Crash of a Convair CV-580 in Buena Vista

Date & Time: Jan 20, 1989 at 0925 LT
Type of aircraft:
Operator:
Registration:
N73160
Flight Phase:
Survivors:
Yes
Schedule:
Denver - Durango
MSN:
336
YOM:
1968
Crew on board:
3
Crew fatalities:
Pax on board:
23
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
18644
Captain / Total hours on type:
6224.00
Aircraft flight hours:
54108
Circumstances:
During flight, crew shut down the right engine when warning light for gearbox oil pressure illuminated and pressure was noted below minimum limit of 130 psi. Shortly after securing right engine, left engine lost power (fuel tank shutoff valve switch and fuel crossfeed valve switch were located near each other). Attempts to restart left engine were unsuccessful. With lack of alternative current electrical power, captain could not unfeather right engine for restart. During emergency landing, aircraft was damaged on uneven terrain. Operational check of right engine (at ground level) revealed no malfunction that would have prevented normal operation. Examination of left engine revealed turbine section had overheated and turbine blades had severe heat damage. Captain said that when he tried to restart left engine, fuel valves were in normal position and power lever was 1' above idle. He recalled an engine rpm of 8000, but didn't recall if he had used feather button to reduce rpm to 3000 (as directed by checklist). He verified fuel switches were 'on' and he tried to crossfeed fuel (in event of blockage). Cross feeding of fuel was not part of restart procedure. Flight manual cautioned about importance of reducing power to flight idle, to decrease fuel flow to engine and minimize possible overheating.
Probable cause:
Inadvertent deactivation of fuel to the left engine as the pilot was making a precautionary shutdown of the right engine, and his failure to follow the emergency checklist procedure. Related factors were: low gearbox oil pressure (at flight altitude), and uneven terrain that was encountered during the emergency landing.
Occurrence #1: loss of engine power (total) - nonmechanical
Phase of operation: cruise - normal
Findings
1. 1 engine
2. (f) lubricating system - pressure too low
3. Propeller feathering - intentional
----------
Occurrence #2: loss of engine power (total) - nonmechanical
Phase of operation: cruise
Findings
4. All engines
5. (c) fuel supply - inadvertent deactivation - pilot in command
----------
Occurrence #3: forced landing
Phase of operation: descent - emergency
Findings
6. (c) emergency procedure - improper - pilot in command
7. (c) checklist - not followed - pilot in command
----------
Occurrence #4: on ground/water encounter with terrain/water
Phase of operation: landing - roll
Findings
8. (f) terrain condition - rough/uneven
Final Report:

Crash of a Cessna 208B Super Cargomaster in Aspen

Date & Time: Jan 5, 1989 at 0739 LT
Type of aircraft:
Operator:
Registration:
N945FE
Flight Type:
Survivors:
Yes
Schedule:
Denver - Aspen
MSN:
208B-0046
YOM:
1987
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
5347
Captain / Total hours on type:
322.00
Aircraft flight hours:
1041
Circumstances:
Pilot said he encountered severe to extreme turbulence upon reaching missed approach point and felt aircraft might stall if he began immediate right turn as called for in missed approach procedure. Pilot said he made left turn at 15 DME (missed approach point is at 11.5 DME) because there was higher terrain to right. Aircraft collided with trees on mountain 3 miles east of airport. Weather analysis indicated potential for light to moderate turbulence but not severe to extreme turbulence. Pilots landing and departing airport prior to and after accident reported light to moderate chop. Radar showed aircraft speed at 183.1 kts between iaf and faf. Between faf and missed approach point, aircraft speed was 95.7 kts. Pilot said he referred to current commercial instrument approach chart while executing approach. Only obsolete government instrument approach book was found in aircraft. Radios were not tuned to missed approach navaids. Pilot-rated passenger said pilot panicked after encountering turbulence.
Probable cause:
Pilot's improper ifr procedure. Contributing factors included moderate turbulence, low ceilings, obscuration and snow.
Occurrence #1: in flight encounter with weather
Phase of operation: missed approach (ifr)
Findings
1. (f) weather condition - turbulence in clouds
2. (f) weather condition - low ceiling
3. (f) weather condition - obscuration
4. (f) weather condition - snow
----------
Occurrence #2: in flight collision with object
Phase of operation: missed approach (ifr)
Findings
5. (c) ifr procedure - improper - pilot in command
6. Terrain condition - mountainous/hilly
7. Object - tree(s)
Final Report:

Crash of a Cessna 404 Titan in Aurora

Date & Time: Jun 10, 1988 at 1604 LT
Type of aircraft:
Operator:
Registration:
N8827K
Flight Type:
Survivors:
Yes
Site:
Schedule:
Greeley - Denver
MSN:
404-0424
YOM:
1978
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
1400
Captain / Total hours on type:
400.00
Aircraft flight hours:
3486
Circumstances:
The pilot was on a flight from Greeley to Denver, Colorado to obtain minor maintenance on a cargo door. As the aircraft was being vectored on final approach, the pilot reported that he believed the aircraft had fuel starvation. Subsequently, the aircraft was observed to make a complete roll and crash in a residential area. Only about 1.5 gallon of fuel was found in the right wing tank. The left wing and fuel tank were destroyed, but no odor of fuel was noted on the ground around the left wing. Also, a lack of fuel was noted in the fuel lines. The aircraft had not been refueled after the previous flight. The pilot that had flown the aircraft on a previous flight estimated there was 100 lbs of fuel remaining in each tank after his flight.
Probable cause:
Occurrence #1: loss of engine power (total) - nonmechanical
Phase of operation: approach - vfr pattern - final approach
Findings
1. 1 engine
2. (f) aircraft preflight - improper - pilot in command
3. (f) refueling - not performed - pilot in command
4. (f) in-flight planning/decision - improper - pilot in command
5. (f) fluid, fuel - starvation
6. (f) fuel supply - inadequate - pilot in command
----------
Occurrence #2: loss of control - in flight
Phase of operation: approach - vfr pattern - final approach
Findings
7. (c) airspeed (vmc) - not maintained - pilot in command
8. (c) aircraft control - not maintained - pilot in command
----------
Occurrence #3: in flight collision with terrain/water
Phase of operation: descent - uncontrolled
Final Report:

Crash of a Convair CV-580 in Durango

Date & Time: Feb 2, 1988 at 2032 LT
Type of aircraft:
Operator:
Registration:
N5808
Survivors:
Yes
Schedule:
Denver - Durango
MSN:
348
YOM:
1966
Crew on board:
3
Crew fatalities:
Pax on board:
38
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
7342
Captain / Total hours on type:
2858.00
Aircraft flight hours:
53781
Circumstances:
After making an IFR approach, the pilot made a go-around because he was blinded by the reflection of the landing/taxi lights against the falling snow. The pilot landed the aircraft after the second approach. The pilot said he sensed the aircraft drifting to the left and he tried to correct, but it collided with a snow bank. The investigation disclosed no evidence of aircraft hydroplaning or skidding. Airport management elected to delay plowing the runway for fear of it freezing over. Passengers claimed there was 2-3 inches of snow on top of a 3/4- inch layer of slush. Further investigation revealed that the runway lights were of various intensities because some unapproved light bulbs of different amperage were used. The runway was not equipped with centerline lighting. The painted white centerline stripe was covered by snow and slush.
Probable cause:
Occurrence #1: on ground/water collision with object
Phase of operation: landing - roll
Findings
1. (f) airport facilities, runway marking - foreign substance covered
2. (c) airport snow removal - inadequate - airport personnel
3. (f) airport facilities, runway/landing area condition - snow covered
4. (f) airport facilities, runway/landing area condition - slush covered
5. (c) proper alignment - not maintained - pilot in command
6. Terrain condition - snowbank
7. (f) airport facilities, centerline lights - unavailable
8. (f) airport facilities, runway edge lights - unapproved
9. (f) light condition - dark night
Final Report:

Crash of a Swearingen SA227AC Metro III in Durango: 9 killed

Date & Time: Jan 19, 1988 at 1920 LT
Type of aircraft:
Operator:
Registration:
N68TC
Survivors:
Yes
Schedule:
Denver - Durango
MSN:
AC-457
YOM:
1981
Flight number:
VJ2286
Crew on board:
2
Crew fatalities:
Pax on board:
15
Pax fatalities:
Other fatalities:
Total fatalities:
9
Captain / Total flying hours:
4184
Captain / Total hours on type:
3028.00
Copilot / Total flying hours:
8500
Copilot / Total hours on type:
305
Aircraft flight hours:
11895
Circumstances:
The aircraft was operating as Continental Express flight 2286. During the approach in IFR conditions, the aircraft went below the minimum descent altitude then struck the terrain at 7,180 feet msl. Examination of the aircraft did not disclose any pre-impact failures or system malfunctions. The evidence indicated that the copilot was flying the airplane during the approach. Evaluation of the radar data showed an excessive rate of descent before the collision with terrain. Postmortem toxicological examination showed that the captain had used cocaine prior to this flight. The safety board concluded that this use had adversely affected his ability to monitor the unstabilized approach flown by the copilot. Records of both crewmembers revealed prior traffic violations and accidents, and, in the case of the captain, a previous aircraft accident. Evaluation of the weather conditions indicated that a 10 to 15 knot tailwind condition existed throughout the approach.
Probable cause:
The first officer's flying and the captain's ineffective monitoring of an unstabilized approach, which resulted in a descent below the published descent profile. Contributing to the accident was the captain's performance resulting from his use of cocaine before the accident.
Final Report:

Crash of a Cessna T303 Crusader near Englewood: 2 killed

Date & Time: Jan 11, 1988 at 2010 LT
Type of aircraft:
Registration:
N9565T
Flight Phase:
Survivors:
No
Site:
Schedule:
Englewood - El Paso
MSN:
303-00027
YOM:
1981
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
4550
Captain / Total hours on type:
42.00
Aircraft flight hours:
1070
Circumstances:
The pilot obtained two weather briefings and filed an IFR flight plan to El Paso, TX. He was not instrument rated. The aircraft departed Englewood at 1959 and disappeared from radar at 2010. The crash site was 11- 1/2 miles southeast of the Kiowa vortac and 36 miles southeast of Englewood. Radar showed a 15-miles wide band of snow showers southeast of the Kiowa vortac. Ground witnesses reported blizzard conditions. Pilot medical certificate stated, 'not valid for night flight or by color control.' Pilot autopsy also disclosed 'myxomatous alteration of the mitral valve, consistent with mitral valve prolapse (floppy mitral valve).' Both occupants were killed.
Probable cause:
Occurrence #1: in flight encounter with weather
Phase of operation: cruise - normal
Findings
1. (f) light condition - dark night
2. (c) flight into known adverse weather - initiated - pilot in command
3. (f) self-induced pressure - pilot in command
4. (f) lack of total instrument time - pilot in command
5. (f) weather condition - high wind
6. (f) weather condition - gusts
7. (f) weather condition - snow
8. (f) weather condition - obscuration
9. (f) weather condition - turbulence
----------
Occurrence #2: loss of control - in flight
Phase of operation: maneuvering
Findings
10. (c) spatial disorientation - pilot in command
----------
Occurrence #3: in flight collision with terrain/water
Phase of operation: descent - uncontrolled
Findings
11. Terrain condition - snow covered
Final Report:

Crash of a Swearingen SA26AT Merlin IIB in Telluride

Date & Time: Dec 29, 1987 at 1707 LT
Type of aircraft:
Operator:
Registration:
N4468M
Flight Type:
Survivors:
Yes
Schedule:
Brenham – Telluride
MSN:
T26-119
YOM:
1969
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3344
Captain / Total hours on type:
200.00
Circumstances:
During a visual approach, the pilot said he encountered 2,000 fpm downdrafts. The pilot stated he added power and executed a normal approach at 120 knots, compensating for downdrafts/crosswinds. After touchdown, the pilot said he did not get a beta light on the right engine. He stated he brought the power levers 'behind the gate into reverse.' The aircraft drifted left. The pilot said he corrected with brakes and nosewheel steering. He applied takeoff power and the aircraft veered right, and ran off the right side of the runway. The aircraft collided with a dirt bank and then trees. Three tire skid marks were observed on the right side of the runway. A pilot-witness said winds were gusting 22-25 knots, variable from 130-220°. He said the aircraft landed fast and long. Examination of the engines and props revealed no evidence of malfunction. The engine manufacturer recommends prop reverse not be used on icy runway or when beta light on one engine does not illuminate. The aircraft manufacturer advises that nosewheel steering should not be used at speeds below 40 knots. All six occupants were injured, two seriously.
Probable cause:
Occurrence #1: loss of control - on ground/water
Phase of operation: landing - roll
Findings
1. (f) weather condition - crosswind
2. (f) weather condition - gusts
3. (f) planned approach - improper - pilot in command
4. (f) airspeed - excessive - pilot in command
5. (c) reversers - improper use of - pilot in command
6. (c) nosewheel steering - improper use of - pilot in command
7. (c) directional control - not maintained - pilot in command
8. (f) aborted landing - delayed - pilot in command
----------
Occurrence #2: on ground/water encounter with terrain/water
Phase of operation: landing - roll
Findings
9. Terrain condition - dirt bank/rising embankment
10. Object - tree(s)
Final Report:

Crash of a Douglas DC-9-14 in Denver: 28 killed

Date & Time: Nov 15, 1987 at 1415 LT
Type of aircraft:
Operator:
Registration:
N626TX
Flight Phase:
Survivors:
No
Schedule:
Denver - Boisé
MSN:
45726
YOM:
1966
Flight number:
CO1713
Crew on board:
5
Crew fatalities:
Pax on board:
77
Pax fatalities:
Other fatalities:
Total fatalities:
28
Captain / Total flying hours:
12125
Captain / Total hours on type:
133.00
Copilot / Total flying hours:
3186
Copilot / Total hours on type:
36
Aircraft flight hours:
42184
Aircraft flight cycles:
54759
Circumstances:
Weather conditions were moderate snow and freezing temperatures. Following a 27 minute delay between deicing and departure, on takeoff the aircraft was over-rotated by the first officer. Aircraft control was lost, the aircraft stalled and impacted off the right side of the runway. Company procedures called for repeat deicing when in icing conditions if a delay exceeds 20 minutes. Confusion between the tower and the flight crew due to procedural errors resulted in the delayed takeoff clearance. Both pilots were inexperienced in their respective crew positions. The captain had 33 hours experience as a DC-9 captain. The first officer had 36 hours jet experience, all in the DC-9. First officer demonstrated weak scan in training and had pilot performance problems with previous employers. First officer was on reserve, and had not flown for 24 days. The trip was assigned to the first officer for proficiency. Flight was first officer's 2nd trip as DC-9 first officer. Wing vortices from a landing aircraft on a parallel runway were not a factor in the accident.
Probable cause:
The captain's failure to have the airplane de-iced a second time after delay before take-off that led to upper wing surface contamination and a loss of control during rapid take-off rotation by the first officer.
Contributing was the absence of regulatory or management controls governing operations by newly qualified flight crew members and the confusion that existed between the flight crew and air traffic controllers that led to the delay in departure.
Final Report:

Crash of a Cessna 340A near Bailey: 1 killed

Date & Time: Oct 21, 1987 at 1135 LT
Type of aircraft:
Registration:
N4132G
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Denver – Buena Vista
MSN:
340A-0303
YOM:
1977
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
4809
Captain / Total hours on type:
364.00
Aircraft flight hours:
2146
Circumstances:
The aircraft crashed on the side of a mountain during visual meteorological conditions. The pilot had been in voice and radar contact with air traffic control until the aircraft disappeared from radar. The pilot reported severe turbulence and a rough running engine to ATC as he was nearing a mountain pass. The pilot stated that he thought the rough running engine was due to fuel contamination. A witness reported that the pilot had said the fuel had contained a lot of water. The pilot reported to ATC that he had just lost the engine and he was attempting to make it through a saddle. A sigmet had been issued for that region and the severe turbulence was confirmed by another pilot. Engine teardown revealed no evidence of preimpact mechanical failure/malfunction.
Probable cause:
Occurrence #1: in flight encounter with weather
Phase of operation: cruise
Findings
1. (c) weather condition - turbulence, clear air
2. (c) flight into known adverse weather - attempted - pilot in command
3. (f) fluid, fuel - contamination
4. (f) preflight planning/preparation - inadequate - pilot in command
5. Powerplant - failure, partial
----------
Occurrence #2: loss of control - in flight
Phase of operation: cruise
Findings
6. (f) weather condition - turbulence
7. (c) preflight planning/preparation - inadequate - pilot in command
8. Powerplant - failure, total
----------
Occurrence #3: in flight collision with terrain/water
Phase of operation: descent - uncontrolled
Final Report: