Crash of a Cessna 421B Golden Eagle II near Tooele: 2 killed

Date & Time: Nov 16, 1988 at 0110 LT
Operator:
Registration:
N222BL
Flight Phase:
Survivors:
No
Site:
Schedule:
Saint George - Salt Lake City
MSN:
421B-0824
YOM:
1974
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
6375
Aircraft flight hours:
2774
Circumstances:
The flight departed St. George, UT, at 0100 mst enroute to Salt Lake City (SLC). A flight plan was not filed. The weather forecast was for IMC with mountain tops obscured. The pilot requested flight following from SLC center and proceeded on the airways until about 40 miles south of SLC where radar contact was lost. Upon loss of radar contact, the controller asked the pilot what his altitude was. The pilot replied that he was at 10,500 feet. That was the last contact with the flight. After repeated attempts to reestablish contact, it was determined that the aircraft had gone down. A search was begun and the wreckage was found 30 miles southwest of SLC at the 9,500 feet level of a mountain. Both occupants were killed.
Probable cause:
Occurrence #1: in flight collision with terrain/water
Phase of operation: cruise - normal
Findings
1. (f) light condition - dark night
2. (f) weather condition - snow
3. (f) weather condition - low ceiling
4. (f) terrain condition - mountainous/hilly
5. (c) in-flight planning/decision - improper - pilot in command
6. (c) became lost/disoriented - inadvertent - pilot in command
7. (c) proper altitude - not maintained - pilot in command
8. (c) flight into known adverse weather - attempted - pilot in command
Final Report:

Crash of a Piper PA-61P Aerostar (Ted Smith 601) in Bear Lake: 1 killed

Date & Time: Oct 20, 1988 at 1530 LT
Registration:
N6069U
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Salt Lake City - Salt Lake City
MSN:
61-0675-7963317
YOM:
1979
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
12150
Circumstances:
The pilot departed Salt Lake City on a pleasure flight to Bear Lake to overfly a home that he owned. Witnesses near the accident site stated they saw the aircraft circle over the house and then depart the area over a ridge of mountains. The aircraft turned out over the lake and was in straight and level flight shortly before it descended at a steep angle into the water. The autopsy performed on the pilot revealed coronary arteriosclerosis. The assistant medical examiner stated in the autopsy report the pilot 'may have been rendered incapacitated by an acute cardiac arrhythmia.'
Probable cause:
Occurrence #1: loss of control - in flight
Phase of operation: cruise
Findings
1. (c) incapacitation (other cardiovascular) - pilot in command
----------
Occurrence #2: in flight collision with terrain/water
Phase of operation: descent - uncontrolled
Final Report:

Crash of a Boeing 727-232 in Dallas: 14 killed

Date & Time: Aug 31, 1988 at 0901 LT
Type of aircraft:
Operator:
Registration:
N473DA
Flight Phase:
Survivors:
Yes
Schedule:
Jackson - Dallas - Salt Lake City
MSN:
20750
YOM:
1973
Flight number:
DL1141
Crew on board:
7
Crew fatalities:
Pax on board:
101
Pax fatalities:
Other fatalities:
Total fatalities:
14
Captain / Total flying hours:
17000
Captain / Total hours on type:
7000.00
Copilot / Total flying hours:
6500
Copilot / Total hours on type:
4000
Aircraft flight hours:
43023
Circumstances:
Flight DL1141 (Jackson - Dallas - Salt Lake City) left Gate 15 at 08:30 and was instructed to taxi to runway 18L. When first in line for takeoff (at 08:59) the flight was cleared for takeoff. The takeoff was uneventful until the airplane reached the rotation phase (at 154 knots, 6017 feet down the runway). As the main gear wheels left the ground, the airplane began to roll violently, causing the right wingtip to contact the runway (1033 feet after lift-off), followed by compressor surges. The plane continued and struck the ILS localizer antenna array 1000 feet past the end of runway 18L. After impacting the antenna installation, the airplane remained airborne for an additional 400 feet, then struck the ground, traversed a ground depression and slid sideways until it came to rest near the airport perimeter fence, 3200 feet from the runway end. Parts of the aircraft had separated in the slide and a fire had erupted in the right wing area, quickly engulfing the rear, right side of the airplane after it came to rest. Twelve passengers and two crew members were killed. The aircraft was destroyed.
Probable cause:
The board determines that the accident was caused mainly by the captain and first officer's inadequate cockpit discipline which resulted in the flight crew's attempt to takeoff without the wing flaps and slats properly configured; and the failure of the takeoff configuration warning system to alert the crew that the airplane was not properly configured for the takeoff. Contributing to the accident was Delta's slow implementation of necessary modifications to its operating procedures, manuals, checklists, training and crew checking programs which were necessitated by significant changes in the airline following rapid growth and merger. Also contributing to the accident was the lack of sufficiently aggressive action by the FAA to have known deficiencies corrected by Delta and the lack of sufficient accountability within the FAA's air carrier inspection process.
Findings:
Occurrence #1: loss of control - in flight
Phase of operation: takeoff - initial climb
Findings
1. (c) preflight planning/preparation - improper - pilot in command
2. (c) overconfidence in personal ability - pilot in command
3. (c) procedures/directives - not followed - copilot/second pilot
4. (c) procedures/directives - not followed - pilot in command
5. (f) procedure inadequate - company/operator management
6. (f) insufficient standards/requirements, operation/operator - FAA (organization)
7. (f) inadequate method of compliance determination record keeping - FAA (organization)
8. (c) lowering of flaps - not performed
9. (c) lowering of slats - not performed
10. (c) safety system (other) - inoperative
----------
Occurrence #2: in flight collision with terrain/water
Phase of operation: descent - uncontrolled
Final Report:

Crash of a Rockwell Grand Commander 680FL in Soda Springs: 2 killed

Date & Time: Apr 8, 1988 at 2125 LT
Operator:
Registration:
N291NC
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Billings - Salt Lake City
MSN:
680-1461-86
YOM:
1964
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
5013
Captain / Total hours on type:
50.00
Aircraft flight hours:
11873
Circumstances:
While en route on a night IFR cargo flight, the pilot requested and was cleared for a descent from an IFR cruise altitude of 16,000 feet to proceed VFR-on-top. The last transmission from the aircraft was at 2106 when the pilot acknowledged that he was familiar with the terrain along the route. At 2121:51 mdt, radar contact was lost after the aircraft made an approximately 360° left turn and descended thru 13,800 feet. Shortly after that, the controller tried to call the pilot to inform him that radar contact was lost, but was unable to make radio contact. Later, wreckage of the aircraft was found where it had crashed about 2 miles southwest of were radar contact was lost. The wreckage was scattered over an area of more than one mile. An investigation revealed the left wing and right horizontal stabilizer had separated upward from overload. No pre-accident fatigue or part failure/malfunction was found. Weather reports and pireps indicated moderate turbulences and towering cumulus clouds in the area. Approximately 60 miles west at Pocatello, ID, snow showers were reported; 2 to 3 inches of snow fell on the wreckage overnight. Both pilots were killed.
Probable cause:
Occurrence #1: airframe/component/system failure/malfunction
Phase of operation: descent
Findings
1. (f) light condition - dark night
2. (f) weather condition - snow
3. (f) weather condition - thunderstorm
4. (f) weather condition - turbulence
5. (c) design stress limits of aircraft - exceeded - pilot in command
6. Wing - overload
7. Wing - separation
8. Horizontal stabilizer surface - overload
9. Horizontal stabilizer surface - separation
----------
Occurrence #2: in flight collision with terrain/water
Phase of operation: descent - uncontrolled
Final Report:

Crash of a Swearingen SA226TC Metro II in Salt Lake City: 8 killed

Date & Time: Jan 15, 1987 at 1252 LT
Type of aircraft:
Operator:
Registration:
N163SW
Survivors:
No
Site:
Schedule:
Pocatello - Salt Lake City
MSN:
TC-327
YOM:
1980
Flight number:
OO1834
Crew on board:
2
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
8
Captain / Total flying hours:
3885
Captain / Total hours on type:
1863.00
Copilot / Total flying hours:
4555
Copilot / Total hours on type:
1205
Aircraft flight hours:
15116
Circumstances:
On January 15, 1987, at 1216 mountain standard time, SkyWest flight 1834, a Fairchild Swearingen SA-226TC (METRO II), registration Nl635W, departed Pocatello, Idaho, on a regularly scheduled passenger flight to Salt Lake City, Utah (SLC). The flight was operating under the provisions of Title 14 Code of Federal Regulations Part 121 with two pilots and six passengers aboard. Flight 1834 was handed off from the SLC Air Route Traffic Control Center to the Bear Sector controller at the SLC Terminal Radar Approach Control (TRACON) for a left downwind arrival to SLC International Airport. At 1237:49, the Bear sector controller issued a heading of 100” to flight 1834 and advised the flight to expect vectors for a visual approach to runway 34L. (See Air Traffic Control Transcript in appendix C). During the next few minutes, flight 1834 was given further vectors and descent clearances, and at 1247:21, it was given a frequency change to the TRACON Final controller. At 1250:28, after being cleared to descend to 7,000 feet mean sea level (msl), the Final controller advised, “SkyWest eight thirty four, traffic ten to nine o’clock, four miles, six thousand, Boeing seven, ah, thirty seven three hundred.” Flight 1834 acknowledged, “SkyWest eight thirty four has the traffic.” At 1250:35, the Final controller advised, “SkyWest eight thirty four, plan to follow that traffic, there’s traffic south of him eleven o’clock, six miles north bound, [a] seven thirty seven out of seven thousand five hundred, for the right.” Flight 1834 responded, “OK, we’ll follow the first one, SkyWest eight thirty four.” At 1250:44, the Final controller advised, “SkyWest eight thirty four, wait a minute, report the other one in sight.” Flight 1834 responded, “We’re looking for him.” At 1251:02, the Final controller transmitted, “SkyWest eight thirty four, ten o’clock four miles, seven thousand four hundred.” Flight 1834 replied, “Eight thirty four, we’re looking.” The Final controller then issued instructions at 1251: 15 for flight 1834 to make a left turn to 070”, and the flight acknowledged. At 1251:32, the Final controller transmitted, “SkyWest eight thirty four, traffic’s ten to eleven o’clock, three miles.” Flight 1834 did not acknowledge that transmission, and at 1251:43, the Final controller advised, “SkyWest eight thirty four, turn left heading zero five zero.” The flight acknowledged and reported, “Still have no contact on that traffic.” At 1251:50, the Final controller transmitted, “SkyWest eight thirty four, roger, turn further left heading three six zero.” Flight 1834 acknowledged and at 1251:58, an expletive was transmitted over the TRACON Final control frequency during a transmission from SkyWest flight 575. There were no further transmissions from flight 1834. According to the UNICOM I/ operator at SLC Municipal 2 Airport (SLC 2) about 1115 or 1120, a pilot in Mooney M20C, registration N6485U, operating under 14 CFR Part 91, called to inquire if the runway was clear. The Mooney was occupied by a private pilot in the left seat and an instructor pilot in the right seat. The UNICOM operator advised that the runway was clear, and a few minutes later, a pilot in the Mooney called for and was given an airport advisory. The UNICOM operator observed the Mooney taxi to runway 34 and take off about 1125 or 1130. The Mooney remained in the traffic pattern at SLC 2 performing touch-and-go landings. There were no other aircraft in the traffic pattern at the time. The UNICOM operator stated that she last talked to the Mooney about 1145 to 1150 when a pilot called, “Final for 34.” The UNICOM operator said that she observed the airplane perform a touch-and: go landing, but she did not observe the direction of departure of the airplane. There were no further known communications with the Mooney regarding departing the traffic pattern or any additional aspects of the flight. According to recorded air traffic control (ATC) radar data, after the Mooney departed the SLC 2 traffic pattern at 1235, y the airplane flew south and maneuvered about 25 miles south southeast of SLC International Airport before beginning a turn to the northwest. The airplane continued in a northwesterly direction until it was about 9 miles south of SLC International Airport where it began a gradual left turn until its target merged with the target of SkyWest flight 1834. The targets merged at 1257 :58--the time the expletive was recorded on the ATC tape at the SLC TRACON. The Final approach controller stated that he did observe a visual flight rules (VFR) target about 3 to 4 miles southwest of SLC 2 moving north to northwest when flight 1834 was on downwind. He said he had no more than normal cause to monitor the target. He also stated that it was not unusual to observe VFR targets in the pattern near SLC 2 during visual meteorological conditions. Other controllers at SLC TRACON also stated that it was not uncommon to observe numerous targets operating in the traffic pattern at SLC 2. The Final controller and other controllers added that they normally would observe the VFR targets near SLC 2 disappear from the radarscope and then reappear during practice touch-and-go landings. The Final controller said that he did not recall seeing any VFR targets in the vicinity of SkyWest 1834 as it was turning toward final just before the collision. The Fin.al controller stated that his workload was moderate, and all of his equipment was operating normally before the accident. In addition, the Local controller in the SLC tower stated that he did not observe the target of the Mooney on the tower Bright Radar Indicator Tower Equipment display. There was no evidence that the Mooney pilots were in radio contact with any ATC facility at the time of the accident. Several eyewitnesses were interviewed who observed the airplanes before and after the collision. Some of the witnesses stated that the nose of the METRO II pitched up just before impact. The witnesses stated that the METRO II was headed northeasterly and the Mooney was headed northwesterly just before impact. They stated that the METRO II had made a few left turns as it turned toward the northeast. In general, the eyewitnesses agreed that the two airplanes collided with the Mooney striking the METRO II’s right forward fuselage area with its nose. After the collision, both airplanes fell to the ground with wreckage scattered over 2 square miles in a residential section of Kearns, Utah. There was no fire. The collision occurred at 7,000 feet msl in daylight visual meteorological conditions. All 10 occupants in both aircraft were killed. There were no casualties on the ground.
Probable cause:
Lack of navigational vigilance by the Mooney instructor pilot which led to the authorized intrusion into the Salt Lake City airport radar service area. Contributing to the accident were the absence of a Mode-C transponder on the Mooney airplane and the limitations of the air traffic control system to provide collision protection under the circumstances of this accident.
Final Report:

Crash of a Rockwell Grand Commander 680FL near Fort Collins: 1 killed

Date & Time: Sep 12, 1985 at 0020 LT
Registration:
N45724
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Fort Collins - Salt Lake City
MSN:
680-1291-2
YOM:
1963
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
3554
Captain / Total hours on type:
43.00
Aircraft flight hours:
9535
Circumstances:
The pilot was operating his aircraft under the rules of 14 cfr 135, i.e., a scheduled domestic cargo flight. He made a normal departure and climb en route to Salt Lake City, UT. Normal communications and radar flight following was established with Denver ARTCC. Approximately 8 miles west of fort collins, the aircraft suddenly disappeared off of radar and voice contact with the pilot was lost.
Probable cause:
Occurrence #1: loss of control - in flight
Phase of operation: climb - to cruise
Findings
1. Light condition - dark night
2. (c) reason for occurrence undetermined
3. Weather condition - turbulence
----------
Occurrence #2: in flight collision with terrain/water
Phase of operation: descent - uncontrolled
Findings
4. Reason for occurrence undetermined
Final Report:

Crash of a Piper PA-31-310 Navajo B in Vernal

Date & Time: Aug 21, 1985 at 0651 LT
Type of aircraft:
Registration:
N7497L
Flight Type:
Survivors:
Yes
Schedule:
Salt Lake City - Vernal
MSN:
31-7300928
YOM:
1973
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
1556
Captain / Total hours on type:
207.00
Aircraft flight hours:
7946
Circumstances:
The pilot cancelled his IFR plan and began descent from 13,000 feet in preparation for landing at Vernal, UT. The aircraft impacted ground in wings level attitude under power. Pilot was seriously burned by postcrash ground fire. Investigation revealed no evidence of flight control failure prior to impact. It was learned pilot had flown small aircraft from Salt Lake City to Price, UT, and to Pierre, SD, the day before the accident. Pilot returned to Salt Lake City at 0200 on day of accident. Accident flight departed Salt Lake City at 0600. FAA physician opined that pilot was asleep at impact. Aircraft was flying into rising sun.
Probable cause:
Occurrence #1: in flight collision with terrain/water
Phase of operation: descent - normal
Findings
1. (f) terrain condition - ground
2. (f) judgment - poor - pilot in command
3. (c) fatigue (chronic) - pilot in command
4. (f) terrain condition - open field
5. (c) fatigue (lack of sleep) - pilot in command
6. (f) light condition – dawn
Final Report:

Crash of a Cessna 414 Chancellor in Cheyenne

Date & Time: Oct 20, 1984 at 1338 LT
Type of aircraft:
Registration:
N1597T
Flight Phase:
Survivors:
Yes
Schedule:
Cheyenne - Salt Lake City
MSN:
414-0377
YOM:
1973
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
13200
Aircraft flight hours:
18035
Circumstances:
The aircraft departed the airport in IFR conditions (snowing) and was observed staggering into the air. Shortly after takeoff the aircraft struck power lines and crashed into homes in a residential area. Investigation revealed that the aircraft had accumulated ice and in addition was over certified max gross weight. There was no evidence of airframe, flight control or engine failure/malfunction prior to impact with the power lines.
Probable cause:
Occurrence #1: in flight encounter with weather
Phase of operation: takeoff - roll/run
Findings
1. (f) weather condition - fog
2. (f) weather condition - snow
3. (c) flight into known adverse weather - performed - pilot in command
4. (f) overconfidence in personal ability - pilot in command
----------
Occurrence #2: in flight collision with object
Phase of operation: takeoff - initial climb
Findings
5. (f) object - wire, static
6. (c) proper climb rate - not maintained - pilot in command
7. (f) aircraft weight and balance - exceeded - pilot in command
----------
Occurrence #3: in flight collision with terrain/water
Phase of operation: descent - uncontrolled
Final Report:

Crash of a Cessna 404 Titan in Aspen: 1 killed

Date & Time: Dec 27, 1982 at 0743 LT
Type of aircraft:
Registration:
N5301J
Flight Phase:
Survivors:
Yes
Schedule:
Aspen - Salt Lake City
MSN:
404-0643
YOM:
1980
Crew on board:
1
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
10000
Captain / Total hours on type:
18.00
Aircraft flight hours:
373
Circumstances:
The right front seat passenger, who is a private pilot, stated that the pilot did not use takeoff flaps. The aircraft lifted off at about 85 knots and immediately started buffeting. The aircraft then impacted a highway in a nose high, left wing low attitude and collided with a rock face mountain. According to the aircraft operating manual the rate-of-climb/maximum climb chart indicates that (with wing flaps up at a density alt of 6,000 feet) the aircraft required a climb speed of 103 knots. Flaps up lift off speed is 95 knots. All six passengers were injured while the pilot was killed.
Probable cause:
Occurrence #1: loss of control - in flight
Phase of operation: takeoff - initial climb
Findings
1. (c) airspeed (vlof) - not attained - pilot in command
2. (c) lift-off - premature - pilot in command
3. Stall - inadvertent - pilot in command
4. (f) weather condition - high density altitude
----------
Occurrence #2: in flight collision with terrain/water
Phase of operation: takeoff - initial climb
Findings
5. Terrain condition - mountainous/hilly
Final Report:

Crash of a Cessna 421C Golden Eagle III near Shoshone: 3 killed

Date & Time: Nov 21, 1981 at 2323 LT
Registration:
N8369G
Flight Phase:
Survivors:
No
Site:
Schedule:
Salt Lake City - Hailey
MSN:
421C-0309
YOM:
1977
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
33930
Captain / Total hours on type:
46.00
Circumstances:
While cruising by night from Salt Lake City to Hailey, the pilot failed to see and avoid mountainous terrain. The twin engine airplane struck the slope of a mountain and crashed near Shoshone, killing all three occupants.
Probable cause:
Controlled collision with ground in normal cruise after the pilot misjudged altitude and clearance. The following contributing factors were reported:
- Low ceiling,
- Dark night,
- Area forecast for mountains occasionally obscured above 7,000 - 9,000 feet.
Final Report: