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Crash of a Short 330-200 in Charleston: 2 killed

Date & Time: May 5, 2017 at 0651 LT
Type of aircraft:
Operator:
Registration:
N334AC
Flight Type:
Survivors:
No
Schedule:
Louisville – Charleston
MSN:
SH3029
YOM:
1979
Flight number:
2Q1260
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
4368
Captain / Total hours on type:
578.00
Copilot / Total flying hours:
652
Copilot / Total hours on type:
333
Aircraft flight hours:
28023
Aircraft flight cycles:
36738
Circumstances:
The flight crew was conducting a cargo flight in instrument meteorological conditions. Takeoff from the departure airport and the en route portion of the flight were normal, with no reported weather or operational issues. As the flight neared Charleston Yeager International Airport (CRW) at an altitude of 9,000 ft, the captain and first officer received the most recent automatic terminal information service (ATIS) report for the airport indicating wind from 080º at 11 knots, 10 miles visibility, scattered clouds at 700 ft above ground level (agl), and a broken ceiling at 1,300 ft agl. However, a special weather observation recorded about 7 minutes before the flight crew's initial contact with the CRW approach controller indicated that the wind conditions had changed to 170º at 4 knots and that cloud ceilings had dropped to 500 ft agl. The CRW approach controller did not provide the updated weather information to the flight crew and did not update the ATIS, as required by Federal Aviation Administration Order 7110.65X, paragraph 2-9-2. The CRW approach controller advised the flight crew to expect the localizer 5 approach, which would have provided a straight-in final approach course aligned with runway 5. The first officer acknowledged the instruction but requested the VOR-A circling instrument approach, presumably because the approach procedure happened to line up with the flight crew's inbound flightpath and flying the localizer 5 approach would result in a slightly longer flight to the airport. However, because the localizer 5 approach was available, the flight crew's decision to fly the VOR-A circling approach was contrary to the operator's standard operating procedures (SOP). The minimum descent altitude (MDA) for the localizer approach was 373 ft agl, and the MDA for the VOR-A approach was about 773 ft agl. With the special weather observation indicating cloud cover at 500 ft agl, it would be difficult for the pilots to see the airport while at the MDA for the VOR-A approach; yet, the flight crew did not have that information. The approach controller was required to provide the flight crew with the special weather report indicating that the ceiling at the arrival airport had dropped below the MDA, which could have prompted the pilots to use the localizer approach; however, the pilots would not have been required to because the minimum visibility for the VOR-A approach was within acceptable limits. The approach controller approved the first officer's request then cleared the flight direct to the first waypoint of the VOR-A approach and to descend to 4,000 ft. Radar data indicated that as the flight progressed along the VOR-A approach course, the airplane descended 120 feet below the prescribed minimum stepdown altitude of 1,720 ft two miles prior to FOGAG waypoint. The airplane remained level at or about 1,600 ft until about 0.5 mile from the displaced threshold of the landing runway. At this point, the airplane entered a 2,500 ft-per-minute, turning descent toward the runway in a steep left bank up to 42º in an apparent attempt to line up with the runway. Performance analysis indicates that, just before the airplane impacted the runway, the descent rate decreased to about 600 fpm and pitch began to move in a nose-up direction, suggesting that the captain was pulling up as the airplane neared the pavement; however, it was too late to save the approach. Postaccident examination of the airplane did not identify any airplane or engine malfunctions or failures that would have precluded normal operation. Video and witness information were not conclusive as to whether the captain descended below the MDA before exiting the cloud cover; however, the descent from the MDA was not in accordance with federal regulations, which required, in part, that pilots not leave the MDA until the "aircraft is continuously in a position from which a descent to a landing on the intended runway can be made at a normal descent rate using normal maneuvers." The accident airplane's descent rate was not in accordance with company guidance, which stated that "a constant rate of descent of about 500 ft./min. should be maintained." Rather than continue the VOR-A approach with an excessive descent rate and airplane maneuvering, the captain should have conducted a missed approach and executed the localizer 5 approach procedure. No evidence was found to indicate why the captain chose to continue the approach; however, the captain's recent performance history, including an unsatisfactory checkride due to poor instrument flying, indicated that his instrument flight skills were marginal. It is possible that the captain felt more confident in his ability to perform an unstable approach to the runway compared to conducting the circling approach to land. The first officer also could have called for a missed approach but, based on text messages she sent to friends and their interview statements, the first officer was not in the habit of speaking up. The difference in experience between the captain and first officer likely created a barrier to communication due to authority gradient. ATC data of three VOR-A approaches to CRW flown by the captain over a period of 3 months before the accident and airport security footage of previous landings by the flight crew 1 month before the accident suggest that the captain's early descent below specified altitudes and excessive maneuvering during landing were not isolated to the accident flight. The evidence suggests that the flight crew consistently turned to final later and at a lower altitude than recommended by the operator's SOPs. The flight crew's performance on the accident flight was consistent with procedural intentional noncompliance, which—as a longstanding concern of the NTSB—was highlighted on the NTSB's 2015 Most Wanted List. The operator stands as the first line of defense against procedural intentional noncompliance by setting a positive safety attitude for personnel to follow and establishing organizational protections. However, the operator had no formal safety and oversight program to assess compliance with SOPs or monitor pilots, such as the captain, with previous performance issues.
Probable cause:
The flight crew's improper decision to conduct a circling approach contrary to the operator's standard operating procedures (SOP) and the captain's excessive descent rate and maneuvering during the approach, which led to inadvertent, uncontrolled contact with the ground. Contributing to the accident was the operator's lack of a formal safety and oversight program to assess hazards and compliance with SOPs and to monitor pilots with previous performance issues.
Final Report:

Ground fire of a Short 360-100 in Houston

Date & Time: May 17, 2012 at 0715 LT
Type of aircraft:
Operator:
Registration:
N617FB
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Houston – Austin
MSN:
3617
YOM:
1983
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
5348
Captain / Total hours on type:
2305.00
Copilot / Total flying hours:
832
Copilot / Total hours on type:
171
Aircraft flight hours:
27504
Circumstances:
The pilots reported that the cargo airplane was about 60 pounds over its maximum takeoff weight. Because their taxi to the assigned runway was long, they decided to reduce weight by using higher-than-normal engine power settings to burn fuel before takeoff while using the wheel brakes to control the airplane’s speed while taxiing. During the taxi, a fire ignited in the right wheel housing. The pilots brought the airplane to a stop on the taxiway, evacuated, and attempted to extinguish the fire with two handheld fire extinguishers. Airport firefighting personnel arrived on scene and extinguished the fire using foam suppressant. Although the fire damage was extensive, postaccident examination of the airplane did not show evidence of mechanical malfunctions or failures with the wheel and brake system that could have caused the fire. The right and left main landing gear tires deflated when the fusible plugs in the wheels blew due to overheating. The fusible plugs are designed to “fail” if the wheels overheat, and those plugs functioned as designed. The pilots stated that they had been trained to not ride the brakes while taxiing. However, the captain stated that he did not realize that he was in danger of blowing the tires much less causing a fire, otherwise he would not have attempted to bum off excess fuel while taxiing.
Probable cause:
The pilots’ improper decision to burn fuel during the taxi by operating the engines at a higher-than-normal power setting and using the wheel brakes to control taxi speed, which resulted in a wheel fire.
Final Report:

Crash of a Short 330-200 in Myrtle Beach

Date & Time: May 18, 2006 at 0745 LT
Type of aircraft:
Operator:
Registration:
N937MA
Flight Type:
Survivors:
Yes
Schedule:
Greensboro – Myrtle Beach
MSN:
3040
YOM:
1980
Flight number:
SNC1340
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Aircraft flight hours:
21095
Circumstances:
Following an uneventful cargo flight from Greensboro, NC, the aircraft made a wheels-up landing on runway 18 at Myrtle Beach Airport, SC. The aircraft slid on its belly for few dozen metres before coming to rest on the main runway. Both pilots escaped uninjured while the aircraft was damaged beyond repair.
Probable cause:
NTSB did not conduct any investigation on this event.

Crash of a Short 360-300 in Watertown

Date & Time: Feb 5, 2006 at 1654 LT
Type of aircraft:
Operator:
Registration:
N372AC
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Milwaukee - Milwaukee
MSN:
3720
YOM:
1987
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
1524
Captain / Total hours on type:
630.00
Copilot / Total flying hours:
519
Copilot / Total hours on type:
122
Aircraft flight hours:
21996
Circumstances:
Prior to departure, both flight crews decided that they would join-up while in flight to take video and still pictures of each airplane. Both aircraft were Shorts Brothers SD-360-300 turboprop airplanes. While flying in formation, N3735W announced over the radio that they would turn right, toward N372AC, and descend. During the turn, N3735W's left wing impacted the left wing and engine of N372AC. After the collision, N372AC rolled to the left and pitched down significantly before the flight crew regained control of the airplane. After the collision, N372AC was losing hydraulic fluid and eventually had a complete hydraulic system failure. The airplane made an emergency landing at a nearby airport with its flaps retracted and its landing gear partially extended. The airplane overran the end of the runway, coming to rest about 100 feet from the departure threshold. White paint transfer markings and scrapes were observed on the left wing deice boot, the outboard side of the left engine cowling was crushed inboard, the left wing-strut leading edge was torn open and bent, and the lower fuselage skin, immediately forward of the landing gear wheel wells and stub wing, was torn from left to right, consistent with a propeller strike. N3735W impacted terrain and the airplane was destroyed during a subsequent ground fire. The flight crew and passenger were killed. The outboard three-quarters of the left wing was separated from the main wreckage and was not fire damaged. The upper wing surface had linear scrapes diagonally across the wing skin. The left aileron from N3735W was found on the runway where N372AC had landed.
Probable cause:
The other airplane's flight crew failure to maintain clearance while maneuvering during formation flight. Contributing to the accident was the decision of both flight crews to fly in formation.
Final Report:

Crash of a Short 360-300 in Watertown: 3 killed

Date & Time: Feb 5, 2006 at 1654 LT
Type of aircraft:
Operator:
Registration:
N3735W
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Milwaukee - Milwaukee
MSN:
3735
YOM:
1988
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
1643
Captain / Total hours on type:
1181.00
Copilot / Total flying hours:
7015
Copilot / Total hours on type:
4984
Aircraft flight hours:
10077
Circumstances:
Prior to departure, both flight crews decided that they would join-up while in flight to take video and still pictures of each airplane. Both aircraft were Shorts Brothers SD-360-300 turboprop airplanes. While flying in formation, N3735W announced over the radio that they would turn right, toward N372AC, and descend. During the turn, N3735W's left wing impacted the left wing and engine of N372AC. After the collision, N372AC rolled to the left and pitched down significantly before the flight crew regained control of the airplane. After the collision, N372AC was losing hydraulic fluid and eventually had a complete hydraulic system failure. The airplane made an emergency landing at a nearby airport with its flaps retracted and its landing gear partially extended. The airplane overran the end of the runway, coming to rest about 100 feet from the departure threshold. White paint transfer markings and scrapes were observed on the left wing deice boot, the outboard side of the left engine cowling was crushed inboard, the left wing-strut leading edge was torn open and bent, and the lower fuselage skin, immediately forward of the landing gear wheel wells and stub wing, was torn from left to right, consistent with a propeller strike. N3735W impacted terrain and the airplane was destroyed during a subsequent ground fire. The flight crew and passenger were killed. The outboard three-quarters of the left wing was separated from the main wreckage and was not fire damaged. The upper wing surface had linear scrapes diagonally across the wing skin. The left aileron from N3735W was found on the runway where N372AC had landed.
Probable cause:
The flight crew failed to maintain clearance from another aircraft as they turned to break formation flight while maneuvering. Contributing to the accident was the decision of both flight crews to fly in formation.
Final Report:

Crash of a Short 360-300 in Oshawa

Date & Time: Dec 16, 2004 at 2001 LT
Type of aircraft:
Operator:
Registration:
N748CC
Flight Type:
Survivors:
Yes
Schedule:
Toledo – Oshawa
MSN:
3748
YOM:
1988
Flight number:
SNC2917
Location:
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
5300
Captain / Total hours on type:
1000.00
Copilot / Total flying hours:
800
Copilot / Total hours on type:
400
Circumstances:
Air Cargo Carriers, Inc. Flight SNC2917, a Short Brothers SD3-60 aircraft (registration N748CC, serial number SH3748), was on a charter cargo flight from Toledo, Ohio, USA, to Oshawa, Ontario, with two pilots on board. The crew conducted an instrument flight rules approach to Oshawa Municipal Airport in night instrument meteorological conditions. At approximately 2000 eastern standard time, the aircraft landed on Runway 30, which was snow-covered. During the landing roll, the pilot flying noted poor braking action and observed the runway end lights approaching. He rejected the landing and conducted a go-around procedure. The aircraft became airborne, but it started to descend as it flew over lower terrain, striking an airport boundary fence. It continued until it struck rising terrain and then a line of forestation, where it came to an abrupt stop. The flight crew exited the aircraft and waited for rescue personnel to render assistance. The aircraft was substantially damaged, and both pilots sustained serious injuries. There was no post-crash fire.
Probable cause:
Findings as to Causes and Contributing Factors:
1. The crew planned and executed a landing on a runway that did not provide the required landing distance.
2. The flight crew most likely did not reference the Aircraft Flight Manual performance chart “Effect of a Slippery Surface on Landing Distance Required” to determine that landing the aircraft on the 4000-foot, snow-covered runway with flap-15 was inappropriate.
3. After landing long on the snow-covered runway and applying full reverse thrust, the captain attempted a go-around. He rotated the aircraft to a take-off attitude and the aircraft became airborne in ground effect at a slower-than-normal speed.
4. The aircraft had insufficient power and airspeed to climb and remained in ground effect until striking the airport perimeter fence, rising terrain, and a line of large cedar trees.
5. The flight crew conducted a flap-15 approach, based on company advice in accordance with an All Operator Message (AOM) issued by the aircraft manufacturer to not use flap-30. This AOM was superseded on 20 October 2004 by AOM No. SD006/04, which cancelled any potential flap-setting prohibition.
Other Finding:
1. The flight crew members were not advised that the potential Airworthiness Directive announced in the original AOM was not going into effect and that the use of flap-30 was acceptable, as relayed in the follow-up AOM.
Final Report: