Crash of a Learjet 25B in Portland

Date & Time: Nov 17, 2010 at 1553 LT
Type of aircraft:
Operator:
Registration:
N25PJ
Flight Type:
Survivors:
Yes
Schedule:
Boise - Portland
MSN:
25-111
YOM:
1973
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
6000
Copilot / Total flying hours:
652
Copilot / Total hours on type:
10
Aircraft flight hours:
8453
Circumstances:
The airplane was flying a VOR/DME-C approach that was on an oblique course about 40 degrees to the runway 30 centerline; the wind conditions produced an 8-knot tailwind for landing on runway 30. Despite the tailwind, the captain elected to land on the 6,600-foot-long runway instead of circling to land with a headwind. Moderate to heavy rain had been falling for the past hour, and the runway was wet. The crew said that the airplane was flown at the prescribed airspeed (Vref) for its weight with the wing flaps fully extended on final approach, and that they touched down just beyond the touchdown zone. The captain said that he extended the wings' spoilers immediately after touchdown. He tested the brakes and noted normal brake pedal pressure. However, during rollout, he noted a lack of deceleration and applied more brake pressure, with no discernible deceleration. The airplane's optional thrust reversers had been previously rendered non-operational by company maintenance personnel and were therefore not functional. The captain stated that he thought about performing a go-around but believed that insufficient runway remained to ensure a safe takeoff. While trying to stop, he did not activate the emergency brakes (which would have bypassed the anti-skid system) because he thought that there was insufficient time, and he was preoccupied with maintaining control of the airplane. He asked the first officer to apply braking with him, and together the crew continued applying brake pedal pressure; however, when the airplane was about 2,000 feet from the runway's end, it was still traveling about 100 knots. As the airplane rolled off the departure end on runway 30, which was wet, both pilots estimated that the airplane was still travelling between 85 and 90 knots. The airplane traveled 618 feet through a rain-soaked grassy runway safety area before encountering a drainage swale that collapsed the nose gear. As the airplane was traversing the soft, wet field, its wheels partially sank into the ground. While decelerating, soil impacted the landing gear wheels and struts where wiring to the antiskid brake system was located. The crew said that there were no indications on any cockpit annunciator light of a system failure or malfunction; however, after the airplane came to a stop they observed that the annunciator light associated with the antiskid system for the No. 2 wheel was illuminated (indicating a system failure). The other three annunciator lights (one for each wheel) were not illuminated. During the approach, the first officer had completed the landing data card by using a company-developed quick reference card. The quick reference card’s chart, which contained some data consistent with the landing charts in the Airplane Flight Manual (AFM), did not have correction factors for tailwind conditions, whereas the charts in the AFM do contain corrective factors for tailwind conditions. The landing data prepared by the first officer indicated that 3,240 feet was required to stop the airplane on a dry runway in zero wind conditions, with a wet correction factor increasing stopping distance to 4,538 feet. The Vref speed was listed as 127 knots for their landing weight of 11,000 pounds, and the first officer’s verbal and written statements noted that they crossed the runway threshold at 125 knots. During the investigation, Bombardier Lear calculated the wet stopping distances with an 8-knot tailwind as 5,110 feet. The touchdown zone for runway 30 is 1,000 feet from the approach end. The crew’s estimate of their touchdown location on the runway is about 1,200 feet from the approach end, yielding a remaining runway of 5,400 feet. On-duty controllers in the tower watched the landing and said that the airplane touched down in front of the tower at a taxiway intersection that is 1,881 feet from the approach end, which would leave about 4,520 feet of runway to stop the airplane. The controllers observed water spraying off the airplane’s main landing gear just after touchdown. Post accident testing indicated that the brake system, including the brake wear, was within limits, with no anomalies found. No evidence of tire failure was noted. The antiskid system was removed from the airplane for functional tests. The control box and the left and right control valves tested within specifications. The four wheel speed sensors met the electrical resistance specification. For units 1, 2 and 3, the output voltages exceeded the minimum specified voltages for each of the listed frequencies. Unit 4 was frozen and could not be rotated and thus could not be tested. Sensors 1 and 2 exceeded the specified 15% maximum to minimum voltage variation limit. Sensor 3 was within the limit and 4 could not be tested. Based on all the evidence, it is likely that the airplane touched down on the water-contaminated runway beyond the touchdown zone, at a point with about 600 feet less remaining runway than the performance charts indicated that the airplane required for the wet conditions. Since a reverted rubber hydroplaning condition typically follows an encounter with dynamic hydroplaning, the reverted rubber signatures on the No. 2 tire indicate that the airplane encountered dynamic hydroplaning shortly after touchdown, and the left main gear wheel speed sensor anomalies allowed the left tires to progress to reverted rubber hydroplaning. This, along with postaccident testing, indicates that the anti-skid system was not performing optimally and, in concert with the hydroplaning conditions, significantly contributed to the lack of deceleration during the braking attempts.
Probable cause:
The failure of the flight crew to stop the airplane on the runway due to the flying pilot’s failure to attain the proper touchdown point. Contributing to the accident was an anti-skid system that was not performing optimally, which allowed the airplane to encounter reverted rubber hydroplaning, and the company-developed quick reference landing distance chart that did not provide correction factors related to tailwind conditions.
Final Report:

Crash of a Rockwell Aero Commander 500B on Mt Steens: 2 killed

Date & Time: Aug 11, 2010 at 0855 LT
Registration:
N500FV
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Redding - Butte
MSN:
500-1248-73
YOM:
1962
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
1360
Aircraft flight hours:
5375
Circumstances:
The evening prior to the accident, the pilot acquired a computer generated text weather briefing. On the day of the accident, the pilot acquired another computer generated text weather briefing, and then contacted the Flight Service Station (FSS) for an interactive telephonic weather briefing. The information provided in all three briefings indicated that a flight on a direct route between the pilot's point of departure and his planned destination would take him through an area of forecast rain showers, thunderstorms, and cloud tops significantly higher than his intended en route altitude. Although the FSS briefer recommended an alternate route, for which he provided weather information, after departure the pilot flew directly toward his destination airport. While en route, the pilot, who was not instrument rated, encountered instrument meteorological conditions, within which there was an 80 percent probability of icing. After entering the area of instrument meteorological conditions, the airplane was seen exiting the bottom of an overcast cloud layer with a significant portion of its left wing missing. It then made a high velocity steep descent into the terrain. A postaccident inspection of the airplane's structure did not find any evidence of an anomaly that would contribute to the separation of the wing structure, and it is most likely that the wing section separated as a result of the airplane exceeding its structural limitations after the pilot lost control in the instrument meteorological conditions.
Probable cause:
The non-instrument rated pilot's improper decision to continue flight into an area of known instrument meteorological conditions and his failure to maintain control of the airplane after entering those conditions.
Final Report:

Crash of an Epic LT off Astoria

Date & Time: Apr 24, 2009 at 1645 LT
Type of aircraft:
Registration:
N653SB
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Astoria – Seattle
MSN:
025
YOM:
2008
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
1550
Captain / Total hours on type:
75.00
Aircraft flight hours:
72
Circumstances:
The single engine aircraft departed Astoria Airport at 1637LT on a private flight to Seattle-Boeing Field, carrying one passenger (a female passenger aged 84) and one pilot. During a climb to en route cruise, the airplane's engine lost almost all power, and the pilot elected to ditch the airplane into the Columbia River off Astoria. The airplane crash landed eight minutes later, nosed down in water and came to rest partially submerged. Both occupants were quickly rescued and were uninjured. The aircraft was damaged beyond repair.
Probable cause:
The partial loss of engine power during climb to cruise due to the failure of the engine's fuel control unit. Contributing to the accident was the incorrect machining of an internal component of the fuel control unit, and the failure of the assembling technician to correctly inspect the unit's assembly.
Final Report:

Crash of a Cessna 441 Conquest in Sunriver: 1 killed

Date & Time: Jul 16, 2008 at 1015 LT
Type of aircraft:
Operator:
Registration:
N441HK
Flight Type:
Survivors:
No
Schedule:
Bakersfield - Sunriver
MSN:
441-0336
YOM:
1984
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
965
Captain / Total hours on type:
277.00
Aircraft flight hours:
5643
Circumstances:
The pilot was executing a day visual flight rules full-stop landing and touched down on the main landing gear near the approach end of the runway. Soon after the initial touchdown, the airplane became airborne again. Instead of initiating a go-around, the pilot attempted to continue the landing sequence. During that attempt, the airplane bounced on the runway three or four times, each time the rebound back into the air and the runway contact was more severe. During the last contact the airplane impacted the runway with sufficient force to result in the failure of the right main landing gear actuator rod, and in the right propeller contacting the runway surface multiple times. The pilot then initiated a go-around, but since the right engine had failed due to the multiple propeller strikes, the airplane produced asymmetrical thrust and began to roll to the right, veering off the right side of the runway. Soon thereafter its right wing collided with a tree and the airplane impacted terrain in an open field. The airplane was consumed by fire shortly after the collision. Post crash inspection found no evidence of mechanical failure or malfunction with the airframe or either engine.
Probable cause:
The pilot's misjudged landing flare and improper recovery from a bounced landing, and the pilot's failure to maintain directional control during the go-around after one of the airplane's propellers struck the runway.
Final Report:

Crash of a Cessna 208B Super Cargomaster in Portland

Date & Time: Dec 24, 2005 at 0743 LT
Type of aircraft:
Operator:
Registration:
N753FE
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Portland - Medford
MSN:
208B-0248
YOM:
1991
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
4625
Captain / Total hours on type:
2450.00
Aircraft flight hours:
7375
Circumstances:
The pilot stated that during takeoff, "after becoming airborne, the airplane quit accelerating and a positive climb rate was not established." He pushed the power lever all the way forward, but did not feel a response from the airplane. Witnesses reported that the airplane became airborne, but failed to gain altitude and struck an antenna array and a fence off the departure end of the runway. The airplane continued across a slough, struck an embankment and came to rest about 900 feet from the departure end of the runway on a golf course located adjacent to the airport. Examination of the airplane revealed no pre-mishap airframe anomalies. Examination of the engine revealed that the compressor and power turbines displayed moderate circular rubbing damage to the blades suggesting engine operation at impact, likely in the low to mid power range. Examination of the airframe and engine revealed no anomalies that would have prevented the engine from producing power prior to impact. The reason for the partial loss of engine power was not determined.
Probable cause:
A partial loss of engine power for an undetermined reason during the initial takeoff climb resulting in an in-flight collision with objects.
Final Report:

Crash of a Mitsubishi MU-2B-25 Marquise in Hillsboro: 4 killed

Date & Time: May 24, 2005 at 1752 LT
Type of aircraft:
Registration:
N312MA
Flight Phase:
Survivors:
No
Schedule:
Hillsboro – Salem
MSN:
266
YOM:
1973
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
2170
Captain / Total hours on type:
551.00
Aircraft flight hours:
3970
Circumstances:
Witnesses observed the aircraft perform a rolling takeoff and it was airborne by the crossing runway (1,300 feet down the 6,600 foot runway). The aircraft entered an approximate 40 degree nose high climb rate to about 1,000 feet. The aircraft then entered a steep left hand banking turn. The nose dropped and the aircraft rotated up to about 4 times before colliding with the flat terrain adjacent to the departure end of the runway threshold. On site documentation of the airframe found no evidence of a flight control malfunction. An engine examination and teardown found that the gearbox section of the left engine experienced a high cycle fatigue failure of the high speed pinion journal bearing oil supply tube and subsequent degradation of the high speed pinion journal bearings. This failure resulted in a partial power loss to the left engine. The pilot had recently purchased this aircraft and he had accumulated approximately 11 hours since the purchase. The pilot had stated to personnel at the place where he purchased the aircraft that he had not received, nor did he need recurrent training in this aircraft as he had several thousand hours in the aircraft. Flight logs provided by the family indicated that the pilot had accumulated about 551 hours in a Mitsubishi, however, the last time that the pilot had flown this make and model was 14 years prior to the accident. Logbook entries indicated that only a few hours of flight time had been accumulated in all aircraft during the approximately 2 years prior to the accident. Personnel that flew with the pilot in the make and model aircraft involved in the accident described the pilot as "proficiency lacking." Normal takeoff calculations for the aircraft with the flaps configured to 5 degrees, indicated a ground run of 2,900 feet, with a rotation speed of 106 KCAS, and 125 KCAS for the climb out. A maximum pitch attitude of 13 degrees maximum is indicated. Performance calculations indicated that the aircraft was capable of lifting off where the witnesses observed and climbing to 1,000 feet agl by the end of the runway. To achieve this performance the aircraft would have rotated at approximately 84 KCAS and climbed at an airspeed below Vmc (100 KCAS) and close to power-off stall speed (86 KCAS) with 5 degrees of flaps. The airplane's flight manual indicated that if an engine failure occurs in the takeoff climb and the landing gear is fully retracted, the emergency procedures is to maintain 140 KCAS, flaps to 5 degrees, the failed engine condition lever to EMERGENCY STOP, and failed engine power lever to TAKEOFF. On site documentation found the left side condition lever in the takeoff/land position and the power lever was found half-way between takeoff and flight idle.
Probable cause:
The pilot's failure to obtain minimum controllable airspeed during the takeoff climb, which resulted in a loss of aircraft control when the left engine lost partial power. A fatigue failure to an oil tube, which resulted in the partial power loss to the left engine, procedures/directives not followed by the pilot, and the pilot's lack of recent experience and no recurrent training in the type of aircraft were factors.
Final Report:

Crash of a Cessna 340A in Scappoose: 2 killed

Date & Time: Oct 18, 2003 at 1413 LT
Type of aircraft:
Registration:
N340P
Flight Type:
Survivors:
No
Schedule:
Red Bluff – Scappoose
MSN:
340A-0507
YOM:
1978
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
3850
Aircraft flight hours:
4041
Circumstances:
Witnesses first observed the aircraft on final approach for landing, with the engine(s) making a backfiring sound. While the aircraft was on short final, another aircraft pulled onto the runway and initiated its takeoff roll. The accident aircraft was observed to initiate a go-around, but did not appear to be gaining altitude and was at what the witnesses thought was a slow airspeed. About mid-field, the accident aircraft made an approximate 45 degree turn from runway heading. Within 1/4 mile from the runway, the aircraft lost altitude. The witness stated that the aircraft was about 80 feet agl when the aircraft stalled, rolled inverted (left wing down) and collided with the flat open terrain in a nose low attitude. A post-crash fire subsequently consumed the wreckage. During the post-crash inspection of the engines, it was found that both engines displayed signs of operating at a lean mixture setting. The left engine pistons and spark plugs displayed a more serious lean condition than the right side and displayed the early signs of detonation on the piston heads. No other mechanical failure or malfunction was noted to either the engines or airframe.
Probable cause:
The pilot's failure to maintain airspeed while maneuvering. An inadvertent stall, the pilot's failure to follow engine operation procedures and engine detonation were factors.
Final Report:

Crash of a Cessna 207 Skywagon in Grants Pass: 2 killed

Date & Time: Apr 9, 2003 at 0850 LT
Registration:
N9785M
Survivors:
No
Site:
Schedule:
North Bend – Grants Pass
MSN:
207-0729
YOM:
1981
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
34976
Aircraft flight hours:
4516
Circumstances:
During a visual flight rules (VFR) cross-country flight from North Bend, Oregon, to Grants Pass, Oregon, the airplane collided with mountainous terrain approximately seven miles northwest of the pilot's planned destination. Weather data and witness reports outlined areas of low ceilings and low visibility throughout the area during the approximate time of the accident. Post-accident inspection of the aircraft and engine revealed no evidence of a mechanical malfunction or failure.
Probable cause:
The pilot's failure to maintain clearance from mountainous terrain while in cruise flight. Factors include low ceilings and mountainous terrain.
Final Report:

Crash of a Learjet 36A in Astoria

Date & Time: Dec 3, 2002 at 0612 LT
Type of aircraft:
Operator:
Registration:
N546PA
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Astoria - Astoria
MSN:
36-045
YOM:
1980
Location:
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3350
Captain / Total hours on type:
2350.00
Copilot / Total flying hours:
1170
Copilot / Total hours on type:
920
Aircraft flight hours:
12335
Circumstances:
The pilot (PIC) reported that during acceleration for takeoff (approximately V1 [takeoff decision speed]) the airplane collided with an elk. The PIC reported that after the collision, he applied wheel brakes and deployed the airplane's drag chute, however, the airplane continued off the departure end of the runway. The airplane came to rest in a marshy bog approximately 50 feet beyond the departure threshold. Currently, approximately 15,000 feet of the airport's perimeter is bordered with animal control fence. The airport recently received a FAA Aviation Improvement Program (AIP) Grant that will provide funding for an additional 9,000-feet of fence. Airport officials stated that the fencing project should be completed by summer of 2003. At the completion of the project, game control fencing will encompass the entire airport perimeter. The U.S. Government Airport/Facilities Directory (A/FD) contains the following remarks for the Astoria Regional Airport: "Herds of elk on and in the vicinity of airport..."
Probable cause:
Collision with an elk during the takeoff roll. Factors include dark night VFR conditions.
Final Report:

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

Date & Time: Mar 8, 1999 at 2145 LT
Operator:
Registration:
N41096
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
North Bend - Aurora
MSN:
421B-0446
YOM:
1973
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
1200
Captain / Total hours on type:
135.00
Aircraft flight hours:
2342
Circumstances:
Witnesses reported hearing the engines start and shortly thereafter, the airplane taxied to the runway. The pilot then contacted ATC for an IFR clearance. The clearance was given with a short void time. The pilot acknowledged the clearance and began the takeoff ground roll. Witnesses reported that the night-time takeoff roll and engine sound appeared normal. Witnesses near the end of the runway reported that the airplane was observed at about 50 feet above the runway with about 1,000 feet of runway remaining when engine power was reduced on both engines. The airplane was heard to touch down, then engine power was reapplied. Shortly thereafter, the sound of the impact was heard. The airplane collided with the terrain about 600 feet from the end of the runway. During the post-accident inspection of the airplane and engines, no evidence was found to indicate a mechanical failure or malfunction. Documentation of the events indicated that from the time the aircraft began its taxi to the runway, to the time the takeoff roll began, was approximately six minutes in duration. Before the takeoff roll began, the pilot had accepted a clearance with a void time of four minutes. By the time the pilot correctly read back the clearance, less than two minutes remained before the void time. Post accident documentation of the accident site revealed that neither the pilot nor the passenger were wearing their lap belts or shoulder harnesses. It was also noted that the pilot had not yet selected the discrete transponder code as indicated by the clearance.
Probable cause:
A delayed aborted takeoff for an undetermined reason.
Final Report: