Crash of a Douglas DC-9-32 on Mt La Aguada: 45 killed

Date & Time: Mar 5, 1991 at 1617 LT
Type of aircraft:
Operator:
Registration:
YV-23C
Flight Phase:
Survivors:
No
Site:
Schedule:
Maracaibo – Santa Bárbara de Zulia
MSN:
47720
YOM:
1976
Flight number:
LV108
Country:
Crew on board:
5
Crew fatalities:
Pax on board:
40
Pax fatalities:
Other fatalities:
Total fatalities:
45
Aircraft flight hours:
32452
Aircraft flight cycles:
50298
Circumstances:
After departure from Maracaibo-La Chinita Airport, the crew followed a wrong heading to Santa Bárbara de Zulia (153° instead of 193°), which caused the aircraft to fly to the southeast over the lake of Maracaibo. While cruising at an altitude of 16,500 feet, the crew was cleared by ATC to descend to 5,500 feet. The crew reported to ATC that the VOR seemed to be inoperative but this was denied by the air traffic controller. At an altitude of 9,900 feet, the captain realized something was wrong about the heading selection, stopped the descent and initiated a right turn to gain height when the GPWS alarm sounded. Shortly later, the aircraft struck the slope of Mt La Aguada (3,320 meters high) located about 27 km northeast of Valera, some 170 km northeast of Santa Bárbara de Zulia. The aircraft disintegrated on impact and all 45 occupants were killed.
Probable cause:
The accident was the consequence of the combination of the following factors:
- The crew failed to prepare the flight according to published procedures and failed to follow various checklists,
- The crew failed to realize he was following a wrong heading after takeoff and failed to proceed to the en-route checks as required,
- The crew was distracted by conversations with a third person who was seating on the jumpseat all flight,
- The crew failed to supervise the flight according to standard operations,
- Poor crew coordination,
- Lack of discipline,
- At the time of impact, the aircraft was flying under VFR mode in IMC conditions,
- Poor visibility due to low clouds surroundings the mountains struck by the airplane.

Crash of a Boeing 737-291 in Colorado Springs: 25 killed

Date & Time: Mar 3, 1991 at 0944 LT
Type of aircraft:
Operator:
Registration:
N999UA
Survivors:
No
Schedule:
Peoria – Moline – Denver – Colorado Springs
MSN:
22742
YOM:
1982
Flight number:
UA585
Crew on board:
5
Crew fatalities:
Pax on board:
20
Pax fatalities:
Other fatalities:
Total fatalities:
25
Captain / Total flying hours:
9902
Captain / Total hours on type:
1732.00
Copilot / Total flying hours:
3903
Copilot / Total hours on type:
1077
Aircraft flight hours:
26050
Aircraft flight cycles:
19734
Circumstances:
On March 3, 1991, a United Airlines Boeing 737, registration number N999UA, operating as flight 585, was on a scheduled passenger flight from Denver, Colorado, to Colorado Springs, Colorado. Visual meteorological conditions prevailed at the time, and the flight was on an instrument flight rules flight plan. Numerous witnesses reported that shortly after completing its turn onto the final approach course to runway 35 at Colorado Springs Municipal Airport, about 0944 mountain standard time, the airplane rolled steadily to the right and pitched nose down until it reached a nearly vertical attitude before hitting the ground in an area known as Widefield Park. The airplane was destroyed, and the 2 flight crewmembers, 3 flight attendants, and 20 passengers aboard were fatally injured.
Probable cause:
A loss of control of the airplane resulting from the movement of the rudder surface to its blowdown limit. The rudder surface most likely deflected in a direction opposite to that commanded by the pilots as a result of a jam of the main rudder power control unit servo valve secondary slide to the servo valve housing offset from its neutral position and overtravel of the primary slide.
Final Report:

Crash of a Let L-410UVP in Muslyumovo

Date & Time: Feb 17, 1991
Type of aircraft:
Operator:
Registration:
CCCP-67145
Flight Phase:
Survivors:
Yes
MSN:
80 04 11
YOM:
1980
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
15
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
During the takeoff roll on a snow covered runway, the crew lost control of the airplane that veered off runway and came to rest in a ravine. All 17 occupants escaped uninjured while the aircraft was damaged beyond repair.

Crash of a PZL-Mielec AN-2P near Iquitos

Date & Time: Feb 14, 1991
Type of aircraft:
Operator:
Registration:
OB-1350
Flight Phase:
Survivors:
Yes
MSN:
1G139-12
YOM:
1972
Location:
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
13
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The crew attempted an emergency landing near Iquitos following an engine failure. The aircraft crash landed and was damaged beyond repair while all 15 occupants were injured.
Probable cause:
Engine failure for unknown reasons.

Crash of a De Havilland DHC-6 Twin Otter 300 near Taisha: 22 killed

Date & Time: Feb 14, 1991
Operator:
Registration:
FAE447
Flight Phase:
Survivors:
No
Site:
Schedule:
Macas - Taisha
MSN:
832
YOM:
1986
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
20
Pax fatalities:
Other fatalities:
Total fatalities:
22
Circumstances:
En route from Macas to Taisha on behalf of the Mission Aviation Fellowship (MAF), the crew encountered poor weather conditions and limited visibility. The aircraft struck the slope of Mt Paso Macuna (1,500 meters high) located about 34 km west of Taisha. The wreckage was found 35 meters below the summit and all 22 occupants were killed.
Probable cause:
Controlled flight into terrain.

Crash of an Antonov AN-12 in Monrovia

Date & Time: Feb 5, 1991
Type of aircraft:
Operator:
Survivors:
Yes
Schedule:
Conakry - Monrovia
Country:
Region:
Crew on board:
7
Crew fatalities:
Pax on board:
65
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Crashed on approach to Monrovia-Roberts Airport for unknown reasons. All 72 occupants were rescued and the aircraft was damaged beyond repair.

Crash of a Swearingen SA227AC Metro III in Los Angeles: 12 killed

Date & Time: Feb 1, 1991 at 1807 LT
Type of aircraft:
Operator:
Registration:
N683AV
Flight Phase:
Survivors:
No
Schedule:
Los Angeles - Palmdale
MSN:
AC-683
YOM:
1987
Flight number:
OO5569
Crew on board:
2
Crew fatalities:
Pax on board:
10
Pax fatalities:
Other fatalities:
Total fatalities:
12
Captain / Total flying hours:
8808
Captain / Total hours on type:
2107.00
Copilot / Total flying hours:
8000
Copilot / Total hours on type:
1363
Circumstances:
SKW5569, N683AV, had been cleared to runway 24L, at intersection 45, to position and hold. The local controller, because of her preoccupation with another airplane, forgot she had placed SKW5569 on the runway and subsequently cleared US1493, N388US, for landing. After the collision, the two airplanes slid off the runway into an unoccupied fire station. The tower operating procedures did not require flight progress strips to be processed through the local ground control position. Because this strip was not present, the local controller misidentified an airplane and issued a landing clearance. The technical appraisal program for air traffic controllers is not being fully utilized because of a lack of understanding by supervisors and the unavailability of appraisal histories.
Probable cause:
The failure of the los angeles air traffic facility management to implement procedures that provided redundancy comparable to the requirements contained in the national operational position standards and the failure of the faa air traffic service to provide adequate policy direction and oversight to its air traffic control facility managers. These failures created an environment in the Los Angeles air traffic control tower that ultimately led to the failure of the local controller 2 (lc2) to maintain an awareness of the traffic situation, culminating in the inappropriate clearances and the subsequent collision of the usair and skywest aircraft. Contributing to the cause of the accident was the failure of the faa to provide effective quality assurance of the atc system.
Final Report:

Crash of a Boeing 737-3B7 in Los Angeles: 22 killed

Date & Time: Feb 1, 1991 at 1807 LT
Type of aircraft:
Operator:
Registration:
N388US
Survivors:
Yes
Schedule:
Columbus - Los Angeles
MSN:
23310
YOM:
1985
Flight number:
US1493
Crew on board:
6
Crew fatalities:
Pax on board:
83
Pax fatalities:
Other fatalities:
Total fatalities:
22
Captain / Total flying hours:
16300
Captain / Total hours on type:
4300.00
Copilot / Total flying hours:
4316
Copilot / Total hours on type:
982
Circumstances:
SKW5569, N683AV, had been cleared to runway 24L, at intersection 45, to position and hold. The local controller, because of her preoccupation with another airplane, forgot she had placed SKW5569 on the runway and subsequently cleared US1493, N388US, for landing. After the collision, the two airplanes slid off the runway into an unoccupied fire station. The tower operating procedures did not require flight progress strips to be processed through the local ground control position. Because this strip was not present, the local controller misidentified an airplane and issued a landing clearance. The technical appraisal program for air traffic controllers is not being fully utilized because of a lack of understanding by supervisors and the unavailability of appraisal histories.
Probable cause:
The failure of the los angeles air traffic facility management to implement procedures that provided redundancy comparable to the requirements contained in the national operational position standards and the failure of the faa air traffic service to provide adequate policy direction and oversight to its air traffic control facility managers. These failures created an environment in the Los Angeles air traffic control tower that ultimately led to the failure of the local controller 2 (lc2) to maintain an awareness of the traffic situation, culminating in the inappropriate clearances and the subsequent collision of the usair and skywest aircraft. Contributing to the cause of the accident was the failure of the faa to provide effective quality assurance of the atc system.
Final Report:

Crash of a BAe 3101 Jetstream 31 in Beckley

Date & Time: Jan 30, 1991 at 2355 LT
Type of aircraft:
Operator:
Registration:
N167PC
Survivors:
Yes
Schedule:
Charlotte - Beckley
MSN:
710
YOM:
1986
Crew on board:
2
Crew fatalities:
Pax on board:
17
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
5000
Captain / Total hours on type:
3400.00
Aircraft flight hours:
8841
Circumstances:
Aircraft was dispatched with inoperative airframe deice system, tho an operational deice system was required for flight in known icing conditions. During descent to land, aircraft encountered light icing conditions. Capt believed aircraft could 'handle it' and continued descent. As he began ILS final approach, he noted significant increase of ice accumulation and used higher than normal approach speed. As full (50°) flaps were set, aircraft began buffet and pitched nose down. Capt corrected with full back pressure on control column, but aircraft landed hard, gear collapsed and aircraft slid about 3,600 feet to a stop. No preimpact mechanical anomaly was found, except for inoperative deice system. Investigation revealed pilots had received printout of weather from company computer system with surface observation and terminal forecast, but no area forecast (FA). Pilots and ground personnel were not aware that FA was available at company weather terminal. FA forecasted light and occasional moderate rime and mixed icing in clouds and precipitation above freezing level. Weather deteriorated, but pilots did not require inflight weather info or pireps. Flight mnl noted tailplane ice may cause nose down trim change with flap extension. There was evidence of tail plane stall, lack of company training in cold weather operations, deficiencies in use of deicing systems, and lack of FAA surveillance.
Probable cause:
Flight into known adverse weather conditions by the pilot, which resulted in ice accumulation on the aircraft and subsequent loss of aircraft control (tail plane stall) as the flaps were fully extended. Factors related to the accident were: the pilot's inadequate use of the preflight briefing service, inadequate training provided to the pilots by company/management personnel, inadequate surveillance by the faa, and icing conditions.
Final Report:

Crash of a Casa 212 Aviocar 200 near Gorontalo: 1 killed

Date & Time: Jan 30, 1991 at 1300 LT
Type of aircraft:
Operator:
Registration:
PK-NCY
Flight Phase:
Survivors:
Yes
Site:
Schedule:
Manado - Gorontalo
MSN:
258/78N
YOM:
1985
Flight number:
MZ540
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
18
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
The approach to Gorontalo-Jalaluddin Airport was initiated in thunderstorm activity with heavy rain falls. Too low, the airplane struck the slope of a mountain (1,500 meters high) located about 59 km from the airport. The wreckage was found about 30 meters below the summit. A passenger aged 80 died while all other occupants were rescued.
Probable cause:
For undetermined reasons, the crew started the approach prematurely, causing the aircraft to descend below the minimum safe altitude. The lack of visibility was a contributing factor.