Crash of a Cessna 441 Conquest II in Saint Louis: 2 killed

Date & Time: Nov 22, 1994 at 2203 LT
Type of aircraft:
Operator:
Registration:
N441KM
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Saint Louis - Iron Mountain
MSN:
441-0196
YOM:
1981
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
7940
Captain / Total hours on type:
2060.00
Circumstances:
During the takeoff roll on runway 30R, the MD-82, N954U, collided with the Cessna 441, N441KM, which was positioned on the runway waiting for takeoff clearance. The pilot of the Cessna acted on an apparently preconceived idea that he would use his arrival runway, runway 30R, for departure. After receiving taxi clearance to back-taxi into position and hold on runway 31, the pilot taxied into a position at an intersection on runway 30R, which was the assigned departure runway for the MD-82. The ATIS current at the time the Cessna pilot was operating in the Lambert-St. Louis area listed runways 30R and 30L as the active runways for arrivals and departures; there was no mention of the occasional use of runway 31. Air traffic control personnel were not able to maintain visual contact with the Cessna after it taxied from the well lighted ramp area into the runway/taxiway environment of the northeast portion of the airport. An operational ASDE-3, particularly ASDE-3 enhanced with AMASS, could be used to supplement visual scan of the northeast portion of the airport.
Probable cause:
The Cessna 441 pilot's mistaken belief that his assigned departure runway was runway 30R, which resulted in his undetected entrance onto runway 30R, which was being used by the MD82 for its departure. Contributing to the accident was the lack of Automatic Terminal Information Service and other air traffic control (ATC) information regarding the occasional use of runway 31 for departure. The installation and utilization of Airport Surface Detection Equipment (ASDE-3), and particularly ASDE-3 enhanced with the Airport Movement Area Safety System (AMASS), could have prevented this accident.
Final Report:

Crash of a Cessna 441 Conquest in Fort Frances

Date & Time: Jun 18, 1994 at 0425 LT
Type of aircraft:
Operator:
Registration:
N441CA
Flight Phase:
Survivors:
Yes
Schedule:
Milwaukee – Fort Frances – God’s Lake Narrows
MSN:
441-0046
YOM:
1978
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
4800
Captain / Total hours on type:
40.00
Aircraft flight hours:
2447
Circumstances:
The pilot of the Cessna 441 Conquest was conducting an international charter flight from General Mitchell International Airport in Milwaukee, Wisconsin, to Gods Lake Narrows, Manitoba. The pilot landed the aircraft at Fort Frances, Ontario, to clear customs and refuel, and then continued his visual flight rules (VFR) flight to Gods Lake Narrows. During the take-off at Fort Frances, the aircraft experienced a power loss in the left engine. The pilot elected to continue the take-off but was unable to control the aircraft after it became airborne. The aircraft veered to the left and crashed on the airfield. The accident occurred at 0425 central daylight time (CDT), at night, on the Fort Frances Municipal Airport. All seven occupants sustained minor injuries and the aircraft was damaged beyond repair.
Probable cause:
The pilot lost control of the aircraft during take-off when the left engine lost power as a result of bird ingestion. Contributing to the loss of aircraft control were a take-off weight in excess of the maximum allowable, and a centre of gravity aft of the centre of gravity limit.
Final Report:

Crash of a Cessna 441 Conquest in Gainesville

Date & Time: Aug 10, 1992 at 1750 LT
Type of aircraft:
Registration:
N920C
Flight Phase:
Survivors:
Yes
Schedule:
Gainesville - Nashville
MSN:
441-0020
YOM:
1978
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
8000
Captain / Total hours on type:
305.00
Circumstances:
The pilot reported that immediately after takeoff, he had a collision with a flight of birds. He stated that the right engine immediately had a partial loss of power. He stated that he did not attempt to raise the landing gear nor the flaps following the loss of engine power, and the aircraft would not maintain altitude. Examination of the aircraft engines revealed that there was rotational scratching of the turbine housings on the right engine, and no rotational scratching on the turbine housing of the left engine.
Probable cause:
The poor inflight decision by the pilot in command in that after a partial loss of power, he shut down the wrong engine, did not follow the emergency checklist, did not raise the flaps, and did not retract the landing gear. A factor in the accident was the inflight collision with birds during the takeoff climb.
Final Report:

Crash of a Cessna 441 Conquest II off Papeete: 3 killed

Date & Time: Dec 5, 1990
Type of aircraft:
Registration:
F-ODUK
Flight Type:
Survivors:
No
Schedule:
Papeete - Maupiti
MSN:
441-0270
YOM:
1983
Location:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Circumstances:
The twin engine aircraft departed Papeete-Faaa Airport on an ambulance flight to Maupiti, carrying two doctors and one pilot. After takeoff, while climbing by night, the pilot informed ATC about minor problems with the engine but preferred to return for a safe landing. On final approach, the aircraft went out of control and crashed in the sea few km from the airport. All three occupants were killed. At the time of the accident, it was dark but weather conditions were excellent.

Crash of a Cessna 441 Conquest in Greenland: 8 killed

Date & Time: Sep 12, 1990 at 1745 LT
Type of aircraft:
Operator:
Registration:
OY-CGM
Flight Phase:
Survivors:
No
Schedule:
Söndreströmfjord - Goose Bay
MSN:
441-0229
YOM:
1982
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
8
Circumstances:
The twin engine aircraft departed Sondreströmfjord on a charter flight to Goose Bay, carrying six sailors and two pilots. Seventeen minutes after takeoff, while cruising at FL220, the aircraft entered an uncontrolled descent and the crew did not send any distress call. At an altitude of 7,000 feet, the aircraft disintegrated and debris scattered on a wide area. The wreckage was found about 148 southwest of Sondreströmfjord and all eight occupants were killed.
Probable cause:
The exact cause of the accident could not be determined with certainty. However, the following findings were reported:
- There was no evidence from the post-mortem examination which suggests a contributory factor in this accident.
- There was no radio transmission from the crew indicating that they were concerned of any problem.
- There was no evidence of fire, engine failure, explosion, structural or mechanical defect prior to the in-flight break-up.
- The evaluation of the ATC tape indicates that an impairment of the crew was present, consistent with, but not confirmatory of hypoxia.

Crash of a Cessna 441 Conquest in Saclay: 7 killed

Date & Time: Nov 17, 1988 at 0912 LT
Type of aircraft:
Operator:
Registration:
F-GFHR
Flight Phase:
Survivors:
No
Schedule:
Toussus-le-Noble – Montluçon
MSN:
441-0252
YOM:
1982
Location:
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
7
Circumstances:
Shortly after takeoff from Toussus-le-Noble Airport runway 07L, while climbing in limited visibility due to fog, the twin engine aircraft initiated a right turn when control was lost. It nosed down and eventually crashed in an open field located in Saclay, about 5 km southeast of the airport. The aircraft disintegrated on impact and all seven occupants were killed. At the time of the accident, the visibility was poor due to thick fog. For unknown reasons, the pilot initiated a right turn after takeoff while departure procedures define a straight in climb. Five of the six passengers were automobile journalists flying to Montluçon where they were supposed to visit the Dunlop facilities and perform drive tests on the last BMW M3. The sixth passenger was a marketing Director by a BMW dealer who chartered the aircraft.
Crew:
Daniel Douzard.
Passengers:
François-Xavier Beaudet,
Denis Charpentier,
Raymond Bochet,
Geoffroy Lemaignen,
Marc Duick,
Jean-Claude Depincé.

Crash of a Cessna 441 Conquest in Mexicali: 2 killed

Date & Time: Nov 15, 1987 at 1815 LT
Type of aircraft:
Registration:
N2484B
Flight Phase:
Survivors:
No
Schedule:
San Diego - Palm Springs
MSN:
441-0112
YOM:
1979
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
8000
Aircraft flight hours:
1461
Circumstances:
A Cessna 441 operated by the US Customs Services collided with terrain while on an authorized night tactical flight. The copilot did not meet the currency standards as required by USCS and was not qualified in the aircraft. The flight originated during the daylight hours and continued to astronomical twilight. The pilots did not dark adapt previous to the night conditions. Dark adaption was impeded by flight through various light conditions created by terrain and ambient light levels. With night vision impeded the pilot would not have been able to distinguish relief of the terrain. The acft collided with a small ridge that abruptly rose 300 feet. Both occupants were killed.
Probable cause:
Occurrence #1: in flight collision with terrain/water
Phase of operation: maneuvering
Findings
1. (f) terrain condition - uphill
2. (c) altitude - misjudged - pilot in command
3. (f) excessive workload (task overload) - pilot in command
4. (f) light condition - night
5. (c) proper altitude - not maintained - pilot in command
6. (f) visual lookout - inadequate - pilot in command
7. (f) visual/aural detection - pilot in command
8. (f) visual lookout - inadequate - copilot/second pilot
9. (f) visual/aural detection - copilot/second pilot
10. (f) lack of recent instrument time - copilot/second pilot
11. (f) inadequate transition/upgrade training - copilot/second pilot
12. (f) in-flight planning/decision - inadequate - pilot in command
13. (f) crew/group coordination - inadequate - pilot in command
Final Report:

Crash of a Cessna 441 Conquest II near Maiduguri

Date & Time: Sep 26, 1987
Type of aircraft:
Operator:
Registration:
N1210Y
Flight Phase:
Survivors:
Yes
MSN:
441-0338
YOM:
1984
Location:
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Crashed in unknown circumstances about 10 km from Maiduguri Airport. All four occupants were injured.

Crash of a Cessna 441 Conquest II in Blackbushe: 1 killed

Date & Time: Apr 26, 1987 at 1145 LT
Type of aircraft:
Operator:
Registration:
G-MOXY
Flight Type:
Survivors:
No
Schedule:
Leeds - Blackbushe
MSN:
441-0154
YOM:
1980
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Aircraft flight hours:
5135
Circumstances:
The accident occurred at Blackbushe airfield following a go-around from an approach to land on runway 26. The aircraft appeared to begin the go-around normally but was then seen to bank to the left and start turning left. The turn continued through 135° of heading, at a low height, with the bank angle increasing progressively, until the aircraft crashed into trees, semi-inverted, approximately 550 meters from the runway 26 threshold. The reason for the initiation of the go-around was an unsafe main landing gear indication caused by a defective microswitch. The reasons for the subsequent loss of control could not be determined.
Probable cause:
The effectiveness of the investigations was considerably reduced by the lack of flight recorders. There was no evidence of pilot incapacitation. Extensive examination of the wreckage revealed no flap or flying control malfunction, neither was there any evidence of failure of either engine or propeller control mechanism. The curved flight path of the aircraft from go-around to impact and progressive increase in bank angle suggest that an asymmetric thrust condition was most probable.
Final Report:

Crash of a Cessna 441 Conquest in Flagstaff: 2 killed

Date & Time: Feb 20, 1987 at 1845 LT
Type of aircraft:
Operator:
Registration:
N6858S
Flight Type:
Survivors:
No
Schedule:
Phoenix - Flagstaff
MSN:
441-0253
YOM:
1982
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
2311
Captain / Total hours on type:
24.00
Aircraft flight hours:
3349
Circumstances:
The aircraft was on an emergency medical service (ems/medevac) flight with a pilot and a flight nurse aboard to transport a maternity patient from Flagstaff to Phoenix. During a night arrival, the pilot began a VOR-A approach in IMC, then he reported a problem with his avionics and elected to make a missed approach. During the missed approach, he said that he 'lost' an inverter, then reported the gyros were inoperative. Radar vectors were being provided when he stated 'we have big trouble here.' Soon thereafter, radar and radio contacts were lost and the aircraft crashed approximately 7 miles southeast of the airport. During impact, the aircraft made a deep crater and was demolished. No preimpact engine or airframe failure was found. An investigation revealed the #2 (copilot's) attitude indicator was inoperative on the previous flight. A discrepancy report was taken to the avionics department, but the requested entry was not made in the aircraft form-4. The pilot took off before corrective action was taken. The operations manual requested 1,000 hours multi-engine time as pic and training by esignated cfi's. The pilot had approximately 837 hours multi-engine time, recorded 9 training flights in N6858S with non-designated instructors, completed a part 135 flight check on 2/17/88. Both occupants were killed.
Probable cause:
Occurrence #1: airframe/component/system failure/malfunction
Phase of operation: approach
Findings
1. Maintenance, recordkeeping - improper
2. Procedures/directives - not followed
3. (f) inadequate surveillance of operation - company/operator mgmt
4. (c) electrical system - undetermined
5. Electrical system, inverter - inoperative
6. Flight/nav instruments, attitude indicator - inoperative
----------
Occurrence #2: loss of control - in flight
Phase of operation: approach
Findings
7. (f) light condition - dark night
8. (f) weather condition - low ceiling
9. (f) weather condition - snow
10. (c) aircraft handling - not maintained - pilot in command
11. (c) spatial disorientation - pilot in command
12. (f) lack of total experience in type of aircraft - pilot in command
----------
Occurrence #3: in flight collision with terrain/water
Phase of operation: descent - uncontrolled
Final Report: