Crash of a Beechcraft E18S in Mabie: 2 killed

Date & Time: Mar 6, 1997 at 0021 LT
Type of aircraft:
Registration:
N54BT
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Sanford - Detroit
MSN:
BA-56
YOM:
1955
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
2000
Captain / Total hours on type:
30.00
Aircraft flight hours:
11196
Circumstances:
The flight had been delayed due to severe weather over the departure airport. The preflight weather briefing received by the pilot included AIRMETS and SIGMETS for icing and severe thunderstorms, possible tornadoes, hail to 2 inches, and wind gusts to 70 knots near the ground. The Beech 18 was not equipped with a storm scope or weather radar. Prior to takeoff, a passenger stated to a witness that the weather was 'really really bad,' and that they would have to 'do some deviating to get around it.' After takeoff, the airplane cruised at 10,000 feet uneventfully for 1 hour and 50 minutes, when a center controller advised that radar contact was lost, which the pilot acknowledged. The next and last transmission occurred 13 minutes later when the controller received a 'Mayday' radio transmission that the airplane was 'going down.' The last radar target revealed a 6,000 foot per minute rate of descent. Training records revealed the pilot, also the company chief pilot, had flown solo 6.3 hours in the Beech 18 and credited it as dual flight instruction. He then passed a Part 135 evaluation with the FAA Principal Operations Inspector (POI), which lasted 1.6 hours. The next day the POI issued the pilot check airmen authorization for the Beech 18, all models. According to the POI, the airplane was not approved for Part 135 operations; however, the company had a bogus approval for the airplane, signed by the POI, that allowed the company to apply to Canadian Authorities for authorization to operate in Canada. The bogus approval had been used to justify the accident flight.
Probable cause:
The pilot's disregard of the preflight weather briefing for severe weather along his route of flight, and his departure into the known and forecasted severe weather. A factor in the accident was the inadequate FAA oversight of the operator, which fostered an attitude of rule bending.
Final Report:

Crash of an Embraer EMB-120 Brasília in Detroit: 29 killed

Date & Time: Jan 9, 1997 at 1554 LT
Type of aircraft:
Operator:
Registration:
N265CA
Survivors:
No
Schedule:
Cincinnati - Detroit
MSN:
120-257
YOM:
1991
Flight number:
OH3272
Location:
Crew on board:
3
Crew fatalities:
Pax on board:
26
Pax fatalities:
Other fatalities:
Total fatalities:
29
Captain / Total flying hours:
5329
Captain / Total hours on type:
2302.00
Copilot / Total flying hours:
2582
Copilot / Total hours on type:
1494
Aircraft flight hours:
12752
Aircraft flight cycles:
12734
Circumstances:
The flight was being vectored for the approach to runway 3R at Detroit Metropolitan Wayne County Airport (DTW) when the aircraft descended and impacted the ground. The aircraft struck the ground in a steep nose-down attitude in a level field in a rural area about 19 nm southwest of DTW. The flight carried 26 passengers and 3 crew members. There were no survivors and the airplane was destroyed by impact forces and a post crash fire. Instrument meteorological conditions prevailed at the time of the accident. The investigation revealed that it was likely that the airplane gradually accumulated a thin, rough glaze/mixed ice coverage on the leading edge deicing boot surfaces, possibly with ice ridge formation on the leading edge upper surface, as the airplane descended from 7,000 feet mean sea level (msl) to 4,000 feet msl in icing conditions, which may have been imperceptible to the pilots. The pilots had been instructed by air traffic control to slow to 150 knots and according to flight data recorder information, the airplane began to show signs of departure from controlled flight as it decelerated from 155 to 156 knots while in a flaps-up configuration. The investigation disclosed that the FAA failed to adopt a systematic and proactive approach to the certification, and operational issues of turbopropeller-driven transport airplane icing. The icing certification process has been inadequate because it has not required manufacturers to demonstrate the airplane's flight handling and stall characteristics under a sufficiently realistic range of adverse ice accretion/flight handling conditions. The aircraft manufacturer had issued a revision in April, 1996 to the approved flight manual which included activation of the leading edge deicing boots at the first sign of ice formation. The airplane operator did not incorporate the procedure, because it was contrary to the company's trained procedures and practices and of the belief that enacting the changes would result in potentially unsafe operation. Investigators' discussion with management personnel at each of the seven U.S.-based operators of the aircraft indicated that at the time of the accident only two of these operators had changed their procedures to reflect the information in the revision. The FAA, at the time of the accident, did not require manufacturers of all turbine-engine driven airplanes to publish minimum airspeed information for various flap configurations and phases and conditions of flight. During Safety Board investigators postaccident interviews with company pilots, there were inconsistent answers on the complex and varied minimum airspeed requirements established by the company for both icing and nonicing conditions. It was also noted that the pilots uncertainty of the appropriate airspeeds might have been associated with the language used, the different airspeeds and criteria contained in the guidance, the company's methods of distribution, and the company's failure t o incorporate the guidance as a formal, permanent revision to the flight standards manual.
Probable cause:
The Federal Aviation Administration's (FAA) failure to establish adequate aircraft certification standards for flight in icing conditions, the FAA's failure to ensure that at Centro Tecnico Aeroespacial/FAA-approved procedure for the accident airplane's deice system operation was implemented by U.S.-based air carriers, and the FAA's failure to require the establishment of
adequate minimum airspeeds for icing conditions, which led to the loss of control when the airplane accumulated a thin, rough, accretion of ice on its lifting surfaces. Contributing to the
accident were the flightcrew's decision to operate in icing conditions near the lower margin of the operating airspeed envelope (with flaps retracted) and Comair's failure to establish and adequately disseminate unambiguous minimum airspeed values for flap configurations and for flight in icing conditions.
Final Report:

Crash of a Dassault Falcon 10 in Detroit

Date & Time: Jan 24, 1996 at 1018 LT
Type of aircraft:
Operator:
Registration:
N191MC
Survivors:
Yes
Schedule:
Philadelphia - Flint
MSN:
30
YOM:
1974
Crew on board:
2
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
11163
Captain / Total hours on type:
1330.00
Aircraft flight hours:
9829
Circumstances:
The pilot reported getting an unsafe indication on the right main landing gear when the landing gear was lowered. The crew recycled the landing gear and got the same unsafe indication. The crew retracted the gear and diverted to Detroit. On arrival, the crew performed the 'landing gear abnormal extension checklist,' but the unsafe indication remained. The air traffic control tower reported that the gear appeared normal. During the landing, the right main landing gear retracted. The airplane slid sideways, striking a runway marker as it departed the runway, and came to rest in a field. Examination revealed that the right landing gear downlock mechanism could be overcome with physical force. Examination of the right landing gear actuator revealed that one of the six shims which separate the spacers and help guide the safety lock switch was out of position and lying on top of the lock assembly.
Probable cause:
Failure of the right landing gear locking mechanism.
Final Report:

Crash of a Swearingen SA226AT Merlin IV in Detroit

Date & Time: Dec 15, 1995 at 0423 LT
Registration:
N31AT
Flight Type:
Survivors:
Yes
Schedule:
Flint - Louisville
MSN:
AT-057
YOM:
1977
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
9550
Captain / Total hours on type:
3977.00
Aircraft flight hours:
6965
Circumstances:
The pilot reported that shortly after takeoff, the airplane's left engine started to surge. The airplane also began experiencing intermittent electrical surges which caused the instrument panel lights, cabin lights, and radios to go off and on. The pilot diverted to an alternate airport to land. He did not secure the left engine before landing because it was still developing some usable power. He placed the gear select handle in the down position and observed three green gear-down-and-locked lights. Prior to touchdown, both power levers were positioned to flight idle and no gear warning horn sounded. The airplane landed gear up. Postaccident examination revealed no abnormalities with the landing gear or electrical system. The landing gear emergency extension functioned properly. The landing gear indicating system showed a safe gear indication when the gear was extended during examination. Substantial damage to the gear doors was observed, but no damage to the landing gear was observed.
Probable cause:
The pilot's failure to extend the landing gear. A factor in the accident was the pilot's diverted attention.
Final Report:

Crash of a Douglas DC-9-14 in Detroit: 8 killed

Date & Time: Dec 3, 1990 at 1345 LT
Type of aircraft:
Operator:
Registration:
N3313L
Flight Phase:
Survivors:
Yes
Schedule:
Detroit - Pittsburgh
MSN:
45708
YOM:
1966
Flight number:
NW1482
Crew on board:
4
Crew fatalities:
Pax on board:
40
Pax fatalities:
Other fatalities:
Total fatalities:
8
Captain / Total flying hours:
23000
Captain / Total hours on type:
4000.00
Copilot / Total flying hours:
4500
Aircraft flight hours:
62253
Circumstances:
On December 3, 1990, at 1345 est, Northwest flight 1482, a DC-9 (N3313L), and Northwest flight 299, a Boeing 727 (N278US), collided near the intersection of runway 09/27 and 03C/21C in dense fog at Detriot-Metropolitan-Wayne County Airport, MI. At the time of the collision, the B-727 was on its takeoff roll, and the DC-9 had just taxied onto the active runway. The B-727 was substantially damaged, and the DC-9 was destroyed. Seven of the 40 passengers and 1 crew member aboard the DC-9 received fatal injuries. None of the 146 passengers and 8 crewmembers aboard the B-727 were injured.
Probable cause:
Lack of proper crew coordination, including virtual reversal of roles by the DC-9 pilots, which led to their failure to stop taxiing and alert ground controller of their positional uncertainty in a timely manner before and after intruding onto the active runway. Contributing to cause of accident were:
- Deficiencies in ATC services provided by Detroit tower, including failure of ground control to take timely action to alert local controller to possible runway incursion, inadequate visibility observation, failure to use progressive taxi instructions low-visibility conditions, and issuance of inappropriate and confusing taxi instructions compounded by inadequate backup supervision for level of experience of staff on duty;
- Deficiencies in surface markings, signage and lighting at airport and failure of FAA surveillance to detect or correct any of these deficiencies;
- Failure of Northwest Airlines to provide adequate cockpit resource management training to line aircrews. Contributing to fatalities was inoperability of DC-9 internal tailcone release mechanism. Contributing to number and severity of injuries was failure of crew of DC-9 to properly execute the passenger evacuation.
Final Report:

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

Date & Time: Jul 23, 1990 at 0934 LT
Operator:
Registration:
N8060J
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Detroit – Jackson
MSN:
60-0543-175
YOM:
1978
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
7000
Captain / Total hours on type:
2000.00
Circumstances:
A Piper PA-28, N55354, had departed Plymouth, MI and was climbing from 1,300 feet msl on a course of about 282° with a ground speed of 80 knots. At about the same time, a Piper PA-60, N8060J, was cruising at 2,100 feet msl on a flight from Detroit to Jackson, MI, on a course of about 258° with a ground speed of 165 knots. Subsequently, the 2 aircraft converged and collided at 2,100 feet msl. Both aircraft then plunged to the ground and crashed. Radar data and wreckage exam revealed the PA-60 had converged from the right rear of the PA-28; the PA-28 converged on the PA-60 from its lower, left, forward area. The PA-28 was on an instrument training flight with a rated private pilot and an instructor pilot (cfi) aboard. The investigation did not reveal which seat the cfi was occupying. No flight plan had been filed for either flight, nor was there any indication that either flight crew had obtained ATC/radar assistance. The pilot, sole on board, was killed.
Probable cause:
Inadequate visual lookout by the pilot of the PA-60. A factor related to the accident was that neither of the flight crews had obtained ATC/radar assistance.
Final Report:

Crash of a Beechcraft E18S in Cincinnati: 1 killed

Date & Time: Mar 9, 1989 at 0617 LT
Type of aircraft:
Operator:
Registration:
N3281T
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Cincinnati – Detroit
MSN:
BA-611
YOM:
1962
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
10560
Captain / Total hours on type:
15.00
Aircraft flight hours:
13262
Circumstances:
N3281T was attempting an instrument departure when it crashed left of the extended centerline of runway 18. The flight was observed climbing through 200 feet prior to descending to the ground. Prior to taxiing to takeoff the pilot failed to deice the airframe. Airplanes on the parking ramp around N3281T deiced prior to takeoff. Weather reports indicated that temp/dew point were 26 and 23° respectively. The surface observation also reported fog as a restriction to visibility. According to the airplane's handbook that tests prove that a coat of frost on a wing can destroy its lift. The pilot, sole on board, was killed.
Probable cause:
Pilot attempted a takeoff with coating of frost on the airframe which resulted in a loss of lift during climbout.
Final Report:

Crash of a Cessna 414 Chancellor in Pontiac

Date & Time: Dec 19, 1988 at 2010 LT
Type of aircraft:
Operator:
Registration:
N414CM
Flight Type:
Survivors:
Yes
Schedule:
Detroit - Pontiac
MSN:
414-0035
YOM:
1969
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
1023
Captain / Total hours on type:
98.00
Aircraft flight hours:
5916
Circumstances:
While on final approach to land at night, the left engine lost power due to fuel starvation. Attempts to restart the engine were not successful. While the pilot was attempting a restart, the aircraft drifted to the right of the runway centerline and toward the proximity of hangars. The pilot stated that due to the power loss and wind conditions, he elected to land on airport property. Gear extension was delayed until just before landing. The aircraft touched down before the right main landing gear was fully extended and locked. Subsequently, the right main gear collapsed and the aircraft skidded about 500 feet before coming to rest. An examination revealed the nacelle and main fuel tanks were empty, but fuel was still remaining in the auxiliary tanks.
Probable cause:
Occurrence #1: loss of engine power (total) - nonmechanical
Phase of operation: approach
Findings
1. 1 engine
2. (c) fluid, fuel - starvation
3. (c) fuel tank selector position - improper - pilot in command
----------
Occurrence #2: gear not extended
Phase of operation: landing - flare/touchdown
Findings
4. (f) light condition - dark night
5. (f) weather condition - gusts
6. (f) weather condition - crosswind
7. (c) compensation for wind conditions - improper - pilot in command
8. Precautionary landing - initiated - pilot in command
9. (c) gear down and locked - delayed - pilot in command
----------
Occurrence #3: main gear collapsed
Phase of operation: landing
Final Report:

Crash of a McDonnell Douglas MD-82 in Detroit: 156 killed

Date & Time: Aug 16, 1987 at 2045 LT
Type of aircraft:
Operator:
Registration:
N312RC
Flight Phase:
Survivors:
Yes
Schedule:
Saginaw - Detroit - Phoenix - Santa Ana
MSN:
48090
YOM:
1981
Flight number:
NW255
Crew on board:
6
Crew fatalities:
Pax on board:
149
Pax fatalities:
Other fatalities:
Total fatalities:
156
Captain / Total flying hours:
20859
Captain / Total hours on type:
1359.00
Copilot / Total flying hours:
8044
Copilot / Total hours on type:
1604
Aircraft flight hours:
14928
Circumstances:
A McDonnell Douglas DC-9-82 operating Northwest Airlines flight 255 was destroyed when it crashed onto a road during takeoff from Detroit-Metropolitan Wayne County Airport, Michigan, USA. Just one of the 155 occupants survived the accident. Additionally, Two persons on the ground were killed. Flight NW255 was a regularly scheduled passenger flight between Saginaw, Michigan and Santa Ana, California, with en route stops at Detroit and Phoenix, Arizona. About 18:53, flight 255 departed Saginaw and about 19:42 arrived at its gate at Detroit. About 20:32, flight 255 departed the gate with 149 passengers and 6 crewmembers on board. During the pushback, the flightcrew accomplished the BEFORE (engine) START portion of the airplane checklist, and, at 20:33, they began starting the engines. The flight was then cleared to "taxi via the ramp, hold short of (taxiway) delta and expect runway three center [3C] (for takeoff)..." The ground controller amended the clearance, stating that the flight had to exit the ramp at taxiway Charlie. The crew was requested to change radio frequencies. The first officer repeated the taxi clearance, but he did not repeat the new radio frequency nor did he tune the radio to the new frequency. At 20:37, the captain asked the first officer if they could use runway 3C for takeoff as they had initially expected 21L or 21R. After consulting the Runway Takeoff Weight Chart Manual, the first officer told the captain runway 3C could be used for takeoff. During the taxi out, the captain missed the turnoff at taxiway C. When the first officer contacted ground control, the ground controller redirected them to taxi to runway 3C and again requested that they change radio frequencies. The first officer repeated the new frequency, changed over, and contacted the east ground controller. The east ground controller gave the flight a new taxi route to runway 3C, told them that windshear alerts were in effect, and that the altimeter setting was 29.85 inHg. The flightcrew acknowledged receipt of the information. At 20:42, the local controller cleared flight 255 to taxi into position on runway 3C and to hold. He told the flight there would be a 3-minute delay in order to get the required "in-trail separation behind traffic just departing." At 20:44:04, flight 255 was cleared for takeoff. Engine power began increasing at 20:44:21. The flightcrew could not engage the autothrottle system at first, but, at 20:44:38, they did engage the system, and the first officer called 100 knots at 20:44:45. At 20:44:57, the first officer called "Rotate." Eight seconds later, the stall warning stick shaker activated, accompanied by voice warnings of the supplemental stall recognition system (SSRS). The takeoff warning system indicating that the airplane was not configured properly for takeoff, did not sound at any time prior or during takeoff. After flight 255 became airborne it began rolling to the left and right before the left wing hit a light pole in a rental car lot. After impacting the light pole, flight 255 continued to roll to the left, continued across the car lot, struck a light pole in a second rental car lot, and struck the side wall of the roof of the auto rental facility in the second rental car lot. The airplane continued rolling to the left when it impacted the ground on a road outside the airport boundary. The airplane continued to slide along the road, struck a railroad embankment, and disintegrated as it slid along the ground. Fires erupted in airplane components scattered along the wreckage path. Three occupied vehicles on the road and numerous vacant vehicles in the auto rental parking lot along the airplane's path were destroyed by impact forces and or fire. One passenger, a 4-year-old child was injured seriously.
Probable cause:
The flight crew's failure to use the taxi checklist to ensure that the flaps and slats were extended for take-off. Contributing the accident was the absence of electrical power to the airplane take-off warning system which thus did not warn the flight crew that the airplane was not configured properly for take-off. The reason for the absence of electrical power could not be determined.
Final Report:

Crash of a Casa 212 Aviocar 200 in Detroit: 9 killed

Date & Time: Mar 4, 1987 at 1434 LT
Type of aircraft:
Operator:
Registration:
N160FB
Survivors:
Yes
Schedule:
Cleveland - Detroit
MSN:
160
YOM:
1980
Flight number:
NW2268
Crew on board:
3
Crew fatalities:
Pax on board:
16
Pax fatalities:
Other fatalities:
Total fatalities:
9
Captain / Total flying hours:
17953
Captain / Total hours on type:
3144.00
Copilot / Total flying hours:
1593
Aircraft flight hours:
12918
Aircraft flight cycles:
24218
Circumstances:
At 14:30 the flight was cleared for a runway 21R visual approach and was cleared to land one minute later, At a height of 60-70 feet the aircraft suddenly yawed violently to the left and banked left 80-90° in a descent. The aircraft then rolled right and struck the ramp area 1,010 feet inside and to the left of the runway 21R threshold. It then skidded 398 feet, struck three ground support vehicles in front of Gate F10 at Concourse F and caught fire. Both pilots and seven passengers were killed, 10 other occupants were injured.
Probable cause:
The captain's inability to control the airplane in an attempt to recover from an asymmetric power condition at low speed following his intentional use of the beta mode of propeller operation to descend and slow the airplane rapidly on final approach for landing. Factors that contributed to the accident were an unstabilized visual approach, the presence of a departing DC-9 on the runway, the desire to make a short field landing, and the higher-than-normal flight idle fuel flow settings of both engines. The lack of fire-blocking material in passenger seat cushions contributed to the severity of the injuries.
Final Report: