Crash of a Cessna 421B Golden Eagle II in Jefferson City: 4 killed

Date & Time: May 27, 1999 at 1826 LT
Registration:
N34TM
Survivors:
No
Schedule:
Poplar Bluff – Jefferson City
MSN:
421B-0965
YOM:
1975
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
1850
Captain / Total hours on type:
850.00
Aircraft flight hours:
5530
Circumstances:
The airplane impacted the ground in a nose low, inverted attitude. The pilot reported, 'Jeff Tower, N34TM, I've just lost power on the right engine, eh, left engine.' The airplane's altitude was approximately 200 to 400 feet when the airplane's wings wobbled back and forth. The airplane's wings banked approximately 90 degrees to the left, and then the airplane nosed over and impacted the ground. White smoke was seen coming from the belly of the airplane for 1 to 2 seconds about 20 seconds prior to it impacting the ground. The terrain was a flat, hard packed field used for growing grass sod. Both the left and right propellers were found 12 to 18 inches under the hard packed soil. Rotational paint transfer patterns from the propeller blades onto the hard packed soil were evident. The left and right propeller blades exhibited chordwise scratching and leading edge polishing. The #2 cylinder piston was broken and the piston pin was still attached to the piston rod. The NTSB Materials Laboratory examination revealed the fracture face of the #2 exhaust valve stem was consistent with a bending fatigue separation. Both #2 and #6 exhaust valve guides showed heavy wear that ovalized the bores. The annual inspection conducted on March 15, 1999, indicated the compression on the left engine was 80/64, 50, 67, 70, 69, and 62.
Probable cause:
The pilot failed to maintain control of the airplane. A factor was the partial loss of power due to the exhaust valve fatigue failure.
Final Report:

Crash of a Beechcraft B60 Duke in Springfield: 4 killed

Date & Time: Jul 20, 1997 at 1630 LT
Type of aircraft:
Registration:
N3359P
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Springfield – Chesterfield
MSN:
P-400
YOM:
1976
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
10734
Captain / Total hours on type:
46.00
Aircraft flight hours:
3358
Circumstances:
The pilot and passengers departed the Spirit of St. Louis Airport and flew to Springfield Regional Airport, a 50 to 60 minute flight. The fuel on board was about 25 to 30 gallons in the left wing tanks, and 75 to 80 gallons in the right wing tanks. Each engine burned about 25 to 30 gallons per hour. The airplane was not fueled prior to the return flight. About five minutes after takeoff, the airplane had reached 4,300 feet msl (3,033 feet agl) and began a 402 fpm descent. The airplane continued the descent away from the airport for about 7 nm before turning 180 degrees to the left. The airplane had descended to 2,200 feet msl (933 feet agl) and was 10 miles from the airport. The pilot reported to the controller that he had a '...partial engine failure on the left side.' The airplane impacted the ground in an inverted, vertical nose down attitude. The landing gear were down at impact. Neither propeller was feathered. The right wing, right engine, fuselage, and empennage received extensive fire damage. The left wing was consumed by fire between the nacelle and the wing root. The remaining left wing, left nacelle, and engine were not destroyed by fire. Examination of the engines and airframe did not reveal any pre-existing anomalies that prevented normal operation. The Airplane Flight Manual did not contain procedures which explained fuel cross feeding procedures in case of fuel exhaustion to a wing's fuel tanks.
Probable cause:
The pilot's fuel mismanagement and his failure to maintain adequate airspeed which resulted in fuel exhaustion followed by the loss of power in one engine and the loss of aircraft control.
Contributing was the pilot's failure to refuel the aircraft, the pilot's failure to feather the propeller of the non-operating engine, and his extension of the landing gear.
Final Report:

Crash of a Douglas DC-8-63CF in Kansas City: 3 killed

Date & Time: Feb 16, 1995 at 2027 LT
Type of aircraft:
Operator:
Registration:
N782AL
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Kansas City - Westover
MSN:
45929
YOM:
1968
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
9741
Captain / Total hours on type:
4483.00
Copilot / Total flying hours:
4460
Copilot / Total hours on type:
218
Aircraft flight hours:
77096
Aircraft flight cycles:
22404
Circumstances:
The airplane crashed immediately after liftoff during a three-engine takeoff. Flightcrew had shortened rest break; rest periods not required for ferry flights. Flight crew fatigue from lack of rest, sleep, and disruption of circadian rhythms. Flightcrew did not have adequate, realistic training in three-engine takeoff techniques or procedures. Flight crew did not adequately understand three-engine takeoff procedures, including significance of vmcg. Flight engineer improperly determined vmcg speed, resulting in value 9 knots too low. During first takeoff attempt, captain applied power to asymmetrical engine too soon, was unable to maintain directional control, and rejected the takeoff. Captain agreed to modify procedure by allowing flight engineer to advance throttle, a deviation of prescribed procedure. FAA oversight of operator was inadequate because the poi and geographic inspectors were unable to effectively monitor domestic crew training and international operations. Existing far part 121 flight time limits & rest requirements that pertained to the flights that the flightcrew flew prior to the ferry flights did not apply to the ferry flights flown under far part 91. Current one-engine inoperative takeoff procedures do not provide adequate rudder availability for correcting directional deviations during the takeoff roll compatible with the achievement of maximum asymmetric thrust at an appropriate speed greater than ground minimum control speed. All three crew members were killed.
Probable cause:
The accident was the consequence of the following factors:
- The loss of directional control by the pilot in command during the takeoff roll, and his decision to continue the takeoff and initiate a rotation below the computed rotation airspeed, resulting in a premature liftoff, further loss of control and collision with the terrain.
- The flightcrew's lack of understanding of the three-engine takeoff procedures, and their decision to modify those procedures.
- The failure of the company to ensure that the flightcrew had adequate experience, training, and rest to conduct the nonroutine flight. Contributing to the accident was the inadequacy of Federal Aviation Administration oversight of air transport international and federal aviation administration flight and duty time regulations that permitted a substantially reduced flightcrew rest period when conducting a non revenue ferry flight under 14 code of federal regulations part 91.
Final Report:

Crash of a Beechcraft E18S in Kansas City: 1 killed

Date & Time: Dec 8, 1994 at 2038 LT
Type of aircraft:
Registration:
N5647D
Flight Type:
Survivors:
No
Schedule:
Sedalia - Kansas City
MSN:
BA-364
YOM:
1958
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
2523
Captain / Total hours on type:
500.00
Circumstances:
During arrival at night in fog and drizzle, the pilot was cleared for an ILS runway 1l approach. While on the approach, she reported encountering moderate rime ice. Radar data showed that the airplane continued inbound on the localizer until it neared the middle marker, then it deviated about 20° left and collided with the ground, about 300 feet short and 300 feet left of the threshold. According to witnesses, the airplane stopped its descent and slowed down, shortly before entering a steep descent and a spin. An on-scene investigation revealed no preimpact airframe, control system, or powerplant anomalies. The wings had 1/4 inch of ice on the leading edge and a 1/2 inch high ridge of ice, parallel to the deicing boots, about 3 inches aft of the boots. The cockpit and windshield heating system were found in the 'off' position. The pilot's logbook was not available for inspection. Company records showed she had passed a 14 cfr part 135 checkride on may 20, 1994. The faa checkride form was administered and signed by the chief pilot. However, other records/information showed the chief pilot would not have been able to have given the checkride on that date.
Probable cause:
Failure of the pilot to maintain adequate airspeed on final approach, which resulted in an inadvertent stall/spin. Factors related to the accident were: the adverse weather (icing) conditions, the accumulation of airframe/wing ice, the pilot's improper use of the anti-ice/deice equipment, inadequate training of the pilot concerning flight in icing conditions, and inadequate surveillance of the operation by the chief pilot (company/operator management).
Final Report:

Crash of a Cessna 441 Conquest II in Saint Louis: 2 killed

Date & Time: Nov 22, 1994 at 2203 LT
Type of aircraft:
Operator:
Registration:
N441KM
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Saint Louis - Iron Mountain
MSN:
441-0196
YOM:
1981
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
7940
Captain / Total hours on type:
2060.00
Circumstances:
During the takeoff roll on runway 30R, the MD-82, N954U, collided with the Cessna 441, N441KM, which was positioned on the runway waiting for takeoff clearance. The pilot of the Cessna acted on an apparently preconceived idea that he would use his arrival runway, runway 30R, for departure. After receiving taxi clearance to back-taxi into position and hold on runway 31, the pilot taxied into a position at an intersection on runway 30R, which was the assigned departure runway for the MD-82. The ATIS current at the time the Cessna pilot was operating in the Lambert-St. Louis area listed runways 30R and 30L as the active runways for arrivals and departures; there was no mention of the occasional use of runway 31. Air traffic control personnel were not able to maintain visual contact with the Cessna after it taxied from the well lighted ramp area into the runway/taxiway environment of the northeast portion of the airport. An operational ASDE-3, particularly ASDE-3 enhanced with AMASS, could be used to supplement visual scan of the northeast portion of the airport.
Probable cause:
The Cessna 441 pilot's mistaken belief that his assigned departure runway was runway 30R, which resulted in his undetected entrance onto runway 30R, which was being used by the MD82 for its departure. Contributing to the accident was the lack of Automatic Terminal Information Service and other air traffic control (ATC) information regarding the occasional use of runway 31 for departure. The installation and utilization of Airport Surface Detection Equipment (ASDE-3), and particularly ASDE-3 enhanced with the Airport Movement Area Safety System (AMASS), could have prevented this accident.
Final Report:

Crash of a Rockwell Grand Commander 690B in Springfield: 1 killed

Date & Time: Oct 8, 1994 at 1031 LT
Registration:
N27MT
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Springfield - Olathe
MSN:
690-11533
YOM:
1979
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
2750
Captain / Total hours on type:
3.00
Circumstances:
After taking off on an IFR flight, the airplane was observed to climb into a low overcast. The pilot contacted departure control and reported climbing through 2,200 feet for an assigned altitude of 5,000 feet msl. Shortly thereafter, radar and radio contact were lost, and the airplane crashed in a steep dive. During an investigation, no preimpact part failure or malfunction was found, though the airplane was extensively damaged during impact. The pilot's logbook indicated that he had flown three instrument approaches on 3/3/94 and that he had flown 3.1 hours in actual instrument conditions since that date.
Probable cause:
Failure of the pilot to maintain control of the airplane, due to spatial disorientation. A factor related to the accident was: the pilot's lack of recent instrument experience.
Final Report:

Crash of a Cessna 421B Golden Eagle II in Chesterfield: 2 killed

Date & Time: Apr 29, 1993 at 1400 LT
Registration:
N4939M
Flight Type:
Survivors:
No
Schedule:
Chesterfield - Chesterfield
MSN:
421B-0632
YOM:
1974
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
5850
Aircraft flight hours:
3726
Circumstances:
Two foreign pilots took off VFR to remain in the vicinity of an airport on the outskirts of a metropolitan area. No record was found to show the airplane had been fueled either before or after the preceding flight. The flight crew contacted an area approach control and requested an ILS approach to test their ILS equipment without specifying an airport. Approach control issued and the flight crew accepted vectors to another airport for which the pilots had no approach plate or airport information. Vectors took the airplane about 25 miles from the departure airport. The flight crew requested to proceed back to the departure airport. A short time later, the flight crew declared an emergency due to low fuel, then radar contact was lost. Witnesses at a landfill heard an intermittent sound from the engine(s). The airplane came into their view with one engine running, then the engine sound ceased. They indicated the airplane went out of control and crashed, but one engine accelerated just before impact. A small fire was confined to the left wing. Both occupants were killed.
Probable cause:
Improper planning/decision by the pilot, which resulted in fuel exhaustion, due to an inadequate supply of fuel, and the pilot's failure to maintain control of the airplane during approach to an emergency landing. A related factor was: failure of the pilot to refuel the airplane before flight.
Final Report:

Crash of a Beechcraft 200 Super King Air in Vichy

Date & Time: Jan 11, 1991 at 2030 LT
Registration:
N200MR
Flight Type:
Survivors:
Yes
Schedule:
Saint Louis - Vichy
MSN:
BB-219
YOM:
1977
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
7667
Captain / Total hours on type:
258.00
Aircraft flight hours:
1596
Circumstances:
While executing a VOR approach, on a dark, foggy night, depth perception and ground contact were lost when the landing lights were turned on short final. A hard landing resulted, before corrective action became effective, resulting in wing spar, engine mounting support and propeller damage. The runway, and entire airport was covered with about 3 inches of mirror smooth ice, causing considerable glare. All four occupants escaped uninjured.
Probable cause:
A restricted visual outlook and go-around was not performed by the pilot. Factors related to the accident were a dark night, fog and glare, ice covered runway and whiteout conditions.
Final Report:

Crash of a Piper PA-46-310P Malibu in Naylor: 2 killed

Date & Time: May 27, 1990 at 1034 LT
Operator:
Registration:
N22EK
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Sewanee – Springfield
MSN:
46-8508024
YOM:
1985
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
1603
Captain / Total hours on type:
182.00
Circumstances:
After takeoff, the pilot received progressive altitude clearances to FL200. While cruising at FL200, he reported 'moderate chop.' At about 1025 cdt, he requested and received clearance to FL220. About 3 minutes later, he inquired about cloud tops and said he was 'in a layer right now at about flight level 200 to 210.' Soon thereafter, the aircraft began altitude deviations and went above the assigned altitude of FL220 (22,000 feet). It then descended to about 20,500 feet, where it pitched up to an altitude of about 23,000 feet. The aircraft then went into a steep descent. Subsequently, an in-flight breakup of the aircraft occurred at about the time it emerged from the clouds near the 2,000 feet level. Pieces of wreckage were found over a wide area. The left wing was found about 0.2 mile from the fuselage; pieces of the rudder and stabilizers were found about 100 yards from the fuselage. An exam of the fractures on major structural components revealed features typical of overstress separation. No preexisting cracks were found. An area forecast had flight predictions for IFR, thunderstorms, icing in the vicinity of convective activity. The pitot heat switch was found in the 'off' position. Both occupants were killed.
Probable cause:
The pilot's failure to activate the pitot heat before flying in instrument meteorological conditions (IMC) above the freezing level, followed by his improper response to erroneous airspeed indications that resulted from blockage of the pitot tube by atmospheric icing.
Final Report: