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:

Crash of a Beechcraft Beechjet 400A in Macon

Date & Time: Sep 18, 2012 at 1003 LT
Type of aircraft:
Operator:
Registration:
N428JD
Survivors:
Yes
Schedule:
Charleston - Macon
MSN:
RJ-13
YOM:
1986
Location:
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
7000
Captain / Total hours on type:
4000.00
Copilot / Total flying hours:
2500
Copilot / Total hours on type:
450
Aircraft flight hours:
5416
Circumstances:
The aircraft was substantially damaged when it overran runway 28 during landing at Macon Downtown Airport (MAC), Macon, Georgia. The airplane departed from Charleston Air Force Base/International Airport (CHS), Charleston, South Carolina, about 0930. Visual meteorological conditions prevailed and an instrument flight rules (IFR) flight plan was filed. Both Airline Transport Pilots (ATP) and one passenger sustained minor injuries. The airplane was owned by Dewberry, LLC and operated by The Aviation Department. The corporate flight was conducted under the provisions of Title 14 Code of Federal Regulations (CFR) Part 91. According to an interview with the pilots, they arrived at DeKalb-Peachtree Airport (PDK), Atlanta, Georgia, which was their home base airport, about 0400, and then drove about 4 1/2 hours to CHS for the 0930 flight. The flight departed on time, the airspeed index bug was set on the co-pilot's airspeed for a decision takeoff speed (V1) of about 102 knots and a single engine climb speed (V2) on the pilot's side of 115 knots. The flight climbed to 16,000 feet prior to beginning the descent into MAC. When the flight was about 11 miles from the airport the flight crew visually acquired the airport and cancelled their IFR clearance with the Macon Radar Approach controller and proceeded to the airport visually. The second-in-command activated the runway lights utilizing the common traffic advisory frequency for the airport. Both crew members reported that about 3 seconds following activation of the lights and the precision approach path indicator (PAPI) lights, the PAPI lights turned off and would not reactivate. During the approach, the calculated reference speed (Vref) was 108 knots and was set on both pilots' airspeed indicator utilizing the index bug that moved around the outside face of the airspeed instrument. The landing was within the first 1,000 feet of the runway and during the landing roll out the airplane began to "hydroplane" since there was visible standing water on the runway and the water was "funneling into the middle." Maximum reverse thrust, braking, and ground spoilers were deployed; however, both pilots reported a "pulsation" in the brake system. The airplane departed the end of the runway into the grass, went down an embankment, across a road, and into trees. They further added that the airplane "hit hard" at the bottom of the embankment. They also reported that there were no mechanical malfunctions with the airplane prior to the landing. According to an eyewitness statement, a few minutes prior to the airplane landing, the airport experienced a rain shower with a "heavy downpour." The witness reported observing the airplane on approach, heard the engine thrust reverse, and then observed the airplane "engulfed in a large ball of water vapor." However, he did not observe the airplane as it departed the end of the runway. Another witness was located in a hangar on the west side of the airport and heard the airplane, looked outside and then saw the airplane with the reverse thrusters deployed. He watched it depart the end of the runway and travel into the nearby woods.
Probable cause:
The pilot’s failure to maintain proper airspeed, which resulted in the airplane touching down too fast on the wet runway with inadequate runway remaining to stop and a subsequent runway overrun. Contributing to the landing overrun were the flight crew members’ failure to correctly use the appropriate performance chart to calculate the runway required to stop on a contaminated runway and their general lack of proper crew resource management.
Final Report:

Crash of a Piper PA-61p Aerostar (Ted Smith 601P) in Johns Island: 2 killed

Date & Time: Apr 5, 2004 at 1526 LT
Operator:
Registration:
N869CC
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Johns Island - Charleston
MSN:
61-0235-035
YOM:
1975
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
2007
Captain / Total hours on type:
35.00
Aircraft flight hours:
3805
Circumstances:
A witness at a nearby maintenance facility stated the pilot telephoned him and told him that, during engine start, one engine sputtered and abruptly stopped. The witness stated the pilot told him he wanted to fly the airplane over to have the problem looked at. A witness, who was an airline transport-rated corporate pilot, observed the airplane on takeoff roll and stated the airplane rotated "really late," using approximately 4,000 feet of runway. He stated the airplane climbed to about 400 or 500 feet, then descended in a left spin into the trees. The airplane collided with the ground and caught fire. Examination of the right engine revealed external fire damage and no evidence of mechanical malfunction. Examination of the left engine revealed external fire damage. Disassembly examination of the left engine revealed the rear side of the No. 5 piston from top to bottom was eroded away with characteristics consistent with detonation. The spark plugs displayed "normal" deposits and wear, except the No. 5 bottom plug was contaminated with a fragment of piston ring material, the No. 5 top plug had a dark sooty appearance, and the nose core of the No. 2 bottom plug was fragmented. Flow bench examination of the left fuel servo revealed no abnormalities. The fuel flow manifold diaphragm was heat-damaged. Flow bench examination of the fuel injector lines and nozzles on a serviceable fuel flow manifold revealed the lines and nozzles were free of obstruction. A review of Emergency Operating Procedures for the Aerostar 601P revealed the following: "Normal procedures do not require operation below the single engine minimum control speed, however, should this condition inadvertently arise and engine failure occur, power on the operating engine should immediately be reduced and the nose lowered to attain a speed above ... the single engine minimum control speed."
Probable cause:
The pilot's failure to maintain airspeed during emergency descent, which resulted in an inadvertent stall/spin and uncontrolled descent into trees and terrain. A factor was the loss of engine power in one engine due to pre-ignition/detonation.
Final Report:

Crash of a Piper PA-31-350 Navajo Chieftain in Sanderson: 1 killed

Date & Time: Aug 16, 2002 at 1135 LT
Registration:
N680HP
Flight Type:
Survivors:
No
Site:
Schedule:
Charleston - Charleston
MSN:
31-8052205
YOM:
1980
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
5720
Aircraft flight hours:
4493
Circumstances:
The pilot completed a flight without incident, and seemed in good spirits before departing, by himself, on the return flight. The second flight also progressed without a incident until cleared from 8,000 feet msl to 5,000 feet msl, which the pilot acknowledged. Visual meteorological conditions prevailed at the time, and radar data depicted the airplane initiate and maintain a 500-foot per-minute descent until radar contact was lost at approximately 400 feet agl. The pilot made no mention of difficulties while en route or during the descent. The airplane impacted trees at the top of a ridge in an approximate level attitude, and came to rest approximately 1,450 feet beyond, at the bottom of a ravine. Examination of the wreckage revealed no preimpact failures or malfunctions. The pilot had been diagnosed with Crohn's disease (a chronic recurrent gastrointestinal disease, with no clear surgical cure) for approximately 35 years, which required him to undergo several surgeries more than 20 years before the accident. The pilot received a letter from the FAA on June 11, 1998, stating he was eligible for a first-class medical certificate. In the letter there was no requirement for a follow up gastroenterological review, but the pilot was reminded he was prohibited from operating an aircraft if new symptoms or adverse changes occurred, or anytime medication was required. His condition seemed to be stable until approximately 5 months prior to the accident. During this time frame, he experienced weight loss and blood loss, was prescribed several different medications to include intravenous meperidine, received 3 units of blood, and had a peripherally inserted central catheter placed. On the pilot's airmen medical application dated the month prior to the accident, the pilot reported he did not currently use any medications, and did not note any changes to his health. A toxicological test conducted after the accident identified meperidine in the pilot's tissue.
Probable cause:
Physiological impairment or incapacitation likely related to the pilot's recent exacerbation of Crohn's disease. A factor in the accident was the pilot's decision to conduct the flight in his current medical condition.
Final Report:

Crash of a Beechcraft C90 King Air in Newton: 2 killed

Date & Time: Feb 16, 1998 at 0936 LT
Type of aircraft:
Operator:
Registration:
N5WU
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Morgantown - Charleston
MSN:
LJ-635
YOM:
1974
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
12700
Captain / Total hours on type:
6155.00
Aircraft flight hours:
7523
Circumstances:
The airplane was flown from Morgantown to Charleston to drop off passengers. Once there, the pilot called the mechanic who was scheduled to replace the right transfer pump, and told him the right boost pump was also inoperative. The mechanic told the pilot, he would replace both pumps the next morning in Charleston. Adding that de-fueling the airplane would take longer than changing the pumps. The mechanic recalled that the pilot was concerned about the amount of time necessary for the repair. The airplane was then repositioned back to Morgantown for another flight the next day to Charleston. The morning of the accident, the airplane departed Morgantown, and was being vectored for the ILS approach to Charleston when the copilot declared an emergency. He then announced that they had 'a dual engine failure, two souls onboard and zero fuel.' Examination of the wreckage and both engines revealed no pre-impact failures or malfunctions. With the right transfer pump inoperative. 28 gallons of fuel in the right wing would be unusable. In addition, the flight manual states that 'both boost pumps must be operable prior to take-off.'
Probable cause:
The pilot inadequate management of the fuel system which resulted in fuel starvation to both engines. Factors in the accident were the pilot's concern about maintenance being completed prior to executing a scheduled flight later in the day, and operating the airplane with known deficiencies.
Final Report:

Crash of a Cessna 340 in Columbus: 5 killed

Date & Time: Nov 12, 1991 at 2030 LT
Type of aircraft:
Registration:
N7672Q
Survivors:
No
Schedule:
Charleston – Columbus
MSN:
340-0184
YOM:
1973
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
2617
Captain / Total hours on type:
969.00
Aircraft flight hours:
2653
Circumstances:
On final approach the pilot reported an engine failure. He said he was putting the landing gear down. The airplane crashed 3 miles from the airport. Examination of the engines revealed no discrepancies. The pilot did not feather the propeller after the engine failure. He had no training in this airplane or any other multi-engine airplane in over 5 years. His last before was in a Cessna 172. It was reported that the pilot did not manage the airplane fuel system in the recommended manner. A witness said the pilot used fuel from the main tanks until they were nearly empty. He ignored forecasts of light icing conditions and during his flight he reported ice accumulation. All five occupants were killed.
Probable cause:
The pilot's improper execution of an emergency procedure, after an engine failure, which resulted in the loss of airplane control. Factors related to the accident were: the pilot's improper management of the fuel system; the pilot's lack of proficiency in emergency procedure; and the flight into known icing conditions.
Final Report:

Crash of a Lockheed C-141B Starlifter on Mt Johns Knob: 9 killed

Date & Time: Aug 31, 1982 at 1430 LT
Type of aircraft:
Operator:
Registration:
64-0652
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Charleston - Charleston
MSN:
6065
YOM:
1964
Crew on board:
9
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
9
Aircraft flight hours:
24246
Circumstances:
The aircraft departed Charleston in the early afternoon on a training mission, carrying a crew of nine. Weather conditions worsened en route with sky overcast at 4,500 feet, top of clouds at 8,000 feet and zero visibility below 4,500 feet due to rain falls and fog. The airplane struck the slope of Mt Johns Knob (4,908 feet high) located at the Tennessee - North Carolina border. The wreckage was found 118 feet below the summit and all nine occupants were killed. At the time of the accident, the visibility was below minimums for military training mission.

Crash of a Cessna 421B Golden Eagle II in Charleston: 3 killed

Date & Time: Jun 19, 1979 at 0813 LT
Registration:
N69733
Survivors:
Yes
Schedule:
Newport News - Charleston
MSN:
421B-0867
YOM:
1974
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
2008
Captain / Total hours on type:
543.00
Circumstances:
On a final ILS approach to Charleston-Kanawha Airport in marginal weather conditions, the pilot continued the descent 1'000 feet below the glidepath when the twin engine airplane struck trees and crashed in flames in a wooded area located few hundred yards from the runway threshold. The pilot and two passengers were killed while two other occupants were seriously injured.
Probable cause:
Collision with trees on final approach after the pilot attempted operation beyond experience and ability level. The following contributing factors were reported:
- Improper IFR operation,
- Incorrect trim setting,
- High obstructions,
- Low ceiling,
- Fog,
- Visibility half a mile or less,
- ILS approach,
- Crashed inside outer marker, 1,000 feet below glidepath,
- The pilot did not have medical, multi-engine or instruments ratings.
Final Report:

Crash of a Douglas DC-6BF in Charleston

Date & Time: Jun 6, 1979 at 0417 LT
Type of aircraft:
Operator:
Registration:
AN-BFN
Flight Type:
Survivors:
Yes
MSN:
45322/939
YOM:
1958
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The crew was completing an illegal flight and the airplane was carrying a load of 20,000 lbs of marijuana. After touchdown at an excessive speed, the four engine airplane was unable to stop within the remaining distance, overran and collided with obstacles before coming to rest in fire. All three crew members were seriously injured and the aircraft was destroyed.
Probable cause:
Overshoot and subsequent collision with objects after the crew misjudged distance and speed on approach. The following contributing factors were reported:
- Attempted operation beyond experience/ability level,
- Lack of familiarity with aircraft,
- Ran off end of runway,
- Crew not type-rated in aircraft.
Final Report:

Crash of a Beechcraft D18 in Charleston: 1 killed

Date & Time: May 25, 1979 at 2317 LT
Type of aircraft:
Registration:
N1812D
Flight Type:
Survivors:
No
Schedule:
Charlotte - Youngstown
MSN:
A-826
YOM:
1952
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
7928
Captain / Total hours on type:
1800.00
Circumstances:
While in cruising altitude on a cargo flight from Charlotte to Youngstown, the pilot reported engine problems and elected to divert to Charleston-Kanawha Airport for an emergency landing. After being cleared, he initiated the descent when the airplane went out of control and crashed in flames few miles from the airfield. The aircraft was destroyed and the pilot, sole on board, was killed.
Probable cause:
Uncontrolled collision with ground on final approach after the pilot attempted operation with known deficiencies in equipment. The following contributing factors were reported:
- Improper IFR operation,
- Lubricating system: lines, hoses, fitting,
- Oil leak,
- Pilot fatigue,
- Low ceiling,
- Forced landing off airport on land,
- Pilot departed on last leg of flight despite observing large oil leak,
- Pilot on duty since 0730LT.
Final Report: