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 Beechcraft B200 Super King Air in Tulsa

Date & Time: Dec 9, 2004 at 1831 LT
Operator:
Registration:
N6PE
Survivors:
Yes
Schedule:
La Crosse – Tulsa
MSN:
BB-856
YOM:
1981
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
2089
Captain / Total hours on type:
469.00
Aircraft flight hours:
3084
Circumstances:
The 2,100-hour instrument-rated private pilot stated that prior to departure for a 507 nautical mile cross-country flight, the fuel gauges indicated approximately 800 pounds of fuel on each side for a total of 1600 pounds; however, he did not visually check the amount of fuel that the tanks contained. During his approach to the destination airport, the right engine started to "sputter" before it finally quit. The pilot then "looked over at the fuel gauges and both tanks were showing empty." The left engine quit just a few moments later. The auto ignition installed in the airplane attempted to restart the engines. The engines restarted momentarily and then shut-off once more. The pilot declared an emergency and executed a forced landing onto a street below. After a hard landing onto the street, the right wing hit a telephone pole, and the left wing then hit several tree limbs before the airplane impacted a hill and came to a stop. The Federal Aviation Administration (FAA) inspector, who responded to the accident site, found the fuel transfer switch in the "right-crossfeed" position. The fuel system was examined and no leaks or anomalies were found. Approximately three-quarters of a gallon of unusable fuel was found in the right engine nacelle. Approximately four gallons (28 pounds) of usable fuel was found in the left engine nacelle.
Probable cause:
The loss of engine power due to fuel exhaustion as a result of the pilot's inadequate preflight and in-flight planning / preparation.
Final Report:

Crash of a Piper PA-31-350 Navajo Chieftain in Dayton: 1 killed

Date & Time: Dec 7, 2004 at 0140 LT
Operator:
Registration:
N54316
Flight Type:
Survivors:
No
Schedule:
Knoxville – Dayton
MSN:
31-7405436
YOM:
1974
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
3800
Captain / Total hours on type:
350.00
Aircraft flight hours:
9900
Circumstances:
The pilot was conducting a cargo flight in night instrument meteorological conditions, and was cleared for the ILS Runway 6L approach. The pilot reported that he was established on the localizer, and the control tower stated that the touchdown and mid-point "RVR" was 1,800 feet, and the roll-out "RVR" was 1,600 feet. The pilot also was instructed, and acknowledged, to make a right turn off the runway, after landing. There were no further communications from the airplane. The airplane's last radar target was observed at an altitude of 1,200 feet msl, and a ground speed of 130 knots. The airplane impacted trees, and came to rest inverted on airport property, on a bearing of 053 degrees, and a distance of 1/2 mile to the runway. Examination of the airplane did not reveal any pre-impact mechanical failures. A weather observation taken at the airport about the time of the accident included, winds from 140 degrees at 9 knots, 1/8 mile visibility, runway 06L visual range variable between 1,800, and 2,000 feet in fog, vertical visibility 100 feet, and a temperature and dew point 54 degrees F. The airport elevation was 1,009 feet msl. Review of the approach diagram for the ILS Runway 6L approach revealed a decision height of 1,198 feet msl, and an approach minimum of 1,800 feet runway visual range (RVR), or 1/2 mile visibility. The pilot had accumulated about 3,800 hours of total flight experience, which included about 350 hours in the same make and model as the accident airplane, and 250 total hours logged in instrument meteorological conditions.
Probable cause:
The pilot's failure to maintain adequate altitude\clearance while on approach, which resulted in an in-flight collision with trees. Factors in the accident were the fog and low ceiling conditions.
Final Report:

Crash of a Cessna 208B Grand Caravan in Hailey: 2 killed

Date & Time: Dec 6, 2004 at 1723 LT
Type of aircraft:
Operator:
Registration:
N25SA
Survivors:
No
Schedule:
Salt Lake City – Hailey
MSN:
208B-0866
YOM:
2000
Flight number:
MBI1860
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
9757
Captain / Total hours on type:
202.00
Aircraft flight hours:
2117
Circumstances:
Weather reporting facilities reported icing conditions in the area of the accident site. The pilot of a Cessna Citation flying the same RNAV approach twenty minutes prior to the accident aircraft reported picking up light to occasional moderate rime ice. The last communication between the local air traffic controller and the accident pilot indicated that the flight was two miles south of the final approach fix. The controller inquired if the pilot had the runway in sight, and the pilot reported "negative, still IMC." A witness on the ground near the accident site reported that he heard the aircraft first then saw it at a low level below the cloud base flying in a southeasterly direction. The witness stated that the right wing was lower than the left as the aircraft continued to descend. The witness then noted that the wings were moving "side to side" (up and down) a couple of times before the nose of the aircraft dropped near vertical to the terrain. This witness reported hearing the sound of the engine running steady throughout the event. The wreckage was located in a flat open field about 3,000 feet south of the final approach fix coordinates. The aircraft was destroyed by impact damage and a post crash fire.
Probable cause:
The pilot's failure to maintain aircraft control while on approach for landing in icing conditions. Inadequate airspeed was a factor.
Final Report:

Crash of a Convair CV-580F in McAllen

Date & Time: Dec 4, 2004 at 1441 LT
Type of aircraft:
Operator:
Registration:
N161FL
Flight Type:
Survivors:
Yes
Schedule:
McAllen - McAllen
MSN:
430
YOM:
1957
Location:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
9500
Captain / Total hours on type:
1500.00
Copilot / Total flying hours:
453
Copilot / Total hours on type:
120
Aircraft flight hours:
29586
Circumstances:
The 9,500-hour ATP-rated pilot was forced to secure the left engine during a maintenance test flight following the malfunction of the left propeller. The crew executed single-engine instrument landing system (ILS) approach to runway 13. During short final, the crew noticed that the alternator light was illuminated and the hydraulic pressure gauge indicated "0" pressure. The landing gear was already extended and the flaps were partially extended, so the crew elected to continue the approach to a full-stop landing. Upon landing, the pilot immediately turned on the direct current (DC) hydraulic pump. The pilot added that he then realized that he was unable to maintain directional control of the airplane due to the lack of nose wheel steering and the ineffective wheel brakes. As a result, the airplane continued to veer to the right and exited the runway. The airplane collided with the airport perimeter fence and continued down into a drainage ditch. The examination of the aircraft revealed that the hydraulic pump switch did not appear as if it had been turned on.
Probable cause:
The failure to activate the hydraulic pump which resulted in the pilot's inability to maintain directional control.
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 Cessna 414 Chancellor in Petersburg

Date & Time: Dec 2, 2004 at 1310 LT
Type of aircraft:
Registration:
N2EQ
Flight Type:
Survivors:
Yes
Schedule:
Petersburg - Petersburg
MSN:
414-0373
YOM:
1972
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3000
Captain / Total hours on type:
130.00
Copilot / Total flying hours:
5600
Circumstances:
The purpose of the flight was to "check out" the airplane before delivering it to its new owner, and to provide the copilot with an indoctrination ride in the Cessna 414. During the approach, the pilot provided guidance and corrections to the copilot. The copilot flew the airplane to within 200 feet of the ground when the nose of the airplane yawed abruptly to the right. The pilot took control of the airplane, and pushed the engine and propeller controls to the full forward position. He placed the fuel pump switches to the "high" position, retracted the flaps, and attempted to retract the landing gear. With full left rudder and full left aileron applied, he could neither maintain directional control nor stop a roll to the right. The airplane struck the ground and continued into the parking area where it struck an airplane and a waste-oil tank. Examination of the airplane following the accident revealed that the landing gear was down and locked, and the propeller on the right engine was not feathered. The emergency procedure for an engine inoperative go-around required landing gear retraction and a feathered propeller on the inoperative engine. The pilot's handbook further stated, "Climb or continued level flight is improbable with the landing gear extended and the propeller windmilling." After the accident, both pilots stated that they didn't notice a power loss on the right engine until the copilot surrendered the flight controls. The right engine was removed and placed in a test cell. The engine started immediately on the first attempt and ran continuously without interruption.
Probable cause:
The partial loss of engine power for undetermined reasons, and the pilot's failure to maintain adequate airspeed (Vmc).
Final Report:

Crash of a Gulfstream GIV in Teterboro

Date & Time: Dec 1, 2004 at 1623 LT
Type of aircraft:
Operator:
Registration:
G-GMAC
Survivors:
Yes
Schedule:
Farnborough – Luton – Teterboro
MSN:
1058
YOM:
1988
Flight number:
GMA946
Crew on board:
3
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
10000
Captain / Total hours on type:
1000.00
Copilot / Total flying hours:
8000
Copilot / Total hours on type:
2000
Aircraft flight hours:
7452
Circumstances:
The flight was cleared for the ILS Runway 19 approach, circle-to-land on Runway 24; a 6,013-foot-long, 150-foot wide, asphalt runway. The auto throttle and autopilot were disengaged during the approach, about 800 feet agl. However, the auto throttle reengaged just prior to touchdown, about 35 feet agl. The flightcrew did not recall reengaging the auto throttle, and were not aware of the autothrottle reengagement. According to the auto throttle computers, the reengagement was commanded through one of the Engage/Disengage paddle switches located on each power lever. The target airspeed set for the auto throttle system was 138 knots. After touchdown, as the airplane decelerated below 138 knots, the auto throttle system gradually increased the power levers in an attempt to maintain the target airspeed. Without the power levers in the idle position, the ground spoilers and thrust reversers would not deploy. While the flightcrew was pulling up on the thrust reverser levers, they may not have initially provided enough aft force on the power levers (15 to 32 lbs.) to override and disconnect the auto throttle system. The flight data recorder indicated that the autothrottle system disengaged 16 seconds after the weight-on-wheels switches were activated in ground mode. As the airplane neared the end of the runway, the pilot engaged the emergency brake, and the airplane departed the right side of the runway. The autothrottle Engage/Disengage paddle switches were not equipped with switch guards. Although the autothrottle system provided an audible tone when disengaged, it did not provide a tone when engaged. The reported wind about the time of the accident was from 290 degrees at 16 knots, gusting to 25 knots, with a peak wind from 300 degrees at 32 knots.
Probable cause:
The flightcrew's inadvertent engagement of the autothrottle system, and their failure to recognize the engagement during landing, which resulted in a runway excursion. Factors were the lack of autothrottle switch guards, lack of an autothrottle engagement audible tone, and gusty winds.
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 McDonnell Douglas MD-82 in Surakarta: 25 killed

Date & Time: Nov 30, 2004 at 1815 LT
Type of aircraft:
Operator:
Registration:
PK-LMN
Survivors:
Yes
Schedule:
Jakarta – Surakarta
MSN:
49189
YOM:
1984
Flight number:
JT583
Country:
Region:
Crew on board:
7
Crew fatalities:
Pax on board:
156
Pax fatalities:
Other fatalities:
Total fatalities:
25
Aircraft flight hours:
56674
Aircraft flight cycles:
43940
Circumstances:
While descending to Surakarta-Adisumarmo Airport, the crew was informed about stormy conditions at destination with cumulonimbus and heavy rain falls over the airport with a ceiling at 1,500 feet. The approach was continued and after touchdown on runway 26, the crew started the braking procedure and activated the thrust reverser systems. ON a wet runway, the aircraft was unable to stop within the remaining distance. It overran, lost its undercarriage and slid for few dozen metres, collided with equipments of the localizer antenna, a fence and came to rest in a cemetery. Both pilots and 23 passengers were killed while 70 other occupants were injured. 68 occupants escaped unhurt. The aircraft was destroyed.
Probable cause:
The following findings were identified:
- About 3 mm of water was stagnating on the runway surface, reducing the braking action,
- The crew completed the landing procedure with a 13 knots tailwind component,
- Airbrakes deployed after touchdown but retracted few seconds later due to wrong position of the power levers,
- Power levers were not in idle position after touchdown but slightly forward, so the flight computer increased power,
- Heavy rain falls,
- The crew failed to initiate a go-around procedure.