United States of America

Region:

Piper PA-61 Aerostar (Ted Smith 601)

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Captain / Total flying hours:

26100

Circumstances:

The 70 years old pilot was flying a Douglas A-20 in a flight of 3 aircraft at an airshow (Confederate Air Force 'Airshow 88'). Afterflying on a southerly heading, the flight entered a procedure turn which involved a 90° left turn to the east followed by a 270° right turn back northbound. While maneuvering, the A-20 entered a right descending turn and subsequently crashed on level terrain in a relatively wings level descent. The main wreckage came to rest about 225 feet from the initial impact point. According to a pathological report, the pilot had severe coronary arteriosclerosis and suffered a heart attack.

Probable cause:

Incapacitation of the pilot while flying an aircraft due to loss of consciousness from a cardiac rhythm disturbance.
Findings:
Occurrence #1: loss of control - in flight
Phase of operation: maneuvering
Findings
1. Aircraft control - not maintained
2. (c) incapacitation (cardiovascular) - pilot in command
----------
Occurrence #2: in flight collision with terrain/water
Phase of operation: descent - uncontrolled

Final Report:

Crash of a Piper PA-61P Aerostar (Ted Smith 601) in Columbus: 1 killed

Date & Time: Sep 30, 1988 at 2124 LT

Type of aircraft:

Operator:

Executive Aircraft Leasing

Registration:

N14HR

Flight Phase:

Executive/Corporate/Business

Flight Type:

Survivors:

Site:

Columbus-Ohio State University-Don Scott

Schedule:

Columbus – Doylestown

MSN:

61-0479-193

YOM:

1978

Location:

Ohio

Country:

Region:

Beechcraft 200 Super King Air

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Captain / Total flying hours:

1802

Aircraft flight hours:

3075

Circumstances:

The airplane was destroyed when it collided with terrain shortly after departure. Two witnesses to the accident who saw the accident airplane lift off from the runway described the flight path as erratic in nature with random movement in all three axis, pitch, roll and yaw. The witnesses did not see the actual impact. Evidence shows that the upper half of the main entry clamshell door was not closed at impact. Radio transmissions from the accident airplane while in flight show a elevated voice level indicative of stress as the pic attempted to maintain control the airplane during pitch and roll excursions. The radio transmissions were unintelligible. The tower had cleared the aircraft to land on any runway. The pilot, sole on board, was killed.

Probable cause:

Aerodynamically stalled lifting surface causing an uncommanded pitch over at an altitude too low to affect a recovery.
Findings:
Occurrence #1: miscellaneous/other
Phase of operation: takeoff - initial climb
Findings
1. (f) door - not secured
2. (c) aircraft preflight - inadequate - pilot in command
----------
Occurrence #2: loss of control - in flight
Phase of operation: takeoff - initial climb
Findings
3. (c) door - open
4. (c) aircraft control - not maintained - pilot in command
5. (f) anxiety/apprehension - pilot in command
----------
Occurrence #3: in flight collision with terrain/water
Phase of operation: descent - uncontrolled
Findings
6. Terrain condition - ground

Final Report:

Crash of a Beechcraft 200 Super King Air in Jackson: 1 killed

Date & Time: Sep 11, 1988 at 2157 LT

Type of aircraft:

Operator:

Snowy Butte Aviation

Registration:

N1283

Flight Phase:

Flight Type:

Positioning

Survivors:

Site:

Schedule:

Jackson - Redding

MSN:

BB-90

YOM:

1976

Location:

Jackson Hole

Wyoming

Country:

Region:

Charter/Taxi (Non Scheduled Revenue Flight)

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Captain / Total flying hours:

4400

Captain / Total hours on type:

62.00

Aircraft flight hours:

5677

Circumstances:

The pilot and his two passengers had just arrived at the Jackson-Hole Airport (JAX) approximately 30 minutes prior to the accident. The pilot dropped off his passengers and stepped into operations for a short break. He then returned to the aircraft by himself for a return flight to California. It was a very dark night with a 2,000 feet overcast and no visible horizon. The pilot had departed Redding, CA at 1357 hours and had been on continuous flight duty from that time until the time of the accident. A witness stated the pilot seemed to be tired and hungry. The aircraft was observed making a normal night takeoff. Witnesses stated that as the aircraft turned from crosswind to downwind it appeared that the pilot had trouble controlling the aircraft. After the aircraft made a few extreme up and down maneuvers, it appeared to proceed to the east. The next time the aircraft was observed, it was again climbing and descending rapidly and subsequently impacted the ground in a vertical dive. The pilot, sole on board, was killed.

Probable cause:

Occurrence #1: altitude deviation,uncontrolled
Phase of operation: climb - to cruise
Findings
1. (f) light condition - dark night
2. (c) altitude - uncontrolled - pilot in command
3. (c) planning/decision - poor - pilot in command
4. (f) fatigue (flight schedule) - pilot in command
5. (c) flight controls - improper use of - pilot in command
6. (c) spatial disorientation - pilot in command
----------
Occurrence #2: in flight collision with terrain/water
Phase of operation: descent - uncontrolled

Final Report:

Crash of a Britten-Norman BN-2A-6 Islander near Sitka: 1 killed

Date & Time: Sep 5, 1988 at 1345 LT

Type of aircraft:

Britten-Norman Islander

Operator:

Wrangell Air Service

Registration:

N111VA

Flight Phase:

Flight

Flight Type:

Survivors:

Yes

Site:

Mountains

Schedule:

Sitka - Petersburg

MSN:

215

YOM:

1970

Location:

Sitka

Alaska

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Captain / Total flying hours:

4000

Captain / Total hours on type:

191.00

Circumstances:

The pilot encountered low ceilings, rain and fog while attempting to fly through a narrow mountain pass and successfully reversed course. He then flew into a small canyon off the main pass that terminated in a small glacier-covered bowl surrounded by steep rock walls. When it became apparent during a turn to reverse course that there was insufficient space to complete the maneuver before collision with a rock wall, the pilot retarded the throttles and crash landed on a glacier. A passenger was killed.

Probable cause:

Occurrence #1: in flight collision with terrain/water
Phase of operation: maneuvering - turn to reverse direction
Findings
1. (f) terrain condition - blind/box canyon
2. (c) in-flight planning/decision - improper - pilot in command
3. (f) weather condition - low ceiling
4. (f) aircraft weight and balance - exceeded - pilot in command
5. (f) weather condition - rain
6. (f) weather condition - fog

Final Report:

Crash of a Boeing 727-232 in Dallas: 14 killed

Date & Time: Aug 31, 1988 at 0901 LT

Type of aircraft:

Boeing 727-200

Operator:

Registration:

N473DA

Flight Phase:

Flight Type:

Scheduled Revenue Flight

Survivors:

Yes

Site:

Schedule:

Jackson - Dallas - Salt Lake City

MSN:

20750

YOM:

1973

Flight number:

DL1141

Location:

Dallas-Fort Worth

Texas

Country:

Region:

Landing (descent or approach)

Crew on board:

Crew fatalities:

Pax on board:

101

Pax fatalities:

Other fatalities:

Total fatalities:

Captain / Total flying hours:

17000

Captain / Total hours on type:

7000.00

Copilot / Total flying hours:

6500

Copilot / Total hours on type:

4000

Aircraft flight hours:

43023

Circumstances:

Flight DL1141 (Jackson - Dallas - Salt Lake City) left Gate 15 at 08:30 and was instructed to taxi to runway 18L. When first in line for takeoff (at 08:59) the flight was cleared for takeoff. The takeoff was uneventful until the airplane reached the rotation phase (at 154 knots, 6017 feet down the runway). As the main gear wheels left the ground, the airplane began to roll violently, causing the right wingtip to contact the runway (1033 feet after lift-off), followed by compressor surges. The plane continued and struck the ILS localizer antenna array 1000 feet past the end of runway 18L. After impacting the antenna installation, the airplane remained airborne for an additional 400 feet, then struck the ground, traversed a ground depression and slid sideways until it came to rest near the airport perimeter fence, 3200 feet from the runway end. Parts of the aircraft had separated in the slide and a fire had erupted in the right wing area, quickly engulfing the rear, right side of the airplane after it came to rest. Twelve passengers and two crew members were killed. The aircraft was destroyed.

Probable cause:

The board determines that the accident was caused mainly by the captain and first officer's inadequate cockpit discipline which resulted in the flight crew's attempt to takeoff without the wing flaps and slats properly configured; and the failure of the takeoff configuration warning system to alert the crew that the airplane was not properly configured for the takeoff. Contributing to the accident was Delta's slow implementation of necessary modifications to its operating procedures, manuals, checklists, training and crew checking programs which were necessitated by significant changes in the airline following rapid growth and merger. Also contributing to the accident was the lack of sufficiently aggressive action by the FAA to have known deficiencies corrected by Delta and the lack of sufficient accountability within the FAA's air carrier inspection process.
Findings:
Occurrence #1: loss of control - in flight
Phase of operation: takeoff - initial climb
Findings
1. (c) preflight planning/preparation - improper - pilot in command
2. (c) overconfidence in personal ability - pilot in command
3. (c) procedures/directives - not followed - copilot/second pilot
4. (c) procedures/directives - not followed - pilot in command
5. (f) procedure inadequate - company/operator management
6. (f) insufficient standards/requirements, operation/operator - FAA (organization)
7. (f) inadequate method of compliance determination record keeping - FAA (organization)
8. (c) lowering of flaps - not performed
9. (c) lowering of slats - not performed
10. (c) safety system (other) - inoperative
----------
Occurrence #2: in flight collision with terrain/water
Phase of operation: descent - uncontrolled

Final Report:

Crash of a Boeing 727-31 in Chicago

Date & Time: Aug 27, 1988 at 1650 LT

Type of aircraft:

Boeing 727-100

Operator:

Registration:

N852TW

Flight Phase:

Flight Type:

Scheduled Revenue Flight

Survivors:

Yes

Site:

Schedule:

Saint Louis - Chicago

MSN:

18571

YOM:

1964

Location:

Chicago-O'Hare

Illinois

Country:

Region:

Piper PA-61 Aerostar (Ted Smith 601)

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Captain / Total flying hours:

16899

Captain / Total hours on type:

6411.00

Aircraft flight hours:

56099

Circumstances:

Scheduled domestic part 121 flight could not get landing gear to extend on approach to Chicago-Midway Airport. After missed approach, crew tried unsuccessfully to extend gear manually using procedures in cockpit checklist and flight operations manual. Emergency gear-up landing was made at Chicago-O'Hare International Airport. Investigation revealed a disconnected gear selector actuating rod from the normal landing gear retract/extension actuating assembly. Crew damaged manual gear extension mechanism in manual extension attempts. FAA approved procedural checklist had omitted critical step in manual gear extension procedure.

Probable cause:

Improper procedural checklist in which a critical step was not listed.
Findings
Occurrence #1: airframe/component/system failure/malfunction
Phase of operation: approach - faf/outer marker to threshold (ifr)
Findings
1. Landing gear, normal retraction/extension assembly - inoperative
2. (c) missed approach - performed
3. (f) checklist - inaccurate - company/operator management
4. (c) procedures/directives - improper - company/operator management
5. (c) condition(s)/step(s) not listed - faa (principal maintenance inspector)
----------
Occurrence #2: gear not extended
Phase of operation: landing
Findings
6. Wheels up landing - performed - pilot in command

Final Report:

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

Date & Time: Aug 25, 1988 at 1530 LT

Type of aircraft:

Operator:

Lewis E. Phillips

Registration:

N6069W

Flight Phase:

Flight Type:

Private

Survivors:

Site:

City

MSN:

61-0676-7963318

YOM:

1979

Location:

North Perry

Florida

Country:

Region:

De Havilland DHC-2 Beaver

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Captain / Total flying hours:

3000

Captain / Total hours on type:

50.00

Circumstances:

Witnesses stated that the aircraft used almost the entire length of the runway during the ground run. After rotation and gear retraction, it continued to climb in a nose high attitude to approximately 100-150 feet, then it started an approximately 20° bank to the right until it hit power lines and crashed into the top of a printing shop about 3/4 mile from the airport. Witnesses employed at the airport stated that the aircraft had been having undetermined problems with the right engine for a few weeks prior to the accident, but was still being flown and the right engine running extremely rough. All three occupants were killed.

Probable cause:

Occurrence #1: loss of engine power
Phase of operation: takeoff - initial climb
Findings
1. (c) engine assembly - undetermined
2. (c) operation with known deficiencies in equipment - attempted - pilot in command
3. Propeller feathering - performed
----------
Occurrence #2: forced landing
Phase of operation: descent - emergency
----------
Occurrence #3: in flight collision with object
Phase of operation: maneuvering - turn to landing area (emergency)
Findings
4. (f) object - wire, transmission
5. (f) object - building (nonresidential)

Final Report:

Crash of a De Havilland DHC-2 Beaver in Sitka: 1 killed

Date & Time: Aug 18, 1988 at 0620 LT

Type of aircraft:

Operator:

Registration:

N64398

Flight Phase:

Charter/Taxi (Non Scheduled Revenue Flight)

Flight Type:

Survivors:

Site:

Mountains

Schedule:

Sitka - Rowan Bay

MSN:

251

YOM:

1952

Location:

Sitka

Alaska

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Captain / Total flying hours:

3300

Captain / Total hours on type:

700.00

Aircraft flight hours:

13985

Circumstances:

While on a flight from Sitka to Rowan Bay, Alaska, the pilot flew up a valley intending to cross a pass whose elevation was 2,745 feet msl. Upon approaching the pass the pilot encountered clouds which prevented his transit. The pilot then executed a 180° right course reversal and at some point near the completion of the maneuver and in close proximity to the steep terrain along the western edge of the pass the pilot allowed the aircraft to enter a stall condition. The aircraft impacted the 40° sloped terrain in a steep nose down, near wings level attitude and with a steep flight path. The pilot, sole on board, was killed.

Probable cause:

Occurrence #1: loss of control - in flight
Phase of operation: maneuvering - turn to reverse direction
Findings
1. (c) weather evaluation - inadequate - pilot in command
2. (c) in-flight planning/decision - delayed - pilot in command
3. (f) weather condition - clouds
4. (c) stall - inadvertent - pilot in command
5. (f) terrain condition - mountainous/hilly
----------
Occurrence #2: in flight collision with terrain/water
Phase of operation: descent - uncontrolled

Final Report:

Crash of a Cessna 402B on Mt Torbet: 2 killed

Date & Time: Aug 17, 1988 at 2003 LT

Type of aircraft:

Cessna 402

Operator:

Registration:

N5718M

Flight Phase:

Flight

Flight Type:

Cargo

Survivors:

Site:

Mountains

Schedule:

Sleetmute - Anchorage

MSN:

402B-0354

YOM:

1973

Location:

Mt Torbet

Alaska

Country:

Region: