Crash of a Cessna 208B Grand Caravan in Globe

Date & Time: Jul 22, 2005 at 0830 LT
Type of aircraft:
Registration:
N717BT
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Phoenix – Globe – Safford
MSN:
208B-0863
YOM:
2000
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
5545
Captain / Total hours on type:
203.00
Aircraft flight hours:
4461
Circumstances:
The airplane impacted a road and scrub brush during a forced landing, which was preceded by a total loss of engine power. According to the pilot, he heard a loud "thunk" during takeoff climb and noted a loss of engine power. He manipulated the power lever from the full forward position to the full aft position ("stop-to-stop") and noted he had no power. Post-accident examination of the Pratt & Whitney Canada PT6A -114A engine revealed that the compressor turbine (CT) vane's outer rim liberated a section of metal that damaged the turbine blades downstream. The area of liberated material from the CT vane outer rim was examined by the manufacturer's metallurgists. The fracture surface of the outer rim showed evidence of fatigue with signs of oxidation in some areas indicating the crack had been in existence for some time. The liberated material impact damaged the CT blades and resulted in a loss of power. Review of the operator's records revealed that the engine was approved for an extension beyond the normally recommended 3,600-hour overhaul period, to 5,100 hours. The engine had accumulated 4,461.3 hours at the time of the accident. In addition, the turbine section (hot section) had a recommended overhaul period of 1,800 hours; however, the operator instead elected to utilize an engine trend monitoring program in accordance with a manufacturer issued service bulletin. Many errors were noted with the operator's manually recorded data utilized for the trend monitoring. However, it is not likely that the engine trend data, even had it been correctly recorded and monitored, would have depicted the fatigue cracking in the CT vane outer rim. As a result, the manufacturer issued a service information letter (SIL) PT6A116 in January 27, 2003 (following a similar investigation), which reminded operators to conduct borescope inspections of the CT vane during routine fuel nozzle maintenance, as the manufacturer's maintenance manual recommended. Review of the maintenance record entries for the accident engine revealed no evidence that a borescope inspection had been conducted in conjunction with the fuel nozzle checks.
Probable cause:
The fatigue failure of the compressor turbine stator vane, the liberation of vane material into the compressor turbine, and the total loss of engine power. Also causal was the operator's failure to inspect the compressor turbine vane during fuel nozzle checks.
Final Report:

Crash of a Beechcraft C90 King Air in Marble Canyon

Date & Time: Jun 13, 2005 at 1500 LT
Type of aircraft:
Operator:
Registration:
N49LL
Flight Type:
Survivors:
Yes
Schedule:
Bermuda Dunes – Marble Canyon
MSN:
LJ-1316
YOM:
1992
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
2025
Aircraft flight hours:
3655
Circumstances:
The airplane descended to ground impact while maneuvering during a go-around. The pilot was meeting friends at the airport. The friends and their pilot arrived first, and were waiting at the departure end of runway 03. The airplane approached on a straight-in to runway 03. They thought that everything looked good on the approach. Due to a hump in the runway, they lost sight of the airplane just before it would have touched down. They then saw the airplane climbing back up on a go-around. As the airplane came abeam of their position, they saw it enter a steep banked left turn at an angle of bank they estimated between 60 and 80 degrees. At this point the landing gear was still down and the altitude was 200 feet above the ground. The witnesses saw the airplane's nose suddenly drop and the airplane then descended rapidly to the ground. No evidence of a preimpact mechanical malfunction or failure was found during detailed examination of the airframe systems and engines.
Probable cause:
The pilot's failure to maintain an adequate airspeed while maneuvering during a go-around, which resulted in a stall.
Final Report:

Crash of a Rockwell Aero Commander 500B in Grand Canyon

Date & Time: May 28, 2003 at 1720 LT
Registration:
N64TS
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Grand Canyon - Rialto
MSN:
500-1442-156
YOM:
1964
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
26110
Captain / Total hours on type:
850.00
Aircraft flight hours:
4587
Circumstances:
The airplane did not gain altitude after takeoff and collided with trees and terrain off the departure end of the runway. Prior to takeoff the pilot received a computerized weather briefing that showed generally good conditions. The tower controller cleared the pilot to taxi to the active runway (runway 21) and issued winds, which were 300 degrees at 10 knots, a direct crosswind. During the initial climb after liftoff, the pilot saw that the airplane had stopped climbing and he asked for and received the wind information again. With the airplane not climbing and headed directly for some trees, the pilot maneuvered the airplane towards a clearing but the left wing hit a tree and the airplane descended into the ground. The pilot reported no mechanical problems with the airframe and engines. The density altitude was calculated to be 9,481 feet. The aircraft's gross weight at the time of takeoff was 6,000 pounds. Review of the Airplane Flight Manual climb performance charts for that aircraft weight at the pressure altitude and reported outside air temperature discloses that the airplane should have had a positive rate of climb of about 1,100 feet per minute. The airport was equipped with a wind information recording system, which had four sensors. Three sensors recorded wind information at ground level only. They were placed, one each, at the approach, middle, and departure ends of the runway. Wind data was recorded every 10 seconds. The system does not have the capability to predict or warn of wind shear events. During the aircraft's departure, the approach end sensor recorded winds at 068 degrees at 1 knot; the middle sensor recorded winds at 293 degrees at 5 knots; and the departure sensor recorded winds at 302 degrees at 2 knots. At the next data sampling (10 seconds later), the departure end sensor recorded a wind increase of 10 knots, and the approach end recorded a wind shift from a headwind to a tailwind at 10 knots. A full analysis of the weather conditions indicated that due to developing convection over the runway the airplane likely encountered a wind shear (increasing tailwind) event that seriously degraded the takeoff and climb performance.
Probable cause:
The pilot's encounter with a wind shear just after liftoff.
Final Report:

Crash of a Piper PA-61 Aerostar (Ted Smith 601) in Scottsdale: 2 killed

Date & Time: Jan 26, 2003 at 2023 LT
Registration:
N3636Q
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Scottsdale – Santa Fe
MSN:
61-0785-8063398
YOM:
1980
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
1450
Captain / Total hours on type:
160.00
Aircraft flight hours:
2574
Circumstances:
The airplane collided with mountainous terrain 5 miles from the departure airport during a dark night takeoff. Review of recorded radar data found a secondary beacon code 7267 (the code assigned to the airplane's earlier inbound arrival ) on the runway at 2021:08, with a mode C report consistent with the airport elevation. Two more secondary beacon returns were noted on/over the runway at 2021:12 and 2021:19, reporting mode C altitudes of 1,600 and 1,700 feet, respectively. Between 2021:08 and 2021:38, the secondary beacon target (still on code 7267) proceeded on a northeasterly heading of 035 degrees (runway heading) as the mode C reported altitude climbed to 2,000 feet and the computed ground speed increased to 120 knots. Between 2021:38 and 2021:52, the heading changed from an average 035 to 055 degrees as the mode C reports continued to climb at a mathematically derived 1,300 feet per minute and the ground speed increased to average of 170 knots. At 2022:23, the code 7267 target disappeared and was replaced by a 1200 code target. The mode C reports continued to climb at a mathematically derived rate of 1,200 feet per minute as the ground speed increased to the 180- knot average range. The computed average heading of 055 degrees was maintained until the last target return at 2022:53, which showed a mode C reported altitude of 3,500 feet. The accident site elevation was 3,710 feet and was 0.1 miles from the last target return. The direct point to point magnetic course between Scottsdale and Santa Fe was found to be 055 degrees. Numerous ground witnesses living at the base of the mountain where the accident occurred reported hearing the airplane and observing the aircraft's lights. The witnesses reported observations consistent with the airplane beginning a right turn when a large fireball erupted coincident with the airplane's collision with the mountain. No preimpact mechanical malfunctions or failures were found during an examination of the wreckage. The radar data establishes that the pilot changed the transponder code from his arrival IFR assignment to the VFR code 30 seconds before impact and this may have been a distraction.
Probable cause:
The pilot's failure to maintain an adequate altitude clearance from mountainous terrain. Contributing factors were dark night conditions, mountainous terrain, and the pilot's diverted attention.
Final Report:

Crash of a Cessna 208B Grand Caravan in Parks: 4 killed

Date & Time: Nov 8, 2002 at 1020 LT
Type of aircraft:
Registration:
N514DB
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Las Vegas - Midland
MSN:
208B-0971
YOM:
2002
Location:
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
1880
Captain / Total hours on type:
77.00
Copilot / Total flying hours:
638
Circumstances:
The airplane departed Las Vegas, Nevada, approximately 0919, on an IFR flight plan to Midland, Texas. The pilot climbed to an initial cruising altitude of 13,000 feet. At 1005, the pilot contacted Albuquerque ARTCC (ZAB) and reported that he was level at 13,000 feet. At 1009, the pilot requested to climb to 15,000 and the ZAB controller approved the request. At 1013:55, the pilot contacted Albuquerque Flight Watch and reported that he was approximately 23 miles west of Flagstaff, Arizona at 15,000 feet, and that about 20 miles west of his position, at 13,000 feet, he encountered "light mixed icing." The pilot requested any PIREP's. Flight Watch reported that a PIREP for "a trace of rime icing at 12,000," was reported by an airplane climbing westbound out of Albuquerque. The pilot acknowledged and asked for the weather across New Mexico. Flight Watch advised the pilot to stand by while he gathered the reports. At 1015:15, the pilot contacted ZAB. He reported, "getting...mixed...right...now," and requested to climb to 17,000 feet. At 1015:57 the controller cleared the airplane to 17,000 feet. At 1016:35, the FW specialist repeated the report of trace icing near Albuquerque. The pilot did not reply. ZAB radar indicated the airplane climbed to 15,200 feet then entered a rapid descent. At 1017:08, a broken transmission was received. No further communications were received from the airplane. Radar contact was lost with the airplane at 1017:20. An examination of the airplane wreckage showed no anomalies.
Probable cause:
The pilot's improper in flight planning/decision making, his flight into known icing conditions, and his failure to maintain adequate airspeed which resulted in the inadvertent stall/spin and impact with terrain. Factors contributing to the accident were the pilot's improper pre-flight planning/preparation, the icing conditions, and the inadvertent stall/spin.
Final Report:

Crash of an Airbus A320-231 in Phoenix

Date & Time: Aug 28, 2002 at 1843 LT
Type of aircraft:
Operator:
Registration:
N635AW
Survivors:
Yes
Schedule:
Houston - Phoenix
MSN:
092
YOM:
1990
Flight number:
AWE794
Crew on board:
5
Crew fatalities:
Pax on board:
154
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
19500
Captain / Total hours on type:
7000.00
Copilot / Total flying hours:
11000
Copilot / Total hours on type:
800
Aircraft flight hours:
40084
Aircraft flight cycles:
18530
Circumstances:
After an asymmetrical deployment of the thrust reversers during landing rollout deceleration, the captain failed to maintain directional control of the airplane and it veered off the runway, collapsing the nose gear and damaging the forward fuselage. Several days before the flight the #1 thrust reverser had been rendered inoperative and mechanically locked in the stowed position by maintenance personnel. In accordance with approved minimum equipment list (MEL) procedures, the airplane was allowed to continue in service with a conspicuous placard noting the inoperative status of the #1 reverser placed next to the engine's thrust lever. When this crew picked up the airplane at the departure airport, the inbound crew briefed the captain on the status of the #1 thrust reverser. The captain was the flying pilot for this leg of the flight and the airplane touched down on the centerline of the runway about 1,200 feet beyond its threshold. The captain moved both thrust levers into the reverse position and the airplane began yawing right. In an effort at maintaining directional control, the captain then moved the #1 thrust lever out of reverse and inadvertently moved it to the Take-Off/Go-Around (TOGA) position, while leaving the #2 thrust lever in the full reverse position. The thrust asymmetry created by the left engine at TOGA power with the right engine in full reverse greatly increased the right yaw forces, and they were not adequately compensated for by the crew's application of rudder and brake inputs. Upon veering off the side of the runway onto the dirt infield, the nose gear strut collapsed. The airplane slid to a stop in a nose down pitch attitude, about 7,650 feet from the threshold. There was no fire. Company procedures required the flying pilot (the captain) to give an approach and landing briefing to the non flying pilot (first officer). The captain did not brief the first officer regarding the thrust reverser's MEL'd status, nor was he specifically required to do so by the company operations manual. Also, the first officer did not remind the captain of its status, nor was there a specific requirement to do so. The operations manual did state that the approach briefing should include, among other things, "the landing flap setting...target airspeed...autobrake level (if desired) consistent with runway length, desired stopping distance, and any special problems." The airline's crew resource management procedures tasked the non flying pilot to be supportive of the flying pilot and backup his performance if pertinent items were omitted from the approach briefing. The maintenance, repair history, and functionality of various components associated with the airplane's directional control systems were evaluated, including the brake system, the nose landing gear strut and wheels, the brakes, the antiskid system, the thrust levers and reversers, and the throttle control unit. No discrepancies were found regarding these components.
Probable cause:
The captain's failure to maintain directional control and his inadvertent application of asymmetrical engine thrust while attempting to move the #1 thrust lever out of reverse. A factor in the accident was the crew's inadequate coordination and crew resource management.
Final Report:

Crash of a Pilatus UV-20A Turbo Porter in Marana: 1 killed

Date & Time: Mar 15, 2002 at 1000 LT
Operator:
Registration:
79-23253
Flight Phase:
Survivors:
No
Schedule:
Marana - Marana
MSN:
802
YOM:
1979
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
6187
Captain / Total hours on type:
31.00
Aircraft flight hours:
6267
Circumstances:
A US Army Pilatus UV-20A collided in midair with a Cessna 182C during parachute jumping operations. The collision occurred about 4,800 feet mean sea level (msl) (2,800 feet above ground level (agl)) on the northeast side of runway 12 abeam the approach end. Both aircraft had made multiple flights taking jumpers aloft prior to the accident. The Pilatus departed runway 12 about 5 minutes prior to the Cessna's departure on the same runway. The drop zone was on the airport west of the intersections of runways 12 and 03. The Pilatus departed to the south and began a climb to the jump altitude of 5,500 feet msl, which was 3,500 feet agl. The pilot began the jump run on the southwest side of the runway paralleling it on a heading of about 300 degrees and when he was 1 to 2 minutes from the drop zone broadcast the intent to drop jumpers. The first jumper stated that it normally took him between 1 minute and 1 minute 15 seconds to reach the ground. As he neared the ground he observed everyone running toward the crash site. The Cessna pilot had four jumpers on board and said that his usual practice is to plan his climb so that the jump altitude (5,000 to 5,500 feet msl) is reached about the same time that the aircraft arrives over the jump zone. He departed runway 12 and made a wide sweeping right turn around the airport to set up for the jump. As the Pilatus neared the jump zone the Cessna was greater than 1,000 feet lower and west of the Pilatus climbing on a northerly heading. The Cessna pilot planned to make a right turn to parallel the left side of runway 12, and then turn right toward the drop zone. The jumpers in the Cessna looked out of the right side, and watched the Golden Knights exit their airplane. The jumpers said that their altimeters read 2,500 feet agl. The Cessna pilot turned to a heading of 120 degrees along the left side of the approach end of runway 12. He heard the Pilatus pilot say on Common Traffic Advisory Frequency that the Pilatus was downwind for runway 12. Based on witness observations, at this point the Pilatus was in a descending turn heading generally opposite to the downwind heading on the northeast side of the runway. Everyone in the Cessna heard a loud bang, the Cessna pilot felt something hit him in the head, and the airplane pitched down and lost several hundred feet of altitude. He noticed a blur of yellow and white out of his left window. The lead jumper decided that they should exit, and they all jumped. The Cessna pilot decided that the airplane was controllable, and landed safely. Both civilian and military witnesses on the ground heard the Pilatus pilot call downwind for runway 12. About 10 seconds later they heard intense transmissions over the loud speaker, and looked up and observed the Pilatus in a nearly vertical, nose down slow spiral. There was an open gash in the top of the Cessna's cabin on the left side near the wing root. The green lens and its gold attachment fitting from the Pilatus were on the floor behind the pilot's seat.
Probable cause:
The failure of both pilots to maintain an adequate visual lookout. The failure of the Pilatus pilot to report his proper position was a factor.
Final Report: