Crash of a Cessna 421C Golden Eagle III near Mammoth Lakes: 4 killed

Date & Time: Jan 4, 1992 at 1855 LT
Operator:
Registration:
N2654M
Flight Phase:
Flight Type:
Survivors:
Yes
Site:
Schedule:
Mammoth Lakes - La Verne
MSN:
421C-0691
YOM:
1974
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
1250
Captain / Total hours on type:
270.00
Aircraft flight hours:
3200
Circumstances:
Due to the impending arrival of a snow storm, the certificated commercial pilot and 5 passengers departed one day earlier than planned, from an uncontrolled airport located in mountainous terrain to begin a night, cross country flight. Instrument meteorological conditions prevailed. Prior to departure, the pilot was given an ifr clearance void time from an ARTCC. The pilot was climbing toward a VOR located about 27 miles southeast of the departure airport while attempting to contact the ARTCC to open his instrument flight plan. The pilot failed to maintain terrain clearance, and became lost/disoriented. The airplane struck trees and snow covered terrain at 10,200 feet msl, 7 nautical miles and about 22° to the right of the intended course. Four passengers were killed while two other occupants, among them the pilot, were injured.
Probable cause:
The failure of the pilot to plan and conduct his departure flight to avoid high mountainous terrain, during which the pilot became lost/disoriented. Contributing to the accident was self induced pressure to depart before the arrival of a snow storm.
Final Report:

Crash of a Learjet 25B in Carlsbad

Date & Time: Dec 23, 1991 at 0825 LT
Type of aircraft:
Registration:
N44PA
Flight Type:
Survivors:
Yes
Schedule:
Tulsa - Carlsbad
MSN:
25-144
YOM:
1974
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
6180
Captain / Total hours on type:
117.00
Aircraft flight hours:
8117
Circumstances:
The pilot and copilot reported in their written statements that the airplane was above glideslope on the final approach. They said the airplane touched down about 1,500 feet from the approach end of the 4,700 feet long runway. The pilot said he applied the brakes but could not stop the airplane on the runway. The airplane departed the end of the runway and continued forward over rough and uneven terrain. The main landing gear sheared off and penetrated both wings. The airplane came to a stop in a gully. Other witnesses located on the ground and in the air traffic control tower reported the airplane was 'high and fast' and touched down at about midfield or after.
Probable cause:
The pilot not attaining the proper touchdown point because of excessive altitude and airspeed, and the pilot's failure to perform a go-around. A factor in this accident was the rough and uneven terrain which was encountered after the aircraft departed the runway.
Final Report:

Crash of a Cessna 414 Chancellor in Long Beach: 2 killed

Date & Time: Oct 26, 1991 at 0901 LT
Type of aircraft:
Registration:
N3843C
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Long Beach - Scottsdale
MSN:
414-0846
YOM:
1975
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
1510
Captain / Total hours on type:
317.00
Aircraft flight hours:
2711
Circumstances:
The pilot reported that he had lost the left engine during the initial climb phase of a cross-country flight. Ground witnesses observed that the airplane's landing gear was down and the left propeller was feathered as it turned left onto the downwind leg of the traffic pattern. Other witnesses observed the airplane's wings dip before it nosed over into the terrain while turning onto the final approach course. The airplane struck the ground and a fence that separated two residential yards. The wreckage examination disclosed that the left engine's scavenge pump failed. This failure led the pilot to believe that the engine failed. The pilot's improper emergency procedures by failing to retract the landing gear and maintain airspeed precipitated the resulting stall and uncontrolled descent. Both occupants were killed.
Probable cause:
The pilot's improper emergency procedures by not retracting the landing gear when he shut the engine down and his failure to maintain airspeed. The scavenge pump failure, shutting down the engine and the inadvertent stall were factors in the accident.
Final Report:

Crash of a Cessna 340A in Brawley

Date & Time: Sep 1, 1991 at 1900 LT
Type of aircraft:
Operator:
Registration:
N4298C
Flight Type:
Survivors:
Yes
Schedule:
San Diego - Brawley
MSN:
340A-0601
YOM:
1978
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
1597
Captain / Total hours on type:
332.00
Circumstances:
Returning to the pilot's home base airport, the pilot indicated that he overflew the uncontrolled field and then entered the traffic pattern for runway 26 which was over 4,400 feet long. The pilot reported that he observed the wind sock was parallel to the runway but failed to initially observe that he was landing with a nearly direct 20 to 25 knot tailwind. The airplane touched down long, overran the runway's departure end, collided with a pole and caught on fire. All three occupants escaped with minor injuries.
Probable cause:
The pilot's selection of the wrong landing runway and his failure to attain the proper touchdown location. Factors which contributed to the accident were related to the pilot's inadequate observations of the weather and the tailwind condition which existed.
Final Report:

Crash of a Beechcraft 65 Queen Air in Pioneer: 6 killed

Date & Time: Jun 30, 1991 at 0911 LT
Type of aircraft:
Registration:
N713JB
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Modesto – South Lake Tahoe
MSN:
LC-35
YOM:
1960
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
6
Captain / Total flying hours:
2830
Captain / Total hours on type:
27.00
Aircraft flight hours:
4958
Circumstances:
A Beech 65 collided with trees in mountainous terrain after an inflight loss of control. A pilot observed the airplane start a turn to the right, roll right and continued until inverted and enter into a spin. The aircraft was in a steep nose down attitude when it began its pull out. The engines were heard by a ground witness who initially mistook them for an approach motorcycle. The pilot initially flew the aircraft 45 days before the accident and logged 3.5 dual instruction hours. There was no record in the pilot's logbook of any additional flight training since the initial flight. The pilot satisfactorily completed a before in a Cessna 150 four days before the accident. Examination of the wreckage disclosed the right engine had broken exhaust valve, but the left propeller was feathered. There were no preexisting mechanical malfunctions or failures found with the left engine. The aircraft was destroyed and all six occupants were killed.
Probable cause:
Improper emergency procedures by the pilot, when he inadvertently shut down the left engine after encountering a partial loss of power in the right engine. Factors related to the accident were: improper installation of the right engine's #6 exhaust valve seat by other maintenance personnel, fatigue failure of the #6 exhaust valve, and the pilot's lack of familiarity with the aircraft.
Final Report:

Crash of a Mitsubishi MU-2B-36A Marquise in Santa Barbara: 4 killed

Date & Time: Jun 28, 1991 at 2314 LT
Type of aircraft:
Registration:
N2CJ
Flight Type:
Survivors:
No
Schedule:
Santa Monica - Santa Barbara
MSN:
726
YOM:
1978
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
1730
Captain / Total hours on type:
230.00
Circumstances:
After departing Santa Monica at night, Mitsubishi MU-2 pilot contacted tracon for clearance thru TCA at 6,500 feet. Tracon tried to get automated VFR handoff to ARTCC, but was unable. Radar service was terminated and pilot contacted (non-radar equipped) Santa Barbara FSS (home airport). He was advised weather was 500 feet scattered, 2,700 feet broken, 4,000 feet overcast, visibility 6 miles with fog. Pilot had not filed flight plan and began a VOR runway 25 approach without obtaining clearance. As he continued inbound, MU-2 descended thru clouds and converged with Fairchild SA227 that was on IFR approach to airport. ARTCC controller, who had been controlling SA227, advised FSS specialist of situation. Pilots of both aircraft were advised of other aircraft's position. MU-2 pilot did not respond when asked if he was in IMC. MU-2 plt reported 7 or 8 miles out on VOR approach. He was told again of SA227 on final approach and to phone ARTCC after landing. No further radio calls were received from MU-2 pilot. Radar data showed MU-2 converged with 400 feet of SA227. Pilot began left turn over shoreline as if to circle for spacing, but MU-2 entered descent and crashed in ocean. Examination of light bulbs indicated master caution and battery over temp lights were illuminated during impact. All four occupants were killed.
Probable cause:
The pilot's failure to maintain directional control of the airplane after becoming spatially disoriented. Factors related to the accident were: darkness, low overcast cloud condition, the pilot's decision to continue VFR flight into instrument meteorological conditions (IMC), which resulted in a near collision with another aircraft, his self induced pressure and diversion of attention, while coping with the situation that he had encountered.
Final Report:

Crash of a Piper PA-46-310P Malibu Mirage in Hollywood

Date & Time: Apr 7, 1991 at 1919 LT
Operator:
Registration:
N9113X
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Las Vegas – Santa Monica
MSN:
46-8608044
YOM:
1986
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
398
Captain / Total hours on type:
45.00
Circumstances:
A Piper PA-46-310P loss engine power and collided with a telephone pole during the forced landing. The pilot contacted the tracon and informed the facility he had a partial power loss. The airplane was about two miles east of the airport at about 3,500 feet msl heading in a southwesterly direction. The tracon instructed the pilot to turn 150° for radar vectors to runway 33. The pilot did not turn to the 150° heading, but continued on a southwesterly course. The airplane flew past the approach ends of two runways. The airplane continued westbound and crashed 2.5 miles west of the airport. The pilot indicated the airplane had 300 pounds (about 50 gallons) of fuel on board at takeoff. The pilot operating handbook for the Piper PA-34-310P is about 16 gallons per hour. The duration of the flight was about one hour. There was no evidence of fuel in the airplane's fuel system or any evidence of fuel spillage from either of the wings after the accident.
Probable cause:
The pilot-in-command's poor preflight planning, inadequate fuel consumption calculations which resulted in a loss of engine power due to fuel exhaustion, and the pilot-in-command's failure to follow air traffic control verbal instructions which would have guided him to a probable safe landing at an airport.
Final Report:

Crash of a Hawker-Siddeley HS.125-1A-522 on Mt Otay: 10 killed

Date & Time: Mar 16, 1991 at 0143 LT
Type of aircraft:
Registration:
N831LC
Flight Phase:
Survivors:
No
Site:
Schedule:
San Diego – Amarillo – Evansville
MSN:
25095
YOM:
1966
Crew on board:
2
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
10
Captain / Total flying hours:
15000
Captain / Total hours on type:
150.00
Circumstances:
After flying personnel of entertainment group to Lindbergh Field, aircraft was positioned to nearby Brown Field, since late departure was planned after noise curfew was in effect at Lindbergh. Pilot talked with FSS specialist (splst) 3 times before takeoff. He reported he did not have instruction departure procedures from airport. Splst read departure procedures on phone. On last call to FSS, pilot said he planned to depart VFR toward northeast and obtain IFR clearance after airborne (this route was toward mountains.) During call, pilot expressed concern about remaining cleared of TCA and inquired about staying below 3,000 feet. Splst agreed with pilots concerns, but after accident, splst said he thought pilot was referring to 3,000 feet agl, rather than 3,000 feet msl. Pilot had filed to takeoff at midnight, but didn't get airborne until 0141 pst. Since flight was over 1.5 hours late, IFR flight plan had 'clocked out.' As controller was reentering flight plan in computer, aircraft hit rising terrain near top of mountain, about 8 miles northeast of airport at elevation of about 3,300 feet. No deficiencies were found with aircraft or its engines. Copilot had no type rating for this aircraft, tho he reportedly had made 3 takeoffs and landings in Hawker-Siddeley HS.125. All 10 occupants were killed, among them all members of the country music 'Reba McEntire Band'.
Passengers:
Chris Austin,
Kirk Cappello,
Joey Cigainero,
Paul Kaye Evans,
Jim Hammond,
Terry Jackson,
Anthony Saputo,
Michael Thomas.
Probable cause:
Improper planning/decision by the pilot, the pilot's failure to maintain proper altitude and clearance over mountainous terrain, and the copilot's failure to adequately monitor the progress of the flight. Factors related to the accident were: insufficient terrain information provided by the flight service specialist during the preflight briefing after the pilot inquired about a low altitude departure, darkness, mountainous terrain, both pilot's lack of familiarity with the geographical area, and the copilot's lack of familiarity with the aircraft.
Final Report:

Crash of a Swearingen SA227AC Metro III in Los Angeles: 12 killed

Date & Time: Feb 1, 1991 at 1807 LT
Type of aircraft:
Operator:
Registration:
N683AV
Flight Phase:
Survivors:
No
Schedule:
Los Angeles - Palmdale
MSN:
AC-683
YOM:
1987
Flight number:
OO5569
Crew on board:
2
Crew fatalities:
Pax on board:
10
Pax fatalities:
Other fatalities:
Total fatalities:
12
Captain / Total flying hours:
8808
Captain / Total hours on type:
2107.00
Copilot / Total flying hours:
8000
Copilot / Total hours on type:
1363
Circumstances:
SKW5569, N683AV, had been cleared to runway 24L, at intersection 45, to position and hold. The local controller, because of her preoccupation with another airplane, forgot she had placed SKW5569 on the runway and subsequently cleared US1493, N388US, for landing. After the collision, the two airplanes slid off the runway into an unoccupied fire station. The tower operating procedures did not require flight progress strips to be processed through the local ground control position. Because this strip was not present, the local controller misidentified an airplane and issued a landing clearance. The technical appraisal program for air traffic controllers is not being fully utilized because of a lack of understanding by supervisors and the unavailability of appraisal histories.
Probable cause:
The failure of the los angeles air traffic facility management to implement procedures that provided redundancy comparable to the requirements contained in the national operational position standards and the failure of the faa air traffic service to provide adequate policy direction and oversight to its air traffic control facility managers. These failures created an environment in the Los Angeles air traffic control tower that ultimately led to the failure of the local controller 2 (lc2) to maintain an awareness of the traffic situation, culminating in the inappropriate clearances and the subsequent collision of the usair and skywest aircraft. Contributing to the cause of the accident was the failure of the faa to provide effective quality assurance of the atc system.
Final Report:

Crash of a Boeing 737-3B7 in Los Angeles: 22 killed

Date & Time: Feb 1, 1991 at 1807 LT
Type of aircraft:
Operator:
Registration:
N388US
Survivors:
Yes
Schedule:
Columbus - Los Angeles
MSN:
23310
YOM:
1985
Flight number:
US1493
Crew on board:
6
Crew fatalities:
Pax on board:
83
Pax fatalities:
Other fatalities:
Total fatalities:
22
Captain / Total flying hours:
16300
Captain / Total hours on type:
4300.00
Copilot / Total flying hours:
4316
Copilot / Total hours on type:
982
Circumstances:
SKW5569, N683AV, had been cleared to runway 24L, at intersection 45, to position and hold. The local controller, because of her preoccupation with another airplane, forgot she had placed SKW5569 on the runway and subsequently cleared US1493, N388US, for landing. After the collision, the two airplanes slid off the runway into an unoccupied fire station. The tower operating procedures did not require flight progress strips to be processed through the local ground control position. Because this strip was not present, the local controller misidentified an airplane and issued a landing clearance. The technical appraisal program for air traffic controllers is not being fully utilized because of a lack of understanding by supervisors and the unavailability of appraisal histories.
Probable cause:
The failure of the los angeles air traffic facility management to implement procedures that provided redundancy comparable to the requirements contained in the national operational position standards and the failure of the faa air traffic service to provide adequate policy direction and oversight to its air traffic control facility managers. These failures created an environment in the Los Angeles air traffic control tower that ultimately led to the failure of the local controller 2 (lc2) to maintain an awareness of the traffic situation, culminating in the inappropriate clearances and the subsequent collision of the usair and skywest aircraft. Contributing to the cause of the accident was the failure of the faa to provide effective quality assurance of the atc system.
Final Report: