Ground explosion of a Douglas DC-9-32 in Atlanta

Date & Time: Jun 8, 1995 at 1908 LT
Type of aircraft:
Operator:
Registration:
N908VJ
Flight Phase:
Survivors:
Yes
Schedule:
Atlanta - Miami
MSN:
47321
YOM:
1969
Flight number:
VJA597
Crew on board:
5
Crew fatalities:
Pax on board:
57
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
9500
Captain / Total hours on type:
3500.00
Copilot / Total flying hours:
3800
Copilot / Total hours on type:
552
Aircraft flight hours:
63000
Circumstances:
As ValuJet Flight 597 began its takeoff roll, a 'loud Bang' was heard by the occupants, the right engine fire warning light illuminated, the crew of a following airplane reported to the ValuJet crew that the right engine was on fire, and the takeoff was rejected. Shrapnel from the right engine penetrated the fuselage and the right engine main fuel line, and a cabin fire erupted. The airplane was stopped on the runway, and the captain ordered evacuation of the airplane. A flight attendant (F/A) received serious puncture wounds from shrapnel and thermal injuries; another F/A and 5 passengers received minor injuries. Investigation revealed that an uncontained failure of the right engine had occurred due to fatigue failure of its 7th stage high compressor disc. The fatigue originated at a stress redistribution hole in the disc. Analysis of fatigue striation measurements indicated that the fatigue crack had originated before the disc was last overhauled at a repair station (Turk Hava Yollari) in 1991, but was not detected. Also, investigation of the repair station revealed evidence concerning a lack of adequate recordkeeping and a failure to use 'process sheets' to document the step-by-step overhaul/inspection procedures.
Probable cause:
Failure of Turk Hava Yollari maintenance and inspection personnel to perform a proper inspection of a 7th stage high compressor disc, thus allowing the detectable crack to grow to a length at which the disc ruptured, under normal operating conditions, propelling engine fragments into the fuselage; the fragments severed the right engine main fuel line, which resulted in a fire that rapidly engulfed the cabin area. The lack of an adequate record keeping system and the failure to use 'process sheets' to document the step-by-step overhaul/inspection procedures contributed to the failure to detect the crack and, thus, to the accident.
Final Report:

Crash of a Beechcraft C99 Airliner in Anniston: 3 killed

Date & Time: Jun 8, 1992 at 0853 LT
Type of aircraft:
Operator:
Registration:
N118GP
Survivors:
Yes
Schedule:
Atlanta - Anniston - Tuscaloosa
MSN:
U-185
YOM:
1982
Flight number:
8G861
Crew on board:
2
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
1700
Captain / Total hours on type:
24.00
Copilot / Total hours on type:
90
Aircraft flight hours:
9725
Aircraft flight cycles:
11109
Circumstances:
This was the first day on duty in the southern region operation for both pilots. In addition, they had never flown together. During the flight, the flight crew lost awareness of their airplane's position, erroneously believed that the flight was receiving radar services from ATC, and commenced the approach from an excessive altitude and at a cruise airspeed without accomplishing the published procedure specified on the approach chart. The crew believed that the airplane was south of the airport, and turned toward the north to execute the ILS runway 05 approach. In actuality, the airplane had intercepted the back course localizer signal, and the airplane continued a controlled descent until it impacted terrain. The captain and two passengers were killed while the copilot and two other passengers were seriously injured.
Probable cause:
The failure of senior management of GP Express to provide adequate training and operational support for the startup of the southern operation, which resulted in the assignment of an inadequately prepared captain with a relatively inexperienced first officer in revenue passenger service, and the failure of the flightcrew to use approved instrument flight procedures, which resulted in a loss of situational awareness and terrain clearance. Contributing to the causes of the accident was GP Express' failure to provide approach charts to each pilot and to establish stabilized approach criteria. Also contributing were the inadequate crew coordination and a role reversal on the part of the captain and first officer.
Final Report:

Crash of an Embraer EMB-120RT Brasilía in Brunswick: 23 killed

Date & Time: Apr 5, 1991 at 1451 LT
Type of aircraft:
Operator:
Registration:
N270AS
Survivors:
No
Schedule:
Atlanta - Brunswick
MSN:
120-218
YOM:
1990
Flight number:
EV2311
Crew on board:
3
Crew fatalities:
Pax on board:
20
Pax fatalities:
Other fatalities:
Total fatalities:
23
Captain / Total flying hours:
11724
Captain / Total hours on type:
5720.00
Copilot / Total flying hours:
3925
Copilot / Total hours on type:
2795
Aircraft flight hours:
816
Aircraft flight cycles:
845
Circumstances:
Witnesses reported that the airplane suddenly turned or rolled left until the wings were perpendicular to the ground. The airplane then fell in a nose-down attitude. Examination of the left propeller components indicated a blade angle of about 3°, while the left propeller control unit (pcu) ballscrew position was consistent with a commanded blade angle of 79.2°. Extreme wear on the pcu quill spline teeth, which normally engaged the titanium-nitrided splines of the propeller transfer tube, was found. The titanium-nitrided surface was much harder and rougher than the nitrided surface of the quill. Therefore, the transfer tube splines acted like a file and caused abnormal wear of the gear teeth on the quill. Wear of the quill was not considered during the certification of the propeller system. The aircraft was totally destroyed upon impact and all 23 occupants were killed, among them John Goodwin Tower, Senator of Texas and the astronaut Manley Sonny Carter.
Probable cause:
The loss of control in flight as a result of a malfunction of the left engine propeller control unit which allowed the propeller blade angles to go below the flight idle position. Contributing to the accident was the deficient design of the propeller control unit by hamilton standard and the approval of the design by the federal aviation administration. The design did not correctly evaluate the failure mode that occurred during this flight, which resulted in an uncommanded and uncorrectable movement of the blades of the airplane's left propeller below the flight idle position.
Final Report:

Crash of a Beechcraft A100 King Air in Atlanta: 1 killed

Date & Time: Jan 18, 1990 at 1904 LT
Type of aircraft:
Operator:
Registration:
N44UE
Flight Type:
Survivors:
Yes
Schedule:
Atlanta - Atlanta
MSN:
B-140
YOM:
1973
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
1653
Circumstances:
During arrival at night, Beechcraft A100 (King Air, N44UE) was cleared for an ILS runway 26R approach behind Continental flight 9687, then Eastern Airline (EA) flight 111 (Boeing 727, N8867E) was cleared for the same approach behind the King Air. After landing, flight 9687 had a radio problem and the tower controller had difficulty communicating with flight 9687. Meanwhile, the King Air landed and its crew had moved the aircraft to the right side of the runway near taxiway Delta (the primary taxiway for general aviation aircraft). The turnoff for taxiway Delta was about 3,800 feet from the approach end of runway 26R. Before the King Air was clear of the runway, EA111 landed and converged on the King Air. The crew of EA111 did not see the King Air until moments before the accident. The captain tried to avoid a collision, but the Boeing's right wing struck the King Air, shearing the top of its fuselage and cockpit. Some of the King Air's strobe/beacon lights were inoperative, though they most likely would have been extinguished for the IMC approach. The local controller did not issue a traffic advisory to EA111 with the landing clearance. One of the pilot on board the King Air was killed while the second was seriously injured.
Probable cause:
1) Failure of the Federal Aviation Administration to provide air traffic control procedures that adequately take into consideration human performance factors such as those which resulted in the failure of the north local controller to detect the developing conflict between N44UE and EA111, and
2) the failure of the north local controller to ensure the separation of arriving aircraft which were using the same runway.
Contributing to the accident was the failure of the north local controller to follow the prescribed procedure of issuing appropriate traffic information to EA111, and failure of the north final controller and the radar monitor controller to issue timely speed reductions to maintain adequate separation between aircraft on final approach.
Final Report:

Crash of a Piper PA-60 Aerostar (Ted Smith 600) in Jacksonville: 1 killed

Date & Time: Mar 22, 1989 at 2244 LT
Registration:
N77BR
Flight Type:
Survivors:
No
Schedule:
Atlanta – Jacksonville
MSN:
60-0600-7961193
YOM:
1979
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
2575
Captain / Total hours on type:
1250.00
Aircraft flight hours:
3891
Circumstances:
During arrival, the pilot was cleared for an ILS runway 07 approach. Also, he was advised of a DC-9 that was 4 miles ahead and was told to use caution for wake turbulence. As the aircraft was on final approach, it descended below the ILS glide slope and subsequently hit trees and crashed about 1.8 mile short of the runway. No preimpact part failure or malfunction of the aircraft or engines was found that would have resulted in an accident. Also, there were no reported problems with the ILS system and it tested normal after the accident. The pilot held a commercial pilot certificate which was good for single engine land aircraft; his multi-engine privileges were authorized as a private pilot, only. An NTSB performance study showed the aircraft was 2 minutes and 57 seconds behind the DC-9. Radar data indicated the aircraft did not exceed a bank angle of 32° and no excessive g-values were evident during the approach. The pilot, sole on board, was killed.
Probable cause:
Improper use of the IFR procedure by the pilot, his failure to maintain a proper glide path, and his failure to identify the decision height.
Final Report:

Crash of a Cessna 402B in West Columbia: 1 killed

Date & Time: May 25, 1988 at 2106 LT
Type of aircraft:
Registration:
N8493A
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
West Columbia - Atlanta
MSN:
402B-0236
YOM:
1972
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
1400
Captain / Total hours on type:
160.00
Aircraft flight hours:
5672
Circumstances:
The airplane used about 1/2 of the 8,602 feet runway for the t/o roll. After t/o it pitched nose-down briefly over the runway during initial climb. The pilot radioed that he was having a problem with the elevator which required 'full back pressure' to keep the nose up, and that he was returning to land. After maneuvering around the airport, the aircraft pitched 70-80° nose down and dove into terrain off the approach end of the runway. The wreckage examination revealed that the bolt securing the elevator trim tab pushrod to the actuator was missing. The rod had become wedged inside the elevator which resulted in an extreme tab up (nose down) condition. The aircraft underwent an annual inspection two days/5 flight hours earlier. The ia mechanic reported that no maintenance was performed on the tab system, and that he was certain the bolt was properly safetied. Another pilot who flew the aircraft the day of the accident reported that he found the pushrod to be secure during his preflight inspection. The 402B poh indicated that the aircraft should have request about 1,200 feet for the t/o ground roll. The pilot, sole on board, was killed.
Probable cause:
Occurrence #1: airframe/component/system failure/malfunction
Phase of operation: takeoff
Findings
1. (c) flt control syst, elevator trim/tab control - disconnected
2. (c) aircraft preflight - inadequate - pilot in command
3. (c) flight control, elevator tab - jammed
4. (f) aborted takeoff - not performed - pilot in command
----------
Occurrence #2: loss of control - in flight
Phase of operation: maneuvering
----------
Occurrence #3: in flight collision with terrain/water
Phase of operation: descent - uncontrolled
Final Report:

Crash of a Douglas DC-9-31 in Pensacola

Date & Time: Dec 28, 1987 at 2339 LT
Type of aircraft:
Operator:
Registration:
N8948E
Survivors:
Yes
Schedule:
Richmond – Atlanta – Pensacola
MSN:
47184/274
YOM:
1968
Flight number:
EA573
Crew on board:
4
Crew fatalities:
Pax on board:
103
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
13246
Captain / Total hours on type:
4397.00
Aircraft flight hours:
55645
Circumstances:
Eastern flight 573 contacted approach control at 2323 cst, was advised to expect an ILS runway 16 approach and was vectored around weather. At 2330, the controller advised the ILS glide slope (g/s) had gone into 'alarm' but the loc appeared normal. At 2333, the wind shifted to 310° at 7 knots. Since the bc approach to runway 34 was notamed as inop, the crew continued to runway 16, using 50° of flaps. At 2334, they told the controller, 'if you don't get the g/s up, we'll do a... loc approach.' They reported receiving the g/s, but were advised the g/s was still in alarm. The aircraft broke out of clouds in rain at 900 feet; light turbulence was encountered on final approach. At about 1 mile out, the f/o noted the aircraft was high and advised the captain. The captain pushed the nose over and reduced power, increasing speed and rate of descent. Requested altitude callouts were not made. F/O advised captain to flare, but flare was inadequate. The aircraft touched down hard and the fuselage failed between stations 813 and 756. Aircraft was stopped with the tail resting on the runway. Four passengers received minor injuries during evacuation. Weather study showed a moderate to strong (vip level 2 to 3) weather echo over the approach end of runway 16.
Probable cause:
The captain's failure to maintain a proper descent rate on final approach or to execute a missed approach, which caused the airplane to contact the runway with a sink rate exceeding the airplane's design limitations. Contributing to the cause of the accident was the failure of the captain and first officer to make required altitude callouts and to properly monitor the flight instruments during the approach.
Final Report:

Crash of a Beechcraft H18 in Rockford: 1 killed

Date & Time: Sep 22, 1987 at 0802 LT
Type of aircraft:
Operator:
Registration:
N5850S
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Kenosha - Atlanta
MSN:
BA-720
YOM:
1965
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
3200
Captain / Total hours on type:
800.00
Aircraft flight hours:
6716
Circumstances:
The commercial pilot was on a repositioning flight from Kenosha, Wisconsin to Atlanta, Georgia, after having been without sleep for about 20 hours. Witnesses observed the aircraft circling a subdivision near Rockford, Illinois at a low altitude, just above the treetops. The aircraft was in a steep left bank, described as 70-90°, when it reversed direction into a steep right bank and descended into the trees. The pilot, sole on board, was killed.
Probable cause:
Occurrence #1: abrupt maneuver
Phase of operation: maneuvering - turn to reverse direction
Findings
1. (c) clearance - misjudged - pilot in command
2. (f) fatigue (lack of sleep) - pilot in command
3. (c) judgment - poor - pilot in command
----------
Occurrence #2: in flight collision with object
Phase of operation: maneuvering - turn to reverse direction
Findings
4. (f) object - tree(s)
Final Report:

Crash of a Rockwell Grand Commander 690A in Hilliard: 2 killed

Date & Time: Jun 24, 1987 at 0235 LT
Operator:
Registration:
N57169
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Jacksonville - Atlanta
MSN:
690-11203
YOM:
1974
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
6129
Captain / Total hours on type:
170.00
Aircraft flight hours:
6970
Circumstances:
Radar data indicated the aircraft climbed normally to 9,200 feet at which time some maneuver was performed with the aircraft. The aircraft then entered a near vertical dive and the last radar hit was at 6,900 feet. Examination of the aircraft revealed it experienced an inflight structural breakup and there was no evidence to indicate prebreakup failure or malfunction of the aircraft structure, flight controls, engines, engine mounts, autopilot, or systems. The operator reported one employee overheard the pilot and passenger talk about rolling the aircraft prior to departure, and two company employees reported being onboard when the pilot had rolled it on prior occasions. One of these was at night. Both occupants were killed.
Probable cause:
Occurrence #1: abrupt maneuver
Phase of operation: climb - to cruise
Findings
1. (c) aerobatics - performed - pilot in command
2. (c) overconfidence in personal ability - pilot in command
----------
Occurrence #2: loss of control - in flight
Phase of operation: maneuvering
Findings
3. (c) directional control - not maintained - pilot in command
4. (c) altitude - not maintained - pilot in command
5. Light condition - dark night
----------
Occurrence #3: airframe/component/system failure/malfunction
Phase of operation: descent - uncontrolled
Findings
6. (c) design stress limits of aircraft - exceeded - pilot in command
----------
Occurrence #4: in flight collision with terrain/water
Phase of operation: descent - uncontrolled
Final Report:

Crash of a Beechcraft G18S in Copperhill: 1 killed

Date & Time: Feb 22, 1986 at 0627 LT
Type of aircraft:
Operator:
Registration:
N74FA
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Kenosha - Milwaukee - Atlanta
MSN:
BA-504
YOM:
1960
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
7500
Captain / Total hours on type:
2500.00
Aircraft flight hours:
14640
Circumstances:
The pilot was alerted at 0100 for 0200 flight from Kenosha to Milwaukee, WI to pick up cargo for a flight to Atlanta, GA. At 0310, the aircraft departed Milwaukee in VFR. En route, the pilot obtained weather and an IFR clearance. Some of his radio transmissions were not standard. At 0433, he complied with ATC request for frequency change, but his radio transmissions were not clear. Approximately 5 minutes later, ATC asked the pilot to change frequency again, but 5 calls were made before he replied. His last transmission was at 0445:48; he didn't respond to further ATC calls. The aircraft continued cruising at 11,000 feet until 0621, then it descended without clearance. Radar contact was lost at 0627 cst (0727 est). Shortly thereafter, it impacted trees on a mountain, then crashed to the ground and burned. A witness believed the engines were throttled back before impact. Also, the witness reported low clouds and fog, but said the mountain was visible and was not obscured. The pilot had a 1,58‰ alcohol level in blood, no sleep for 21.5 hours, history of alcohol abuse, 7 prior dwi convictions (and ndr rec). Also, he falsified FAA medical applications. FAA was advised in 1984, but took no action.
Probable cause:
Occurrence #1: loss of control - in flight
Phase of operation: cruise - normal
Findings
1. (c) preflight planning/preparation - inadequate - pilot in command
2. (c) impairment (alcohol) - pilot in command
3. (f) fatigue - pilot in command
4. (f) fatigue (flight schedule) - company/operator management
5. (f) insuff standards/requirements, operation/operator - company/operator mgmt
6. (f) inadequate surveillance of operation - faa (organization)
7. (c) judgment - poor - pilot in command
8. (f) company-induced pressure - company/operator management
9. (f) procedures/directives - not followed - pilot in command
10. (c) descent - uncontrolled - pilot in command
11. (f) fatigue (lack of sleep) - pilot in command
----------
Occurrence #2: in flight collision with object
Phase of operation: descent - uncontrolled
Findings
12. Terrain condition - mountainous/hilly
13. Object - tree(s)
----------
Occurrence #3: in flight collision with terrain/water
Phase of operation: descent - uncontrolled
Final Report: