Crash of a Learjet 35A in Kansas City

Date & Time: Jan 28, 2005 at 2217 LT
Type of aircraft:
Operator:
Registration:
N911AE
Flight Type:
Survivors:
Yes
Schedule:
Salt Lake City - Kansas City
MSN:
35-109
YOM:
1977
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
5127
Captain / Total hours on type:
1236.00
Copilot / Total flying hours:
4301
Copilot / Total hours on type:
482
Aircraft flight hours:
11138
Circumstances:
The Learjet 35A received substantial damage on impact with airport property and terrain during a landing overrun on runway 19 (7,002 feet by 150 feet, grooved asphalt) at Charles B. Wheeler Downtown Airport (MKC), Kansas City, Missouri. The airplane was operated by a commercial operator as a positioning flight to Kansas City International Airport (MCI), Kansas City, Missouri, with a filed alternate destination of Lincoln Airport (LNK), Lincoln, Nebraska. Night instrument meteorological conditions prevailed at the time of the accident. LNK was a certificated airport with a snow removal plan and was served by runway 17R (12,901 feet by 200 feet, grooved asphalt and concrete). The flight was en route to MCI to pick up passengers and continue on as an on-demand charter but diverted to MKC following the closure of MCI. MCI was closed due to a McDonnell Douglas MD83 sliding off a taxiway during an after landing taxi on contaminated runway/taxiway conditions. MKC held a limited airport certificate that did not have a snow removal plan and was served by runway 19. Following a precision approach and landing on runway 19 at MKC, the Learjet 35A slid off the departure end of the runway and impacted airport property and terrain. The Learjet 35A was operated with inoperative thrust reversers as per the airplane's minimum equipment list at the time of the accident. About 1:05 hours before the accident, runway 19 Tapley values were recorded as 21-22-22 with 1/2 inch of wet snow. About 17 minutes before the accident, MKC began snow removal operations. About 7 minutes before the accident, the MKC air traffic control tower (TWR) instructed the snow removal vehicles to clear the runway for inbound traffic. TWR was advised by airport personnel that runway 19 was plowed and surface conditions were 1/4 inch of snow of snow; friction values were not taken or reported. While inbound, the Learjet 35A requested any braking action reports from TWR. The first airplane to land was a Cessna 210 Centurion, and the pilot reported braking action to the TWR as "moderate", which was then transmitted by TWR as "fair" from a Centurion in response to the Learjet 35A's query. The Cessna 210 Centurion pilot did not use brakes during landing and did not indicate this to TWR during his braking action report. The Aeronautical Information Manual states that no correlation has been established between MU values and the descriptive terms "good," fair," and "nil" used in braking action reports. The Airport Winter Safety and Operations advisory circular (AC) states that "pilot braking action reports oftentimes have been found to vary significantly, even when reported on the same frozen contaminant surface conditions." The AC also states, "It is generally accepted that friction surveys will be reliable as long as the depth of snow does not exceed 1 inch (2.5 cm) and/or depth of wet snow/slush does not exceed 1/8 inch (3mm). The Learjet 35A flightcrew calculated a landing distance 5,400 feet. Two of the cockpit voice recording channels, which normally contain the pilot and copilot audio panel information, were blank.
Probable cause:
The contaminated runway conditions during landing. Contributing factors were the operation of the airplane without thrust reversers, flight to the planned alternate airport not performed by the flightcrew, and the insufficient runway information. Additional factors were the airport property and terrain that the airplane impacted.
Final Report:

Crash of a MBB HFB-320 Hansa Jet in Chesterfield: 2 killed

Date & Time: Nov 30, 2004 at 1956 LT
Type of aircraft:
Operator:
Registration:
N604GA
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Chesterfield – Toledo
MSN:
1037
YOM:
1969
Flight number:
GAE604
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
11500
Captain / Total hours on type:
2500.00
Copilot / Total flying hours:
10377
Aircraft flight hours:
6875
Circumstances:
The Hansa 320, a corporate turbojet airplane departed runway 26L at night on a maintenance ferry flight at 1954 central standard time, and was destroyed when it impacted a river two miles west of the departure airport. Radar track data indicated that the airplane climbed to about 900 feet msl at about 180 knots before it began losing altitude and impacted the river. The current weather was: winds 270 degrees at 13 knots gusting to 19 knots, visibility 7 miles, light rain, 1,000 feet scattered ceiling, 1,800 feet broken, 2,400 feet overcast, temperature 2 degrees Celsius (C), dew point 2 degrees C, altimeter 29.90. The FAA had issued the pilot a Special Flight Permit for the flight. The limitations listed in the flight permit included the following limitations: Limitation number 6 stipulated, "IFR in VMC conditions approved, provided all equipment required for IFR flight is operational and certified iaw 14 CFR Part 91.413. If this equipment is NOT certified and operational, then VFR in VMC conditions ONLY." The ferry permit listed, "Additional Limitations: Engine power assurance runs, compass swing, and functional check of avionics equipment must be performed, and appropriate maintenance entries in the aircraft log prior to departure." The pilot was informed that none of the additional limitations had been performed prior to takeoff. The pilot had aborted a previous takeoff at about 1830 due to no airspeed indications. At the request of the pilot, maintenance personnel disconnected the lines to the pitot tubes and blew out the tubes, but no leak check, as required by FAR 91.411, was performed prior to the accident flight. The pilot performed a high-speed taxi to test the airspeed indicators prior to takeoff. The copilot did not have any ground school or flight time in a Hansa 320. The second-in-command requirements stated in FAR 61.55 9 (f) (1), required that the flight be conducted under day VFR or day IFR. The Toxicology report for the pilot indicated that 0.106 (ug/ml, ug/g) Diphenhydramine was detected in the blood. Diphenhydramine is an antihistamine commonly used in over-the-counter cold/allergy preparations. In therapeutic doses, the medication commonly results in drowsiness, and has measurable effects on performance of complex cognitive and motor tasks (e.g. flying an aircraft). The pilot's currency in the Hansa 320 expired on November 30, 2004, the day of the accident. He would be required to have an FAA checkride in a Hansa 320 to be a pilot-in-command (PIC) after November 30th. Engine teardown inspections revealed that both engines were developing power at the time of impact. The inspection of the elevator trim system revealed that the elevator trim cables were improperly installed when they were replaced to comply with an Airworthiness Directive (AD) 224-01-11. The maintenance manager who inspected the installation of the elevator trim cables did not perform an operational check of the elevator trim tabs. The maintenance manager signed the aircraft log stating the "Aircraft is approved for one time ferry flight from SUS to TOL," although all stipulations of the ferry permit had not been met, and that a leak check of the pitot-static system had not been performed after the pitot tubes had been blown out.
Probable cause:
The maintenance facility failed to properly install and inspect the elevator trim system resulting in the reversed elevator trim condition and the pilot's failure to maintain clearance with the terrain. Contributing factors included the dark night and low ceiling.
Final Report:

Crash of a BAe 3201 Jetstream 32EP in Kirksville: 13 killed

Date & Time: Oct 19, 2004 at 1937 LT
Type of aircraft:
Operator:
Registration:
N875JX
Survivors:
Yes
Schedule:
Saint Louis – Kirksville
MSN:
875
YOM:
1990
Flight number:
AA5966
Crew on board:
2
Crew fatalities:
Pax on board:
13
Pax fatalities:
Other fatalities:
Total fatalities:
13
Captain / Total flying hours:
4234
Captain / Total hours on type:
2510.00
Copilot / Total flying hours:
2856
Copilot / Total hours on type:
107
Aircraft flight hours:
21979
Aircraft flight cycles:
28973
Circumstances:
On October 19, 2004, about 1937 central daylight time, Corporate Airlines (doing business as American Connection) flight 5966, a BAE Systems BAE-J3201, N875JX, struck trees on final approach and crashed short of runway 36 at Kirksville Regional Airport (IRK), Kirksville, Missouri. The flight was operating under the provisions of 14 Code of Federal Regulations Part 121 as a scheduled passenger flight from Lambert-St. Louis International Airport, in St. Louis, Missouri, to IRK. The captain, first officer, and 11 of the 13 passengers were fatally injured, and 2 passengers received serious injuries. The airplane was destroyed by impact and a post impact fire. Night instrument meteorological conditions (IMC) prevailed at the time of the accident, and the flight operated on an instrument flight rules flight plan.
Probable cause:
the pilots' failure to follow established procedures and properly conduct a non precision instrument approach at night in IMC, including their descent below the minimum descent altitude (MDA) before required visual cues were available (which continued unmoderated until the airplane struck the trees) and their failure to adhere to the established division of duties between the flying and non flying (monitoring) pilot.
Contributing to the accident was the pilots' failure to make standard callouts and the current Federal Aviation Regulations that allow pilots to descend below the MDA into a region in which safe obstacle clearance is not assured based upon seeing only the airport approach lights. The pilots' unprofessional behavior during the flight and their fatigue likely contributed to their degraded performance.
Final Report:

Crash of a Canadair RegionalJet CRJ-200LR in Jefferson City: 2 killed

Date & Time: Oct 14, 2004 at 2215 LT
Operator:
Registration:
N8396A
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Little Rock – Minneapolis
MSN:
7396
YOM:
2000
Flight number:
NW3701
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
6900
Captain / Total hours on type:
973.00
Copilot / Total flying hours:
761
Copilot / Total hours on type:
222
Aircraft flight hours:
10168
Aircraft flight cycles:
9613
Circumstances:
On October 14, 2004, about 2215:06 central daylight time, Pinnacle Airlines flight 3701 (doing business as Northwest Airlink), a Bombardier CL-600-2B19, N8396A, crashed into a residential area about 2.5 miles south of Jefferson City Memorial Airport, Jefferson City, Missouri. The airplane was on a repositioning flight from Little Rock National Airport, Little Rock, Arkansas, to Minneapolis-St. Paul International Airport, Minneapolis, Minnesota. During the flight, both engines flamed out after a pilot-induced aerodynamic stall and were unable to be restarted. The captain and the first officer were killed, and the airplane was destroyed. No one on the ground was injured.
Probable cause:
The National Transportation Safety Board determines that the probable causes of this accident were:
1) the pilots' unprofessional behavior, deviation from standard operating procedures, and poor airmanship, which resulted in an in-flight emergency from which they were unable to recover, in part because of the pilots' inadequate training;
2) the pilots' failure to prepare for an emergency landing in a timely manner, including communicating with air traffic controllers immediately after the emergency about the loss of both engines and the availability of landing sites; and
3) the pilots' failure to achieve and maintain the target airspeed in the double engine failure checklist, which caused the engine cores to stop rotating and resulted in the core lock engine condition.
Contributing to this accident were:
1) the engine core lock condition, which prevented at least one engine from being restarted, and
2) the airplane flight manuals that did not communicate to pilots the importance of maintaining a minimum airspeed to keep the engine cores rotating.
Final Report:

Crash of a Dassault Falcon 20C in Saint Louis

Date & Time: Apr 8, 2003 at 1850 LT
Type of aircraft:
Operator:
Registration:
N179GA
Flight Type:
Survivors:
Yes
Schedule:
Del Rio – Saint Louis
MSN:
100
YOM:
1967
Flight number:
GAE179
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3221
Captain / Total hours on type:
1270.00
Copilot / Total flying hours:
5758
Copilot / Total hours on type:
1532
Aircraft flight hours:
15899
Circumstances:
The twin engine turbofan powered airplane was ditched into a river after a complete loss of power from both engines. The airplane was on a second approach to land on runway 30R after having been instructed by air traffic control (ATC) to climb during the final approach segment of the first approach due to inadequate separation from another airplane. Subsequent to the first approach, the airplane was issued vectors for the second approach by ATC. Communications transcripts show that the flight crew asked ATC how far they would be vectored during the second approach, but the flight crew did not inform ATC of their low fuel state until the airplane was already on a "base turn...to join final." The airplane subsequently lost power from both engines. During interviews, both pilots stated that there were no problems with the airplane. The second-in-command (SIC) stated that the airplane "ran out of fuel" and that the fuel quantity indicators read 0 and 100 pounds when each respective engine stopped producing power. The SIC also stated that after being instructed to climb to 5,000 feet after their first approach, he questioned the pilot-in-command about landing at another airport located about 14 nautical miles west-southwest of the destination airport. The SIC said that the PIC elected to continue with the second approach to the original destination. Research indicated that the flight crew did not obtain a weather briefing prior to the accident flight. Additionally, the Terminal Aerodrome Forecast that was valid at the time the aircraft's flight plan was filed showed a forecast ceiling consisting of overcast clouds at 1,500 feet above ground level at the aircraft's arrival time at the destination. 14 CFR Part 91.169 requires that an alternate airport be listed in the flight plan when forecast ceilings are less than 2,000 feet. No alternate was listed in the flight plan for the accident flight. Additionally, 14 CFR Part 91.167 requires that aircraft operated in instrument meteorological conditions maintain fuel reserves that allow flight to the intended destination and then continued flight to the listed alternate, and an additional 45 minutes at normal cruise speed. In 1993, the FAA/industry advisory committee developed advisory material for fuel planning and management for 14 CFR Part 121 and 135 air carrier flight operations, but the material was never published.
Probable cause:
The pilot in command's improper in-flight decision not to divert to an alternate destination resulting in the exhaustion of the airplane's fuel supply, and his failure to relay his low fuel state to air traffic control in a timely manner.
Final Report:

Crash of a Pilatus PC-12/45 in Westphalia: 2 killed

Date & Time: Sep 14, 2002 at 1555 LT
Type of aircraft:
Registration:
N451ES
Flight Phase:
Survivors:
No
Schedule:
Lake Ozark – South Bend
MSN:
425
YOM:
2001
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
1645
Captain / Total hours on type:
58.00
Aircraft flight hours:
505
Aircraft flight cycles:
470
Circumstances:
The turbo-prop airplane departed controlled flight after initiating an ATC directed turn during cruise climb. The airplane subsequently entered a rapidly descending spiral turn, impacting the terrain and exploding. A witness reported hearing an "unusually loud" engine sound prior to seeing the airplane in a nose-low descent. The witness stated the airplane was "heading straight down, and did between a quarter and half of turn, but was not spinning wildly." The witness reported the airplane disappeared behind a nearby ridgeline and was followed by a "loud sound, and an immediate large cloud of black smoke." Aircraft radar track data showed the airplane heading to the northeast, while climbing to a maximum altitude of 13,800 feet msl. The airplane then entered an increasingly tighter, right descending turn. The calculated descent rate was 7,000 feet/min. Instrument flight rules (IFR) conditions prevailed at altitude and marginal visual flight rules (MVFR) conditions prevailed at the accident site. The instrument-rated pilot received a weather briefing prior to departure. During the briefing the pilot was told of building thunderstorm activity near the departure airport and along the route of flight. The pilot told the briefer he was going to depart shortly to keep ahead of the approaching weather. A witness at the departure airport reported that the passenger was concerned about flying in "bad weather" and the pilot told the passenger that the weather was only going to get worse and that they "needed to go to get ahead of it." A two-dimensional reconstruction determined that all primary airframe structural components, flight control surfaces, powerplant components, and propeller blades were present. Flight control continuity could not be established due to the extensive damage to all components. Inspection of the recovered flight control components did not exhibit any evidence of pre-impact malfunction. The standby attitude indicator gyro and its case showed evidence of rotational damage, consistent with the gyro rotating at the time of impact. Both solid-state Attitude & Heading Reference System (AHRS) units were destroyed during the accident, and as a result no information was available.
Probable cause:
The pilot's spatial disorientation while turning in a cruise climb in instrument meteorological conditions, which resulted in the pilot's loss of aircraft control, and his failure to recover from a resultant tight descending spiral.
Final Report:

Crash of a Cessna 411 in Lee's Summit

Date & Time: Apr 30, 2002 at 0600 LT
Type of aircraft:
Operator:
Registration:
N411CT
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Lee's Summit - Harrisonville
MSN:
411-0097
YOM:
1965
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The airplane impacted the terrain following a loss of control during a takeoff initial climb. A witness stated the airplane was noisier than what he is used to hearing. This witness reported the airplane was in a steep left bank in a level pitch attitude. The airplane then began to descent rapidly as it turned to a northerly heading. The witness reported the airplane then seemed to enter a right bank prior to impacting the ground. Another witness reported what sounded like an engine backfire. The pilot reported the airplane lost power. Torsional twisting was visible on the propeller blades following the accident. Following the accident, the undamaged emergency exit from the airplane was found next to the runway. The latching mechanism on the exit was not damaged and the pins were not found with the exit. It was reported that the airplane had sat on the ramp at the departure airport for at least 15 years without being flown. Although the registration for the airplane had not been changed, the pilot reportedly purchased it shortly before the accident. The pilot did not hold a multi-engine rating.
Probable cause:
The pilot failed to maintain control of the airplane during the initial takeoff climb. Factors associated with the accident were the pilot's inadequate preflight of the airplane, the separation of the emergency exit, and the pilot's lack of a multi-engine rating.
Final Report:

Crash of a Beechcraft B200 Super King Air in Chesterfield

Date & Time: Oct 25, 2001 at 1538 LT
Operator:
Registration:
N200RW
Survivors:
Yes
Schedule:
Chesterfield - Osage Beach
MSN:
BB-242
YOM:
1977
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
19213
Captain / Total hours on type:
13242.00
Aircraft flight hours:
11416
Circumstances:
The Beech 200 was substantially damaged during an aborted landing. The winds were gusting in excess of the airplane's maximum demonstrated crosswind component. A witness reported finding landing gear strut pieces on the runway after the Beech 200's landing attempt. The flight then aborted the landing and continued on to its originating airport where the airplane veered off the runway and damaged airport property during its landing.
Probable cause:
The inadequate planning/decision and the exceeded crosswind component by the pilot. The gusts were a contributing factor.
Final Report:

Crash of a Cessna 525 CitationJet CJ1 in Point Lookout: 6 killed

Date & Time: Dec 9, 1999 at 1512 LT
Type of aircraft:
Operator:
Registration:
N525KL
Survivors:
No
Schedule:
Saint Louis - Point Lookout
MSN:
525-0136
YOM:
1996
Crew on board:
2
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
6
Captain / Total flying hours:
10150
Captain / Total hours on type:
328.00
Copilot / Total flying hours:
1000
Copilot / Total hours on type:
70
Aircraft flight hours:
783
Circumstances:
Prior to takeoff from Lambert Field/St. Louis International Airport, St. Louis, Missouri, the pilot contacted the operations manager at M. Graham Clark Airport, Point Lookout, Missouri, and asked about the current weather conditions there. The operations manager told the pilot that the weather was "pretty poor." The airplane took off from St. Louis, at 1411 cst. At 1447:12 cst, the pilot checked in with Springfield Approach Control. The pilot was told to expect the ILS approach to runway 2 at the Springfield-Branson Regional Airport. At 1501:01 cst, the pilot requested to go to Point Lookout and shoot the GPS to runway 11. Springfield Approach instructed the pilot to descend to 3,000 feet msl and cleared him for the approach. At 1507:08 cst, Springfield radar showed the airplane crossing the initial waypoint at 3,000 feet msl, and turn to 116 degrees approach heading. At 1507:17 cst, the airplane descended to 2,500 feet msl. At 1508:51 cst, Springfield Approach cleared the pilot to change to advisory frequency. "Call me back with your cancellation or your miss." The pilot responded, "Okay we're, we're RAWBE inbound and we will call you on the miss or cancellation." The operations manager at M. Graham Clark Airport said that he heard the pilot on the airport's common frequency radio say, "Citation 525KL is RAWBE inbound on the GPS 11 approach." At 1509:01 cst, Springfield radar showed the airplane begin a descent out of 2,500 feet msl. The last radar contact was at 1509:48 cst. The airplane was five nautical miles from the airport on a 296 degree radial, at 2,100 feet msl. At 1530 cst, the operations manager heard Springfield approach trying to contact the airplane. The operations manager initiated a search for the airplane. At 1430 cst, the weather observation at the M. Graham Clark Airport was 300 feet overcast, rain and mist, 3/4 miles visibility, temperature 53 degrees F, winds variable at 3 knots, altimeter 29.92 inches HG. Approach minimum weather for the GPS RWY11 straight in approach to Point Lookout are a minimum ceiling of 600 feet and visibility of 1 mile for a category B aircraft. An examination of the airplane wreckage revealed no anomalies. The results of FAA toxicology testing of specimens from the pilot revealed concentrations of Doxepin in kidney and liver. The Physicians' Desk Reference states that "... drowsiness may occur with the use of this drug, patients should be warned of the possibility and cautioned against driving a car or operating dangerous machinery while taking the drug." The physician who prescribed the Doxepin to the pilot said that he was using it to treat the pilot's "irritable bowel" condition. According to his wife, the pilot had not slept well for several nights, up to the day of the accident, due to problems he was having with the FAA. A friend, who spoke with the pilot just before the accident flight, confirmed the pilot saying "I haven't slept for three days." The friend stated further that the pilot "wasn't himself that day."
Probable cause:
The pilot descended below the minimum altitude for the segment of the GPS approach. Factors relating to the accident were low ceilings, rain, and pilot fatigue.
Final Report:

Crash of a Cessna 421B Golden Eagle II in Jefferson City: 4 killed

Date & Time: May 27, 1999 at 1826 LT
Registration:
N34TM
Survivors:
No
Schedule:
Poplar Bluff – Jefferson City
MSN:
421B-0965
YOM:
1975
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
1850
Captain / Total hours on type:
850.00
Aircraft flight hours:
5530
Circumstances:
The airplane impacted the ground in a nose low, inverted attitude. The pilot reported, 'Jeff Tower, N34TM, I've just lost power on the right engine, eh, left engine.' The airplane's altitude was approximately 200 to 400 feet when the airplane's wings wobbled back and forth. The airplane's wings banked approximately 90 degrees to the left, and then the airplane nosed over and impacted the ground. White smoke was seen coming from the belly of the airplane for 1 to 2 seconds about 20 seconds prior to it impacting the ground. The terrain was a flat, hard packed field used for growing grass sod. Both the left and right propellers were found 12 to 18 inches under the hard packed soil. Rotational paint transfer patterns from the propeller blades onto the hard packed soil were evident. The left and right propeller blades exhibited chordwise scratching and leading edge polishing. The #2 cylinder piston was broken and the piston pin was still attached to the piston rod. The NTSB Materials Laboratory examination revealed the fracture face of the #2 exhaust valve stem was consistent with a bending fatigue separation. Both #2 and #6 exhaust valve guides showed heavy wear that ovalized the bores. The annual inspection conducted on March 15, 1999, indicated the compression on the left engine was 80/64, 50, 67, 70, 69, and 62.
Probable cause:
The pilot failed to maintain control of the airplane. A factor was the partial loss of power due to the exhaust valve fatigue failure.
Final Report: