stalled, went out of control, and impacted open ranch land nose low, in a vertical descent angle. A post-impact fire occurred. The pilot lacked knowledge of the airplane systems and lacked experience in the Cessna 421. The pilot, sole on board, was killed.
Probable cause:
The pilot's improper emergency procedure after losing power in the right engine, and his failure to maintain minimum control speed (VMC), which resulted in a loss of aircraft control. Factors related to the accident were: fuel starvation of the right engine, the pilot's lack of experience in this type of aircraft, and his lack of understanding of the fuel system.
Final Report:

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

Date & Time: Mar 22, 1989 at 2244 LT
Registration:
N77BR
Flight Type:
Survivors:
No
Schedule:
Atlanta – Jacksonville
MSN:
60-0600-7961193
YOM:
1979
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
2575
Captain / Total hours on type:
1250.00
Aircraft flight hours:
3891
Circumstances:
During arrival, the pilot was cleared for an ILS runway 07 approach. Also, he was advised of a DC-9 that was 4 miles ahead and was told to use caution for wake turbulence. As the aircraft was on final approach, it descended below the ILS glide slope and subsequently hit trees and crashed about 1.8 mile short of the runway. No preimpact part failure or malfunction of the aircraft or engines was found that would have resulted in an accident. Also, there were no reported problems with the ILS system and it tested normal after the accident. The pilot held a commercial pilot certificate which was good for single engine land aircraft; his multi-engine privileges were authorized as a private pilot, only. An NTSB performance study showed the aircraft was 2 minutes and 57 seconds behind the DC-9. Radar data indicated the aircraft did not exceed a bank angle of 32° and no excessive g-values were evident during the approach. The pilot, sole on board, was killed.
Probable cause:
Improper use of the IFR procedure by the pilot, his failure to maintain a proper glide path, and his failure to identify the decision height.
Final Report:

Crash of a Douglas DC-9-33RC at Carswell AFB: 2 killed

Date & Time: Mar 18, 1989 at 0216 LT
Type of aircraft:
Operator:
Registration:
N931F
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Carswell - Tinker
MSN:
47192
YOM:
1968
Flight number:
EV417
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
7238
Captain / Total hours on type:
1938.00
Copilot / Total flying hours:
10863
Copilot / Total hours on type:
1213
Aircraft flight hours:
41931
Aircraft flight cycles:
40808
Circumstances:
The DC-9 arrived at Carswell AFB at 01:12 CST after a flight from Kelly AFB. The aircraft was off-loaded and re-loaded with cargo by USAF personnel. The engines were then started at 02:04. The crew received taxi instructions for runway 17 and took off from this runway at 02:09. At (or immediately after) rotation, the main cargo door opened. An emergency was declared and the crew climbed to 2500 feet msl before entering a right turn. When about 5nm north of the airport the captain began a shallow turn to the right (for base leg). The aircraft crossed the extended centreline and the captain tightened the turn to establish their position relative to the runway threshold. In doing so, the air load on the door probably caused it to rapidly move to its full open over the top position. A sudden opening of the door would also have produced an unexpected change in the yawing and rolling moments. The captain, possibly partially disoriented, may not have sensed the increasing roll and nose tuck and thus failed to correct a changing attitude until a critical bank angle and loss of altitude had occurred. The DC-9 struck the ground in an inverted, nose down, left wing low attitude and disintegrated. It appeared that the first officer, when closing the main cargo door, didn't hold the door control valve 'T' handle in the closed position long enough for the latching hooks to move into place over the door sill spools. External latched and locked indicators were applied incorrectly, so the first officer thought the door was latched properly when the handle was pointed more toward the 'locked' than the 'unlocked' chevron. It also appeared that one of the two open door warning light switches was malfunctioning. Because of their wiring, this malfunction made the entire door warning system ineffective.
Probable cause:
The loss of control of the airplane for undetermined reasons following the in-flight opening of the improperly latched cargo door. Contributing to the accident were inadequate procedures used by Evergreen Airlines and approved by the FAA for pre-flight verification of external cargo door lock pin manual control handle, and the failure of McDonnell Douglas to provide flight crew guidance and emergency procedures for an in-flight opening of the cargo door. Also contributing to the accident was the failure of the FAA to mandate modification to the door-open warning system for DC-9 cargo-configured airplanes, given the previously known occurrences of in-flight door openings.
Final Report:

Crash of a NAMC YS-11A-300F in West Lafayette: 2 killed

Date & Time: Mar 15, 1989 at 0726 LT
Type of aircraft:
Operator:
Registration:
N128MP
Flight Type:
Survivors:
No
Schedule:
Terre Haute - West Lafayette
MSN:
2139
YOM:
1970
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
7294
Captain / Total hours on type:
2097.00
Aircraft flight hours:
24088
Circumstances:
An IFR flight was terminated with a visual approach. Conditions were conducive to airframe icing. The aircraft was being positioned empty, with a cg at 22.1% mac. On short final, at approximately 400 feet agl, 35° of landing flap was selected. The aircraft was observed to pitch downward to an unusual attitude and to enter a steep descent. A partial recovery was observed before the aircraft impacted a dirt hill 500 feet short of runway 28. Examination of the airframe after the accident revealed 1/2 to 3/4 inch of rime ice adhering to the leading edge of the horizontal stabilizer. No ice was found on any other portion of the airframe. Evidence in the cockpit indicated that engine, pitot, and windshield anti-ice systems were on, but wing/empennage deice was off. No evidence of a powerplant or systems malfunction was found. Both pilots were killed.
Probable cause:
A loss of control due to the improper inflight decisions by the crew and the undetected accumulation of ice on the leading edge of the horizontal stabilizer, during flight in a forward center of gravity condition and exacerbated by the extension of full landing flaps.
Final Report:

Crash of a Beechcraft A60 Duke in Manassas: 5 killed

Date & Time: Mar 11, 1989 at 1615 LT
Type of aircraft:
Operator:
Registration:
N98DS
Flight Phase:
Survivors:
No
Schedule:
Manassas – Wilmington
MSN:
P-227
YOM:
1973
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
25130
Aircraft flight hours:
1775
Circumstances:
Witnesses reported the aircraft took off and climbed to about 300 feet while in a wide left turn. According to witnesses, the wings were rocking and erratic engine sounds were noted. The aircraft was turning downwind when it abruptly pitched down, rolled left until inverted, descended and crash. Examination of the aircraft revealed no evidence of malfunction, although the left prop had less rotational damage than the right prop. Examination of aircraft records revealed the aircraft was inactive for about 9 years until it was returned to service less than a year before the accident. The aircraft accumulated about 17 hours since it was returned to service. The pilot stated to a witness before the accident that he had not done single engine operation in the aircraft. The aircraft was overloaded more than 200 lbs. All five occupants were killed.
Probable cause:
A loss of aircraft control due to the pilot's failure to maintain minimum engine control speed after a partial loss of power of the left engine for undetermined reasons. The pilot's inexperience in type of aircraft and an over maximum gross weight aircraft were contributing factors.
Final Report:

Crash of a Beechcraft E18S in Cincinnati: 1 killed

Date & Time: Mar 9, 1989 at 0617 LT
Type of aircraft:
Operator:
Registration:
N3281T
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Cincinnati – Detroit
MSN:
BA-611
YOM:
1962
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
10560
Captain / Total hours on type:
15.00
Aircraft flight hours:
13262
Circumstances:
N3281T was attempting an instrument departure when it crashed left of the extended centerline of runway 18. The flight was observed climbing through 200 feet prior to descending to the ground. Prior to taxiing to takeoff the pilot failed to deice the airframe. Airplanes on the parking ramp around N3281T deiced prior to takeoff. Weather reports indicated that temp/dew point were 26 and 23° respectively. The surface observation also reported fog as a restriction to visibility. According to the airplane's handbook that tests prove that a coat of frost on a wing can destroy its lift. The pilot, sole on board, was killed.
Probable cause:
Pilot attempted a takeoff with coating of frost on the airframe which resulted in a loss of lift during climbout.
Final Report:

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

Date & Time: Mar 4, 1989 at 1200 LT
Registration:
C-FHGH
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Portland - Reno
MSN:
61-0829-8163438
YOM:
1981
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
1300
Captain / Total hours on type:
108.00
Aircraft flight hours:
1297
Circumstances:
While en route, the pilot encountered headwinds and trace rime icing. He made a climb from 17,000 feet to FL190, then to FL210. After cruising at FL210 for about 27 minutes, the aircraft entered a descent (without ATC clearance). Radio and radar contact were lost in the vicinity of were the aircraft crashed. Just before impact, the aircraft was observed to descend out of low clouds in a spin. The pilot had been issued a Canadian instrument rating on 1/11/88, but it was valid for only 12 months. A person, who had given the pilot proficiency flight training in preparation for an instrument qualification check, reported that he had reservations about the pilot's ability to fly in instrument conditions without an autopilot. Avionics personnel at the departure airport reported the pilot had encountered an autopilot malfunction on the previous flight and that they had found an electrical short in the autopilot disconnect switch on the copilot control yoke. However, they were unable to repair it due to lack of a replacement part. Reportedly, the pilot borrowed a soldering iron to repair it himself. All three occupants were killed.
Probable cause:
Failure of the pilot to maintain control of the aircraft, which resulted in a spin and an uncontrolled descent. Factors related to the accident were: improper maintenance by the pilot, an autopilot malfunction, the adverse weather conditions, continued flight by the pilot into adverse weather conditions, and his lack of recent instrument experience.
Final Report:

Crash of a Cessna 421B Golden Eagle II in San Antonio

Date & Time: Mar 3, 1989 at 0245 LT
Registration:
N5999M
Survivors:
Yes
Schedule:
Memphis - San Antonio
MSN:
421B-0242
YOM:
1972
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
732
Captain / Total hours on type:
34.00
Aircraft flight hours:
2897
Circumstances:
The airplane had made one approach, followed by a missed approach during a dark night with low ceilings and low visibility. During the next approach the airplane was high on the glide slope and touched down fast and long. The airplane hit the terrain 300 feet past the end of the runway, hit a second time 115 feet further down, then flew into the ils localizer. Part of the left wing burned. There were no indications of an attempted go-around.
Probable cause:
The failure of the pilot to follow the proper procedures/directives by not following the glideslope which resulted in not being able to attain the proper touchdown point.
Final Report: