Crash of a Cessna 425 Conquest in Ronkonkoma: 3 killed

Date & Time: Dec 16, 1996 at 1840 LT
Type of aircraft:
Registration:
N425EW
Survivors:
No
Schedule:
Macon – Ronkonkoma
MSN:
425-0150
YOM:
1983
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
10846
Captain / Total hours on type:
2089.00
Circumstances:
The pilot had received clearance for the ILS Runway 6 approach and was advised that the previous landing traffic reported '...breaking out at minimums.' Radar data revealed that the airplane descended in instrument meteorological conditions to the decision height altitude of 294 feet, approximately 3 miles from the missed approach point. The pilot did not perform the missed approach procedure. The airplane leveled off and continued at or below decision height altitude for approximately 28 seconds, traveling a distance of approximately 1 mile. Four low altitude alerts appeared on the tower controller's display. The controller stated he withheld the alert because '...it was a critical phase of flight and the aircraft appeared to be climbing...' The airplane collided with trees and terrain approximately 1.5 miles from the approach end of the landing runway.
Probable cause:
The pilot's early descent to decision height and his failure to perform the missed approach procedure. A factor was the failure of air traffic control to issue a safety advisory.
Final Report:

Ground fire of a Douglas DC-10-10CF in Newburgh

Date & Time: Sep 5, 1996 at 0554 LT
Type of aircraft:
Operator:
Registration:
N68055
Flight Type:
Survivors:
Yes
Schedule:
Memphis - Boston
MSN:
47809
YOM:
1975
Flight number:
FDX1406
Crew on board:
3
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
12344
Captain / Total hours on type:
2504.00
Copilot / Total flying hours:
6535
Copilot / Total hours on type:
1101
Aircraft flight hours:
38271
Aircraft flight cycles:
17818
Circumstances:
The airplane was at FL 330 when the flightcrew determined that there was smoke in the cabin cargo compartment. An emergency was declared and the flight diverted to Newburgh/Stewart International Airport and landed. The airplane was destroyed by fire after landing. The fire had burned for about 4 hours after after smoke was first detected. Investigation revealed that the deepest and most severe heat and fire damage occurred in and around container 06R, which contained a DNA synthesizer containing flammable liquids. More of 06R's structure was consumed than of any other container, and it was the only container that exhibited severe floor damage. Further, 06R was the only container to exhibit heat damage on its bottom surface, and the area below container 06R showed the most extensive evidence of scorching of the composite flooring material. However, there was insufficient reliable evidence to reach a conclusion as to where the fire originated. The presence of flammable chemicals in the DNA synthesizer was wholly unintended and unknown to the preparer of the package and shipper. The captain did not adequately manage his crew resources when he failed to call for checklists or to monitor and facilitate the accomplishment of required checklist items. The Department of Transportation hazardous materials regulations do not adequately address the need for hazardous materials information on file at a carrier to be quickly retrievable in a format useful to emergency responders.
Probable cause:
An in-flight cargo fire of undetermined origin.
Final Report:

Crash of a Boeing 747-131 off East Moriches: 230 killed

Date & Time: Jul 17, 1996 at 2031 LT
Type of aircraft:
Operator:
Registration:
N93119
Flight Phase:
Survivors:
No
Schedule:
New York – Paris
MSN:
20083
YOM:
1971
Flight number:
TW800
Crew on board:
18
Crew fatalities:
Pax on board:
212
Pax fatalities:
Other fatalities:
Total fatalities:
230
Captain / Total flying hours:
18800
Captain / Total hours on type:
5490.00
Copilot / Total flying hours:
17000
Copilot / Total hours on type:
4700
Aircraft flight hours:
93303
Aircraft flight cycles:
16869
Circumstances:
On July 17, 1996, about 2031 eastern daylight time, Trans World Airlines, Inc. (TWA) flight 800, a Boeing 747-131, N93119, crashed in the Atlantic Ocean near East Moriches, New York. TWA flight 800 was operating under the provisions of 14 Code of Federal Regulations Part 121 as a scheduled international passenger flight from John F. Kennedy International Airport (JFK), New York, New York, to Charles De Gaulle International Airport, Paris, France. The flight departed JFK about 2019, with 2 pilots, 2 flight engineers, 14 flight attendants, and 212 passengers on board. All 230 people on board were killed, and the airplane was destroyed. Visual meteorological conditions prevailed for the flight, which operated on an instrument flight rules flight plan. The investigation revealed that the crash occurred as the result of a fuel/air explosion in the airplane's center wing fuel tank (CWT) and the subsequent in-flight breakup of the airplane. The investigation further revealed that the ignition energy for the CWT explosion most likely entered the CWT through the fuel quantity indication system wiring; neither the ignition energy release mechanism nor the location of the ignition inside the CWT could be determined from the available evidence. There was no evidence of a missile or bomb detonation.
Probable cause:
An explosion of the center wing fuel tank (CWT), resulting from ignition of the flammable fuel/air mixture in the tank. The source of ignition energy for the explosion could not be determined with certainty, but, of the sources evaluated by the investigation, the most likely was a short circuit outside of the CWT that allowed excessive voltage to enter it through electrical wiring associated with the fuel quantity indication system. Contributing factors to the accident were the design and certification concept that fuel tank explosions could be prevented solely by precluding all ignition sources and the design and certification of the Boeing 747 with heat sources located beneath the CWT with no means to reduce the heat transferred into the CWT or to render the fuel vapor in the tank non flammable.
Final Report:

Crash of a Boeing 747-136 in New York

Date & Time: Dec 20, 1995 at 1136 LT
Type of aircraft:
Operator:
Registration:
N605FF
Flight Phase:
Survivors:
Yes
Schedule:
New York - Miami
MSN:
20271
YOM:
1971
Flight number:
FF041
Crew on board:
17
Crew fatalities:
Pax on board:
451
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
16455
Captain / Total hours on type:
2905.00
Copilot / Total flying hours:
17734
Copilot / Total hours on type:
4804
Aircraft flight hours:
90456
Aircraft flight cycles:
17726
Circumstances:
The captain initiated a takeoff on runway 04L, which was covered with patches of ice and snow. The wind was from 330 degrees at 11 knots. Before receiving an 80-knot call from the 1st officer, the airplane began to veer to the left. Subsequently, it went off the left side of the runway and collided with signs and an electric transformer. Investigation revealed evidence that the captain had overcontrolled the nosewheel steering through the tiller, then applied insufficient or untimely right rudder inputs to effect a recovery. The captain abandoned an attempt to reject the takeoff, at least temporarily, by restoring forward thrust before the airplane departed the runway. The current Boeing 747 operating procedures provide inadequate guidance to flightcrews regarding the potential for loss of directional control at low speeds on slippery runways with the use of the tiller. Current Boeing 747 flight manual guidance was inadequate about when a pilot should reject a takeoff following some indication of a lack of directional control response. Improvements in the slippery runway handling fidelity of flight simulators used for Boeing 747 pilot training were considered to be both needed and feasible.
Probable cause:
The captain's failure to reject the takeoff in a timely manner when excessive nosewheel steering tiller inputs resulted in a loss of directional control on a slippery runway. Inadequate Boeing 747 slippery runway operating procedures developed by Tower Air, Inc., and the Boeing Commercial Airplane Group and the inadequate fidelity of B-747 flight training simulators for slippery runway operations contributed to the cause of this accident. The captain's reapplication of forward thrust before the airplane departed the left side of the runway contributed to the severity of the runway excursion and damage to the airplane.
Final Report:

Crash of a Piper PA-31-350 Navajo Chieftain off New York: 1 killed

Date & Time: Oct 18, 1995 at 2055 LT
Registration:
N711EX
Flight Phase:
Survivors:
Yes
Schedule:
Atlantic City – Farmingdale
MSN:
31-7952075
YOM:
1979
Crew on board:
2
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
6950
Captain / Total hours on type:
425.00
Aircraft flight hours:
7335
Circumstances:
While descending from 5,000 feet to 3,000 feet, the pilot informed ATC that the left engine had failed and the engine cowling was open. The crew said that after feathering the left propeller, and with the right engine at full power, they could not arrest a 300-500 fpm rate of descent. The crew informed ATC that they would be landing in the water. All the occupants exited the airplane from the left front pilot's emergency door. The victims were in the water for approximately 30 minutes before being rescued. One of the passengers was in cardiac arrest when he was retrieved from the water. Examination of the left engine revealed that the #2 cylinder had separated from the engine in flight as a result of high stress fatigue cracking of the cylinder hold down studs and the #3 main bearing thru-studs. The fatigue in the studs occurred as a result of the cylinder fastener preload forces either initially inadequate or lost during service. Maintenance records indicated that the thru-stud was replaced 80 service hours prior to the accident. Examination of the cylinder hold down studs and the #3 main bearing thru-studs revealed that they were improperly torqued, resulting in low initial preload on the fasteners. Incorrect installation of the oversize thru-studs, per existing service information, could have also been a factor in the improper torquing of the studs. The locations of the fatigue origins and the edge worn into the deck indicate that the upper studs were probably the first to fail, allowing the cylinder to rock on the lower rear corner of the cylinder flange.
Probable cause:
A total loss of left engine power as a result of an in-flight separation of the #2 cylinder. The cylinder separated due to high stress fatigue cracking of the cylinder hold down studs and the #3 main bearing thru-studs. Factors in this accident were: improper torquing of the studs and failure of maintenance personnel to properly comply with service information.
Final Report:

Crash of a Douglas C-47A-75-DL in Independence: 1 killed

Date & Time: Jul 19, 1995 at 1050 LT
Registration:
N54NA
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Elmira - Kansas City
MSN:
19475
YOM:
1944
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
12534
Captain / Total hours on type:
2865.00
Aircraft flight hours:
16700
Circumstances:
The new owner/co-pilot of the 50-year-old airplane and another pilot, who was typed rated in the airplane, departed on a 1,700 mile ferry flight. After the first 250 mile leg, the airplane was landed at another airport with a right engine problem. The owner replaced the right engine and continued the ferry flight. Twenty minutes into the second flight, the replacement right engine lost power. The owner stated that they applied maximum power to the left engine, were unable to feather the right propeller, and performed a forced landing to a field. However, the airplane collided with trees before reaching the field, then burned after impact. Investigation revealed that during the past 5 years, the airplane had neither flown nor had an annual inspection, except for 3 recent maintenance flights, totaling 1.5 Hours. The right propeller blades had chordwise scratches. The left propeller blades had no chordwise scratches. Examination of the wreckage revealed three propeller strikes in the ground, near the right engine ground scar, and no propeller strikes in the ground, near the left engine ground scar. The right engine mixture was locked in the auto-cruise position, while the left was locked in the emergency position. Airplane charts listed the single-engine rate of climb with a feathered propeller to be 350 feet per minute, and 10 feet per minute with a windmilling propeller.
Probable cause:
The loss of engine power for undetermined reasons, and the pilot's shutdown of the wrong engine, which resulted in a forced landing and collision with trees.
Final Report: