Crash of a Cessna 414 Chancellor in Guyton: 2 killed

Date & Time: Dec 29, 1997 at 0845 LT
Type of aircraft:
Registration:
N414MT
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Orlando – White Sulphur
MSN:
414-0205
YOM:
1971
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
3996
Captain / Total hours on type:
1545.00
Aircraft flight hours:
3872
Circumstances:
About 26 minutes after takeoff while at 21500 feet, the pilot requested a non existent route. Seven minutes later, the passenger stated the pilot was light headed and fading then he had passed out. The passenger had once held a student pilot certificate and about 5 years earlier she had accrued 73 hours of flight time in Cessna 150/152 aircraft. The air traffic controller, and other pilots on the radio frequency tried to assist the passenger. The passenger was advised to provide oxygen for herself and the pilot, but she was unable. The airplane climbed to 34,200 feet where the airplane departed controlled flight, recovered, then departed controlled flight several more times before beginning a nose low descent. Witnesses reported hearing the airplane orbiting several times while flying above a cloud layer then observed the airplane orbiting beneath the clouds. While in a descending right wing low attitude, the airplane impacted the ground and came to rest submerged in a pond. Examination of the flight controls, engines, and propellers revealed no evidence of preimpact failure or malfunction. A discrepancy with the regulating valve was noted. Two small holes were noted in the cabin door seal. The left wing pressurization duct had been replaced about 8 years earlier but the right wing pressurization duct, had not been replaced. The ducts are on-condition components. There was no preimpact failure or malfunction noted with the barometric pressure switch, the cabin altitude annunciator bulbs, the safety valve, solenoid valve, or differential pressure/cabin altitude gauge. Testing for carbon monoxide for both was negative.
Probable cause:
Inadequate maintenance of the cabin pressurization system, which resulted in inadequate pressurization and incapacitation of the pilot due to the hypoxia. Also causal was the pilot's failure to adequately monitor the cabin pressurization system.
Final Report:

Crash of a Beechcraft 200 Super King Air in Dalton: 1 killed

Date & Time: Aug 14, 1997 at 0611 LT
Operator:
Registration:
N74EJ
Flight Type:
Survivors:
No
Schedule:
Athens - Dalton
MSN:
BB-340
YOM:
1978
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
2398
Captain / Total hours on type:
103.00
Aircraft flight hours:
6328
Circumstances:
The pilot was cleared for a localizer approach by Atlanta Center and told to maintain 5,000 feet until crossing the final approach fix (FAF). Normal altitude at the FAF was 2,700 feet. The pilot was unable to land from this approach and performed a missed approach. He was handed off to Chattanooga Approach, then was cleared to cross the FAF at 3,000 feet and perform another localizer approach. About one mile from the FAF, the pilot was told to change to the airport advisory frequency. The pilot acknowledged, then there was no further communication with the aircraft. A short time later, witnesses heard the aircraft crash near the approach end of the runway. Examination of the crash site showed the aircraft had touched down in a grass area about 1,100 feet from the end of the runway, while on the localizer. Propeller slash marks showed both engines were operating at approach power and the aircraft was at approach speed. No evidence of precrash mechanical failure or malfunction of the aircraft structure, flight controls, systems, engines, or propellers was found. The 0621 weather was in part: 300 feet overcast and 1/2 mile visibility with fog. Minimum descent altitude (MDA) for the localizer approach was 1,180 feet msl; airport elevation was 710 feet. The pilot had flown 8 flight hours, was on duty for 13.6 hours the day before the accident, was off duty for about 6 hrs, and had about 4 hours of sleep before the accident flight.
Probable cause:
The pilot's improper IFR procedure, by failing to maintain the minimum descent altitude (MDA) during the ILS localizer approach, until the runway environment was in sight, which resulted in a collision with terrain short of the runway. Factors relating to the accident were: darkness, low ceiling, fog, pilot fatigue, and improper scheduling by the aircraft operator.
Final Report:

Crash of a Beechcraft RC-12N Huron on Ossabaw Island: 2 killed

Date & Time: Apr 16, 1997
Type of aircraft:
Operator:
Registration:
89-0272
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Hunter AFB - Hunter AFB
MSN:
FE-18
YOM:
1989
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
The crew departed Hunter AFB on a local training mission when the aircraft crashed in unknown circumstances on Ossabaw Island, south of Savannah. Both pilots were killed.

Crash of an Aviation Traders ATL-98 Carvair in Griffin: 2 killed

Date & Time: Apr 4, 1997 at 0016 LT
Registration:
N83FA
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Griffin – Americus – Rockford
MSN:
5/10365
YOM:
1944
Location:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
12000
Captain / Total hours on type:
1000.00
Aircraft flight hours:
50558
Circumstances:
During the airplane's takeoff roll, about 3/4 down the 3,700 foot runway, a witness reported that the color of the #1 exhaust flame changed from blue to yellow, accompanied by an audible change in the engine power level. The nose of the airplane yawed left and the left wing dipped. Directional control was regained and the takeoff continued. Skid marks were found about 650 feet before the departure end of the runway that continued about 1360 feet to an abandoned grocery store impacted by the plane. About 315 feet before the building, the left wing contacted a privacy fence, and a utility pole, resulting in a fire at the disrupted left wing main fuel tank. A pilot/mechanic who helped dispatch the airplane observed that the elevator was free as it taxied. Fire damage to all engines precluded a detailed post crash examination of essential fuel and ignition systems. The toxicological report regarding the second pilot indicated that 1.110 mcg/ml (ug/ml, ug/g) of Diphenhydramine, was detected in the blood. According to NTSB medical personnel, Diphenhydramine is a sedating antihistamine often found in over-the-counter allergy medications. A single oral dose of medication containing Diphenhydramine, at twice the recommended maximum of over-the-counter dosage, resulted in maximal blood levels of between 0.08 and 0.16 mcg/ml. The level of Diphenhydramine found during the toxicology examination of the second pilot approximated ten times the levels found following a dosage at twice the recommended strength. Diphenhydramine was also found in the urine. Additional prescription and nonprescription medications were also found during the toxicological examination of the second pilot.
Probable cause:
The flightcrew's inadequate procedures, during a rejected takeoff following a possible engine malfunction at a critical time in the takeoff, and the second pilot's physical impairment.
Final Report:

Crash of a Convair CV-240-27 near Hampton

Date & Time: Mar 7, 1997 at 1400 LT
Type of aircraft:
Registration:
N357T
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Griffin - Augusta
MSN:
340
YOM:
1953
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
18000
Captain / Total hours on type:
35.00
Aircraft flight hours:
16331
Circumstances:
About two minutes into the flight, the pilot noticed a high cylinder head temperature on the right engine. The pilot opened the cowl flap doors and the cylinder head temperature dropped 200 degrees. When the pilot noticed a reduction in right engine power, he elected to shut down the engine. The copilot was instructed to secure the right engine in accordance with the emergency procedures. Unable to maintain altitude, the pilot selected an emergency landing to a large open field, and the landing gear collapsed during the landing. Examination of the airplane at the accident site disclosed that the engine cowl flaps on both engines were in the open position. Examinations of the right engine subsystems failed to disclose a mechanical malfunction or component failure. A review of the normal and emergency procedures for the aircraft disclosed that the cowl flaps normal position for the shutdown engine is closed. A review of the aircraft performance data revealed that the airplane was capable of maintaining flight and a climb attitude with one engine. There was no cargo on the airplane. During the pilot's subsequent type rating reexamination in the Convair 240-27, the pilot failed to demonstrate a satisfactory level of knowledge in emergency procedures during the oral examination. The pilot subsequently surrendered the Convair 240-27 type rating to the FAA.
Probable cause:
A partial loss of power on one engine for undetermined reason(s), and the pilot's failure to follow aircraft emergency procedures. A factor was inadequate transition/upgrade training.
Final Report:

Crash of a Piper PA-46-350P Malibu in Peachtree City: 2 killed

Date & Time: Jan 16, 1996 at 0900 LT
Registration:
N9210F
Survivors:
No
Schedule:
Lakeland – Peachtree City
MSN:
46-22119
YOM:
1991
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
1080
Captain / Total hours on type:
92.00
Aircraft flight hours:
1064
Circumstances:
During the preflight briefing, the pilot was informed of reduced visibility and low ceiling in the vicinity of the destination airport, at the approximate time of the planned arrival. Upon arriving in the Atlanta area, the pilot was issued radar vectors to a final for the localizer runway 31 approach. The pilot was also given the current Atlanta altimeter setting, and was cleared for the localizer runway 31 approach. The airplane collided with a 60-foot tall light pole at a nearby baseball complex 2 miles short of the runway. The weather observation from the Hartsfield International Airport indicated that visual weather conditions prevailed at the time of the accident. However, according to a witness at the accident site, the weather conditions were foggy with reduced visibility. The wreckage distribution path was 2,467 feet right of the localizer course. The minimum descent altitude for this approach, using Atlanta's altimeter setting, was 1260 feet. The ground check of the localizer and DME facility was within normal operating range. Examination of the aircraft navigational radios also tested within normal ranges. The average field elevation in the vicinity of the accident site is 800 feet. The pilot's toxicological examinations detected pseudoephedrine (decongestant), phenylpropanolamine (decongestant), and chlorpheniramine (antihistamine). No samples were available to quantify the blood levels of these medications.
Probable cause:
The pilot's failure to follow the published instrument approach procedure. The fog was a factor.
Final Report:

Crash of an Embraer EMB-120RT Brasília in Carrollton: 8 killed

Date & Time: Aug 21, 1995 at 1253 LT
Type of aircraft:
Operator:
Registration:
N256AS
Survivors:
Yes
Schedule:
Atlanta - Gulfport
MSN:
120-122
YOM:
1989
Flight number:
EV529
Crew on board:
3
Crew fatalities:
Pax on board:
26
Pax fatalities:
Other fatalities:
Total fatalities:
8
Captain / Total flying hours:
9876
Captain / Total hours on type:
7374.00
Copilot / Total flying hours:
1193
Copilot / Total hours on type:
363
Aircraft flight hours:
17151
Aircraft flight cycles:
18171
Circumstances:
Atlantic Southeast Airline Flight 529 was climbing through 18,000 feet, when a blade from the left propeller separated. This resulted in distortion of the left engine nacelle, excessive drag, loss of wing lift, and reduced directional control. The degraded performance resulted in a forced landing. While landing, the airplane passed through trees, impacted the ground, and was further damaged by post impact fire. An exam of the left propeller revealed the blade had failed due to a fatigue crack that originated from multiple corrosion pits in the taper bore surface of the blade spar. The crack had propagated toward the outside of the blade and around both sides of the taper bore. Due to 2 previous blade failures (separations), a borescope inspection procedure had been developed by Hamilton Standard to inspect returned blades (that had rejectable ultrasonic indications) for evidence of cracks, pits and corrosion. The accident blade was one of 490 rejected blades that had been sent to Hamilton Standard for further evaluation and possible repair. Maintenance technicians, who inspected the blade, lacked proper NDI familiarization training and specific equipment to identify the corrosion that resulted in fatigue. The captain and seven passengers were killed.
Probable cause:
The in-flight fatigue fracture and separation of a propeller blade resulting in distortion of the left engine nacelle, causing excessive drag, loss of wing lift, and reduced directional control of
the airplane. The fracture was caused by a fatigue crack from multiple corrosion pits that were not discovered by Hamilton Standard because of inadequate and ineffective corporate inspection and repair techniques, training, documentation, and communications. Contributing to the accident was Hamilton Standard's and FAA's failure to require recurrent on-wing ultrasonic inspections of the affected propellers. Contributing to the severity of the accident was the overcast cloud ceiling at the accident site.
Final Report:

Ground explosion of a Douglas DC-9-32 in Atlanta

Date & Time: Jun 8, 1995 at 1908 LT
Type of aircraft:
Operator:
Registration:
N908VJ
Flight Phase:
Survivors:
Yes
Schedule:
Atlanta - Miami
MSN:
47321
YOM:
1969
Flight number:
VJA597
Crew on board:
5
Crew fatalities:
Pax on board:
57
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
9500
Captain / Total hours on type:
3500.00
Copilot / Total flying hours:
3800
Copilot / Total hours on type:
552
Aircraft flight hours:
63000
Circumstances:
As ValuJet Flight 597 began its takeoff roll, a 'loud Bang' was heard by the occupants, the right engine fire warning light illuminated, the crew of a following airplane reported to the ValuJet crew that the right engine was on fire, and the takeoff was rejected. Shrapnel from the right engine penetrated the fuselage and the right engine main fuel line, and a cabin fire erupted. The airplane was stopped on the runway, and the captain ordered evacuation of the airplane. A flight attendant (F/A) received serious puncture wounds from shrapnel and thermal injuries; another F/A and 5 passengers received minor injuries. Investigation revealed that an uncontained failure of the right engine had occurred due to fatigue failure of its 7th stage high compressor disc. The fatigue originated at a stress redistribution hole in the disc. Analysis of fatigue striation measurements indicated that the fatigue crack had originated before the disc was last overhauled at a repair station (Turk Hava Yollari) in 1991, but was not detected. Also, investigation of the repair station revealed evidence concerning a lack of adequate recordkeeping and a failure to use 'process sheets' to document the step-by-step overhaul/inspection procedures.
Probable cause:
Failure of Turk Hava Yollari maintenance and inspection personnel to perform a proper inspection of a 7th stage high compressor disc, thus allowing the detectable crack to grow to a length at which the disc ruptured, under normal operating conditions, propelling engine fragments into the fuselage; the fragments severed the right engine main fuel line, which resulted in a fire that rapidly engulfed the cabin area. The lack of an adequate record keeping system and the failure to use 'process sheets' to document the step-by-step overhaul/inspection procedures contributed to the failure to detect the crack and, thus, to the accident.
Final Report:

Crash of a Cessna 208B Grand Caravan in Gainesville: 2 killed

Date & Time: Mar 3, 1995 at 1943 LT
Type of aircraft:
Registration:
N227DM
Survivors:
No
Schedule:
Savannah - Gainesville
MSN:
208B-0364
YOM:
1993
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
2005
Captain / Total hours on type:
201.00
Circumstances:
The flight was executing the non-precision NDB runway 04 approach, had reported procedure turn inbound, and was cleared to change to advisory frequency. Witnesses observed the airplane descend out of the base of the overcast clouds in a 10° nose down, 45° left wing down attitude. The airplane impacted terrain about 3/4 mile south-southeast of the airport. Witnesses in the area reported that the weather was ceilings of about 100 feet and visibility of about 500 feet in light rain and fog. The minimum descent altitude for the approach is 465 feet agl. Both pilots were killed.
Probable cause:
The pilots failure to maintain the minimum descent altitude during the approach. The weather and dark night light condition were factors.
Final Report:

Crash of a Cessna 414 Chancellor in Augusta: 4 killed

Date & Time: Jan 12, 1995 at 0904 LT
Type of aircraft:
Registration:
N13SE
Flight Phase:
Survivors:
No
Schedule:
Swainsboro - Columbia
MSN:
414-0437
YOM:
1973
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
1312
Captain / Total hours on type:
23.00
Aircraft flight hours:
4526
Circumstances:
While climbing through 6,300 feet, the pilot reported the complete loss of power on the right engine. Approx 4 min later, and after the pilot had established an emergency descent for a landing, he reported that the left engine had also lost power. The airplane impacted a driveway and skidded into a building. Examination revealed that the right engine failed due to shifting of the engine case halves. Review of the engine maintenance records indicated that several cylinders had been replaced in recent months; the cylinder through bolts are used to torque the engine case. A reason for the loss of power on the left engine was not determined.
Probable cause:
The loss of power on the left engine for undetermined reasons. A factor was the failure of the right engine due to maintenance personnel's failure to properly torque the cylinder through bolts.
Final Report: