Crash of a Swearingen SA226T Merlin III in Chino

Date & Time: Sep 18, 1995 at 0624 LT
Registration:
N693PG
Flight Type:
Survivors:
Yes
Schedule:
Apple Valley - Chino
MSN:
T-207
YOM:
1970
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3282
Captain / Total hours on type:
346.00
Aircraft flight hours:
5218
Circumstances:
During arrival at dawn, the pilot contacted Approach Control about 22 miles from the airport at 8,500 feet and requested an ILS runway 26 approach. The ATIS was reporting 1/8 mile visibility with fog; the minimum published visibility for the ILS landing was 3/4 mile. The controller vectored the aircraft so that it intercepted the ILS localizer at the outer marker at an intercept angle that was 5 degrees greater than the maximum allowable intercept of 30 degrees. The intercept point should have been at least 3 miles further away from the airport. The aircraft was 650 feet above the ILS glideslope at the outer marker (which was outside the ILS glideslope parameter). Instead of making a missed approach, the pilot elected to continue the ILS. As he attempted to intercept the glideslope from above, the airplane entered a high rate of descent and passed through the glideslope. The pilot was arresting the descent, when the airplane collided with level terrain about 1,000 feet short of the runway. After the accident, at 0646 edt, the visibility was 1/16 mile with fog.
Probable cause:
The pilot's improper IFR procedure by not initiating a missed approach at the outer marker, by attempting to intercept the glideslope from above after passing the outer marker, and by allowing the airplane to continue descending after reaching the decision height. Factors relating to the accident were: the adverse weather condition, and the approach controller's improper technique in vectoring the airplane onto the ILS localizer.
Final Report:

Crash of a Cessna T207A Skywagon in San Diego

Date & Time: Aug 23, 1995 at 1318 LT
Operator:
Registration:
N91004
Flight Type:
Survivors:
Yes
Schedule:
Wendover - San Diego
MSN:
207-0004
YOM:
1969
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
900
Aircraft flight hours:
2085
Circumstances:
The local controller instructed the pilot to go-around because of inadequate spacing in the traffic pattern. While executing the go-around, the engine lost power and the airplane crashed on a bridge after colliding with the guard railing about 1 mile from the airport. The wreckage examination showed that the fuel line between the engine driven pump and the fuel control servo was empty. The left main tank leaked for about 5 minutes; the right main fuel tank was not compromised and contained between 5 and 10 gallons of fuel. Both auxiliary fuel tanks were empty. The fuel selector valve was found selected between the right main fuel tank and the off position. There were no other engine or airframe anomalies found.
Probable cause:
The pilot's improper fuel management and improper use of the fuel selector valve.
Final Report:

Crash of a Douglas C-54G-15-DO Skymaster in Ramona: 2 killed

Date & Time: Jun 21, 1995 at 1108 LT
Type of aircraft:
Operator:
Registration:
N4989P
Flight Type:
Survivors:
No
Schedule:
Hemet - Ramona
MSN:
36082
YOM:
1945
Flight number:
Tanker 19
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
6100
Aircraft flight hours:
23507
Circumstances:
A Douglas C-54G & Beech 58P were on a fire suppression mission with the USDA Forest Service. The C-54 (Tanker 19) was being used as an aerial tanker, while the Beech 58 (Lead 56) was on a lead operation. Lead 56 departed the fire area about 5 minutes before Tanker 19. Both airplanes proceeded to an uncontrolled airport at Ramona, CA, for landing on runway 27 with a 360° overhead approach. Tanker 19 was on the initial approach about 1 mile east of the airport, when the two planes collided. Investigation revealed that Lead 56 struck the vertical stabilizer of Tanker 19, while descending. The empennages of both airplanes separated, and both crashed in uncontrolled descents. Before the accident, a Grumman S2 pilot was following Tanker 19. While in a shallow descent to the airport, he saw Tanker 19 slightly below the horizon and heard Tanker 19 make two calls (at 8 and 2 miles on initial approach). He also heard a transmission from Lead 56 moments before the collision, but did not see Lead 56, nor was he watching Tanker 19 when the collision occurred. Investigators were unable to determine Lead 56's activities after departing the fire area. Transmissions were heard from Lead 56 on the forest service tactical (operations) frequency when the plane was within 10 miles of the airport. Moments before the collision, Lead 56 was heard on the airport's common traffic advisory frequency (ctaf). Forest service procedures required that all pilots transmit their position on the ctaf within 10 miles of the airport. The forest service had not made arrangements with the airport manager to perform overhead approaches, nor were parameters published for initial approach altitude or airspeed.
Probable cause:
Inadequate visual lookout by the Beech 58P pilot, and the operator's inadequate procedures concerning 360° overhead approaches.
Final Report:

Crash of a Cessna 208B Super Cargomaster in Pleasanton: 1 killed

Date & Time: Jan 12, 1995 at 1747 LT
Type of aircraft:
Operator:
Registration:
N754FE
Flight Type:
Survivors:
No
Site:
Schedule:
Visalia - Oakland
MSN:
208B-0249
YOM:
1991
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
25500
Captain / Total hours on type:
516.00
Aircraft flight hours:
2073
Circumstances:
A Cessna 208B struck a ridge line about 14 miles from the destination airport. The pilot reported to atc he had the airport in sight from 7,000 feet msl more than 30 miles away. A weather reporting station located 5 miles east of the accident site was reporting two cloud layers; a scattered layer at 1,500 feet agl, and a broken layer at 5,000 feet agl. The airplane was descending after the pilot was cleared for a visual approach. The airplane collided with a tree and the ground in a wings level attitude at an elevation of 1,500 feet msl. There was no evidence of mechanical failure or malfunction found with the airplane.
Probable cause:
Failure of the pilot-in-command to maintain visual contact with terrain and sufficient altitude for terrain clearance. Factors in the accident were the pilot's decision to initiate a descent 14 miles from the airport, and weather, specifically cloud conditions and darkness.
Final Report:

Crash of a Learjet 35A in Fresno: 4 killed

Date & Time: Dec 14, 1994 at 1146 LT
Type of aircraft:
Operator:
Registration:
N521PA
Flight Type:
Survivors:
No
Schedule:
Fresno - Fresno
MSN:
35-239
YOM:
1979
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
7109
Captain / Total hours on type:
2747.00
Aircraft flight hours:
6673
Aircraft flight cycles:
5254
Circumstances:
At about 1146 pst, Learjet 35A, N521PA, operating as a public use aircraft, crashed in Fresno, CA. Operating with call sign Dart 21, the flightcrew had declared an emergency inbound to Fresno Air Terminal due to engine fire indications. They flew the airplane toward a right base for their requested runway, but the airplane continued past the airport. The flightcrew was heard on tower frequency attempting to diagnose the emergency conditions and control the airplane until it crashed, with landing gear down, on an avenue in fresno. Both pilots were fatally injured. Twenty-one persons on the ground were injured, and 12 apartment units in 2 buildings were destroyed or substantially damaged by impact or fire. Investigation revealed that special mission wiring was not installed properly, leading to a lack of overload current protection. The in-flight fire most likely originated with a short of the special mission power supply wires in an area unprotected by current limiters. The fire resulted in false engine fire warning indications to the pilots that led them to a shutdown of the left engine. An intense fire burned through the aft engine support beam, damaging the airplane structure and systems in the aft fuselage and may have precluded a successful emergency landing.
Probable cause:
The accident was the consequence of the following factors:
- Improperly installed electrical wiring for special mission operations that led to an in-flight fire that caused airplane systems and structural damage and subsequent airplane control difficulties,
- Improper maintenance and inspection procedures followed by the operator,
- Inadequate oversight and approval of the maintenance and inspection practice by the operator in the installation of the special mission systems.
Final Report:

Crash of a Beechcraft C99 Airlines near Avenal: 1 killed

Date & Time: Nov 16, 1994 at 0240 LT
Type of aircraft:
Operator:
Registration:
N63995
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Burbank - Oakland
MSN:
U-178
YOM:
1981
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
4880
Aircraft flight hours:
20031
Circumstances:
The pilot was on an IFR flight plan level at 10,000 feet msl in VFR conditions. The ATP rated pilot was the sole occupant, and there was no autopilot installed in the Beech C99 Airliner. About 10 minutes after a hand-off from Los Angeles center to Oakland center was acknowledged, radar contact was lost at 0239 hours. A review of the radar data revealed that over the last 4 minutes the airplane's altitude increased to 10,500 feet, then it started a left descending turn with a maximum diameter of about 2.1 nm. The last radar returns indicate the airplane continuing the left turn and descending through 5,600 feet msl, with a descent rate of about 18,000 feet per minute. There was no evidence of a mechanical malfunction of the aircraft, engines, or propellers.
Probable cause:
Loss of aircraft control at night by the pilot for unknown reasons.
Final Report:

Crash of a Rockwell Aero Commander 560 near Essex: 1 killed

Date & Time: Oct 5, 1994 at 1209 LT
Registration:
N251VW
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Thermal - Las Vegas
MSN:
560-0212
YOM:
1955
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
3000
Circumstances:
The private pilot with about 3,000 hours of reported flight time and no instrument rating departed his home base, Thermal, California, for a short cross-country flight to Las Vegas, Nevada. There was no record of a preflight weather briefing, and no flight plan was filed. When the pilot failed to arrive at his destination, a search was initiated. The wreckage was located 6 days after it departed Thermal with the help of radar data. According to the radar data, the airplane was at 16,100 feet when it started a series of maneuvers while descending. Postcrash examination of the wreckage revealed that the left wing outer panel, aileron, and left engine were located some distance from the main wreckage. The weather at the time of the accident was reported as marginal VFR with thunderstorm cell activity in the area. The airplane did not have a working oxygen system nor was it equipped for instrument flight nor icing conditions.
Probable cause:
The pilot's inadvertent flight into IMC conditions. Contributing to the accident was a loss of control of the aircraft and exceeding the structural limits of the aircraft. The weather conditions were factors.
Final Report:

Crash of a Lockheed C-130A Hercules near Pearblossom: 3 killed

Date & Time: Aug 13, 1994 at 1331 LT
Type of aircraft:
Operator:
Registration:
N135FF
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Hemet - Hemet
MSN:
3148
YOM:
1957
Flight number:
Tanker 82
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
11000
Captain / Total hours on type:
2000.00
Aircraft flight hours:
20300
Circumstances:
While in level flight, the airplane's right wing separated and, during the separation sequence, wing fuel ignited. Subsequent laboratory examination of right-side, center-wing fragments revealed two fatigue cracks that propagated to overstress fractures. One of the cracks was within the underside wing skin below a doubler, and the other was within the doubler itself. The total size and origin of the fatigue regions could not be determined due to damage to fracture surfaces and a lack of available material. The airplane was delivered new to the U.S. Air Force in December 1957 and was retired from military service in 1986. In May 1990, the FAA issued a restricted-category special airworthiness certificate authorizing the airplane to dispense aerial fire retardant. At the time of the accident, the airplane had a total of 20,289 flight hours, 19,547 of which were acquired during its military service. The inspection and maintenance programs used by the operator, which were based on military standards, included general visual inspections for cracks but did not include enhanced or focused inspections of highly stressed areas, such as the wing sections, where the fatigue cracks that led to those accidents were located. The operator did not possess the engineering expertise necessary to conduct studies and engineering analysis to define the stresses associated with the firefighting operating environment and to predict the effects of those stresses on the operational life of the airplanes.
Probable cause:
The inflight failure of the right wing due to fatigue cracking in the underside right wing skin and overlying doubler. A factor contributing to the accident was inadequate maintenance procedures to detect fatigue cracking.
Final Report:

Crash of a Cessna 414 Chancellor in Taft: 1 killed

Date & Time: Jul 19, 1994 at 1420 LT
Type of aircraft:
Registration:
N414RH
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Taft - Fresno
MSN:
414-0457
YOM:
1974
Location:
Crew on board:
3
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
10000
Aircraft flight hours:
3739
Circumstances:
The emergency medical service (EMS/medevac) flight was dispatched to transport a patient in response to a medical emergency. During arrival to the destination, the pilot contacted the airport unicom for advisories and was advised to land on runway 25. Runway 25 had a 2.2 percent uphill grade and was restricted to landings only. After landing, the airplane was refueled and the patient was put on board. The pilot back-taxied on runway 25 and proceeded to take off uphill with the airplane near its maximum gross weight. According to ground witnesses, there was a tailwind, which they estimated was between 4 and 15 knots. The temperature was about 100 degrees, and the density altitude was about 3,200 feet. After the airplane became airborne, the pilot started an immediate left turn to avoid rising terrain. However, the left tip tank contacted the ground, and the airplane cartwheeled. It came to rest about 711 feet from the departure end of the runway. The flaps and landing gear were found fully extended; the published configuration for takeoff data in the flight manual was for 'wing flaps - up.' The airport had no signs to indicate runway use restrictions; however, the restrictions were published in the airport facility directory.
Probable cause:
The pilot's inadequate preflight planning/preparation and selection of the wrong runway for takeoff. Factors related to the accident were: the uphill slope of the runway, tailwind, high density altitude, and failure of the pilot to correctly configure the flaps for takeoff.
Final Report: