Crash of an Avro 748-FAA-2A near Pinckneyville: 10 killed

Date & Time: Oct 11, 1983 at 2053 LT
Type of aircraft:
Operator:
Registration:
N748LL
Flight Phase:
Survivors:
No
Schedule:
Chicago - Springfield - Carbondale
MSN:
1716
YOM:
1972
Flight number:
UX710
Crew on board:
3
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
10
Captain / Total flying hours:
5891
Captain / Total hours on type:
3170.00
Copilot / Total flying hours:
5119
Copilot / Total hours on type:
1746
Aircraft flight hours:
21182
Aircraft flight cycles:
32350
Circumstances:
Flight 710 departed Chicago, IL for a flight to Carbondale, IL via Springfield, IL. The flight was about 45 minutes behind schedule when it arrived at Springfield, about 20:05. At 20:11, the flightcrew were provided with the latest Carbondale weather: ceiling and visibility were 2,000 feet overcast and 2 miles, respectively, with light rain and fog. The crew then requested its IFR clearance, with 5,000 feet for its en route altitude. At 20:16, Flight 710 was cleared to taxi to runway 15 for takeoff. The aircraft took off at 20:20 and climbed to cruising altitude. At 20:21:34, Flight 710 informed the departure controller that it had experienced a "slight electrical problem..." and that it would keep the controller "advised." The flight then requested and was cleared to maintain 3,000 feet. At 20:23:54, the first officer told the captain that "the left (generator) is totally dead, the right (generator) is putting out voltage but I can't get a load on it." At 20:24:26, the first officer reported, "zero voltage and amps (amperes) on the left side, the right (generator) is putting out twenty-seven and a half (volts) but I can't get it to come on the line." The battery voltage further dropped to 22 volts. The crew a.o. shut off excess cabin lights because of the electrical problem. About 20:38, the first officer mistakenly isolated the right generator and right generator bus bar from the aircraft's dc electrical distribution system. Radio contact was lost when the flight was requested to change radio frequencies. At 20:52 the captain decided to descend to 2,400 feet and the voltage had further dropped to 13 volts. The aircraft continued to descend and struck the ground in an open pasture area.
Probable cause:
The captain's decision to continue the flight toward the more distant destination airport after the loss of d.c. electrical power from both aircraft generators instead of returning to the nearby departure airport. The captain's decision was adversely affected by self-imposed psychological factors which led him to assess inadequately the aircraft's battery endurance after the loss of generator power and the magnitude of the risks involved in continuing to the destination airport. Contributing to the accident was the airline management's failure to provide and the FAA's failure to assure an adequate company recurrent flight crew training programme which contributed to the captain's inability to assess properly the battery endurance of the aircraft before making the decision to continue, and led to the inability of the captain and the first officer to cope promptly and correctly with the aircraft's electrical malfunction."
Patricia A. Goldman, Vice Chairman, filed the following concurring/dissenting statement:
"While the accident report correctly identifies training and surveillance, I believe that inclusion of these items in the probable cause statement obscures and detracts from the basic reason the accident occurred and the attendant safety lesson. The pilot should never have continued the flight to the destination airport, but should have returned to the nearby airport on realizing that electrical d.c. power had been lost."
Final Report:

Crash of a Rockwell Aero Commander 560 off Lower Matecumbe Key: 1 killed

Date & Time: Sep 30, 1983 at 1800 LT
Operator:
Registration:
N70C
Flight Phase:
Flight Type:
Survivors:
Yes
MSN:
560-549
YOM:
1957
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
1525
Captain / Total hours on type:
35.00
Circumstances:
The aircraft crashed in the water in an isolated area of the Florida Bay while in a near inverted, left wing low, nose down attitude and at a high rate of descent with slow forward speed. The landing gear were down and locked, and the flaps were extended about 10°. Examination of the cargo door revealed evidence to suggest that it was not hinged to the aircraft during impact. The purpose of the flight is still under investigation by other gov't agencies. The passenger was seriously injured and the pilot was killed.
Probable cause:
Occurrence #1: loss of control - in flight
Phase of operation: maneuvering
Findings
1. (c) airspeed - not maintained - pilot in command
2. Stall - inadvertent - pilot in command
----------
Occurrence #2: in flight collision with terrain/water
Phase of operation: maneuvering
Final Report:

Crash of a Beechcraft 60 Duke in Wichita

Date & Time: Sep 29, 1983 at 1720 LT
Type of aircraft:
Registration:
N7277R
Survivors:
Yes
Schedule:
Wichita – Grand Rapids
MSN:
P-318
YOM:
1975
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3600
Captain / Total hours on type:
60.00
Aircraft flight hours:
1100
Circumstances:
Shortly after takeoff, the left engine began to progressively lose power and was shut down. The aircrew notified Beech Tower of the problem and reported they would like to return and land. The aircraft was observed on final approach to runway 18 with the gear extended and the left prop stopped. Before landing, the aircraft began veering to the left. It crossed over the end of the airport at about 40 feet agl and 300 feet left (east) of the runway. The left wing and nose dropped and the aircraft impacted the ramp, left wing first. The aircraft then skidded across the ramp on a heading of 160° and collided with and damaged three other aircraft; a Beechcraft F33A registered N1833S; another Beechcraft 60 Duke registered N6747D and a Beechcraft 58 registered N5800B. An investigation revealed that the #2 exhaust valve lifter had become flat and the #2 exhaust valve had failed from fatigue. Both pilots escaped uninjured.
Probable cause:
Occurrence #1: loss of engine power (total) - mech failure/malf
Phase of operation: climb - to cruise
Findings
1. (c) engine assembly, valve,intake - other
2. (c) engine assembly, valve,intake - fatigue
3. Propeller feathering - performed - pilot in command
4. Performed - pilot in command
----------
Occurrence #2: in flight collision with terrain/water
Phase of operation: landing - flare/touchdown
Findings
5. Precautionary landing - performed - pilot in command
6. (c) airspeed (VMC) - not maintained - pilot in command
Final Report:

Crash of a Beechcraft 65-80 Queen Air in Miami

Date & Time: Sep 19, 1983 at 1643 LT
Type of aircraft:
Operator:
Registration:
N55ED
Flight Type:
Survivors:
Yes
Schedule:
Miami - Miami
MSN:
LD-3
YOM:
1962
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
368
Captain / Total hours on type:
2.00
Circumstances:
Several days prior, a fam flight was intended in the aircraft to be given to the pilot by another person who represented himself as a pilot. The flight was cancelled due to a problem with the left engine. On the day of the accident, the other person told the pilot that the engine was repaired and they proceeded to conduct a local test flight with the other person conducting the takeoff from the left seat. They reportedly switched seats prior to landing. The approach appeared normal until just prior to landing. A burst of sound from the engines was heard and the aircraft yawed and rolled left. The left wing impacted the ground and the aircraft cartwheeled. The last logbook entry was in 10/82. The owner could not be located. The other pilot could not be located and there is no record of him being issued a pilot's certificate. During teardown of the left engine the servo fuel injector was found rigged extremely lean at the idle stop.
Probable cause:
Occurrence #1: loss of engine power (total) - mech failure/malf
Phase of operation: approach - VFR pattern - final approach
Findings
1. (c) fuel system,injector - improper
2. (c) maintenance, adjustment - improper - other maintenance personnel
----------
Occurrence #2: loss of control - in flight
Phase of operation: go-around (VFR)
Findings
3. (c) judgment - poor - pilot in command
4. (c) aborted landing - performed - pilot in command
5. (c) go-around - initiated - pilot in command
6. (c) aircraft handling - uncontrolled - pilot in command
----------
Occurrence #3: in flight collision with terrain/water
Phase of operation: go-around (VFR)
Final Report:

Crash of a Rockwell Grand Commander 690A in Nacogdoches: 2 killed

Date & Time: Sep 18, 1983 at 1955 LT
Operator:
Registration:
N111QL
Flight Type:
Survivors:
No
Schedule:
Oklahoma City – Longview – Nacogdoches
MSN:
690-11312
YOM:
1976
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
3310
Captain / Total hours on type:
135.00
Aircraft flight hours:
3077
Circumstances:
After transporting passengers from Longview, TX to Oklahoma City, OK and return to Longview, the aircraft was refueled for a flight back to Nacogdoches, TX, where the aircraft was based. About 12 min after takeoff, the pilot was cleared for an NDB approach to Nacogdoches and instructed to contact the Lufkin FSS for weather and current altimeter setting. During the NDB approach, the aircraft collided with trees, crashed and burned. An investigation revealed no evidence of either an engine or airframe failure or malfunction. Initial impact occurred with trees about 700 yards east of the NDB site. Initially, trees were cut in an upsloping manner where the terrain sloped upwards. Elevation of the crash site was 530 feet msl. The minimum descent altitude (MDA) was 900 feet msl. About 28 miles north, the 1955 cdt weather at Lufkin was, in part: 3,500 feet broken, visibility 5 miles. However, witnesses at Nacogdoches reported considerably lower ceilings, reduced visibility and some hilltops obscured by clouds. A pilot witness reported light rain, fog in the treetops. Reportedly, the airport was below minimums. Both occupants were killed.
Probable cause:
Occurrence #1: in flight encounter with weather
Phase of operation: approach - FAF/outer marker to threshold (IFR)
Findings
1. (f) preflight planning/preparation - inadequate - pilot in command
2. (f) light condition - dusk
3. (f) weather condition - low ceiling
4. (f) weather condition - fog
5. (f) weather condition - rain
6. (f) weather condition - below approach/landing minimums
----------
Occurrence #2: in flight collision with object
Phase of operation: approach - FAF/outer marker to threshold (IFR)
Findings
7. (c) IFR procedure - improper - pilot in command
8. (f) overconfidence in personal ability - pilot in command
9. (c) minimum descent altitude - not maintained - pilot in command
10. (f) object - tree(s)
----------
Occurrence #3: in flight collision with terrain/water
Phase of operation: descent - uncontrolled
Findings
11. Terrain condition - mountainous/hilly
Final Report:

Crash of a Partenavia P.68C in Plainview: 1 killed

Date & Time: Sep 11, 1983 at 1425 LT
Type of aircraft:
Registration:
N29561
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Plainview - Plainview
MSN:
266
YOM:
1982
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Aircraft flight hours:
342
Circumstances:
The pilot was executing a high speed pass over the runway at about 250 feet agl. The pilot then began a rapid pull-up and both wings separated just outboard of the engine nacelles. Reconstruction of the sequence from a videotape revealed that the aircraft's speed at the time of the wing separations was 220 knots. Vne for the aircraft is 193 knots. It was calculated that, at 220 knots and an 8° nose-up pitch, the 'g' load at the time of the wing separations would have been 8.3 g's. The pilot, sole on board, was killed.
Probable cause:
Occurrence #1: airframe/component/system failure/malfunction
Phase of operation: maneuvering
Findings
1. (c) in-flight planning/decision - improper - pilot in command
2. (c) overconfidence in aircraft's ability - pilot in command
3. (c) airspeed - exceeded - pilot in command
4. (c) wing - overload
5. (c) design stress limits of aircraft - exceeded - pilot in command
6. (f) wing - failure,total
7. (f) wing - separation
----------
Occurrence #2: in flight collision with terrain/water
Phase of operation: maneuvering
Final Report:

Crash of a Cessna 411 in Fort Lauderdale

Date & Time: Sep 10, 1983 at 0759 LT
Type of aircraft:
Registration:
N256EL
Flight Type:
Survivors:
Yes
Schedule:
Fort Lauderdale - Atlantic
MSN:
411-0242
YOM:
1967
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
7200
Captain / Total hours on type:
500.00
Aircraft flight hours:
2439
Circumstances:
The aircraft crashed while maneuvering at low airspeed and altitude right after takeoff. The pilot said the left engine started losing power intermittently at 90 knots. The pilot had rotated the aircraft and tried to continue the takeoff. He was cleared to land on any runway and in attempting a turn with landing gear and partial flaps extended control was lost and a crash occurred. The aircraft flight manual states that if an engine fails below 105 mph the takeoff should be aborted. An on scene examination revealed no evidence to suggest a pre-impact failure or malfunction. Both propellers showed evidence of torsional overload damage. When the engines were further examined the left engine fuel strainer was partially clogged with dirt. During a run-up test the left engine would not develop more than 23 inches hg. At 2,750 rpm and magneto rpm drop was erratic. The engine would not run with the aux fuel boost pump off. The reason for the low power output was a disconnected pressure line for the turbocharger which appeared to have been disconnected for some time. All five occupants were injured, two of them seriously.
Probable cause:
Occurrence #1: loss of engine power (partial) - mech failure/malf
Phase of operation: takeoff - initial climb
Findings
1. (c) fuel system, strainer - blocked (partial)
2. (c) exhaust system, turbocharger - disconnected
----------
Occurrence #2: loss of control - in flight
Phase of operation: takeoff - initial climb
Findings
3. (c) flight controls - improper use of - pilot in command
4. (c) throttle/power control - improper use of - pilot in command
5. (c) abort - not performed - pilot in command
----------
Occurrence #3: in flight collision with terrain/water
Phase of operation: maneuvering

Crash of a Beechcraft B90 King Air in Burlington

Date & Time: Sep 10, 1983 at 0525 LT
Type of aircraft:
Operator:
Registration:
N400AM
Survivors:
Yes
Schedule:
Denver - Burlington
MSN:
LJ-354
YOM:
1968
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Total fatalities:
0
Captain / Total flying hours:
3030
Captain / Total hours on type:
1200.00
Aircraft flight hours:
10540
Circumstances:
During arrival, the pilot checked the lighted windsock and estimated that the wind was from 020° at 10 knots. He elected not to land on runway 31 since there were obstacles near the approach end. He stated that when the aircraft was about to touch down on runway 13, there was a big gust of wind which made the aircraft land long. As the aircraft landed, the pilot selected max reverse, but got no response. He decide he could not make a successful go-around so he applied max braking, but was unable to stop on the remaining runway. Subsequently, the aircraft departed the runway, went thru a fence, crossed a road, hit a pole and then the gear collapsed as it went over railroad tracks. A witness estimated that at about the time the aircraft was landing, the wind shifted to the north and increased to about 35 to 40 mph. Reportedly, the final approach speed was about 13 knots too fast. Skid marks were found on the runway, starting about 2,000 feet from the approach end. With a 35 knots tailwind, landing roll without reverse thrust would have been 3,015 feet. No malfunctions found, but it was noted that reverse system was inoperative above 90 knots. All three occupants escaped uninjured.
Probable cause:
Occurrence #1: overrun
Phase of operation: landing - roll
Findings
1. (f) light condition - dark night
2. (f) terrain condition - high obstruction(s)
3. (f) weather condition - unfavorable wind
4. (f) weather condition - tailwind
5. (f) weather condition - gusts
6. (c) distance - misjudged - pilot in command
7. (c) airspeed - misjudged - pilot in command
8. (c) go-around - not performed - pilot in command
9. Thrust reverser - inoperative
10. (f) airspeed - excessive - pilot in command
11. (f) terrain condition - high obstruction(s)
12. Aborted landing - not possible - pilot in command
----------
Occurrence #2: gear collapsed
Phase of operation: landing - roll
Findings
13. (f) object - fence
14. (f) object - utility pole
----------
Occurrence #3: gear collapsed
Phase of operation: landing - roll
Findings
15. (f) terrain condition - rough/uneven
16. Landing gear - overload
Final Report:

Crash of a Beechcraft H18 off Kona

Date & Time: Sep 8, 1983 at 0934 LT
Type of aircraft:
Operator:
Registration:
N2990F
Flight Phase:
Survivors:
Yes
Schedule:
Kona - Honolulu
MSN:
BA-753
YOM:
1968
Flight number:
PV060
Crew on board:
1
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
8026
Captain / Total hours on type:
2960.00
Aircraft flight hours:
16873
Circumstances:
About one minute after takeoff, between 400-500 feet msl and during the first power reduction, the right engine backfired. Following some more violent backfires the rpm went to zero. The right engine was restarted but the same result occurred. The pilot attempted to feather the right prop but to no avail. The aircraft was then deliberately ditched to avoid an outcropping of lava. The aircraft came to rest in about 25-30 feet of water. Engine inspection revealed that the #2 cylinder exhaust rocker arm shaft, p/n45937, was missing. Drive train continuity was established with the exception of the #2 exhaust valve. Centrifugal stops prevent feathering of the prop below an engine speed of 500 rpm. All 10 occupants were rescued.
Probable cause:
Occurrence #1: loss of engine power (total) - mech failure/malf
Phase of operation: takeoff - initial climb
Findings
1. (c) exhaust system, actuator - separation
----------
Occurrence #2: ditching
Phase of operation: landing - flare/touchdown
Findings
2. (f) propeller feathering - not possible - pilot in command
Final Report:

Crash of a Cessna 421C Golden Eagle III in Altus: 8 killed

Date & Time: Sep 4, 1983 at 1607 LT
Registration:
N111FN
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Altus - Bartlesville
MSN:
421C-0321
YOM:
1977
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
8
Captain / Total flying hours:
7620
Captain / Total hours on type:
269.00
Aircraft flight hours:
1505
Circumstances:
The pilot initiated a takeoff on a hot afternoon with 7 passengers on board. Shortly after liftoff, two witnesses observed what they described as a puff of black smoke from the right engine. According to witnesses, the aircraft turned to the left before crossing the departure end of the runway at low altitude and low speed. Subsequently, the aircraft rolled rapidly to the left and impacted the ground in a near flat attitude, with a high rate of sink, and sufficient forward velocity to slide or bounce about 70 feet before coming to rest and burning. An exam of the wreckage, including teardowns of both engines, revealed no pre-impact/mechanical malfunction or failure. The aircraft was estimated to be 80 lbs below its max design gross weight. Its center of gravity was computed to be 1.45 inches aft of its rear limit. The temperature was 101° and the density altitude was about 4,000 feet. All eight occupants were killed.
Probable cause:
Occurrence #1: loss of engine power
Phase of operation: takeoff - initial climb
Findings
1. (c) reason for occurrence undetermined
----------
Occurrence #2: loss of control - in flight
Phase of operation: maneuvering - turn to landing area (emergency)
Findings
2. (c) airspeed (VMC) - not maintained - pilot in command
----------
Occurrence #3: in flight collision with terrain/water
Phase of operation: descent - uncontrolled
Findings
3. (c) aircraft handling - not maintained - pilot in command
Final Report: