Crash of a Douglas C-47A-70-DL in Laredo

Date & Time: Jan 18, 1989 at 2043 LT
Operator:
Registration:
XB-DYP
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Laredo - Torreón
MSN:
19239
YOM:
1943
Location:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
8000
Captain / Total hours on type:
3800.00
Circumstances:
The pilot stated that during takeoff from runway 35L, the copilot on the flight controls reduced left propeller and right engine power at an altitude of less than 100 feet agl. He attempted to restore takeoff power while applying forward pressure on the control yoke, but lost control of the aircraft and impacted the terrain adjacent to the departure runway. He further stated that the cargo may have shifted to the rear of the aircraft during takeoff. The aircraft was destroyed and both pilots were seriously injured.
Probable cause:
The pic's disregard for the security of the cargo that permitted its shift during the takeoff roll. This resulted in an aft cg situation and a subsequent stall and loss of aircraft control. A contributing factor in the accident was the mismanagement of the engine power by the crew and the lack of experience of the copilot.
Occurrence #1: cargo shift
Phase of operation: takeoff - initial climb
Findings
1. (f) security of cargo - disregarded - pilot in command
2. (f) procedure inadequate - pilot in command
3. (c) aircraft weight and balance - exceeded
----------
Occurrence #2: loss of control - in flight
Phase of operation: takeoff - initial climb
Findings
4. (f) throttle/power control - reduced - copilot/second pilot
5. (f) lack of total experience in type of aircraft - copilot/second pilot
6. (f) propeller - reduced - copilot/second pilot
7. (c) airspeed (vs) - not maintained - pilot in command
8. Stall/mush - inadvertent - pilot in command
----------
Occurrence #3: in flight collision with terrain/water
Phase of operation: descent - uncontrolled
Findings
9. Terrain condition - grass
Final Report:

Crash of a De Havilland DHC-3 Otter in Ketchikan: 2 killed

Date & Time: Jan 15, 1989 at 0810 LT
Type of aircraft:
Operator:
Registration:
N11250
Flight Phase:
Survivors:
No
Schedule:
Ketchikan - Klawock
MSN:
171
YOM:
1956
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
1470
Captain / Total hours on type:
150.00
Aircraft flight hours:
10366
Circumstances:
After departing the floatplane base on a company VFR flight plan, the scheduled commuter flight proceeded northwest along a saltwater strait at a low altitude above water. Two miles northwest of the airport the aircraft entered a snow squall and the pilot attempted a steep turn to reverse course. During the turn the aircraft impacted and sank in 167 feet deep water. Search and rescue efforts were suspended after 4 days.
Probable cause:
The pilot's inadvertent flight into IFR conditions and the stall which occurred during the turn to reverse course. Contributing to the accident were the snow conditions encountered.
Occurrence #1: in flight encounter with weather
Phase of operation: cruise
Findings
1. (f) weather condition - snow
2. (c) vfr flight into imc - inadvertent - pilot in command
3. (c) weather evaluation - poor - pilot in command
----------
Occurrence #2: loss of control - in flight
Phase of operation: maneuvering - turn to reverse direction
Findings
4. Maneuver - excessive - pilot in command
5. (c) stall - inadvertent
----------
Occurrence #3: in flight collision with terrain/water
Phase of operation: descent - uncontrolled
Final Report:

Crash of a Lockheed P-3A-55-LO Orion at Whidbey Island NAS

Date & Time: Jan 15, 1989
Type of aircraft:
Operator:
Registration:
152166
Flight Type:
Survivors:
Yes
Schedule:
Whidbey Island NAS - Whidbey Island NAS
MSN:
5136
YOM:
1965
Crew on board:
0
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
For unknown reasons, the aircraft landed hard at Whidbey Island NAS and was considered as damaged beyond repair. There were no casualties.

Crash of an Avro 748-215-2 in Dayton: 2 killed

Date & Time: Jan 12, 1989 at 0445 LT
Type of aircraft:
Operator:
Registration:
C-GDOV
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Dayton - Montreal
MSN:
1582
YOM:
1966
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
5847
Captain / Total hours on type:
3200.00
Aircraft flight hours:
35817
Circumstances:
During night cargo operation, check captain (right seat) was evaluating the 1st officer (f/o, left seat) for possible upgrade to captain. Before departing, flight was cleared for right turn after takeoff to 020°. Takeoff began at 0441:11. Water/methanol injection was used (to 1st power reduction). At 0441:49, landing gear was retracted; 8 seconds later 1st power reduction was made, then a frequency change was approved. Captain noted they should climb to 1,500 feet msl (approximately 500 feet agl) before turning. At about 300 feet agl, aircraft entered overcast and began a steep right turn. CVR indicated captain was performing cockpit duties at this time and giving info to f/o about the departure. FDR showed aircraft reached max alt of 423 feet agl and began descending. At 0442:22, captain remarked to f/o, 'don't go down . . . Get up . . . Up up up . . . Up, oh!' At about that time, aircraft hit in an open field, but continued flying for approximately 3/4 mile. It then hit a tree and crashed in a wooded area. Investigation revealed that during several training flights and 2 check flights, the f/o demonstrated difficulty in performing instrument flight due to disorientation, narrow focus of attention, or lack of instrument scan (instrument fixation), especially during high task workload. Both pilots were killed.
Probable cause:
Improper IFR procedure by the first officer (copilot) during takeoff, his lack of instrument scan (improper use of flight/navigation instruments), his failure to maintain a positive rate of climb or to identify the resultant descent, and the captain's inadequate supervision of the flight. Contributing factors were: dark night, low ceiling, drizzle, the first officer's lack of total experience in the type of operation, and possible spatial disorientation of the first officer.
Occurrence #1: in flight collision with terrain/water
Phase of operation: takeoff
Findings
1. (f) light condition - dark night
2. (f) weather condition - low ceiling
3. (f) weather condition - drizzle/mist
4. (c) ifr procedure - improper - copilot/second pilot
5. (c) flight/navigation instrument(s) - improper use of - copilot/second pilot
6. (c) climb - not maintained - copilot/second pilot
7. (c) descent - not identified - copilot/second pilot
8. (f) spatial disorientation - copilot/second pilot
9. (f) lack of total experience in type operation - copilot/second pilot
10. (c) supervision - inadequate - pilot in command
----------
Occurrence #2: in flight collision with object
Phase of operation: other
Findings
11. Object - tree(s)
Final Report:

Crash of a Cessna 208B Super Cargomaster in Rockingham County

Date & Time: Jan 11, 1989 at 0728 LT
Type of aircraft:
Operator:
Registration:
N9330B
Flight Type:
Survivors:
Yes
Schedule:
Roanoke - Greensboro
MSN:
208B-0053
YOM:
1987
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
2100
Captain / Total hours on type:
360.00
Aircraft flight hours:
896
Circumstances:
As the pilot was en route to Greensboro (his destination), he flew past Shiloh and noted that weather at the airport was clear, but from about 10 south of Shiloh, ground fog extended to the south. At 0634 est, he contacted Greensboro tower and was advised the RVR was 1,600 feet. His minimums were 1,800 feet. He held for a period of time, but the weather continued to deteriorate, so he diverted to the Rockingham County-Shiloh Airport, where no weather reporting facilities were available. After being vectored over the alternate airport, he was unable to get enough visual cues for a visual approach, so he elected to make an sdf approach. The pilot stated that when he reached the minimum descent altitude (MDA), he saw the runway and proceeded to make a visual approach. As he continued, patchy fog began to obscure the runway, so he maneuvered the aircraft to keep it in site, then elected to go around. However, as he began the go-around, the aircraft hit trees and crashed. Elevation of the crash site was approximately 700 feet. MDA for the approach was 1,120 feet msl.
Probable cause:
Improper IFR procedure by the pilot and his failure to maintain the minimum descent altitude (MDA). Contributing factors were: low ceiling, fog, delayed missed approach by the pilot, and trees.
Occurrence #1: in flight collision with object
Phase of operation: approach - faf/outer marker to threshold (ifr)
Occurrence #1: in flight collision with object
Phase of operation: approach - faf/outer marker to threshold (ifr)
Findings
1. (f) weather condition - low ceiling
2. (f) weather condition - fog
3. (f) missed approach - delayed - pilot in command
4. (c) ifr procedure - improper - pilot in command
5. (f) object - tree(s)
6. (c) minimum descent altitude - not maintained - pilot in command
Final Report:

Crash of a Cessna 414 Chancellor in Pleasanton: 1 killed

Date & Time: Jan 9, 1989 at 1124 LT
Type of aircraft:
Operator:
Registration:
N1672T
Flight Type:
Survivors:
No
Site:
Schedule:
Santa Ana - Oakland
MSN:
414-0465
YOM:
1974
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
471
Captain / Total hours on type:
149.00
Circumstances:
During arrival, the pilot was cleared for an ILS runway 27R approach to the metro Oakland Intl Airport. As she began the approach, the ATC controller noted the aircraft had descended thru 2,900 feet msl. He provided a low altitude alert to the pilot and warned her the aircraft should be at 3,300 feet. The pilot acknowledged by saying 'thank you.' The ATC controller suggested the pilot climb to 3,300 feet immediately, then he canceled the clearance and told the pilot to climb immediately to 3,300 feet. Subsequently, the aircraft crashed approximately 15 miles east of the airport. Impact occurred with a 1,500 feet ridge at about the 1,000 feet level. No preimpact part failure or malfunction of the aircraft was found. The pilot, sole on board, was killed.
Probable cause:
Failure of the pilot to properly follow the IFR (instrument flight rules) procedures by not maintaining the minimum descent altitude for that segment of the approach. The weather conditions and mountainous terrain were considered to be related factors.
Occurrence #1: in flight collision with terrain/water
Phase of operation: approach - iaf to faf/outer marker (ifr)
Findings
1. (c) ifr procedure - improper - pilot in command
2. (f) weather condition - low ceiling
3. (f) weather condition - fog
4. (f) terrain condition - mountainous/hilly
5. (c) minimum descent altitude - not maintained - pilot in command
Final Report:

Crash of a Beechcraft B90 King Air in Paducah

Date & Time: Jan 7, 1989 at 1935 LT
Type of aircraft:
Registration:
N784K
Flight Type:
Survivors:
Yes
Schedule:
Shenandoah - Decatur
MSN:
LJ-427
YOM:
1969
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
1061
Captain / Total hours on type:
115.00
Aircraft flight hours:
5293
Circumstances:
During a return flight at night to Decatur, AL, the pilot noted his weather radar was inoperative. He visually avoided thunderstorms (tstms), which had been forecasted. While avoiding tstms, he noted a reduction in engine power, a slight yaw, indications of fuel flow irregularity and that the left and right boost pumps were inoperative. These occurred at about the time, he saw a white arc which he said had jumped from the prop, spinner or nacelle area to the aircraft's nose. Due to the weather, he elected to divert to Paducah. After the airport was in sight, he needed to lose altitude before landing and was cleared to make a 360° turn. While turning, he lost sight of the airport, then rolled out on the wrong heading and started flying toward a strobe light at an industrial complex. When he realized his error and saw the airport, he turned toward the runway; but as he was maneuvering, the aircraft lost altitude, hit trees and crashed. An examination of the engines and fuel pumps revealed no indication of a preimpact failure. No physical evidence of a lightning strike was found, but the nose and engines were badly damaged from impact.
Probable cause:
Pilot failed to maintain proper altitude while maneuvering to land. Probable contributing factors were inoperative weather radar, thunderstorms, lightning, an undetermined electrical problem, dark night, the pilot's improperly planned approach and visual perception, and the trees.
Occurrence #1: in flight encounter with weather
Phase of operation: cruise
Findings
1. (f) flight/nav instruments, weather radar system - inoperative
2. (f) weather condition - thunderstorm
3. (f) weather condition - lightning
4. (f) electrical system - undetermined
5. Fuel system, electric boost pump - inoperative
----------
Occurrence #2: in flight collision with object
Phase of operation: approach
Findings
6. (f) light condition - dark night
7. (f) planned approach - improper - pilot in command
8. (f) visual/aural perception - pilot in command
9. Maneuver - initiated
10. (f) object - tree(s)
11. (c) proper altitude - not maintained - pilot in command
----------
Occurrence #3: in flight collision with terrain/water
Phase of operation: descent - uncontrolled
Final Report:

Crash of a Cessna 208B Super Cargomaster in Aspen

Date & Time: Jan 5, 1989 at 0739 LT
Type of aircraft:
Operator:
Registration:
N945FE
Flight Type:
Survivors:
Yes
Schedule:
Denver - Aspen
MSN:
208B-0046
YOM:
1987
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
5347
Captain / Total hours on type:
322.00
Aircraft flight hours:
1041
Circumstances:
Pilot said he encountered severe to extreme turbulence upon reaching missed approach point and felt aircraft might stall if he began immediate right turn as called for in missed approach procedure. Pilot said he made left turn at 15 DME (missed approach point is at 11.5 DME) because there was higher terrain to right. Aircraft collided with trees on mountain 3 miles east of airport. Weather analysis indicated potential for light to moderate turbulence but not severe to extreme turbulence. Pilots landing and departing airport prior to and after accident reported light to moderate chop. Radar showed aircraft speed at 183.1 kts between iaf and faf. Between faf and missed approach point, aircraft speed was 95.7 kts. Pilot said he referred to current commercial instrument approach chart while executing approach. Only obsolete government instrument approach book was found in aircraft. Radios were not tuned to missed approach navaids. Pilot-rated passenger said pilot panicked after encountering turbulence.
Probable cause:
Pilot's improper ifr procedure. Contributing factors included moderate turbulence, low ceilings, obscuration and snow.
Occurrence #1: in flight encounter with weather
Phase of operation: missed approach (ifr)
Findings
1. (f) weather condition - turbulence in clouds
2. (f) weather condition - low ceiling
3. (f) weather condition - obscuration
4. (f) weather condition - snow
----------
Occurrence #2: in flight collision with object
Phase of operation: missed approach (ifr)
Findings
5. (c) ifr procedure - improper - pilot in command
6. Terrain condition - mountainous/hilly
7. Object - tree(s)
Final Report:

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

Date & Time: Jan 3, 1989 at 0812 LT
Type of aircraft:
Operator:
Registration:
N9034Y
Flight Type:
Survivors:
No
Site:
Schedule:
Indianapolis - Columbus
MSN:
31-47
YOM:
1967
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
1041
Captain / Total hours on type:
57.00
Aircraft flight hours:
5906
Circumstances:
The pilot was making a contract cargo flight under far 91 rules and had experienced icing enroute. When just past Dayton, he indicated that he 'had a little fuel problem' and needed to get into OSU without delays. A short time later he indicated that he needed to go to the nearest airport. He was vectored toward SGH for landing. He then indicated that he had lost an engine and a short time later indicated that he had lost the other engine. The aircraft crashed in a residential area. There was no fire and only residual fuel was found in the airplane. The company president indicated that he did not encourage his pilots to carry 'excess fuel'. It was reported that this pilot, along with others, had been 'chewed out' for carrying 'excess fuel'. The operation should have been conducted under far 135 rules since the company had retained operational control of the operation. The pilot, sole on board, was killed.
Probable cause:
Fuel exhaustion precipitated by the inadequate fuel consumption calculations performed by the pilot, pressure from the company president to not carry excess fuel and improper in-flight planning/decisions by the pilot by not refueling enroute before fuel was exhausted. Contributing to the accident was the inadequate surveillance and certification of the operator by the FAA.
Occurrence #1: loss of engine power (total) - nonmechanical
Phase of operation: descent
Findings
1. (c) fuel consumption calculations - inadequate - pilot in command
2. (c) company-induced pressure - company/operator management
3. (c) inadequate surveillance of operation - faa (organization)
4. (c) fluid, fuel - exhaustion
5. (c) aircraft preflight - inadequate - pilot in command
6. (c) inadequate certification/approval - faa (organization)
7. (c) refueling - not performed - pilot in command
8. (c) in-flight planning/decision - inadequate - pilot in command
----------
Occurrence #2: forced landing
Phase of operation: descent - emergency
----------
Occurrence #3: in flight collision with terrain/water
Phase of operation: descent - uncontrolled
Final Report:

Crash of a Mitsubishi MU-2B-60 Marquise in Mansfield: 4 killed

Date & Time: Jan 2, 1989 at 1643 LT
Type of aircraft:
Operator:
Registration:
N500V
Flight Type:
Survivors:
No
Schedule:
Greenville - Mansfield
MSN:
379
YOM:
1973
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
11700
Captain / Total hours on type:
2860.00
Aircraft flight hours:
3288
Circumstances:
During arrival, the flight was vectored for an ILS runway 32 approach. As the arrival continued, the ATC controller provided the latest info on cloud tops and in-cloud icing. The pilot acknowledged, then inquired about the status of the 'locator.' The controller advised that all components of the ILS, including the outer marker locator, were monitoring normal. Four miles from the outer marker/faf, the pilot was given a final vector, was cleared for the approach and was cleared to circle and land on runway 23. He acknowledged, then radio and radar contact with the aircraft were lost. The aircraft crashed approximately 2 miles southeast of the faf, while in a steep descent on a heading of 140°. No preimpact part failure/malfunction of the aircraft was found, though it was extensively damaged. About three weeks after a boating accident on 7/2/88, the pilot was admitted to a hospital and treated for a stroke, but an autopsy and toxicological checks failed to reveal any condition which would have prevented the pilot from performing his duties. Ad 88-13-01, concerning aircraft equipped with m-4c/d autopilots, was not complied with. All four occupants were killed.
Probable cause:
Failure of the pilot to maintain control of the aircraft, due to spatial disorientation, at about the time he was changing radio frequencies during an IFR approach.
Occurrence #1: loss of control - in flight
Phase of operation: approach - iaf to faf/outer marker (ifr)
Findings
1. Weather condition - clouds
2. Weather condition - icing conditions
3. Weather condition - low ceiling
4. (c) aircraft control - not maintained - pilot in command
5. (c) spatial disorientation - pilot in command
----------
Occurrence #2: in flight collision with terrain/water
Phase of operation: descent - uncontrolled
Final Report: