Crash of a Cessna 421C Golden Eagle III in Olathe: 5 killed

Date & Time: Jan 21, 2005 at 0943 LT
Operator:
Registration:
N844JK
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Olathe – Zephyrhills
MSN:
421C-0681
YOM:
1979
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
6064
Aircraft flight hours:
2957
Circumstances:
The airplane received substantial damage on impact with trees, terrain, and a residence about one mile from the departure airport during instrument meteorological conditions. The airport elevation was 1,096 feet mean sea level. The personal flight was operating on an instrument flight rules (IFR) flight plan with a filed equipment suffix designating that the airplane was equipped with a Global Positioning System. Airplane records indicate that the airplane was equipped with a GPS but was not approved for IFR navigation. The pilot was issued a departure clearance to 3,000 feet and heading of 130 degrees. Radar data indicates that the airplane leveled off at an altitude approximately 2,000 feet during a 32 second period while executing a right turn to the assigned heading. Witnesses reported that the airplane impacted terrain in a right wing nose low attitude. Wreckage distribution and ground scarring was indicative of a high-speed impact with terrain. No anomalies that would have precluded normal operation of the airplane were noted. The calculated airplane weight was approximately 597 lbs above the maximum gross weight of the airplane.
Probable cause:
The pilot's failure to maintain adequate altitude/clearance during cruise flight, resulting in collision with trees. Contributing factors were the low altitude and low ceiling.
Final Report:

Crash of a Piper PA-61 Aerostar (Ted Smith 601) in Hamilton

Date & Time: Dec 30, 2004 at 1300 LT
Registration:
N601DF
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Hamilton – Stevensville
MSN:
61-0014
YOM:
1968
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
13409
Captain / Total hours on type:
1000.00
Aircraft flight hours:
3289
Circumstances:
Immediately after taking off and raising the landing gear, the pilot noticed the left engine began to lose power. The airplane subsequently veered to the left before impacting up slopping terrain in a left wing low attitude, resulting in a fire breaking out which consumed the left side of the airplane. A postaccident examination revealed that the left engine had sustained thermal but no impact damage, and that the engine's right hand turbocharger had no thermal or impact damage. A further examination indicated that no restrictions were found in the center section of the turbocharger and there was no damage to the housing or the impeller; however, the impeller was frozen in the center section and would not turn. Indications of grooving and scraping from a lack of lubrication to the bearings and drive shaft was observed. No mechanical anomalies with the aircraft were noted by the pilot prior to takeoff which would have prevented normal operations.
Probable cause:
A partial loss of engine power due to the lack of lubrication and subsequent failure of the left engine's right turbocharger for undetermined reasons, and subsequent forced landing after takeoff. A factor was the unsuitable terrain for the forced landing.
Final Report:

Crash of a Cessna 421A Golden Eagle I in Denver: 3 killed

Date & Time: Dec 17, 2004 at 1522 LT
Type of aircraft:
Registration:
N421FR
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Denver - Denver
MSN:
421A-0069
YOM:
1968
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
12000
Copilot / Total flying hours:
414
Copilot / Total hours on type:
31
Aircraft flight hours:
2666
Circumstances:
The pilot's father had just purchased the airplane for his daughter, and she was receiving model-specific training from a contract flight instructor. Her former flight instructor was aboard as a passenger. The engines were started and they quit. They were restarted and they quit again. They were started a third time, and the airplane was taxied for takeoff. Shortly after starting the takeoff roll, the pilot reported an unspecified engine problem. The airplane drifted across the median and parallel runway, then rolled abruptly to the right, struck the ground, and cartwheeled. The landing gear was down. Neither propeller was feathered. Disassembly of the right engine and turbocharger revealed no anomalies. Disassembly and examination of the left engine and turbocharger revealed the mixture shaft and throttle valve in the throttle and fuel control assembly were jammed in the idle cutoff and idle rpm positions, respectively. Manifold valve and fuel injector line flow tests produced higher-than-normal pressures, indicative of a flow restriction. Disassembly of the manifold valve revealed the needle valve in the plunger assembly was stuck in the full open position, collapsing the needle valve spring. A scribe was used to free the needle valve, and the manifold valve and fuel injector lines were again flow tested. The result was a lower pressure. Plunger disassembly revealed the threads had been tapped inside the retainer and metal shavings were found between the retainer and spring. The Teledyne Continental Motor (TCM) retainer has no threads. GPS download showed that 2,698 feet had been covered between the start of the takeoff roll and the attainment of rotation speed. Maximum speed attained was 132 mph. Computations indicated distance to clear a 50-foot obstacle was 2,000 feet, distance to clear a 50-foot obstacle (single engine) was 2,600 feet, and accelerate-stop distance was 3,000 feet.
Probable cause:
Loss of engine power due to fuel starvation, and the instructor's failure to maintain aircraft control. Contributing factors were a partially blocked fuel line resulting in restricted fuel flow, the instructor's failure to perform critical emergency procedures, and his failure to abort the takeoff in a timely manner.
Final Report:

Crash of a Beechcraft 200 Super King Air in Bayview

Date & Time: Dec 10, 2004 at 1250 LT
Operator:
Registration:
N648KA
Flight Phase:
Survivors:
Yes
Schedule:
Bayview - Houston
MSN:
BB-648
YOM:
1980
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
5800
Captain / Total hours on type:
400.00
Aircraft flight hours:
6532
Circumstances:
While attempting to depart from the 3,500-foot long grass airstrip with a 14 knot quartering tailwind, the 5,800-hour pilot reported that at an airspeed of approximately 95 knots, "the airplane yawed left and rolled left abruptly as the aircraft came off the ground briefly." The airplane settled back onto the ground, before again climbing back into the air approximately 20 degrees left of the runway heading. Subsequently, the airplane’s landing gear struck tree tops before it impacted the ground. A passenger added that he "noticed the flaps were up during takeoff." Approximately three minutes after the accident, a weather reporting station located 5.6 nautical miles southwest of the accident site reported wind from 010 degrees at 14 knots. Examination of the engines revealed rotational scoring throughout the first and second stage turbines. No mechanical anomalies were observed.
Probable cause:
The pilot's failure to maintain directional control as result of his improper runway selection for takeoff. A contributing factor was the prevailing right quartering tailwind.
Final Report:

Crash of a Convair CV-340-70 in Miami

Date & Time: Dec 4, 2004 at 0851 LT
Type of aircraft:
Operator:
Registration:
N41626
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Miami – Nassau
MSN:
274
YOM:
1955
Location:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3100
Captain / Total hours on type:
2400.00
Copilot / Total flying hours:
9169
Copilot / Total hours on type:
964
Aircraft flight hours:
18465
Circumstances:
The pilot stated that when the airplane was 3 miles east of the shoreline, at 3,000 feet, he felt a short tremor in the left engine followed by loss of power from the left engine. The pilot elected to return to the departure airport while declaring an emergency to air traffic control. During the process of securing the left engine the pilot noticed the propeller did not feathered and the airplane was descending quickly. He maneuvered the airplane and ditched in a lake. On September 26, 2003 engine s/n: 34592 was removed from the accident airplane due to high oil consumption with 1,225 hours of time in service. It was reportedly preserved and stored at the operator's warehouse. The mechanic who reportedly preserved the engine stated he followed the steps in the manual that was provided by the operator. On October 27, 2004 the left engine, s/n: NK510332, which was producing metal for months, was removed and engine s/n: 34592 was taken out of preservation and installed in the left position on the accident airplane with a new overhauled propeller assembly. On November 06, 2004, the left engine's, s/n: 34592, propeller governor was replaced due to the left propeller slow to response to power setting. During the post accident engine examination, the engine's main oil screen was observed with deposits of metal flakes and fragments, the oil scavenge pump would not rotate and had deposits of metal fragments internally; the engine was seized and wound not rotate. Catastrophic damage was observed to the accessories drive gears, oil transfer tube, and protection covers in the front accessory area. It was observed during a visual inspection of the crankshaft and bearings, including the front journal and front crankpin had damaged and sections of their respective bearings missing. The master rod bearing had incurred a catastrophic failure. Several cylinders skirts were found with impact marks from piston rods. Before removing the propeller assembly from the engine, the propeller feather system was flush with fresh oil and pressured with a feathering pump; the propeller blades were observed moving toward the feather position. Examination of the propeller assembly revealed metal contamination throughout the system; the propeller's governor screen gasket was clogged with metal contamination. The maintenance manual provided by the operator used for the engine preservation details several tasks required to be accomplished to the engine for proper engine preservation (i.e. thrust bear, cylinder, and propeller shaft treatments), which the mechanic did not mention he performed. No documentation for inspection and condition status of the dehydrator plugs were available. Documentation for flushing of contamination from the metal producing engine, s/n NK510332, was not available nor knowledge by the operator if since a process was preformed to the left engine's oil tank and its system before installation of engine s/n: 34592. An FAA review of the cargo manifest discovered two different manifest weights. The cargo manifest obtained at the accident scene showed a total of 267 pieces of cargo annotated at a total weight of 10, 837 lbs. The sealed cargo manifest package showed a total of 267 pieces of cargo annotated at a total weight of 14,182 lbs. The maximum payload weight for the accident airplane is 13,586 lbs.
Probable cause:
The improper maintenance of the left engine by company maintenance personnel (failure to flush metal from the oil system and failure to properly preserve the engine for storage) resulting in a total failure of the master rod bearing and contamination of the engine oil system with metal, which prevented the left propeller from feathering. This resulted in the airplane being unable to maintain altitude following loss of engine power and subsequent ditching in a lake. A factor in this accident is the aircraft operator and flight crew exceeding the maximum allowable takeoff weight for the airplane.
Final Report:

Crash of a Cessna 421B Golden Eagle II in Collegedale: 5 killed

Date & Time: Dec 2, 2004 at 1324 LT
Operator:
Registration:
N421SD
Flight Phase:
Survivors:
Yes
Schedule:
Collegedale – Knoxville
MSN:
421B-0386
YOM:
1973
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
4475
Captain / Total hours on type:
2000.00
Aircraft flight hours:
6808
Circumstances:
The airline transport pilot (ATP) stated the airplane was between 200 to 300 feet on initial takeoff climb when the right engine lost power and the airplane yawed to the right. The pilot lowered the nose of the airplane to gain airspeed, pulled the right power lever rearward and nothing happened. The pilot did not feather the right propeller and started moving switches in the vicinity of the boost pump switches. The ATP passenger stated, he did not think the left engine was producing full power. He scanned the instruments with his eyes looking at the manifold pressure gauges. "One needle was at zero and the other was at 25-inches. The manifold pressure should have been 39-inches of manifold pressure. The ATP passenger observed trees to their front and thought the pilot was trying to make a forced landing in an open field to their left. The ATP passenger realized the airplane was going to collide with the trees. Just before the airplane collided with the trees, the pilot feathered the right engine. The ATP passenger observed the right propeller going into the feather position, and the propeller came to a complete stop. Examination of the right engine revealed no anomalies. Examination of the left engine revealed the starter adapter gear teeth had failed due to overload.
Probable cause:
The pilot's improper identification of a partial loss of engine power on initial takeoff climb resulting in a collision with trees and the ground. A factor was a partial failure of the left engine starter adapter due to overload.
Final Report:

Crash of a MBB HFB-320 Hansa Jet in Chesterfield: 2 killed

Date & Time: Nov 30, 2004 at 1956 LT
Type of aircraft:
Operator:
Registration:
N604GA
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Chesterfield – Toledo
MSN:
1037
YOM:
1969
Flight number:
GAE604
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
11500
Captain / Total hours on type:
2500.00
Copilot / Total flying hours:
10377
Aircraft flight hours:
6875
Circumstances:
The Hansa 320, a corporate turbojet airplane departed runway 26L at night on a maintenance ferry flight at 1954 central standard time, and was destroyed when it impacted a river two miles west of the departure airport. Radar track data indicated that the airplane climbed to about 900 feet msl at about 180 knots before it began losing altitude and impacted the river. The current weather was: winds 270 degrees at 13 knots gusting to 19 knots, visibility 7 miles, light rain, 1,000 feet scattered ceiling, 1,800 feet broken, 2,400 feet overcast, temperature 2 degrees Celsius (C), dew point 2 degrees C, altimeter 29.90. The FAA had issued the pilot a Special Flight Permit for the flight. The limitations listed in the flight permit included the following limitations: Limitation number 6 stipulated, "IFR in VMC conditions approved, provided all equipment required for IFR flight is operational and certified iaw 14 CFR Part 91.413. If this equipment is NOT certified and operational, then VFR in VMC conditions ONLY." The ferry permit listed, "Additional Limitations: Engine power assurance runs, compass swing, and functional check of avionics equipment must be performed, and appropriate maintenance entries in the aircraft log prior to departure." The pilot was informed that none of the additional limitations had been performed prior to takeoff. The pilot had aborted a previous takeoff at about 1830 due to no airspeed indications. At the request of the pilot, maintenance personnel disconnected the lines to the pitot tubes and blew out the tubes, but no leak check, as required by FAR 91.411, was performed prior to the accident flight. The pilot performed a high-speed taxi to test the airspeed indicators prior to takeoff. The copilot did not have any ground school or flight time in a Hansa 320. The second-in-command requirements stated in FAR 61.55 9 (f) (1), required that the flight be conducted under day VFR or day IFR. The Toxicology report for the pilot indicated that 0.106 (ug/ml, ug/g) Diphenhydramine was detected in the blood. Diphenhydramine is an antihistamine commonly used in over-the-counter cold/allergy preparations. In therapeutic doses, the medication commonly results in drowsiness, and has measurable effects on performance of complex cognitive and motor tasks (e.g. flying an aircraft). The pilot's currency in the Hansa 320 expired on November 30, 2004, the day of the accident. He would be required to have an FAA checkride in a Hansa 320 to be a pilot-in-command (PIC) after November 30th. Engine teardown inspections revealed that both engines were developing power at the time of impact. The inspection of the elevator trim system revealed that the elevator trim cables were improperly installed when they were replaced to comply with an Airworthiness Directive (AD) 224-01-11. The maintenance manager who inspected the installation of the elevator trim cables did not perform an operational check of the elevator trim tabs. The maintenance manager signed the aircraft log stating the "Aircraft is approved for one time ferry flight from SUS to TOL," although all stipulations of the ferry permit had not been met, and that a leak check of the pitot-static system had not been performed after the pitot tubes had been blown out.
Probable cause:
The maintenance facility failed to properly install and inspect the elevator trim system resulting in the reversed elevator trim condition and the pilot's failure to maintain clearance with the terrain. Contributing factors included the dark night and low ceiling.
Final Report:

Crash of a Canadair CL-601-1A Challenger in Montrose: 3 killed

Date & Time: Nov 28, 2004 at 0955 LT
Type of aircraft:
Operator:
Registration:
N873G
Flight Phase:
Survivors:
Yes
Schedule:
Montrose – South Bend
MSN:
3009
YOM:
1983
Flight number:
HPJ073
Crew on board:
3
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
12396
Captain / Total hours on type:
913.00
Copilot / Total flying hours:
1586
Copilot / Total hours on type:
30
Aircraft flight hours:
14317
Aircraft flight cycles:
8910
Circumstances:
On November 28, 2004, about 0958 mountain standard time, a Canadair, Ltd., CL-600-2A12, N873G, registered to Hop-a-Jet, Inc., and operated by Air Castle Corporation dba Global Aviation as Glo-Air flight 73, collided with the ground during takeoff at Montrose Regional Airport (MTJ), Montrose, Colorado. The on-demand charter flight was operated under the provisions of 14 Code of Federal Regulations (CFR) Part 135 on an instrument flight rules (IFR) flight plan. Instrument meteorological conditions prevailed, and snow was falling. Of the six occupants on board, the captain, the flight attendant, and one passenger were killed, and the first officer and two passengers were seriously injured. The airplane was destroyed by impact forces and post crash fire. The flight was en route to South Bend Regional Airport (SBN), South Bend, Indiana.
Probable cause:
The flight crew's failure to ensure that the airplane’s wings were free of ice or snow contamination that accumulated while the airplane was on the ground, which resulted in an attempted takeoff with upper wing contamination that induced the subsequent stall and collision with the ground. A factor contributing to the accident was the pilots’ lack of experience flying during winter weather conditions.
Final Report:

Crash of a Reims Cessna F406 Caravan II in Arusha

Date & Time: Nov 27, 2004 at 1618 LT
Type of aircraft:
Operator:
Registration:
5H-RAS
Flight Phase:
Survivors:
Yes
Schedule:
Arusha – Seronera
MSN:
406-0005
YOM:
1986
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total hours on type:
80.00
Circumstances:
The aircraft was taking off for a scheduled flight from Arusha to Seronera. At 12:15 hours the aircraft taxied from the apron to the threshold of runway 27 at which point take off for Seronera was initiated. The controller, who was handling the flight, said that the initial segment of the take off roll was normal. When the aircraft had covered about 500 metres he saw the left main landing gear collapsing and the aircraft swinging to the left of the runway. It continued to run on its belly pod on a grass hedge parallel to runway 27 and came to rest at the eastern edge of the apron. There was no fire and all the occupants deplaned without injuries. The aircraft sustained damage to propellers, the right wing, the fuselage and underside structure. The cargo pod in the belly was completely destroyed and its debris was scattered along the wreckage trail.
Probable cause:
There does not appear to be any defects in the aircraft, which could have contributed to this accident. The available evidence would point to premature rotation and premature retraction of the landing gear. Much of the pilot’s recent flying was on low speed aircraft. He had flown Cessna 208s and Twin Otters for many years. His experience on the Cessna 406 was 80 hours. In fact he had flown a Twin Otter only hours before switching to the Cessna 406.

Crash of a Cessna 411 in Corona: 2 killed

Date & Time: Nov 25, 2004 at 1434 LT
Type of aircraft:
Operator:
Registration:
N747JU
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Corona - Corona
MSN:
411-0050
YOM:
1965
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
650
Circumstances:
The multiengine airplane impacted terrain shortly after departing from the airport. The airplane began the initial climb after liftoff and initially maintained a track along the extended runway centerline. Witnesses indicated that about 1 mile into the initial climb, the aircraft began to make erratic yawing maneuvers and the engines began to emit smoke. The airplane rolled to the left and dove toward the ground, erupting into fire upon impact. Prior to the accident, the pilot had reportedly been having mechanical problems with the fuel tank bladder installations and had attempted to install new ones. He was performing his own maintenance on the airplane in an attempt to rectify the problem. The day before the accident, the pilot told his hangar mate that he took the airplane on a test flight and experienced mechanical problems with an engine. Neither the nature of the engine problems nor the actions to resolve the discrepancies could be determined. On site examination of the thermally destroyed wreckage disclosed evidence consistent with the right engine producing significantly more power than the left engine at ground impact. The extent of the thermal destruction precluded any determination regarding the fuel selector positions, the positions for the boost pump switches, or the fuel tanks/lines.
Probable cause:
A loss of engine(s) power for undetermined reasons. Also causal was the pilot's failure to maintain the airplane's minimum controllable airspeed (Vmc) during the initial climb following a loss of power in one engine, which resulted in a loss of aircraft control and subsequent impact with terrain.
Final Report: