Crash of a Cessna 441 Conquest in York: 1 killed

Date & Time: Dec 22, 2011 at 1725 LT
Type of aircraft:
Operator:
Registration:
N48BS
Flight Type:
Survivors:
No
Schedule:
Long Beach - York
MSN:
441-0125
YOM:
1980
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
1409
Captain / Total hours on type:
502.00
Aircraft flight hours:
5995
Circumstances:
Toward the end of a 6 hour, 20 minute flight, during a night visual approach, the pilot flew the airplane to a left traffic pattern downwind leg. At some point, he lowered the landing gear and set the flaps to 30 degrees. He turned the airplane to a left base leg, and after doing so, was heard on the common traffic frequency stating that he had an "engine out." The airplane then passed through the final leg course, the pilot called "base to final," and the airplane commenced a right turn while maintaining altitude. The angle of bank was then observed to increase to where the airplane's wings became vertical, then inverted, and the airplane rolled into a near-vertical descent, hitting the ground upright in a right spin. Subsequent examination of the airplane and engines revealed that the right engine was not powered at impact, and the propeller from that engine was not in feather. No mechanical anomalies could be found with the engine that could have resulted in its failure. The right fuel tank was breeched; however, fuel calculations, confirmed by some fuel found in the right fuel tank as well as fuel found in the engine fuel filter housing, indicated that fuel exhaustion did not occur. Unknown is why the pilot did not continue through a left turn descent onto the final approach leg toward airport, which would also have been a turn toward the operating engine. The pilot had a communication device capable of voice calls, texting, e-mail and alarms, among other functions. E-mails were sent by the device until 0323, and an alarm sounded at 0920. It is unknown if or how much pilot fatigue might have influenced the outcome.
Probable cause:
The pilot's failure to maintain minimum control airspeed after a loss of power to the right engine, which resulted in an uncontrollable roll into an inadvertent stall/spin. Contributing to the accident was the failure of the airplane's right engine for reasons that could not be determined because no preexisting mechanical anomalies were found, and the pilot's subsequent turn toward that inoperative engine while maintaining altitude.
Final Report:

Crash of a Beechcraft 200 Super King Air in Long Beach: 5 killed

Date & Time: Mar 16, 2011 at 1029 LT
Registration:
N849BM
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Long Beach - Salt Lake City
MSN:
BB-849
YOM:
1981
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
2080
Circumstances:
Witnesses reported that the airplane’s takeoff ground roll appeared to be normal. Shortly after the airplane lifted off, it stopped climbing and yawed to the left. Several witnesses heard abnormal sounds, which they attributed to propeller blade angle changes. The airplane’s flight path deteriorated to a left skid and its airspeed began to slow. The airplane’s left bank angle increased to between 45 and 90 degrees, and its nose dropped to a nearly vertical attitude. Just before impact, the airplane’s bank angle and pitch began to flatten out. The airplane had turned left about 100 degrees when it impacted the ground about 1,500 feet from the midpoint of the 10,000-foot runway. A fire then erupted, which consumed the fuselage. Review of a security camera video of the takeoff revealed that the airplane was near the midpoint of the runway, about 140 feet above the ground, and at a ground speed of about 130 knots when it began to yaw left. The left yaw coincided with the appearance, behind the airplane, of a dark grayish area that appeared to be smoke. A witness, who was an aviation mechanic with extensive experience working on airplanes of the same make and model as the accident airplane, reported hearing two loud “pops” about the time the smoke appeared, which he believed were generated by one of the engines intermittently relighting and extinguishing. Post accident examination of the airframe, the engines, and the propellers did not identify any anomalies that would have precluded normal operation. Both engines and propellers sustained nearly symmetrical damage, indicating that the two engines were operating at similar low- to mid-range power settings at impact. The airplane’s fuel system was comprised of two separate fuel systems (one for each engine) that consisted of multiple wing fuel tanks feeding into a nacelle tank and then to the engine. The left and right nacelle tanks were breached during the impact sequence and no fuel was found in either tank. Samples taken from the fuel truck, which supplied the airplane's fuel, tested negative for contamination. However, a fuels research engineer with the United States Air Force Fuels Engineering Research Laboratory stated that water contamination can result from condensation in the air cavity above a partially full fuel tank. Both diurnal temperature variations and the atmospheric pressure variations experienced with normal flight cycles can contribute to this type of condensation. He stated that the simplest preventive action is to drain the airplane’s fuel tank sumps before every flight. There were six fuel drains on each wing that the Pilot’s Operating Handbook (POH) for the airplane dictated should be drained before every flight. The investigation revealed that the pilot’s previous employer, where he had acquired most of his King Air 200 flight experience, did not have its pilots drain the fuel tank sumps before every flight. Instead, maintenance personnel drained the sumps at some unknown interval. No witnesses were identified who observed the pilot conduct the preflight inspection of the airplane before the accident flight, and it could not be determined whether the pilot had drained the airplane’s fuel tank sumps. He had been the only pilot of the airplane for its previous 40 flights. Because the airplane was not on a Part 135 certificate or a continuous maintenance program, it is unlikely that a mechanic was routinely draining the airplane's fuel sumps. The witness observations, video evidence, and the postaccident examination indicated that the left engine experienced a momentary power interruption during the takeoff initial climb, which was consistent with a power interruption resulting from water contamination of the left engine's fuel supply. It is likely that, during the takeoff rotation and initial climb, water present in the bottom of the left nacelle tank was drawn into the left engine. When the water flowed through the engine's fuel nozzles into the burner can, it momentarily extinguished the engine’s fire. The engine then stopped producing power, and its propeller changed pitch, resulting in the propeller noises heard by witnesses. Subsequently, a mixture of water and fuel reached the nozzles and the engine intermittently relighted and extinguished, which produced the grayish smoke observed in the video and the “pop” noises heard by the mechanic witness. Finally, uncontaminated fuel flow was reestablished, and the engine resumed normal operation. About 5 months before the accident, the pilot successfully completed a 14 Code of Federal Regulations Part 135 pilot-in-command check flight in a King Air 90. However, no documentation was found indicating that he had ever received training in a full-motion King Air simulator. Although simulator training was not required, if the pilot had received this type of training, it is likely that he would have been better prepared to maintain directional control in response to the left yaw from asymmetrical power. Given that the airplane’s airspeed was more than 40 knots above the minimum control speed of 86 knots when the left yaw began, the pilot should have been able to maintain directional control during the momentary power interruption. Although the airplane’s estimated weight at the time of the accident was about 650 pounds over the maximum allowable gross takeoff weight of 12,500 pounds, the investigation determined that the additional weight would not have precluded the pilot from maintaining directional control of the airplane.
Probable cause:
The pilot’s failure to maintain directional control of the airplane during a momentary interruption of power from the left engine during the initial takeoff climb. Contributing to the accident was the power interruption due to water contamination of the fuel, which was likely not drained from the fuel tanks by the pilot during preflight inspection as required in the POH.
Final Report:

Crash of a Cessna 525 CJ1 in Van Nuys: 2 killed

Date & Time: Jan 12, 2007 at 1107 LT
Type of aircraft:
Operator:
Registration:
N77215
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Van Nuys - Long Beach
MSN:
525-0149
YOM:
1996
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
38000
Captain / Total hours on type:
800.00
Aircraft flight hours:
3001
Circumstances:
Line personnel reported that as the airplane was being fueled, the second pilot loaded more than one bag in the left front baggage compartment. With fueling complete, line personnel saw the second pilot pull the front left baggage door down, but not lock or latch it. Witnesses near midfield of the 8,001-foot long runway, reported that the airplane was airborne, and the front left baggage door was closed. Witnesses near the end of the runway, reported that the airplane was about 200 feet above ground level (agl) and they noted that the front left baggage door was open and standing straight up. All of the witnesses reported that the airplane turned slightly left, leveled off, and was slow. The airplane began to descend, and the wings were slightly rocking before it stalled, broke right, and collided with the terrain. Investigators found no anomalies with the airframe or engines that would have precluded normal operation. The forward baggage doors' design incorporates a key lock in the lower center of each door, and two latches in the left and right bottom section of the doors. There are two hinges in the upper left and right sections of the door. The handles latched the door to the door frame in the fuselage. The key would be in the horizontal position in an unlocked condition, and in the vertical position in a locked condition. The front left baggage door was found within the main wreckage debris field and had sustained mechanical and thermal damage. The key lock was in the horizontal position. Several instances of a baggage door opening in flight have been recorded in Cessna Citation airplanes. In some cases, the door separated, and in others it remained attached. The crews of these other airplanes returned to the airport and landed successfully.
Probable cause:
The pilot's failure to maintain an adequate airspeed during the initial climb resulting in an inadvertent stall/spin. Contributing to the accident were the second pilots inadequate preflight, failure to properly secure the front baggage door, and the front left baggage door opening in flight, which likely distracted the first pilot.
Final Report:

Crash of a Cessna 421C Golden Eagle III in Santa Monica

Date & Time: Sep 23, 1999 at 0703 LT
Registration:
N26585
Survivors:
Yes
Schedule:
Long Beach – Santa Monica
MSN:
421C-0832
YOM:
1980
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
4050
Captain / Total hours on type:
2150.00
Aircraft flight hours:
3915
Circumstances:
During the final approach, while executing a VOR-A instrument approach, the airplane landed hard, collided with the runway VASI display, and caught fire. The airplane had received radar vectors for the approach and was turned to a 20-degree intercept for the final approach course when 2.5 miles from the initial approach fix. Radar track data showed the airplane continued inbound to the field slightly left of course with a ground speed varying between 135 and 125 knots and a descent rate of approximately 700 feet per minute. The pilot said he descended through the clouds about 850 feet above ground level and saw the airport approximately 1 to 2 miles ahead. He noticed that he was left of the runway centerline and corrected to the right. He realized that he had overcorrected and turned back to the left. The pilot reported that he felt that the approach was stabilized although the descent rate was greater than usual. The airplane impacted the ground about 1,000 feet from the approach end of the runway abeam the air traffic control tower on an approximate heading of 185 degrees. The impact collapsed the landing gear and the airplane slid forward another 1,000 feet down the runway and came to rest approximately midfield on the runway. The pilot stated that he had not experienced any mechanical problems with the aircraft or the navigation equipment prior to the accident. A Special Weather Observation taken at the time of the accident contained the following: sky condition overcast at 500 feet; winds from 230 degrees at 3 knots; visibility 2 miles.
Probable cause:
The failure of the pilot to establish and maintain a stabilized approach, which resulted in a hard landing and on-ground collision with the airport VASI display.
Final Report:

Crash of a Piper PA-31-310 Navajo off Monterey

Date & Time: Apr 14, 1999 at 1800 LT
Type of aircraft:
Registration:
N141CM
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Honolulu – Long Beach
MSN:
31-234
YOM:
1968
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
427
Captain / Total hours on type:
42.00
Aircraft flight hours:
4882
Circumstances:
The pilot reported that about 150 miles southwest of Monterey, the right engine made unusual noises, began to run rough, and exhibited high cylinder head temperature at the limits of the gauge. He advised Oakland Center of his position and situation, but did not declare an emergency. The pilot attempted to open the right engine cowl flap; however, it malfunctioned. He then increased fuel flow to the right engine in order to cool it and eventually had to reduce power on that side to keep it running. To compensate for the power loss in the right engine, he had to add power to the left engine. The combination of remedial actions increased the fuel consumption beyond his planned fuel burn rate. The flight attitude required by the asymmetric power also induced a periodic unporting condition in the outboard fuel tank pickups. The pilot said he was forced to switch to the inboard tanks until that supply was exhausted and then attempted to feed from the outboard tanks. The pilot said he was unsuccessful in maintaining consistent engine power output and was forced to ditch 20 miles short of the coastline. The pilot's VFR flight plan indicated that the total time en route would be 13 hours 10 minutes and total fuel onboard was 14 hours. The lapsed time from departure until the aircraft ditching was approximately 13 hours 12 minutes.
Probable cause:
An undetermined system malfunction in the right engine, which led to an increase in fuel usage beyond the pilot's planned fuel consumption rate and eventual fuel supply exhaustion.
Final Report:

Crash of a Swearingen SA227AC Metro III in Bullhead City

Date & Time: Jan 5, 1997 at 1243 LT
Type of aircraft:
Registration:
N165SW
Survivors:
Yes
Schedule:
Long Beach - Grand Canyon
MSN:
AC-514
YOM:
1982
Crew on board:
2
Crew fatalities:
Pax on board:
19
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3200
Captain / Total hours on type:
300.00
Copilot / Total flying hours:
640
Copilot / Total hours on type:
56
Aircraft flight hours:
25111
Circumstances:
After executing a missed approach at the Grand Canyon Airport, the pilots diverted to the Bullhead City Airport. The pilots reported that minimal icing conditions were encountered with about 1/8 inch of ice accumulating on the aircraft wings. The pilots stated they cycled the deice boots to shed ice. They did not observe ice on the propeller spinners, and they did not activate the engines' 'override' ignition systems, as required by the airplane's flight manual. Use of 'override' ignition was required for flight into visible moisture at or below +5 degrees Celsius (+41 degrees Fahrenheit) to prevent ice ingestion/flameouts. Subsequently, both engines flamed out as the airplane was on about a 3 mile final approach for landing with the landing gear and flaps extended. The aircraft was destroyed during an off-airport landing.
Probable cause:
Failure of the pilot(s) to use 'override' ignition as prescribed by checklist procedures during an encounter with icing conditions, which subsequently led to ice ingestion and dual engine flame-outs. Factors related to the accident were: the adverse weather (icing) conditions, the accumulation of airframe/engine ice, and lack of suitable terrain in the emergency landing area.
Final Report:

Crash of a Canadair CL-601-3A Challenger in Bassett

Date & Time: Mar 20, 1994 at 0036 LT
Type of aircraft:
Registration:
N88HA
Flight Type:
Survivors:
Yes
Schedule:
Lawrence – Burlington – Long Beach
MSN:
5072
YOM:
1990
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
7110
Captain / Total hours on type:
2570.00
Aircraft flight hours:
1109
Circumstances:
The pilots flew to Lawrence, MA to refuel for the return flight back to the west coast. They stated the fuel truck malfunctioned and stopped after it had pumped about 221 gallons into the airplane. They were warned about possible fuel contamination, but they reported sump samples did not reveal abnormal amounts of water. The pilots observed erroneous fuel totalizer indications during the low alt flight to Burlington, VT, where they topped off with fuel. The flight crew stated while in cruise flight at FL410, the left engine low fuel pressure light illuminated. Sometime later, the left engine lost power, followed by a loss of power in the right engine. Numerous restart attempts on both engines and the apu were unsuccessful. The pilots maneuvered towards the nearest airport, but were unable to visually identify the runway in time to land on it. The airplane touched down in a field, striking an irrigation structure and trees. Water-contaminated fuel was found in the fuel tanks, fuel filters, and throughout the fuel system.
Probable cause:
The pilot in command's inadequate planning/decision making and inadequate preflight inspection after receiving a load of contaminated fuel. Related factors are the contaminated fuel, improper refueling by FBO personnel, and the dark night light conditions.
Final Report:

Crash of a Cessna 414 Chancellor in Long Beach: 2 killed

Date & Time: Oct 26, 1991 at 0901 LT
Type of aircraft:
Registration:
N3843C
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Long Beach - Scottsdale
MSN:
414-0846
YOM:
1975
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
1510
Captain / Total hours on type:
317.00
Aircraft flight hours:
2711
Circumstances:
The pilot reported that he had lost the left engine during the initial climb phase of a cross-country flight. Ground witnesses observed that the airplane's landing gear was down and the left propeller was feathered as it turned left onto the downwind leg of the traffic pattern. Other witnesses observed the airplane's wings dip before it nosed over into the terrain while turning onto the final approach course. The airplane struck the ground and a fence that separated two residential yards. The wreckage examination disclosed that the left engine's scavenge pump failed. This failure led the pilot to believe that the engine failed. The pilot's improper emergency procedures by failing to retract the landing gear and maintain airspeed precipitated the resulting stall and uncontrolled descent. Both occupants were killed.
Probable cause:
The pilot's improper emergency procedures by not retracting the landing gear when he shut the engine down and his failure to maintain airspeed. The scavenge pump failure, shutting down the engine and the inadvertent stall were factors in the accident.
Final Report:

Crash of a Piper PA-31-310 Navajo in Sparks

Date & Time: Jan 31, 1989 at 2159 LT
Type of aircraft:
Registration:
N88RG
Flight Type:
Survivors:
Yes
Schedule:
Sparks – Long Beach
MSN:
31-667
YOM:
1970
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
2200
Captain / Total hours on type:
200.00
Circumstances:
During the climbout, in night visual meteorological conditions, the aircraft lost right engine power. The pilot was initially cleared for one runway, but was unable to get a safe gear indication. The pilot made a 180° turn to land on the opposite runway while attempting to get a safe gear indication. On turn from base to final, with the gear down and locked, the pilot overshot final approach. The pilot then chose an unlit parking lot to make an off-airport landing. The aircraft struck a tree and a power line. The aircraft struck several parked unoccupied vehicles during the landing. The faa reported that an on-site inspection revealed a failed right turbocharger. Both occupants were seriously injured.
Probable cause:
The pilot's misjudgement of the forced landing profile. Contributing to the accident was the failure of the right turbocharger and the pilot's improper handling of the landing gear system. Occurrence #1: loss of engine power (partial) - mech failure/malf
Phase of operation: climb
Findings
1. 1 engine
2. (f) exhaust system, turbocharger - failure, total
----------
Occurrence #2: airframe/component/system failure/malfunction
Phase of operation: approach - vfr pattern - downwind
Findings
3. (f) landing gear, normal retraction/extension assembly - improper
----------
Occurrence #3: in flight collision with object
Phase of operation: approach
Findings
4. (f) light condition - dark night
5. (c) planned approach - misjudged - pilot in command
6. (f) object - tree(s)
7. (f) object - wire, static
----------
Occurrence #4: on ground/water collision with object
Phase of operation: landing - flare/touchdown
Findings
8. Object - vehicle
Final Report:

Crash of a Piper PA-46-310P Malibu in Long Beach: 1 killed

Date & Time: Nov 29, 1987 at 1843 LT
Operator:
Registration:
N4369V
Flight Type:
Survivors:
Yes
Schedule:
Carslbad - Long Beach
MSN:
46-8408076
YOM:
1984
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
4782
Captain / Total hours on type:
237.00
Circumstances:
During the return flight to San Jose and subsequent descent and approach to the Long Beach Airport, the two pilots experienced, in succession, a failure of the turbocharger system, loss of an alternator, loss of engine oil pressure, an unsafe landing gear indication, and an in-flight fire followed by the loss of engine power during a night time circling approach to an unfamiliar airport in visual meteorological conditions. The aircraft crashed onto the southbound lanes of the San Diego freeway at Long Beach after making a flyby of the tower to confirm the landing gear position. The investigation revealed an improperly installed turbocharger, a cracked manifold exhaust, a burned main power lead, a separated cylinder, and a low fluid level in the hydraulic reservoir. Two years prior to this accident, the instructor pilot made an unintentional gear up landing in another aircraft. One year prior to this accident the FAA revoked the mechanic's inspection authorization.
Probable cause:
The National Transportation Safety Board determines the probable cause(s) of this accident to be:
Pilot's failure to land the aircraft after experiencing the pilot's Faulty decision was his previous experience with a gear up landing a Couple of years before.
Findings
Occurrence #1: airframe/component/system failure/malfunction
Phase of operation: cruise - normal
Findings
1. Exhaust system, turbocharger - failure, partial
2. (f) exhaust system, turbocharger - disengaged
3. (f) engine installation, mounting bolt - separation
4. (c) maintenance, installation - improper - company maintenance personnel
5. (f) maintenance, inspection - poor - company maintenance personnel
----------
Occurrence #2: airframe/component/system failure/malfunction
Phase of operation: descent - emergency
Findings
6. (f) electrical system, electric wiring - burned
7. Electrical system, alternator - disabled
8. (c) hydraulic system, accumulator - low level
9. Landing gear, gear indicating system - false indication
10. (c) low pass - intentional - pilot in command (cfi)
11. (f) anxiety/apprehension - pilot in command (cfi)
----------
Occurrence #3: fire
Phase of operation: go-around (vfr)
Findings
12. (c) engine assembly, cylinder - fatigue
13. Engine assembly, cylinder - separation
14. Go-around - performed - pilot in command (cfi)
15. (f) judgment - poor - pilot in command (cfi)
----------
Occurrence #4: loss of engine power (total) - mech failure/malf
Phase of operation: approach - vfr pattern - base leg/base to final
Findings
16. (f) fluid, oil - starvation
----------
Occurrence #5: in flight collision with terrain/water
Phase of operation: descent - uncontrolled
Findings
17. Light condition - night
18. (c) stall/mush - encountered - pilot in command (cfi)
Final Report: