Crash of a Learjet 25D in Washington DC: 12 killed

Date & Time: Jun 18, 1994 at 0625 LT
Type of aircraft:
Operator:
Registration:
XA-BBA
Survivors:
No
Schedule:
Mexico City – New Orleans – Washington DC
MSN:
25-223
YOM:
1977
Crew on board:
2
Crew fatalities:
Pax on board:
10
Pax fatalities:
Other fatalities:
Total fatalities:
12
Captain / Total flying hours:
1706
Captain / Total hours on type:
1314.00
Copilot / Total flying hours:
852
Copilot / Total hours on type:
426
Aircraft flight hours:
6118
Aircraft flight cycles:
5663
Circumstances:
The airplane crashed 0.8 nm south of the threshold of the runway during an ILS approach in instrument meteorological conditions. The captain was not authorized to attempt the approach and was relatively inexperienced for an approach under the weather conditions. The captain failed to adhere to acceptable standards of airmanship during two unstabilized approaches. After the unsuccessful ils approach to runway 01R, the captain should have held for improvements in the weather, requested the runway 19L ILS, or proceeded to his alternate. An operating gpws aboard the airplane would have provided continuous warning to the crew for the last 64 seconds of flight and might have prevented the accident. All 10 passengers were Mexican citizens flying to Washington DC to assist a game of the World Football Championship.
Probable cause:
Poor decision making, poor airmanship, and relative inexperience of the captain in initiating and continuing an unstabilized instrument approach that led to a descent below the authorized altitude without visual contact with the runway environment. Contributing to the cause of the accident was the lack of a GPWS on the airplane.
Final Report:

Crash of a Swearingen SA26T Merlin II in Winchester: 1 killed

Date & Time: Mar 18, 1994 at 0050 LT
Type of aircraft:
Operator:
Registration:
N20PT
Flight Type:
Survivors:
No
Schedule:
Washington DC - Winchester
MSN:
T26-128
YOM:
1969
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
3382
Captain / Total hours on type:
568.00
Aircraft flight hours:
5869
Circumstances:
While on approach at night, in VMC, the left engine lost power due to fuel starvation. The propeller was not feathered, the l/g was left down, and the aircraft drifted left of crs, struck trees, and then the ground. One gallon of fuel was drained from the right wing, engine and fuel line. No fuel was found in the left wing, engine and fuel line. The copilot said the fuel quantity system was erratic with the left side more erratic, and the right side reading about 10 gallons more than the left side. Testing found the right side indicated about 45 gallons more than was present while the left side was inoperative. There was no requirement for periodic recalibration of the fuel quantity system. The owner/pilot had operated the aircraft on 32 flights, over 23 hours, and refueled 23 times using partial fills, since he had full tanks. The pilot was checked out 17 months prior and the instructor said the pilot was fine, however, he was cautioned him to enroll in recurrent training. There was no record he did. The pilot had received an FAA checkride 19 months prior to the accident, which he passed.
Probable cause:
The pilot's decision to operate the airplane with known deficiencies in the fuel quantity measuring system which resulted in a power loss due to fuel starvation, followed by improper emergency procedures which resulted in a loss of control inflight and uncontrolled contact with the ground. Factors were the lack of a requirement for periodic calibration of the fuel quantity measuring system from the manufacturer, and the erratic and inaccurate fuel quantity measuring system.
Final Report:

Crash of a Beechcraft 300 Super King Air on Mt Knob: 3 killed

Date & Time: Oct 26, 1993 at 1552 LT
Operator:
Registration:
N82
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Atlantic City - Winchester - Newport News
MSN:
FF-17
YOM:
1988
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
6700
Captain / Total hours on type:
2000.00
Aircraft flight hours:
3353
Circumstances:
The airplane departed Winchester Regional Airport under VFR mode and was completing a routine point-to-point flight to Newport News/Williamsburg International Airport (PHF), Virginia after conducting a flight inspection of the ILS at Winchester Regional Airport. After takeoff, while flying at an altitude of 2,000 feet, the crew requested permission to climb but this was denied by ATC due to traffic. Awaiting an IFR clearance, the aircraft struck the slope of Mt Knob located about 30 miles southwest from Winchester Airport. All three occupants were killed.
Probable cause:
Failure of the pilot-in-command to ensure that the airplane remained in visual meteorological conditions over mountainous terrain, and the failure of Federal Aviation Administration executives and managers responsible for the FAA flying program to:
(1) establish effective and accountable leadership and oversight of flying operations;
(2) establish minimum mission and operational performance standards;
(3) recognize and address performance-related problems among the organization's pilots; and
(4) remove from flight operations duty pilots who were not performing to standards.
Final Report:

Crash of a Beechcraft B65 Queen Air near Madison: 2 killed

Date & Time: May 16, 1992 at 1400 LT
Type of aircraft:
Registration:
N30RR
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Allentown - Charlottesville
MSN:
LC-186
YOM:
1965
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
6003
Circumstances:
The instrument rated pilot was en route to his granddaughter's graduation exercises scheduled for the following day. He had received two preflight weather briefings from flight service and he was advised that marginal VFR conditions existed en route, and instrument meteorological conditions at his destination, and that VFRflight was not recommended. A witness who was below the mountain said he heard a low flying aircraft overhead. He stated that he caught a glimpse of the airplane and said it was 'well below the crest of the mountain' heading south. The weather as reported by the witness was about 200 overcast and visibility below 1 mile in fog. He also mentioned that the clouds had obscured the mountain. Shortly thereafter, he heard what was later determined to be the collision. Search personnel located the burning wreckage on top of Mitchells mountain 50 miles north of Charlottesville. Both occupants were killed.
Probable cause:
The pilot initiated VFR flight into known adverse weather conditions. Contributing to the accident was low ceiling, high terrain, and low altitude.
Final Report:

Crash of a Cessna 421B Golden Eagle II in Chesapeake

Date & Time: Nov 28, 1989 at 1815 LT
Registration:
N3359Q
Survivors:
Yes
Schedule:
Washington - Chesapeake
MSN:
421B-0243
YOM:
1972
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
10800
Captain / Total hours on type:
35.00
Aircraft flight hours:
3760
Circumstances:
The pilot returned to the airport at dusk and made a visual approach to runway 23. He reported that as the aircraft was descending thru 350 feet msl on final approach, it was aligned with the runway, the airspeed was 105 knots and the flaps were extended 25°. However, the aircraft hit trees and crashed about 1/8 mile short of the runway. No mechanical malfunction was reported. The airport elevation was 20 feet. Both occupants were slightly injured.
Probable cause:
The pilot misjudged distance and altitude to the runway, while on final approach to land. The light condition at dusk was a related factor.
Final Report:

Crash of a Piper PA-31-350 Navajo Chieftain in Lynchburg: 5 killed

Date & Time: Aug 28, 1989 at 0045 LT
Registration:
N234J
Survivors:
No
Schedule:
Salisbury - Lynchburg
MSN:
31-7952021
YOM:
1979
Crew on board:
2
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
1345
Captain / Total hours on type:
190.00
Circumstances:
The pilot unsuccessfully tried twice to land on runway 03. He did a visual approach and then an ILS approach. The pilot and witnesses reported foggy conditions at the airport. The pilot flew the ILS approach as a third attempt to land when the crash occurred. Radar data showed the aircraft descended to 1,100 feet msl on the approach, about 1/2 mile from the runway. The published decision height was 1,118 feet. The radar data indicated the aircraft passed east of the runway threshold at an altitude of 1,000 feet msl. The next and last radar data shows the aircraft about 2,300 feet beyond and 400 feet east of the runway. The investigation revealed the aircraft struck trees east of the runway and then crashed in a cornfield. An examination did not disclose evidence of a malfunction. The landing gear was retracted and the flaps were extended 10°. All five occupants were killed.
Probable cause:
Pilot's failure to maintain clearance from obstructions because of improper ifr operation. Contributing to the accident was descent below decision height, delay in initiating the missed approach, and fog conditions.
Final Report:

Crash of a Beechcraft A60 Duke in Manassas: 5 killed

Date & Time: Mar 11, 1989 at 1615 LT
Type of aircraft:
Operator:
Registration:
N98DS
Flight Phase:
Survivors:
No
Schedule:
Manassas – Wilmington
MSN:
P-227
YOM:
1973
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
25130
Aircraft flight hours:
1775
Circumstances:
Witnesses reported the aircraft took off and climbed to about 300 feet while in a wide left turn. According to witnesses, the wings were rocking and erratic engine sounds were noted. The aircraft was turning downwind when it abruptly pitched down, rolled left until inverted, descended and crash. Examination of the aircraft revealed no evidence of malfunction, although the left prop had less rotational damage than the right prop. Examination of aircraft records revealed the aircraft was inactive for about 9 years until it was returned to service less than a year before the accident. The aircraft accumulated about 17 hours since it was returned to service. The pilot stated to a witness before the accident that he had not done single engine operation in the aircraft. The aircraft was overloaded more than 200 lbs. All five occupants were killed.
Probable cause:
A loss of aircraft control due to the pilot's failure to maintain minimum engine control speed after a partial loss of power of the left engine for undetermined reasons. The pilot's inexperience in type of aircraft and an over maximum gross weight aircraft were contributing factors.
Final Report:

Crash of a De Havilland DHC-6 Twin Otter 200 in Washington-Dulles: 1 killed

Date & Time: Jul 20, 1988 at 1608 LT
Registration:
N7267
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Washington - Washington
MSN:
195
YOM:
1969
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
12400
Aircraft flight hours:
10513
Circumstances:
This was the first flight after a maintenance inspection. The flaps were left full down after a post-inspection by company mechanics, before the flight. Witnesses stated the flaps were down when the aircraft taxied to takeoff on runway 19L. Witnesses stated the aircraft climbed steeply after it lifted off with a pitch attitude up to 60°. According to witnesses, the aircraft climbed to 200 to 500 feet agl, before it stalled and descended nose down in a left turn. The aircraft crashed about 300 ft left of and 2000 ft down the rwy. Examination of the aircraft revealed the flaps were full down. The scroll type checklist was positioned at the beginning of the takeoff check. The flight manual recommends a 10 degree flap setting for takeoff and prohibits flap full down takeoff. Review of previous DHC-6 accidents involving flap full down resulted in a steep takeoff climb and excessive pitch attitude followed by a stall. The position of the control lock suggests it may have been in the locked position during the takeoff. The pilot, sole on board, was killed.
Probable cause:
The pilot inadvertently misused the flaps, by failing to set the flaps to the proper setting. The flaps were set full down. This caused the aircraft to pitch up steeply after liftoff. Additionally, the flight control lock was probably installed during some portion, if not the entire flight, which prevented flight control operation. The pilot subsequently failed to maintain adequate flying speed and the aircraft stalled. Contributing factors are the pilot's inattention and his failure to adequately use the checklist.
Findings:
Occurrence #1: loss of control - in flight
Phase of operation: takeoff - initial climb
Findings
1. (c) raising of flaps - not performed - pilot in command
2. (f) inattentive - pilot in command
3. (f) checklist - not used - pilot in command
4. (f) procedures/directives - not followed - pilot in command
5. (f) removal of control/gust lock(s) - inadvertent use - pilot in command
----------
Occurrence #2: in flight collision with terrain/water
Phase of operation: descent - uncontrolled
Final Report:

Crash of a Swearingen SA226TC Metro II in Washington-Dulles

Date & Time: Dec 18, 1987 at 1936 LT
Type of aircraft:
Operator:
Registration:
N23AZ
Survivors:
Yes
Schedule:
Newark - Washington DC
MSN:
TC-260
YOM:
1978
Crew on board:
2
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
7200
Captain / Total hours on type:
400.00
Aircraft flight hours:
12820
Circumstances:
The aircraft had descended through a cloud layer enroute for the scheduled landing at IAD and according to the crew had picked up some trace rime ice on its wing surfaces. Although pitot and sas (stall avoidance system) heat were used the captain elected not to use engine inlet anti-ice. Just inside the outer marker the left engine lost power followed shortly by the right engine. The captain was able to set the aircraft down in an open field where the gear collapsed during the landing roll. The engines were successfully run-up at the Garrett facility. The flight manual contains a warning and a note stating that engine heat and continuous ignition must be used after leaving icing conditions until the pilot is confident that any significant residual ice will not be ingested into the engines. Ice was found lying beneath the right wing which matched the curvature of the leading edge of the wing. A round conical shaped piece of ice was found along the wreckage path which matched the nose of the propeller spinner.
Probable cause:
Occurrence #1: loss of engine power (total) - nonmechanical
Phase of operation: approach - faf/outer marker to threshold (ifr)
Findings
1. All engines
2. (f) weather condition - icing conditions
3. (c) in-flight planning/decision - improper - pilot in command
4. (c) anti-ice/deice system - not used - pilot in command
5. (c) inadequate initial training - check pilot
6. (c) inadequate certification/approval, airman - company/operator mgmt
7. (f) wing, skin - ice
----------
----------
Occurrence #3: gear collapsed
Phase of operation: landing - flare/touchdown
Findings
8. (f) terrain condition - open field
9. (f) terrain condition - downhill
10. (f) light condition - dark night
Final Report:

Crash of a Cessna 421A Golden Eagle I in Gordonsville

Date & Time: Jul 22, 1987 at 0930 LT
Type of aircraft:
Registration:
N9764J
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Gordonsville - Charlottesville
MSN:
421A-0028
YOM:
1967
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
1723
Captain / Total hours on type:
201.00
Aircraft flight hours:
1975
Circumstances:
The pilot began taking off from a downward sloping, 2,300 feet runway in light winds. The reported temperature was 92°; the density altitude was about 2,500 feet. The pilot reported the aircraft accelerated normally to V1 speed; however, it hit the tops of trees about 350 to 500 feet beyond the runway, then struck the ground after traveling about another 1,000 feet. Performance charts showed the aircraft would have needed a takeoff distance of 2,200 feet to clear a 50 feet obstacle in calm wind. The pilot reported the wind was from 010° at 3 to 5 knots. A witness reported a 3 to 5 knot tailwind. No preimpact part failure or malfunction was found.
Probable cause:
Occurrence #1: in flight collision with object
Phase of operation: takeoff - initial climb
Findings
1. (c) preflight planning/preparation - inadequate - pilot in command
2. (f) weather condition - high density altitude
3. (f) weather condition - unfavorable wind
4. (f) object - tree(s)
5. Proper altitude - not attained
----------
Occurrence #2: in flight collision with terrain/water
Phase of operation: descent - uncontrolled
Final Report: