Las Vegas-Harry Reid (McCarran)

On approach to Temecula-French Airport Runway 36 at night, the crew encountered foggy conditions. Due to poor visibility, the crew initiated a go around then made a right hand turn and followed a circuit for a second attempt to land. On short final, at a speed of approximately 130 knots, the airplane impacted the ground and crashed short of runway, bursting into flames. The airplane was totally destroyed and all six occupants were killed.

The flight crew, which consisted of the pilot- and second-in-command (PIC and SIC), and a non-type-rated observer pilot, reported that during takeoff near 100 knots a violent shimmy developed at the nose landing gear (NLG). The PIC aborted the takeoff and during the abort procedure, the NLG separated. The airplane veered off the runway, and the right wing and right main landing gear struck approach lights, which resulted in substantial damage to the fuselage and right wing. The passengers and flight crew evacuated the airplane without incident through the main cabin door. Postaccident interviews revealed that following towing operations prior to the flight crew’s arrival, ground personnel were unable to get the plunger button and locking balls of the NLG’s removable pip pin to release normally. Following a brief troubleshooting effort by the ground crew, the pip pin’s plunger button remained stuck fully inward, and the locking balls remained retracted. The ground crew re-installed the pip pin through the steering collar with the upper torque link arm connected. However, with the locking balls in the retracted position, the pin was not secured in position as it should have been. Further, the ground personnel could not install the safety pin through the pip pin because the pin’s design prevented the safety pin from being inserted if the locking balls and plunger were not released. The ground personnel left the safety pin hanging from its lanyard on the right side of the NLG. The ground personnel subsequently informed their ramp supervisor of the anomaly. The supervisor reported that he informed the first arriving crewmember at the airplane (the observer pilot) that the nose pin needed to be checked. However, all three pilots reported that no ground crewmember told them about any issues with the NLG or pins. Examination of the runway environment revealed that the first item of debris located on the runway was the pip pin. Shortly after this location, tire swivel marks were located near the runway centerline, which were followed by large scrape and tire marks, leading to the separated NLG. The safety pin remained attached to the NLG via its lanyard and was undamaged. Postaccident examination and testing of the NLG and its pins revealed no evidence of preimpact mechanical malfunctions or failures. The sticking of the pip pin plunger button that the ground crew reported experiencing could not be duplicated during postaccident testing. When installed on the NLG, the locking ball mechanism worked as intended, and the pip pin could not be removed by hand. Although the airplane’s preflight checklist called for a visual check of the NLG’s torque link to ensure that it was connected to the steering collar by the pip pin and that the safety pin was installed, it is likely that none of the pilots noticed that the pip pin did not have its safety pin installed during preflight. Subsequently, during the takeoff roll, without the locking balls extended, the pip pin likely moved outward and fell from its position holding the upper torque link arm. This allowed the upper torque link arm to move freely, which resulted in the violent shimmy and NLG separation. The location of the debris on the runway, tire marks, and postaccident examination and testing support this likely chain of events. Contributing to the PIC and SIC’s omission during preflight was the ground crew’s failure to directly inform the PIC or SIC that there was a problem with the NLG pip pin. The ground crew also failed to discard the malfunctioning pip pin per the airplane’s ground handling procedures and instead re-installed the pip pin. Although the observer pilot was reportedly informed of an issue with a nose gear pin, he was not qualified to act as a required flight crewmember for the airplane and was on his cell phone when he was reportedly informed of the issue by the ramp supervisor. These factors likely contributed to the miscommunication and the PIC’s and SIC’s subsequent lack of awareness of the NLG issue.

The airplane departed Las Vegas-McCarran Airport at 1452LT on a charter flight to Monterrey, carrying two pilots and 11 passengers who were returning to Mexico after taking part to a boxing match in Las Vegas. The flight was completed at FL370 until the crew was cleared to climb to FL390 for five minutes then to FL410. Suddenly, the airplane entered an uncontrolled descent and eventually crashed in an almost flat attitude in a desert area located near La Rosita, Coahuila. The aircraft was destroyed by impact forces and a post crash fire and all 13 occupants were killed. The wreckage was found the following day.

The pilots reported that, during the approach, the main hydraulic system lost pressure. They selected the auxiliary hydraulic system "on," continued the approach, and extended the landing gear using the emergency landing gear extension procedures. During the landing roll, about two-thirds down the runway, the pilots noticed that the brakes were not working normally and then turned onto a taxiway to clear the runway. The captain reported that, once on the taxiway, he was unable to stop or steer the airplane as it proceeded across a parallel runway and into an adjacent field where it subsequently struck a metal beam. A postaccident examination of the airplane revealed brake system continuity with the cockpit controls. The tires, brake assemblies, and brake pads were intact and undamaged. The hydraulic lines from the hydraulic pump to the wheel brakes were intact. No hydraulic fluid was observed leaking on the exterior or interior portions of the airplane. The hydraulic fluid reservoir was found about 1/4 full. Further, testing of the two hydraulic pumps revealed that they were both functional, and no mechanical failures or anomalies that would have precluded normal operation were noted. The airplane's hydraulic system failure emergency procedures state that, if hydraulic pressure is lost, the electrically driven hydraulic pump should be reset and that, if the hydraulic pressure was not restored, that the primary hydraulic system should be disengaged and the landing gear should be lowered using the emergency landing gear extension procedures. After the gear is extended, the auxiliary hydraulic system should be selected "on" for landing. However, the pilots stated that they did not attempt to reset the electric hydraulic pump and that they performed the emergency landing gear extension procedures with the auxiliary hydraulic pump engaged. It is likely that the pilots' failure to select the auxiliary hydraulic system "off" before extending the landing gear caused the hydraulic pressure in the auxiliary system to dissipate, which left only the emergency brake accumulator available for braking during the landing. The number of emergency brake applications that can be made by the pilots depends on the accumulator charge, which may be depleted in a very short time. The airplane's emergency braking procedures state that, as soon as the airplane is safely stopped, the pilots should request towing assistance. However, the pilots did not stop the airplane on the runway despite having about 3,900 ft of runway remaining; instead, they turned off the runway at an intersection, which resulted in a loss of directional control.

After passing the initial approach fix, during an instrument approach to the destination airport, radar and radio contact were lost with the business jet. One witness reported hearing "distressed engine noises overhead," and looked up and saw what appeared to be a small private jet flying overhead. The engine seemed to be "cutting in and out." The witness further reported observing the airplane in a left descending turn until his view was blocked by a ridge. The witness then heard an explosion and saw a big cloud of smoke rising over the ridge. A second witness heard a loud noise and looked up and saw a small white airplane with two engines. The witness stated that the airplane started to turn left with the nose of the airplane slightly pointing toward the ground. The airplane appeared to be trying to land on a road. A third witness heard the roar of the airplane's engines, and looked toward the noise and observed the airplane in a vertical descent (nose dive) impact the ground. The witness "heard the engines all the way to the ground." Examination of the airframe and engines did not disclose any structural or mechanical anomalies that would have prevented normal operation. The National Weather Service had issued a SIGMET for severe turbulence and mountain wave activity. Satellite images depicted bands of altocumulus undulates and/or rotor clouds over the accident site.

The aircraft collided with the ground in a steep nose down descent angle while maneuvering to return to the runway during the takeoff initial climb from the airport. Pilot and mechanic witnesses on the airport described the engine sounds during the takeoff as abnormal. The takeoff ground roll was over 3,000 feet in length, and the airplane's climb out angle was much shallower than usual. Two other witnesses said the engine sounded "like a radial engine," and both believed that the power output was lower than normal. One mechanic witness said the engine was surging and not developing full power; he believed the symptoms could be associated with a fuel feed problem, a turbocharger surge, or an excessively lean running condition. The ground witnesses located near the impact site said the airplane began a steep left turn between 1/4- and 1/2-mile from the runway's end at a lower than normal altitude. The bank angle was estimated by the witnesses as 45 degrees or greater. The turn continued until the nose suddenly dropped and the airplane entered a spiraling descent to ground impact. The majority of these witnesses stated that they heard "sputtering" or "popping" noises coming from the airplane. Engineering personnel from the manufacturer developed a performance profile for a normal takeoff and climb under the ambient conditions of the accident and at gross weight. The profile was compared to the actual aircraft performance derived from recorded radar data and the witness observations. The ground roll was 1,300 feet longer than it should have been, and the speed/acceleration and climb performance were consistently well below the profile's predictions. Based on the radar data and factoring in the winds, the airplane's estimated indicated airspeed during the final turn was 82 knots; the stall speed at 45 degrees of bank is 82 knots and it increases linearly to 96 knots at 60 degrees of bank. No evidence was found that the pilot flew the airplane from December until the date of the accident. The airplane sat outside during the rainy season with only 10 gallons of fuel in each tank. Comparison of the time the fueling began and the communications transcripts disclosed that the pilot had 17 minutes 41 seconds to refuel the airplane with 120 gallons, reboard the airplane, and start the engine for taxi; the maximum nozzle discharge flow rate of the pump he used is 24 gallons per minute. Review of the communications transcripts found that a time interval of 3 minutes 35 seconds elapsed from the time the pilot asked for a taxi clearance from the fuel facility until he reported ready for takeoff following a taxi distance of at least 2,000 feet. During the 8 seconds following the pilot's acknowledgment of his takeoff clearance, he and the local controller carried on a non pertinent personal exchange. The aircraft was almost completely consumed in the post crash fire; however, extensive investigation of the remains failed to identify a preimpact mechanical malfunction or failure in the engine or airframe systems. The pistons, cylinder interiors, and spark plugs from all six cylinders were clean without combustion deposits. The cockpit fuel selector lever, the intermediate linkages, and the valve itself were found in the OFF position; however, an engineering analysis established that insufficient fuel was available in the lines forward of the selector to start, taxi, and perform a takeoff with the selector in the OFF position.

On March 5, 2000, about 1811 Pacific standard time (PST), Southwest Airlines, Inc., flight 1455, a Boeing 737-300 (737), N668SW, overran the departure end of runway 8 after landing at Burbank-Glendale-Pasadena Airport (BUR), Burbank, California. The airplane touched down at approximately 182 knots, and about 20 seconds later, at approximately 32 knots, collided with a metal blast fence and an airport perimeter wall. The airplane came to rest on a city street near a gas station off of the airport property. Of the 142 persons on board, 2 passengers sustained serious injuries; 41 passengers and the captain sustained minor injuries; and 94
passengers, 3 flight attendants, and the first officer sustained no injuries. The airplane sustained extensive exterior damage and some internal damage to the passenger cabin. During the accident sequence, the forward service door (1R) escape slide inflated inside the airplane; the nose gear collapsed; and the forward dual flight attendant jump seat, which was occupied by two flight attendants, partially collapsed. The flight, which was operating on an instrument flight rules flight plan, was conducted under 14 Code of Federal Regulations (CFR) Part 121. Visual meteorological conditions (VMC) prevailed at the time of the accident, which occurred
in twilight lighting conditions.

The pilot landed with the landing gear in the retracted position, when both the main and auxiliary hydraulic systems failed to extend the gear. The airplane caught fire as it skidded down the runway. The left inboard main tire had blown on takeoff and a 30-inch section of tread was loose. Black marks were along the length of the landing gear strut and up into the wheel well directly above the left inboard wheel. The normal and emergency hydraulic systems both connect to a common valve body on the landing gear actuator. This valve body also had black marks on it. A gap of 0.035 inch was measured between the valve body and actuator. When either the normal or auxiliary hydraulic system was pressurized, red fluid leaked from this gap. Examination revealed that one of two bolts holding the hydraulic control valve in place had fractured and separated. The fractured bolt experienced a shear load that was oriented along the longitudinal axis of the actuator in a plane consistent with impact forces from the flapping tire tread section.. Separation of only one bolt allowed the control valve to twist about the remaining bolt in response to the load along the actuator's longitudinal axis. This led to a loss of clamping force on that side of the actuator. Hydraulic line pressure lifted the control valve, which resulted in rupture of an o-ring that sealed the hydraulic fluid passage. 14 CFR 25.739 describes the requirement for protection of equipment in wheel wheels from the effects of tire debris. The revision of this regulation in effect at the time the airplane's type design was approved by the FAA requires that equipment and systems essential to safe operation of the airplane that is located in wheel wells must be protected by shields or other means from the damaging effects of a loose tire tread, unless it is shown that a loose tire tread cannot cause damage. Examination of the airplane and the FAA approved production drawings disclosed that no shields were installed to protect the hydraulic system components in the wheel well.

The charter flight was on a return tour trip after landing at the Grand Canyon National Park Airport. No fueling or maintenance was performed on the airplane while it sat on the ground for three hours. Shortly after takeoff from runway 21, the pilot transmitted that he had a problem and was declaring an emergency. He then stated '...I'm single engine right now....' The airplane was observed to be 100-200 feet above the terrain at the time. It continued flying for about 6 minutes, turning onto a crosswind, downwind, and then a right base leg for runway 21 before colliding with trees about 2.5 miles northeast of the airport. The airport is located in terrain that slopes upward from south to north and west to east. Winds were gusting to 29 knots. The density altitude was 6,870 feet. Examination of the suspect left engine did not reveal any evidence of failures or malfunctions. The investigation revealed deficiencies in the Federal Aviation Administration's oversight of the airline's maintenance program, and in the airline's extension of the time-in-service interval of the engines. The airline's AAIP does not require a maximum rated power check of the engines as required by the engine manufacturer's service instruction. In addition, the TBO of the engines had been extended from 1,800 to 2,400 hours.