Crash of a Piper PA-31T3-T1040 Cheyenne in Atlanta

Date & Time: Sep 24, 1984 at 1609 LT
Type of aircraft:
Registration:
N9193Y
Survivors:
Yes
Schedule:
Florence - Atlanta
MSN:
31T-8275010
YOM:
1982
Crew on board:
2
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3309
Captain / Total hours on type:
439.00
Aircraft flight hours:
1857
Circumstances:
The normal fuel load for the flight was 1,500 lbs, but with a forecast tail wind and an estimated flight time for only 1+10, the crew accepted the lower indicated (950 lb) fuel load. The flight was uneventful until an indication of 250 lbs per side, then the fuel 'seemed to dissipate faster.' With an indication of 150 lbs on downwind, the copilot recommended declaring an emergency. The captain's response was to ask ATC for the anticipated length of the downwind leg. He was told 20 miles. Priority handling was requested, but was only available for a declared emergency. The approach was continued with normal handling for approximately 10 minutes. At 1608:39, the crew declared an emergency, then reported the aircraft was out of fuel. It crash landed on rough terrain, short of runway 08. An exam revealed fuel sensors had been improperly installed (interchanged between the inboard and outboard tanks). Thus the gages indicated about 180 lbs more than the approximately 763 lbs that was actually aboard at takeoff. A special 500 hour inspection of the entire fuel system was made on 7/8/84 using the 'wet' method, but only the capacitance method checks each individual sensor. All 11 occupants were injured and the aircraft was destroyed.
Probable cause:
Occurrence #1: loss of engine power (total) - nonmechanical
Phase of operation: approach - faf/outer marker to threshold (ifr)
Findings
1. (f) fuel system - incorrect
2. (f) maintenance, installation - improper
3. (f) engine instruments, fuel quantity gage - false indication
4. Maintenance, inspection - inadequate
5. (f) procedure inadequate - manufacturer
6. (f) fluid, fuel - low level
7. (c) in-flight planning/decision - improper - pilot in command
8. (c) remedial action - delayed - pilot in command
9. (c) fluid, fuel - exhaustion
10. Fuel supply - inadequate
----------
Occurrence #2: forced landing
Phase of operation: approach - faf/outer marker to threshold (ifr)
----------
Occurrence #3: in flight collision with terrain/water
Phase of operation: landing - flare/touchdown
Findings
11. (f) terrain condition - rough/uneven
Final Report:

Crash of a Cessna 414A Chancellor off Carlsbad

Date & Time: Sep 20, 1984 at 0644 LT
Type of aircraft:
Operator:
Registration:
N2700S
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Carlsbad - Las Vegas
MSN:
414A-0607
YOM:
1980
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
1565
Captain / Total hours on type:
173.00
Aircraft flight hours:
1056
Circumstances:
The aircraft was on IFR departure in minimal weather conditions. On takeoff roll, a power loss occurred on the right engine and the aircraft veered to the right. The pilot-in-command (owner) in left seat initiated aborted takeoff, but right seat pilot took control, continued takeoff and feathered the right propeller. Both pilots observed smoke from the engines on their respective sides, both thought landing gear was retracted. (Investigation revealed landing gear was down.) Aircraft could not maintain altitude, pilots elected to ditch in ocean. Investigation revealed aircraft had been serviced with 147 gallons of Jet fuel instead of Avgas at 0445 hrs by a fbo lineman. The lineman had 3 weeks total experience, 1 1/2 hrs video tape training and was working 2 jobs 7 days per week. All three occupants escaped uninjured.
Probable cause:
Occurrence #1: loss of engine power (partial) - nonmechanical
Phase of operation: takeoff - roll/run
Findings
1. (c) fluid, oil grade - improper
2. (c) maintenance, service of aircraft/equipment - improper - fbo personnel
3. (f) fatigue (ground schedule) - fbo personnel
4. (f) lack of total experience in type operation - fbo personnel
5. (f) inadequate surveillance of operation - company/operator mgmt
6. Light condition - dark night
----------
Occurrence #2: loss of engine power (total) - nonmechanical
Phase of operation: takeoff - initial climb
Findings
7. Aborted takeoff - attempted - pilot in command
8. (f) relinquishing of control - improper - pilot in command
9. (c) aborted takeoff - not performed - copilot/second pilot
10. Propeller feathering - selected - copilot/second pilot
11. (c) emergency procedure - improper - copilot/second pilot
12. Weather condition - low ceiling
13. Weather condition - fog
----------
Occurrence #3: forced landing
Phase of operation: descent - emergency
----------
Occurrence #4: ditching
Phase of operation: landing - flare/touchdown
Final Report:

Crash of a Piper PA-60 Aerostar (Ted Smith 602P) in Dayton: 1 killed

Date & Time: Sep 14, 1984 at 1008 LT
Registration:
N6897L
Survivors:
No
Schedule:
Lenoir – Dayton
MSN:
62-0932-8165055
YOM:
1981
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
2600
Aircraft flight hours:
676
Circumstances:
On arrival at destination, pilot found airport obscured by fog, reported by unicom as one mile visibility. Pilot circled to await improvement. 15 minutes later, visibility improved to 1-1/2 mi. Aircraft observed briefly through breaks, then heard maneuvering to north and seen once on approximate downwind heading. Aircraft heard approaching airport then appeared in diving left turn below fog and to right of runway before impact. Approved ndb/vor dme/rnav approaches to airport have 700 feet ceiling minimum. Aircraft found configured for landing. No record of request for instrument approach. The pilot, sole on board, was killed.
Probable cause:
Occurrence #1: in flight encounter with weather
Phase of operation: approach - vfr pattern - final approach
Findings
1. (f) in-flight planning/decision - improper - pilot in command
2. (f) not selected - pilot in command
3. (f) ifr procedure - not selected - pilot in command
4. (c) vfr flight into imc - initiated - pilot in command
5. (f) weather condition - fog
----------
Occurrence #2: in flight collision with terrain/water
Phase of operation: maneuvering
Findings
6. (c) proper alignment - not attained - pilot in command
7. (c) clearance - misjudged - pilot in command
Final Report:

Crash of a Piper PA-31-325 Navajo C/R in Lynchburg

Date & Time: Sep 9, 1984 at 1115 LT
Type of aircraft:
Registration:
N29RH
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Lynchburg - Sussex
MSN:
31-243
YOM:
1968
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
955
Circumstances:
Shortly after takeoff the pilot reported to the tower that the left engine had failed. The propeller was feathered and a left turn to downwind initiated. In the turn the right engine failed and the aircraft flew into trees in a residential area about 1 mile from the airport. No mechanical malfunctions were discovered. No fuel was found in either engine. The fuel selectors for both engines were on the outboard positions. Prior to departure the main fuel tanks were filled. No fuel was added to the outboard tanks. Impact ruptured the right outboard tank. Approximately one cup of fuel was drained from the left tank.
Probable cause:
Occurrence #1: loss of engine power (total) - nonmechanical
Phase of operation: takeoff - initial climb
Findings
1. (c) checklist - not followed - pilot in command
2. (c) fluid, fuel - starvation
3. (c) fuel tank selector position - improper - pilot in command
----------
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. Object - tree(s)
Final Report:

Crash of a Cessna 402C in Naples: 1 killed

Date & Time: Sep 7, 1984 at 2110 LT
Type of aircraft:
Operator:
Registration:
N89PB
Flight Phase:
Survivors:
Yes
Schedule:
Naples - Tampa
MSN:
402C-0650
YOM:
1982
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
2639
Captain / Total hours on type:
412.00
Aircraft flight hours:
1495
Circumstances:
Shortly after takeoff, both engines lost power and a wheels up landing was made in an open field. The aircraft was destroyed by impact and fire. An investigation revealed that the aircraft had been refuel with Jet-A fuel rather than 100 low lead avgas. The lineman had inadvertently used the Jet-A fuel truck which was identical to the Avgas truck except for a decal, appx 4' by 16', which identified the type of fuel. The lineman stated that his training consisted of approximately 30 minutes of reading the company maintenance manual on how to refuel the different company aircraft, then was given on-the-job training for a brief time. When he went to refuel N89PB prior to the accident flight, he went to the parking space where the Avgas truck was normally parked, but on that occasion, the Jet-A fuel truck was there.
Probable cause:
Occurrence #1: loss of engine power (total) - nonmechanical
Phase of operation: climb - to cruise
Findings
1. (c) fluid, fuel grade - improper
2. (c) maintenance, service of aircraft/equipment - improper - ground personnel
3. (f) habit interference - ground personnel
4. (f) inadequate surveillance, inadequate procedure - company/operator mgmt
----------
Occurrence #2: forced landing
Phase of operation: landing - flare/touchdown
----------
Occurrence #3: in flight collision with terrain/water
Phase of operation: landing - flare/touchdown
Findings
5. Terrain condition - rough/uneven
6. Wheels up landing - performed - pilot in command
Final Report:

Crash of a Rockwell Grand Commander 680V off Bridgeport: 1 killed

Date & Time: Sep 3, 1984 at 2008 LT
Registration:
N100CT
Flight Type:
Survivors:
No
Schedule:
West Palm Beach - Bridgeport
MSN:
680-1618-50
YOM:
1966
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
7000
Circumstances:
The aircraft descended into the water six and 1/2 miles southwest of Bridgeport, CT. The aircraft was on an ILS approach to runway 06. The aircraft was in communication with NY tracon arrival radar and on his initial call had indicated a desire for a clearance direct to Bridgeport. A brief radio exchange resulted in the desired clearance. There was no indication of any problems or low fuel state in the communication. Approximately 15 minutes after initial call, the controller was giving the final approach instructions to N100CT, after having used some turns and changes in airspeed to space the flight behind landing traffic, when radar and radio contact was lost. Post accident fuel calculations based on fuel aboard vs flight time en route and normal fuel consumption showed approximately 6 gallons of fuel remaining. The normal unusable fuel for this aircraft is 13 gallons which increases during maneuvering. Identifiable parts of the aircraft and some paper documents were recovered by the coast guard. The pilot's body was not recovered.
Probable cause:
Occurrence #1: in flight collision with terrain/water
Phase of operation: descent
Findings
1. (f) weather condition - low ceiling
2. (c) preflight planning/preparation - inadequate - pilot in command
3. (f) terrain condition - water, rough
4. (c) fuel supply - inadequate - pilot in command
5. (c) emergency procedure - not performed - pilot in command
6. (c) radio communications - inadequate - pilot in command
Final Report:

Crash of a Cessna 402C in Albertville: 2 killed

Date & Time: Aug 31, 1984 at 0810 LT
Type of aircraft:
Registration:
N55LP
Survivors:
No
Schedule:
Decatur - Albertville
MSN:
402C-0102
YOM:
1979
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
7500
Captain / Total hours on type:
400.00
Aircraft flight hours:
5319
Circumstances:
Pilot was executing an non-directional beacon approach to runway 23. Instrument meteorological conditions prevailed at the time of the accident. Radar information obtained during the investigation revealed the pilot did not stabilize the airspeed while executing the approach. Witnesses near the accident site indicated they had heard a low flying aircraft at the approximate time of the accident. The wreckage path revealed a gradual descent swath in the trees which terminated with ground impact. Witnesses near the airport stated that the airport was obscured by fog. Both occupants were killed.
Probable cause:
Occurrence #1: in flight collision with terrain/water
Phase of operation: approach - faf/outer marker to threshold (ifr)
Findings
1. (f) weather condition - fog
2. (f) not performed - pilot in command
3. (c) overconfidence in personal ability - pilot in command
4. (c) minimum descent altitude - exceeded - pilot in command
5. (c) clearance - not maintained - pilot in command
6. (c) decision height - disregarded - pilot in command
7. (c) airspeed - uncontrolled - pilot in command
8. (c) ifr procedure - not followed - pilot in command
9. (c) in-flight planning/decision - poor - pilot in command
Final Report:

Crash of a Piper PA-31-350 Navajo Chieftain near Saint Petersburg

Date & Time: Aug 31, 1984
Operator:
Registration:
N4469R
Flight Type:
Survivors:
Yes
MSN:
31-8152120
YOM:
1981
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The pilot, sole on board, was completing an illegal flight and attempted to land in a remote area near St Petersburg when the aircraft crash landed in unclear circumstances. The aircraft was destroyed and the pilot was not found.

Crash of a Rockwell Grand Commander 690 in Little America: 4 killed

Date & Time: Aug 25, 1984 at 1030 LT
Registration:
N9150N
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Ogden - Aurora
MSN:
690-11063
YOM:
1973
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
3410
Circumstances:
About 10 minutes after takeoff at 1005 mdt, the pilot was cleared to climb to FL190. This was ATC's last communication with the aircraft. At 1030:39, the controller attempted to contact the pilot to advise that he had lost radar contact and to recycle the transponder and squawk 6062. There was no response. Two witnesses reported seeing the aircraft just before it impacted the ground. According to them, they saw fire and/or an explosion before impact and one witness reported the aircraft broke up after it came below an estimated 1,000 to 1,200 feet ceiling. However, the wreckage was scattered over a 2 miles area. An exam revealed evidence of a catastrophic in-flight breakup from overload which included positive overload of both wings. Radar data showed that just before radar contact was lost, the aircraft's speed varied between 221 and 272 knots, heading varied from 072° to 014° and vertical velocity varied from +300 to -2,400 feet/min. Thunderstorms, turbulences, rain and cloud tops to 25,000 feet were reported. Probable light to moderate icing in clouds above the freezing level of 14,000 feet. Aircraft had weather radar aboard. All four occupants were killed.
Probable cause:
Occurrence #1: in flight encounter with weather
Phase of operation: cruise
Findings
1. (f) weather condition - clouds
2. (f) weather condition - thunderstorm
3. (f) weather condition - turbulence in clouds
4. (f) weather condition - rain
5. (f) weather condition - low ceiling
6. (f) weather condition - icing conditions
7. (c) flight into known adverse weather - continued - pilot in command
----------
Occurrence #2: loss of control - in flight
Phase of operation: cruise
Findings
8. Aircraft handling - not maintained
----------
Occurrence #3: airframe/component/system failure/malfunction
Phase of operation: descent - uncontrolled
Findings
9. Design stress limits of aircraft - exceeded
10. Wing - overload
11. Fuel system, tank - overload
----------
Occurrence #4: fire
Phase of operation: descent - uncontrolled
----------
Occurrence #5: in flight collision with terrain/water
Phase of operation: descent - uncontrolled
Final Report:

Crash of a Beechcraft C99 Airliner near San Luis Obispo: 15 killed

Date & Time: Aug 24, 1984 at 1118 LT
Type of aircraft:
Operator:
Registration:
N6399U
Flight Phase:
Survivors:
No
Schedule:
Los Angeles – Santa Maria – San Luis Obispo – San Francisco
MSN:
U-187
YOM:
1982
Flight number:
RM628
Crew on board:
2
Crew fatalities:
Pax on board:
13
Pax fatalities:
Other fatalities:
Total fatalities:
15
Captain / Total flying hours:
4110
Captain / Total hours on type:
873.00
Copilot / Total flying hours:
6194
Copilot / Total hours on type:
62
Circumstances:
Wings West Airlines Flight 628, a commuter flight, departed Los Angeles for San Francisco, with scheduled en route stops at Santa Maria and San Luis Obispo. At 11:10, Flight 628 left the gate at San Luis Obispo. The weather at the time was essentially clear and the visibility was 15 miles. At 11:16, after taking off from runway 29, Flight 628 called the Los Angeles ARTCC and reported that it was climbing through 2,700 feet 'IFR to San Francisco.' At 11:17:23, the Los Angeles ARTCC’s radar controller cleared Flight 628 to the San Francisco airport, as filed, to climb and maintain 7,000 feet. At 11:17:38 the aircraft collided head-on with Rockwell Commander N112SM at 3,400 feet. This single-engined aircraft had departed Paso Robles Airport on a training flight with two pilots on board. Nll2SM was flying in visual meteorological conditions and under VFR in the vicinity of the San Luis Obispo Airport just before the collision.
Probable cause:
The failure of the pilots of both aircraft to follow the recommended communications and traffic advisory practices for uncontrolled airports contained in the Airman’s Information Manual to alert each other to their presence and to enhance the controller’s ability to provide timely traffic advisories. Underlying the accident were the physiological limitations of human vision and reaction time. Also underlying the accident was the short time available to the controller to detect and appraise radar data and to issue a safety advisory. Contributing to the accident was the Wings West Airlines policy which required its pilots to tune one radio to the company frequency at all times.
Final Report: