Crash of a Learjet 24D near Juneau: 4 killed

Date & Time: Oct 22, 1985 at 2043 LT
Type of aircraft:
Operator:
Registration:
N456JA
Flight Type:
Survivors:
No
Site:
Schedule:
Anchorage – Juneau
MSN:
24-265
YOM:
1973
Location:
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
5578
Captain / Total hours on type:
547.00
Aircraft flight hours:
6303
Circumstances:
During arrival to pick up a medevac patient, the flight was cleared for an LDA-1 runway 08 approach via the Asort transition. Thus, the pilot should have continued southeast on J-541 toward the SSR vortac and intercepted the localizer (loc) at Asort; then track inbound on the loc (062°), using I-JDL frequency 109.9 MHz (frequency for loc and co-located DME). After Asort, minimum altitude was 6,500 feet to Dibol intersection, 5,100 feet to Lynns intersection and 3,400 feet to the faf at Barlo intersection. DME from I-JDL to the intersections was: 18.2, 13.5 and 8 miles. DME from SSR (south of loc track) to the intersections was 11.2, 12.7 and approximately 16 miles. Flight reported Asort inbound while descending thru approximately 9,500 feet. Last radio call was 30 seconds later while descending thru 8,200 feet, 14 miles west of Dibol. Approximately 4 miles west of Dibol, aircraft impacted mountain side at 3,500 feet msl. No preimpact mechanical malfunction was found. There was evidence that both nav's were tuned to 109.9 MHz, but DME control head was inadvertently left in 'hold' position (locking DME to SSR rather than I-JDLl) and crew began a premature descent. Juneau weather was in part: 600 feet scattered, 3,000 feet overcast, 7 miles visibility. Pilot-in-command was currently flying both Learjet and DHC-7. All four occupants, two pilots and two doctors, were killed.
Probable cause:
Occurrence #1: in flight collision with terrain/water
Phase of operation: approach - iaf to faf/outer marker (ifr)
Findings
1. (f) comm/nav equipment,distance measuring eqpt(dme) - not switched
2. (c) flight/navigation instrument(s) - improper use of
3. (f) habit interference - pilot in command
4. (c) became lost/disoriented - inadvertent - pilot in command
5. (c) descent - premature
6. (c) unsafe/hazardous condition - not identified - copilot/second pilot
7. (f) light condition - dark night
8. (f) weather condition - clouds
9. (f) terrain condition - mountainous/hilly
10. (c) proper altitude - not maintained - pilot in command
11. (f) terrain condition - rising
Final Report:

Crash of a De Havilland DHC-2 Beaver in Merrill Pass: 3 killed

Date & Time: Sep 26, 1985 at 1230 LT
Type of aircraft:
Operator:
Registration:
N5317G
Flight Phase:
Survivors:
No
Site:
Schedule:
Hidden River - Willow
MSN:
617
YOM:
1954
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
4900
Captain / Total hours on type:
1200.00
Aircraft flight hours:
7640
Circumstances:
The aircraft collided with terrain in a mountain pass at an elevation of 3,600 feet msl. The pilot obtained a weather briefing at 1329 gmt on 9/26/85 at which time Merrill Pass was forecast to be closed by 1100 adt due to deteriorating weather. The last radio communication with the aircraft was at 1803 gmt when contact was made with McGrath FSS. At this time the pilot made a pilot report stating the weather at Merrill Pass was marginal; 2 miles visibility with snow and occasional moderate turbulence. The wreckage was located on 9/29/85 and indicated the aircraft contacted the terrain in a relatively level attitude with considerable airspeed. All three occupants were killed.
Probable cause:
Occurrence #1: in flight encounter with weather
Phase of operation: cruise
Findings
1. (c) in-flight planning/decision - improper - pilot in command
2. (f) improper use of procedure - pilot in command
3. (c) flight into known adverse weather - continued - pilot in command
4. (f) weather condition - turbulence
5. (f) weather condition - snow
6. (f) weather condition - obscuration
----------
Occurrence #2: in flight collision with terrain/water
Phase of operation: maneuvering
Findings
7. (c) terrain condition - mountainous/hilly
8. (c) altitude - not maintained - pilot in command
Final Report:

Crash of a Learjet 24XR in Gulkana: 3 killed

Date & Time: Aug 20, 1985 at 0205 LT
Type of aircraft:
Operator:
Registration:
N455JA
Survivors:
No
Schedule:
Anchorage - Gulkana
MSN:
24-300
YOM:
1974
Location:
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
5582
Captain / Total hours on type:
801.00
Aircraft flight hours:
6645
Circumstances:
During a night arrival, the flight was on an instrument approach to the Gulkana Airport when radio contact with the aircraft was lost. A search was initiated and the wreckage was found 7.4 miles north of the terminal VOR on the 330° radial. The inbound course for the VOR runway 14 approach was on the 315° radial. An on-scene exam revealed the aircraft was tracking inbound when it collided with trees, crashed and burned about 2.4 miles before reaching the final approach fix. Both engines were operating during impact and both had ingested considerable tree material. No preimpact mechanical failure was evident. The captain and 1st officer were currently responsible for flying both the Learjet and DHC-7 aircraft. This was the captain's 1st day of work after returning from a vacation trip to Hawaii (approximately 1-1/2 weeks). The 1st officer had an adequate period for crew rest prior to reporting for work; however, he had previously been working a varied schedule. The operator repeatedly shifted pilots from 14 cfr 135 rest/duty requirements to those of 14 cfr 121. All three occupants were killed.
Probable cause:
Occurrence #1: in flight collision with object
Phase of operation: approach - iaf to faf/outer marker (ifr)
Findings
1. (f) weather condition - rain
2. (f) light condition - dark night
3. (c) ifr procedure - improper - pilot in command
4. (c) remedial action - not attained - copilot/second pilot
5. (f) fatigue (circadian rhythm) - copilot/second pilot
6. (f) fatigue (flight schedule) - company/operator management
7. (f) object - tree(s)
8. (c) minimum descent altitude - not maintained
----------
Occurrence #2: in flight collision with terrain/water
Phase of operation: descent - uncontrolled
Final Report:

Crash of a De Havilland DHC-2 Beaver near Tutna Lake: 4 killed

Date & Time: Aug 18, 1985 at 1403 LT
Type of aircraft:
Registration:
N68085
Survivors:
No
Site:
Schedule:
Anchorage - Tutna Lake
MSN:
1332
YOM:
1959
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
4190
Captain / Total hours on type:
406.00
Aircraft flight hours:
9018
Circumstances:
The aircraft crashed on the side of a mountain at an elevation of 2,200 feet approximately 3 miles from its intended destination, a remote lake. Purpose of the flight was to discharge caribou hunters into an area where caribou were spotted early that day. The aircraft was destroyed by fire. Inspection of the wreckage failed to reveal a mechanical failure/malfunction. All four occupants were killed.
Probable cause:
Occurrence #1: in flight collision with terrain/water
Phase of operation: maneuvering
Findings
1. (f) terrain condition - mountainous/hilly
2. (c) in-flight planning/decision - poor - pilot in command
3. (c) proper altitude - not maintained - pilot in command
Final Report:

Crash of a Douglas C-118A in Egegik

Date & Time: Jul 7, 1985 at 0115 LT
Type of aircraft:
Registration:
N2878F
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Egelik - Kodiak
MSN:
44660
YOM:
1955
Location:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
18640
Captain / Total hours on type:
468.00
Aircraft flight hours:
22655
Circumstances:
Airplane accelerated to V1 and struck through on sandy beach. The nose pitched up and the pilot lost directional control. The airplane struck adjacent bank caught fire. It was totally destroyed.
Probable cause:
Occurrence #1: loss of control - on ground/water
Phase of operation: takeoff - roll/run
Findings
1. Airport facilities, runway/landing area condition - inadequate
2. Airport facilities, runway/landing area condition - dirt bank/rising embankment
3. Airport facilities, runway/landing area condition - rough/uneven
4. (c) directional control - not maintained - pilot in command
5. (c) ground loop/swerve - uncontrolled - pilot in command
----------
Occurrence #2: on ground/water encounter with terrain/water
Phase of operation: takeoff - roll/run
Findings
6. (c) unsuitable terrain or takeoff/landing/taxi area - not identified - pilot in command
7. (c) preflight planning/preparation - disregarded - pilot in command
Final Report:

Crash of a Douglas C-47B-1-DL in King Salmon

Date & Time: Jun 30, 1985 at 1200 LT
Operator:
Registration:
N168Z
Survivors:
Yes
Schedule:
Homer - King Salmon
MSN:
20850
YOM:
1944
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
4250
Captain / Total hours on type:
1125.00
Aircraft flight hours:
18000
Circumstances:
During an instrument approach, the aircraft's right engine lost power. The pilot moved the right fuel selector to the left main tank and began emergency procedures. Shortly after that, the aircraft broke out of the overcast and the aircrew saw the airport. However, the left engine also lost power. The captain noted the fuel pressure was dropping and elected to land on tundra beside a road. During the landing, the aircraft was substantially damaged. No fuel was found in the aircraft during an exam of the fuel system. The captain noted that the left fuel cap was missing after the accident, but he did not see any fuel stains on the wing.
Probable cause:
Occurrence #1: loss of engine power (total) - nonmechanical
Phase of operation: approach - faf/outer marker to threshold (ifr)
Findings
1. (f) preflight planning/preparation - improper - pilot in command
2. Fuel system, cap - separation
3. (f) fluid, fuel - siphoning
4. (c) in-flight planning/decision - improper - pilot in command
5. (c) fluid, fuel - exhaustion
----------
Occurrence #2: forced landing
Phase of operation: maneuvering - turn to landing area (emergency)
----------
Occurrence #3: in flight collision with terrain/water
Phase of operation: landing
Final Report:

Crash of a Grumman G-44 Widgeon in Dillingham

Date & Time: Jun 20, 1985 at 1045 LT
Type of aircraft:
Registration:
N176MS
Survivors:
Yes
Schedule:
Anchorage - Dillingham
MSN:
1324
YOM:
1943
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
13000
Captain / Total hours on type:
400.00
Aircraft flight hours:
6830
Circumstances:
The amphibious aircraft crashed as the pilot was landing on glassy water at the inlet of Nerka Lake. Subsequently, it sank and came to rest inverted in clear water on the bottom of wood river with the gear retracted and the flaps extended. Moderate rain was falling when the pilot was landing. All three occupants escaped with minor injuries.
Probable cause:
Occurrence #1: hard landing
Phase of operation: landing - flare/touchdown
Findings
1. (f) weather condition - rain
2. (f) terrain condition - water,glassy
3. (c) altitude - misjudged - pilot in command
4. (c) flare - improper - pilot in command
----------
Occurrence #2: nose over
Phase of operation: landing
Final Report:

Crash of a Cessna 207A Skywagon in Golovin: 2 killed

Date & Time: May 16, 1985 at 1345 LT
Operator:
Registration:
N73635
Flight Phase:
Survivors:
Yes
Site:
Schedule:
Golovin - Elim
MSN:
207-0610
YOM:
1981
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
4280
Captain / Total hours on type:
420.00
Aircraft flight hours:
5132
Circumstances:
According to the pilot-in-command, he was attempting to fly through a mountain saddle. As he turned towards the mountain and began his climb the weather deteriorated rapidly with ceilings zero, visibility zero and severe turbulence. The airplane struck the side of a 1,707 foot high mountain at the 1,590 foot level on a magnetic heading of 015°. The pilot-in-command stated that just prior to impact he could not see anything. Two passengers were killed while three other occupants were seriously injured.
Probable cause:
Occurrence #1: in flight encounter with weather
Phase of operation: climb - to cruise
Findings
1. (c) in-flight planning/decision - improper - pilot in command
2. (c) pressure - pilot in command
3. (f) weather condition - obscuration
4. (c) vfr flight into imc - continued - pilot in command
5. (c) weather evaluation - poor - pilot in command
6. (c) judgment - poor - pilot in command
7. (c) improper use of equipment/aircraft - pilot in command
8. (f) weather evaluation - poor - company/operator management
----------
Occurrence #2: in flight collision with terrain/water
Phase of operation: maneuvering
Findings
9. (f) terrain condition - high terrain
10. (f) terrain condition - snow covered
11. (f) weather condition - clouds
12. (f) weather condition - whiteout
13. (f) visual/aural perception - pilot in command
Final Report:

Crash of a De Havilland DHC-6 Twin Otter 300 in Kaktovik

Date & Time: Mar 12, 1985 at 0015 LT
Operator:
Registration:
N540N
Survivors:
Yes
Schedule:
Prudhoe Bay – Kaktovik
MSN:
401
YOM:
1973
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
5311
Captain / Total hours on type:
2098.00
Aircraft flight hours:
13652
Circumstances:
Aircraft crashed during missed approach to temporary winter landing strip. Aircraft hit in steep nose down attitude. Marginal weather conditions prevailed, with icing reported. All four occupants were injured, both pilots seriously.
Probable cause:
Occurrence #1: in flight collision with terrain/water
Phase of operation: go-around (vfr)
Findings
1. (f) terrain condition - snow covered
2. (c) flight manuals - not followed - pilot in command
3. (f) overconfidence in aircraft's ability - pilot in command
4. (f) inadequate surveillance of operation - company/operator mgmt
5. (f) weather condition - fog
6. (f) weather evaluation - inaccurate - pilot in command
7. (f) company-induced pressure - company/operator management
8. (f) inadequate surveillance of operation - faa (organization)
9. (f) light condition - dark night
10. (f) in-flight planning/decision - poor - pilot in command
11. (f) expectancy - other person
12. (f) insuff standards/requirements, operation/operator - company/operator mgmt
13. (f) light condition - dark night
14. (f) weather evaluation - inaccurate - pilot in command
15. (f) fatigue (flight and ground schedule) - pilot in command
16. (c) weather condition - icing conditions
17. (f) flight into known adverse weather - intentional - pilot in command
18. Fatigue (flight and ground schedule) - copilot/second pilot
19. (f) wing - ice
20. (f) anti-ice/deice system - not used - pilot in command
21. (c) altitude - inadequate - pilot in command
Final Report:

Crash of a Cessna 207 Skywagon in Dillingham

Date & Time: Mar 2, 1985 at 0925 LT
Registration:
N1715U
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Dillingham - Manokotak
MSN:
207-0315
YOM:
1976
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
4400
Captain / Total hours on type:
3500.00
Circumstances:
The pilot was attempting a 180° turn to reverse direction away from lowering clouds and snow showers when the right wing dug into the snow covered terrain. The pilot stated a virtual 'white out' condition existed at the time. The pilot was uninjured and the aircraft was damaged beyond repair.
Probable cause:
Occurrence #1: in flight collision with terrain/water
Phase of operation: maneuvering - turn to reverse direction
Findings
1. (f) weather condition - snow
2. (f) weather condition - whiteout
3. (c) vfr flight into imc - inadvertent - pilot in command
4. (c) proper altitude - not maintained - pilot in command
Final Report: