Crash of a Mitsubishi MU-2B-30 Marquise in Chillicothe

Date & Time: Sep 28, 1996 at 0835 LT
Type of aircraft:
Operator:
Registration:
N618BB
Survivors:
Yes
Schedule:
Chillicothe - Columbus
MSN:
533
YOM:
1971
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
5400
Captain / Total hours on type:
2150.00
Aircraft flight hours:
6644
Circumstances:
The pilot said that after climbing about 500 feet after takeoff, at 120 knots with the gear retracted, the left engine lost power. He feathered the propeller, lowered the nose to the horizon, and began a shallow left turn back to the airport. He left the flaps at 20° and noted a descent of 200 feet to 300 feet per minute in the turn. After clearing trees, the pilot extended the landing gear, banked the aircraft to the right to align it with the runway and lowered flaps to 40°. After touchdown, he applied single engine reversing. The aircraft went off right side of runway and into a ditch, collapsing the right main and nose gear. Examination of the engine revealed the torque sensor housing had failed, resulting in loss of drive to the fuel pump. Metallurgical exam of the housing arm of the torque sensor revealed it had failed from fatigue. On 9/14/79, a service bulletin (SB) was issued for replacement of the torque sensor housing with an improved housing. The manufacturer overhauled the engine on 12/1979, but SB was not complied with. SB indicated a history of resonant vibration causing cracks in the housing arm of original torque sensor and gear assemblies, and that the housing should be replaced, no later than during next part exposure. Investigation revealed pilot did not comply with engine failure procedures and airspeeds. Flight manual cautioned not to use 40° of flaps during single engine landings.
Probable cause:
Failure of the pilot to follow the published emergency procedures after loss of power in the left engine. Factors relating to the accident were: fatigue failure of the left torque sensor and gear assembly, which resulted in the loss of engine power, failure of the manufacturer to comply with the respective service bulletin, and the pilot's improper use of the flaps and reverse (single-engine) thrust.
Final Report:

Crash of a Piper PA-31-325 Navajo C/R in Dayton: 1 killed

Date & Time: Jun 19, 1996 at 0810 LT
Type of aircraft:
Operator:
Registration:
N62852
Flight Type:
Survivors:
No
Schedule:
Berrien Springs - Dayton
MSN:
31-7612089
YOM:
1976
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
1198
Captain / Total hours on type:
701.00
Aircraft flight hours:
3252
Circumstances:
The parents of the pilot/owner stated that he arrived late in the afternoon prior to the accident. They stayed up with their son until approximately 0100 the morning of the accident. They stated that their son was a doctor and kept a busy schedule. The son told the parents that he had to fly back in order to have new fuel cells installed in the airplane and to work at his clinic. The pilot was airborne by 0700. The weather at his destination had low ceilings and fog restricting the visibility. The pilot was cleared by ATC to fly the localizer approach to the runway. The pilot called his position at the outer marker on the unicom frequency and no further transmissions were heard. Witnesses on the airport heard and saw the bottom of the airplane and stated that the airplane's engines sounded normal as it went overhead. Radar data showed that the airplane's altitude fluctuated and ground speed decreased significantly during the missed approach flight path. The airplane impacted the ground in approximately 40- degree nose-low, right wing down attitude. The toxicology report revealed 0.005 ug/ml Tetrahydrocannabinol (Marihuana) in the blood, and 0.013 ug/ml and 0.017 ug/ml Tetrahydrocannabinol Carboxylic Acid (Marihuana) in the blood and kidney fluid respectively.
Probable cause:
The pilot's impairment of judgment and performance due to drugs which led to spatial disorientation and a loss of aircraft control. The weather was a factor.
Final Report:

Crash of a Piper PA-46-350P Malibu Mirage in Lancaster

Date & Time: Jul 13, 1994 at 1415 LT
Registration:
N800CE
Flight Phase:
Survivors:
Yes
Schedule:
Lancaster – Des Moines
MSN:
46-22020
YOM:
1989
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3300
Captain / Total hours on type:
2400.00
Circumstances:
The airplane was on takeoff climb, about 400 feet above the ground, when the engine partially and then totally lost power. The pilot did a forced landing in a bean field. The flight occurred following maintenance to check a low manifold pressure condition. According to the pilot, a 'full' engine runup was done before takeoff. He stated: 'the takeoff was smooth, we rotated at an airspeed of slightly more than 80 knots. The climb for the first 350 (feet of altitude), airspeed was routine... I felt a power loss and noticed the manifold pressure dropping. At this point I felt I had enough power to return to the airport... as the turn was being completed, power went out completely.' The post-accident examination of the airplane did not disclose evidence of mechanical malfunction.
Probable cause:
The loss of engine power for undetermined reasons.
Final Report:

Crash of a Cessna 414 Chancellor in Defiance: 1 killed

Date & Time: Mar 19, 1994 at 1355 LT
Type of aircraft:
Operator:
Registration:
N1576T
Flight Type:
Survivors:
No
Schedule:
Lancaster - Defiance
MSN:
414-0356
YOM:
1972
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
2000
Aircraft flight hours:
2094
Circumstances:
Just prior to the accident the airplane was seen on final approach flying in an erratic manner at a low altitude. Two witnesses riding in a car wrote they saw the airplane, 'going up and down toward the ground. We could hear a faint clicking noise, and the propellers were going around slowly.' The witnesses saw the airplane take 'a short nosedive and crashed.' They wrote that the airplane was not traveling 'very fast and it was pretty level to the ground.' The witnesses could not hear the engines because they were in a car. According to fuel records, the pilot of N1576T put 112 gallons of fuel on board the airplane on march 17, 1994, and the flight started at 1030 on march 19, 1994. The accident occurred at 1355, for a total flight time of 3 hours and 25 minutes. Using fuel consumption data for this aircraft it was estimated that fuel exhaustion would occur after 3 hours and 4 minutes of flight. The pilot, sole on board, was killed.
Probable cause:
The pilot's inadequate inflight decision and planning, which resulted in fuel exhaustion and the total loss of engine power.
Final Report:

Crash of a Bae 4101 Jetstream 41 in Columbus: 5 killed

Date & Time: Jan 7, 1994 at 2321 LT
Type of aircraft:
Operator:
Registration:
N304UE
Survivors:
Yes
Site:
Schedule:
Washington DC - Columbus
MSN:
41016
YOM:
1993
Flight number:
UA6291
Crew on board:
3
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
3660
Captain / Total hours on type:
192.00
Copilot / Total flying hours:
2430
Copilot / Total hours on type:
31
Aircraft flight hours:
1069
Aircraft flight cycles:
1000
Circumstances:
The airplane stalled and crashed 1.2 nautical miles east of runway 28L during an ILS approach. The captain initiated the approach at high speed & crossed the FAF at a high speed without first having the airplane properly configured for a stabilized approach. The airspeed was not monitored nor maintained by the flightcrew. The airline had no specified callouts for airspeed deviations during instrument approaches. The captain failed to apply full power & configure the airplane in a timely manner. Both pilots had low flight time and experience in in the airplane and in any EFIS-equipped airplane. Additionally, the captain had low time and experience as a captain. Inadequate consideration was given to the possible consequences of pairing a newly upgraded captain, on a new airplane, with a first officer who had no airline experience in air carrier operations, nor do current FAA regulations address this issue.
Probable cause:
The accident was the consequence of the following factors:
(1) An aerodynamic stall that occurred when the flightcrew allowed the airspeed to decay to stall speed following a very poorly planned and executed approach characterized by an absence
of procedural discipline;
(2) Improper pilot response to the stall warning, including failure to advance the power levers to maximum, and inappropriately raising the flaps;
(3) Flightcrew inexperience in 'glass cockpit' automatic aircraft, aircraft type, and in seat position, a situation exacerbated by a side letter of agreement between the company and its pilots;
(4) The company's failure to provide adequate crew resource management training, and the FAA's failure to require such training;
(5) The company's failure to provide adequate stabilized approach criteria, and the FAA's failure to require such criteria; and
(6) The unavailability of suitable training simulators that precluded fully effective flightcrew training.
Note: Items 1, 2, and 3 were approved by a Board vote of 4-0. Item 5 was adopted 3-1, with the dissenting Member believing the item was a contributory cause. The Board was divided 2-2 on items 4 and 6, two Members believing them causal and two Members, contributory.
Final Report:

Crash of a Piper PA-31T Cheyenne II in Norwich: 2 killed

Date & Time: Dec 2, 1993 at 1341 LT
Type of aircraft:
Operator:
Registration:
N515WB
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Easton - Des Moines - Hayward
MSN:
31-7720023
YOM:
1977
Location:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
5200
Captain / Total hours on type:
3.00
Aircraft flight hours:
6685
Circumstances:
En route at FL240, the plane entered a left spiraling descent and subsequently experienced an inflight break-up at 7,000 feet with separation of outboard wings, tail sections and internal vinyl from the nose baggage door. There was no distress call. Witnesses heard the engines and an explosive sound, then they saw the plane in a spin, trailed by falling debris. Debris was strewn over a distance of about 3.5 miles. Light weight pieces including vinyl from the baggage door, wing skin, and tail skin pieces were among the 1st debris on the wreckage path. Tail sections were found about 2.5 miles from the main wreckage with evidence of overload failure; pieces of the wings were found with evidence of downward/overload separation. No preexisting airframe failure was found that would have led to loss of control, inflight breakup, loss of pressurization or hypoxia. The plane was inactive for about 2 years before being purchased 2 months before accident. Last annual inspection was on 6/8/92. Icing was forecast from 9,000 feet to 17,000 feet msl; turbulence was forecast below 8,000 feet msl. Both occupants were killed.
Probable cause:
the pilot's loss of aircraft control for an unknown reason, and subsequent flight that exceeded the design stress limits of the airplane, which resulted in an in-flight airframe breakup.
Final Report:

Crash of a Volpar Turboliner 18 in Cleveland: 1 killed

Date & Time: Dec 15, 1992 at 0912 LT
Type of aircraft:
Registration:
N706M
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Cleveland - Syracuse
MSN:
12360
YOM:
1970
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
4768
Captain / Total hours on type:
91.00
Aircraft flight hours:
16115
Circumstances:
After rotation, during the initial climb, the nose of the airplane pitched up to approximately 60° above the horizon. The airplane continued to climb until about 250 feet above the ground, then rolled right, pitched down and descended. The airplane impacted the ground, approximately 45° nose down, 650 feet to the right of the runway. Post accident investigation of the wreckage revealed the elevator jammed in the full up deflection. The upper end of the elevator control rod was found not connected to the elevator, but was found laying aft, wedged between the tail cone and the elevator faring, holding the elevator in the full up position. The control rod connecting bolt was found laying in the bottom of the tail cone undamaged. The washer, nut and cotter pin related to the control rod connecting bolt were not found. The elevator had been removed, recovered and then installed by company maintenance personnel 166 flight hours prior to the accident. The pilot, sole on board, was killed.
Probable cause:
The improper installation of the elevator by company maintenance personnel and the lack of proper inspections by a company certified mechanic/inspector and the faa certified mechanic with inspector authorization. A factor in this accident was an insufficiently defined maintenance procedures that allowed multiple maintenance tasks to be combined into a single line entry.
Final Report:

Crash of a NAMC YS-11A-205 in Wilmington

Date & Time: Mar 6, 1992
Type of aircraft:
Operator:
Registration:
N918AX
Flight Type:
Survivors:
Yes
Schedule:
Wilmington - Wilmington
MSN:
2112
YOM:
1969
Location:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The crew departed Wilmington-Air park (Clinton County Airport) on a local training flight. On final approach to runway 22, the crew forgot to lower the undercarriage and the aircraft landed on its belly. It slid for few dozen yards and came to rest on the main runway. All three occupants escaped uninjured while the aircraft was damaged beyond repair.
Probable cause:
It was determined that the crew was focused on a flapless landing configuration and failed to follow the approach checklist and forgot to lower the landing gear.

Crash of a Douglas DC-8-63F in Toledo: 4 killed

Date & Time: Feb 15, 1992 at 0326 LT
Type of aircraft:
Operator:
Registration:
N794AL
Flight Type:
Survivors:
No
Schedule:
Seattle - Toledo
MSN:
45923
YOM:
1968
Flight number:
ATI805
Crew on board:
3
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
16382
Captain / Total hours on type:
2382.00
Copilot / Total flying hours:
5082
Copilot / Total hours on type:
1143
Aircraft flight hours:
70425
Aircraft flight cycles:
22980
Circumstances:
ATI Flight 805 departed from Seattle at 23:20 for a flight to Toledo. The 1st officer was flying the ILS approach to runway 07. For undetermined reasons, he failed to properly capture the ILS localizer and/or glide slope during the approach. At 03:13 the captain decided to carry out a go-around. The aircraft was vectored onto a base leg and given a heading of 100° to intercept the final approach course again. With a 35 knots crosswind (at 180°) on the approach the 1st officer had trouble capturing the localizer/glide slope. At 03:24, as the 1st officer was attempting to stabilize the approach, 3 GPWS glideslope warnings and sink rate warnings sounded. The captain took over control at 03:24:17 and performed another missed approach manoeuvre. He became spatially disoriented and inadvertently allowed an unusual attitude to develop with bank angles up to 80° and pitch angles up to 25°. When in a nose-low and left bank angle attitude, control of the airplane was transferred back to the 1st officer who began levelling the wings and raising the nose of the airplane. Impact with the ground occurred before the unusual attitude recovery was completed. All four occupants were killed.
Probable cause:
The failure of the flight crew to properly recognize or recover in a timely manner from the unusual aircraft attitude that resulted from the captain's apparent spatial disorientation, resulting from physiological factors and/or a failed attitude director.
Final Report:

Crash of a Rockwell Shrike Commander 500S in Richmond Heights: 1 killed

Date & Time: Feb 6, 1992 at 2101 LT
Registration:
N725AC
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Richmond Heights - Richmond Heights
MSN:
500-3144
YOM:
1972
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
1111
Captain / Total hours on type:
71.00
Aircraft flight hours:
3276
Circumstances:
The pilot had the waste gates on the turbocharges adjusted and wanted to test fly the airplane after the work was completed. The airplane departed and had reached an altitude of about 1,000 feet when witnesses heard an engine sputter. The airplane was seen making a left turn and enter a nose low, left spin before impacting the terrain. A tear down of the left engine revealed that the exhaust valves in cylinders #3 and #5 were burnt through at the valve head. The #5 exhaust valve had a deep preexisting deep mark on the valve stem. The failures of both valves were sufficient enough to cause a power failure in the left engine. The pilot, sole on board, was killed.
Probable cause:
The pilot's improper emergency procedures and failure to maintain control of the airplane, which resulted in an inadvertent spin at too low an altitude to allow recovery. Factors in this accident were; a power loss in the left engine as result of the exhaust valve failures in cylinders #3 and #5.
Final Report: