Crash of a Cessna 402B in West Columbia: 1 killed

Date & Time: May 25, 1988 at 2106 LT
Type of aircraft:
Registration:
N8493A
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
West Columbia - Atlanta
MSN:
402B-0236
YOM:
1972
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
1400
Captain / Total hours on type:
160.00
Aircraft flight hours:
5672
Circumstances:
The airplane used about 1/2 of the 8,602 feet runway for the t/o roll. After t/o it pitched nose-down briefly over the runway during initial climb. The pilot radioed that he was having a problem with the elevator which required 'full back pressure' to keep the nose up, and that he was returning to land. After maneuvering around the airport, the aircraft pitched 70-80° nose down and dove into terrain off the approach end of the runway. The wreckage examination revealed that the bolt securing the elevator trim tab pushrod to the actuator was missing. The rod had become wedged inside the elevator which resulted in an extreme tab up (nose down) condition. The aircraft underwent an annual inspection two days/5 flight hours earlier. The ia mechanic reported that no maintenance was performed on the tab system, and that he was certain the bolt was properly safetied. Another pilot who flew the aircraft the day of the accident reported that he found the pushrod to be secure during his preflight inspection. The 402B poh indicated that the aircraft should have request about 1,200 feet for the t/o ground roll. The pilot, sole on board, was killed.
Probable cause:
Occurrence #1: airframe/component/system failure/malfunction
Phase of operation: takeoff
Findings
1. (c) flt control syst, elevator trim/tab control - disconnected
2. (c) aircraft preflight - inadequate - pilot in command
3. (c) flight control, elevator tab - jammed
4. (f) aborted takeoff - not performed - pilot in command
----------
Occurrence #2: loss of control - in flight
Phase of operation: maneuvering
----------
Occurrence #3: in flight collision with terrain/water
Phase of operation: descent - uncontrolled
Final Report:

Crash of an Embraer EMB-110P1 Bandeirante in Lawton

Date & Time: May 24, 1988 at 1454 LT
Operator:
Registration:
N65DA
Flight Phase:
Survivors:
Yes
Schedule:
Lawton - Dallas
MSN:
110-389
YOM:
1982
Crew on board:
2
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
2333
Captain / Total hours on type:
483.00
Aircraft flight hours:
13005
Circumstances:
The number one (left) engine failed during the takeoff from runway 35. It was reported that the aircraft yawed sharply left and climbed to between 50 and 100 feet agl before it began losing altitude. The aircraft struck the ground and continued to move forward on the ground several hundred feet until it struck the airport perimeter fence. The aircraft came to rest 1,600 feet west of the runway, on a heading of 290°. A post-crash fire destroyed the cargo area of the aircraft. Examination of the left engine revealed a compressor turbine blade airfoil separation. Disassembly of the propeller on the left engine indicated that the propeller had autofeathered normally after the engine failed. The captain reportedly made the takeoff. All eight occupants were injured, two seriously. The aircraft was damaged beyond repair.
Probable cause:
Occurrence #1: loss of engine power (total) - mech failure/malf
Phase of operation: takeoff - initial climb
Findings
1. 1 engine
2. (f) compressor assembly, blade - previous damage
3. (f) compressor assembly, blade - overtemperature
4. (f) compressor assembly, blade - separation
5. Propeller feathering - performed
----------
Occurrence #2: in flight collision with terrain/water
Phase of operation: takeoff - initial climb
Findings
6. (c) emergency procedure - improper - pilot in command
7. (c) directional control - not maintained - pilot in command
8. Object - fence
Final Report:

Crash of a Learjet 35A in Teterboro: 4 killed

Date & Time: May 24, 1988 at 0316 LT
Type of aircraft:
Registration:
N500RW
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Teterboro - Morristown
MSN:
35-148
YOM:
1978
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
8910
Captain / Total hours on type:
759.00
Aircraft flight hours:
4735
Circumstances:
Witnesses reported a normal takeoff. Radar indicated the aircraft turned right as cleared and began cruise at 1900 feet, heading northwest at 235 knots. 65 seconds after calling clear of the control zone the aircraft's radar track ended. The aircraft was fragmented by the impact with all flight control surfaces and aircraft extremities found at the impact site. Pitch trim was found in the normal cruise setting with gear, flaps, and spoilers in the retracted position. Examination of the engines indicated operation at impact. Aircraft struck the terrain in approx 80° nose down, wings level attitude and heading opposite to the previous direction of flight. In flight simulator tests, with the aircraft initially in level flight at 1,900 feet and then rolled inverted and the pitch control moved aft, the aircraft attitude was similar to the attitude at impact. There were two unauthorized passengers on board, one was the copilot's wife. The impact point was in a very small region of uncontrolled airspace very near the copilot's and relative's homes. The copilot was new to jet operations. The aircraft departed with several discrepancies uncleared. All four occupants were killed.
Probable cause:
Occurrence #1: in flight collision with terrain/water
Phase of operation: maneuvering
Findings
1. (f) light condition - dark night
2. (c) maneuver - attempted - pilot in command
3. (c) judgment - poor - pilot in command
4. (c) altitude - misjudged - pilot in command
5. (f) lack of total experience in type operation - pilot in command
6. (f) lack of total experience in type operation - copilot/second pilot
7. Operation with known deficiencies in equipment - attempted - company maintenance personnel
Final Report:

Crash of a Douglas DC-10-30 in Dallas

Date & Time: May 21, 1988 at 1612 LT
Type of aircraft:
Operator:
Registration:
N136AA
Flight Phase:
Survivors:
Yes
Schedule:
Dallas - Frankfurt
MSN:
47846
YOM:
1972
Flight number:
AA070
Crew on board:
14
Crew fatalities:
Pax on board:
240
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
15660
Captain / Total hours on type:
2025.00
Aircraft flight hours:
61322
Aircraft flight cycles:
12864
Circumstances:
A rejected takeoff was attempted when the slat disagree light illuminated and the takeoff warning horn sounded at 166 knots (V1). The pilot aborted the takeoff, but the aircraft accelerated to 178 knots ground speed before it began to decelerate. The deceleration was normal until 130 knots where an unexpected rapid decay in the deceleration occurred. The aircraft ran off the end of the runway at 95 knots, the nose gear collapsed, and the aircraft came to a stop 1,100 feet beyond the end of the runway. Eight of the ten brake sets failed. Post-accident exam of the brakes revealed that excessive brake wear occurred during the rejected takeoff. Testing showed that dc-10 worn brakes have a much greater wear rate during an rto. The faa does not require worn brake testing. Douglas did not use brake wear data from rto certification tests to set more conservative brake wear replacement limits. New brakes were used for those tests. All 254 occupants were evacuated, among them eight were injured, two seriously. The aircraft was damaged beyond repair.
Probable cause:
Occurrence #1: airframe/component/system failure/malfunction
Phase of operation: takeoff
Findings
1. (f) flt control syst, wing slat system - false indication
----------
Occurrence #2: airframe/component/system failure/malfunction
Phase of operation: takeoff - aborted
Findings
2. Aborted takeoff - attempted
3. Airspeed (v1) - exceeded
4. (c) landing gear, normal brake system - inadequate
5. (c) acft/equip, inadequate aircraft component - manufacturer
6. (c) inadequate substantiation process - manufacturer
7. (c) inadequate certification/approval, aircraft - faa (organization)
8. Landing gear, normal brake system - worn
9. (c) landing gear, normal brake system - failure, total
----------
Occurrence #3: overrun
Phase of operation: takeoff - aborted
Findings
10. Terrain condition - soft
11. Object - approach light/navaid
----------
Occurrence #4: nose gear collapsed
Phase of operation: takeoff - aborted
Final Report:

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

Date & Time: May 20, 1988 at 2121 LT
Type of aircraft:
Registration:
N1435Z
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Anchorage - Anchorage
MSN:
1252
YOM:
1959
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
3000
Aircraft flight hours:
12737
Circumstances:
The airplane had undergone extensive maintenance which included work on the control column. The upper half of the control column was replaced with a throw-over yoke and the aileron system was rerigged. The pilot-in-command picked up the airplane after it was tied down outside for three months. According to a witness, the airplane lifted off the water and started a left bank which increased until the airplane struck the ground. Post accident examination revealed the control cables at the base of the control column operated in reverse of the description in the maintenance manual. Complete control continuity could not be concluded because of the extensive post impact fire which destroyed the overhead bellcrank, pulley, and interconnect system. The pilot, sole on board, was killed.
Probable cause:
Occurrence #1: loss of control - in flight
Phase of operation: takeoff - initial climb
Findings
1. (c) flt control syst, aileron control - incorrect
2. (c) maintenance, major repair - improper - other maintenance personnel
3. (c) aircraft preflight - inadequate - pilot in command
----------
Occurrence #2: in flight collision with terrain/water
Phase of operation: descent - uncontrolled
Final Report:

Crash of a Rockwell Grand Commander 690A in Little Rock: 1 killed

Date & Time: May 17, 1988 at 0532 LT
Operator:
Registration:
N660RB
Flight Type:
Survivors:
No
Schedule:
Atlanta – Memphis – Little Rock
MSN:
690-11305
YOM:
1976
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
6410
Captain / Total hours on type:
1562.00
Aircraft flight hours:
6577
Circumstances:
The pilot had just returned from vacation in the Bahamas before starting a flight from Little Rock to Atlanta with an intermediate stop at Memphis. This itinerary was followed by a return flight to Little Rock via a reverse routing. Witnesses reported the pilot said he had only 2 hours of sleep before departing Little Rock and that he was really tired. Also, company personnel noted the pilot looked 'extremely tired' and was 'really dragging' prior to the last leg of the flight from Memphis to Little Rock. According to ATC personnel, the flight was routine until the aircraft was arriving at Little Rock. During arrival, the pilot was cleared to descend from 7,000 feet to 2,000 feet at his discretion for a visual approach to runway 22. At 0522 cdt, the pilot reported the airport in sight and was cleared for a visual approach. About 4 minutes later, he again reported the airport in sight and was cleared to land. At 1031, radar contact was lost and the aircraft crashed about 4 miles west of the airport. Initial impact was in an open field while descending in a relatively level attitude. The aircraft became airborne for about 3/4 mile, then crashed out of control in the Arkansas River. The pilot, sole on board, was killed.
Probable cause:
Occurrence #1: loss of control - in flight
Phase of operation: approach
Findings
1. (c) judgment - poor - pilot in command
2. (f) light condition - dawn
3. Descent - initiated
4. (c) level off - not performed - pilot in command
5. (c) fatigue (lack of sleep) - pilot in command
----------
Occurrence #2: in flight collision with terrain/water
Phase of operation: approach
Final Report:

Crash of a Beechcraft E18S in Cynthiana

Date & Time: Apr 29, 1988 at 1230 LT
Type of aircraft:
Registration:
N300W
Flight Type:
Survivors:
Yes
Schedule:
Rochester – Louisville – Huntsville
MSN:
BA-92
YOM:
1955
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
1800
Captain / Total hours on type:
900.00
Aircraft flight hours:
9048
Circumstances:
The pilot was repositioning the airplane from an on-demand air taxi freight flight. He was en route from Rochester, NY to Huntsville, AL with a planned refuel stop at Louisville, KY. Near Falmouth, KY he changed his destination to Lexington 'due to a developing engine problem'. He saw the airport at Cynthiana and elected to land there. While on downwind, he noted the left engine cowling turning black and on base noted flames from the left engine. He reptd shutting the engine down and feathering the propeller but did not activate the fire extinguisher. During the landing roll, the airplane departed the runway to the right, and collided with the airport wind 't', a pole and a 't' hangar. Post accident investigation revealed that the left prop was not feathered and the fuel was not shut off. The left brake was ineffective due to fire damage. The evidence indicated that the fire began in the vicinity of the left engine accessory section. The specific fuel source of the fire was not identified.
Probable cause:
Occurrence #1: fire
Phase of operation: approach - vfr pattern - downwind
Findings
1. 1 engine
2. (c) fluid, fuel - leak
3. (f) fire extinguishing equipment - not used - pilot in command
4. (f) procedures/directives - not followed - pilot in command
----------
Occurrence #2: on ground/water collision with object
Phase of operation: landing - roll
Findings
5. (f) landing gear, normal brake system - burned
6. Object - airport facility
7. Object - pole
8. Object - building (nonresidential)
Final Report:

Crash of a Boeing 737-297 in Kahului: 1 killed

Date & Time: Apr 28, 1988 at 1346 LT
Type of aircraft:
Operator:
Registration:
N73711
Flight Phase:
Survivors:
Yes
Schedule:
Hilo - Honolulu
MSN:
20209
YOM:
1969
Flight number:
AQ243
Location:
Crew on board:
5
Crew fatalities:
Pax on board:
90
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
8500
Captain / Total hours on type:
6700.00
Copilot / Total flying hours:
8000
Copilot / Total hours on type:
3500
Aircraft flight hours:
35496
Aircraft flight cycles:
89680
Circumstances:
On April 28, 1988, an Aloha Airline Boeing 737, N73711, was scheduled for a series of interisland flights in Hawaii. The crew flew three uneventful roundtrip flights, one each from Honolulu to Hilo (ITO), Kahului Airport, HI (OGG) on the island of Maui, and Kauai Island Airport (LIH). At 11:00, a scheduled first officer change took place for the remainder of the day. The crew flew from Honolulu to Maui and then from Maui to Hilo. At 13:25, flight 243 departed Hilo Airport en route to Honolulu. The first officer conducted the takeoff and en route climb to FL240 in VMC. As the airplane leveled at 24,000 feet, both pilots heard a loud "clap" or "whooshing" sound followed by a wind noise behind them. The first officer's head was jerked backward, and she stated that debris, including pieces of gray insulation, was floating in the cockpit. The captain observed that the cockpit entry door was missing and that "there was blue sky where the first-class ceiling had been." The captain immediately took over the controls of the airplane. He described the airplane attitude as rolling slightly left and right and that the flight controls felt "loose." Because of the decompression, both pilots and the air traffic controller in the observer seat donned their oxygen masks. The captain began an emergency descent. He stated that he extended the speed brakes and descended at an indicated airspeed (IAS) of 280 to 290 knots. Because of ambient noise, the pilots initially used hand signals to communicate. The first officer stated that she observed a rate of descent of 4,100 feet per minute at some point during the emergency descent. The captain also stated that he actuated the passenger oxygen switch. The passenger oxygen manual tee handle was not actuated. When the decompression occurred, all the passengers were seated and the seat belt sign was illuminated. The No. 1 flight attendant reportedly was standing at seat row 5. According to passenger observations, the flight attendant was immediately swept out of the cabin through a hole in the left side of the fuselage. The No. 2 flight attendant, standing by row 15/16, was thrown to the floor and sustained minor bruises. She was subsequently able to crawl up and down the aisle to render assistance and calm the passengers. The No. 3 flight attendant, standing at row 2, was struck in the head by debris and thrown to the floor. She suffered serious injuries. The first officer tuned the transponder to emergency code 7700 and attempted to notify Honolulu Air Route Traffic Control Center (ARTCC) that the flight was diverting to Maui. Because of the cockpit noise level, she could not hear any radio transmissions, and she was not sure if the Honolulu ARTCC heard the communication. Although Honolulu ARTCC did not receive the first officer's initial communication, the controller working flight 243 observed an emergency code 7700 transponder return about 23 nautical miles south-southeast of the Kahalui Airport, Maui. Starting at 13:48:15, the controller attempted to communicate with the flight several times without success. When the airplane descended through 14,000 feet, the first officer switched the radio to the Maui Tower frequency. At 13:48:35, she informed the tower of the rapid decompression, declared an emergency, and stated the need for emergency equipment. The local controller instructed flight 243 to change to the Maui Sector transponder code to identify the flight and indicate to surrounding air traffic control (ATC) facilities that the flight was being handled by the Maui ATC facility. The first officer changed the transponder as requested. At 13:50:58, the local controller requested the flight to switch frequencies to approach control because the flight was outside radar coverage for the local controller. Although the request was acknowledged, Flight 243 continued to transmit on the local controller frequency. At 13:53:44, the first officer informed the local controller, "We're going to need assistance. We cannot communicate with the flight attendants. We'll need assistance for the passengers when we land." An ambulance request was not initiated as a result of this radio call. The captain stated that he began slowing the airplane as the flight approached 10,000 feet msl. He retracted the speed brakes, removed his oxygen mask, and began a gradual turn toward Maui's runway 02. At 210 knots IAS, the flightcrew could communicate verbally. Initially flaps 1 were selected, then flaps 5. When attempting to extend beyond flaps 5, the airplane became less controllable, and the captain decided to return to flaps 5 for the landing. Because the captain found the airplane becoming less controllable below 170 knots IAS, he elected to use 170 knots IAS for the approach and landing. Using the public address (PA) system and on-board interphone, the first officer attempted to communicate with the flight attendants; however, there was no response. At the command of the captain, the first officer lowered the landing gear at the normal point in the approach pattern. The main gear indicated down and locked; however, the nose gear position indicator light did not illuminate. Manual nose gear extension was selected and still the green indicator light did not illuminate; however, the red landing gear unsafe indicator light was not illuminated. After another manual attempt, the handle was placed down to complete the manual gear extension procedure. The captain said no attempt was made to use the nose gear downlock viewer because the center jumpseat was occupied and the captain believed it was urgent to land the airplane immediately. At 13:55:05, the first officer advised the tower, "We won't have a nose gear," and at 13:56:14, the crew advised the tower, "We'll need all the equipment you've got." While advancing the power levers to maneuver for the approach, the captain sensed a yawing motion and determined that the No.1 (left) engine had failed. At 170 to 200 knots IAS, he placed the No. 1 engine start switch to the "flight" position in an attempt to start the engine; there was no response. A normal descent profile was established 4 miles out on the final approach. The captain said that the airplane was "shaking a little, rocking slightly and felt springy." Flight 243 landed on runway 02 at Maui's Kahului Airport at 13:58:45. The captain said that he was able to make a normal touchdown and landing rollout. He used the No. 2 engine thrust reverser and brakes to stop the airplane. During the latter part of the rollout, the flaps were extended to 40° as required for an evacuation. An emergency evacuation was then accomplished on the runway.
Probable cause:
The failure of the Aloha Airlines maintenance program to detect the presence of significant disbonding and fatigue damage, which ultimately led to failure of the lap joint at S-10L and the separation of the fuselage upper lobe. Contributing to the accident were the failure of Aloha Airlines management to supervise properly its maintenance force as well as the failure of the FAA to evaluate properly the Aloha Airlines maintenance program and to assess the airline's inspection and quality control deficiencies. Also contributing to the accident were the failure of the FAA to require Airworthiness Directive 87-21-08 inspection of all the lap joints proposed by Boeing Alert Service Bulletin SB 737-53A1039 and the lack of a complete terminating action (neither generated by Boeing nor required by the FAA) after the discovery of early production difficulties in the 737 cold bond lap joint, which resulted in low bond durability, corrosion and premature fatigue cracking.
Final Report:

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

Date & Time: Apr 27, 1988 at 0014 LT
Registration:
N3588Y
Flight Type:
Survivors:
Yes
Schedule:
Upland - Hayward
MSN:
31-8052129
YOM:
1980
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
5557
Captain / Total hours on type:
30.00
Aircraft flight hours:
3355
Circumstances:
Upon arriving at his destination the pilot began a visual, night descent to his destination airport. As the aircraft descended the pilot reduced the airspeed and deployed flaps. As the aircraft neared the airport the pilot increased the flap angle and adjusted the propellers to the landing rpm and the airspeed decreased. The pilot stated that at this time he heard a noise that sounded like a flutter which he thought was emanating from the right engine. Full throttle was applied, but the airspeed continued to decrease and the pilot elected to land on a freeway. The aircraft collided with a motor vehicle on touchdown and slid to a stop. Post crash exam revealed the rpm control levers and bellranks to be in the high rpm settings. The left prop was found in the feathered position.
Probable cause:
Pilot's failure to detect an uncommanded propeller feathering procedures established in the pilot's operating handbook.
Findings:
Occurrence #1: loss of engine power (partial) - mech failure/malf
Phase of operation: approach - vfr pattern - base leg/base to final
Findings
1. (c) propeller system/accessories, feathering system - failure, partial
2. (c) emergency procedure - not followed - pilot in command
3. (f) visual/aural perception - pilot in command
----------
Occurrence #2: forced landing
Phase of operation: approach - vfr pattern - final approach
----------
Occurrence #3: in flight collision with object
Phase of operation: landing - flare/touchdown
Findings
4. (f) object - vehicle
5. (f) light condition - dark night
6. (f) terrain condition - roadway/highway
Final Report:

Crash of a De Havilland Dash-8-100 in Seattle

Date & Time: Apr 16, 1988 at 1832 LT
Operator:
Registration:
N819PH
Survivors:
Yes
Schedule:
Seattle - Spokane
MSN:
061
YOM:
1986
Flight number:
QX2658
Crew on board:
3
Crew fatalities:
Pax on board:
37
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
9328
Captain / Total hours on type:
981.00
Copilot / Total flying hours:
3849
Copilot / Total hours on type:
642
Aircraft flight hours:
3106
Aircraft flight cycles:
4097
Circumstances:
Shortly after takeoff from Seattle-Tacoma Intl Airport, the crew noted a right engine power loss and decided to return for a precautionary landing. After lowering the landing gear, a massive fire was discovered in the right engine nacelle. After landing, directional control and all braking were lost. The aircraft departed the left side of the runway 16L after the left power lever was moved to flight idle. The f/o advised tower that the aircraft was out of control. The aircraft rolled onto the ramp area where it struck a runway designator sign, ground equipment, and jetways B7 and B9. The aircraft was subsequently destroyed by fire. Investigation revealed that during overhaul the high pressure fuel filter cover was improperly installed on the engine and the improper installation was not discovered drg company installation of the engine on the aircraft. This led to a massive fuel leak and the nacelle fire. The fire/explosion caused the loss of the engine panels, reducing the effectiveness of the fire suppression system and allowing other systems to be damaged.
Probable cause:
Improper installation of the high-pressure fuel filter cover that allowed a massive fuel leak and subsequent fire to occur in the right engine nacelle. The improper installation probably occurred at the engine manufacturer; however, the failure of airline maintenance personnel to detect and correct the improper installation contributed to the accident. Also contributing to the accident was the loss of the right engine centre access panels from a fuel explosion that negated the fire suppression system and allowed hydraulic line burn-through that in turn caused a total loss of airplane control on the ground.
Final Report: