Crash of a BAe 3101 Jetstream 31 in Hibbing: 18 killed

Date & Time: Dec 1, 1993 at 1950 LT
Type of aircraft:
Operator:
Registration:
N334PX
Survivors:
No
Schedule:
Minneapolis - Hibbing
MSN:
706
YOM:
1986
Flight number:
NW5719
Crew on board:
2
Crew fatalities:
Pax on board:
16
Pax fatalities:
Other fatalities:
Total fatalities:
18
Captain / Total flying hours:
7852
Captain / Total hours on type:
2266.00
Copilot / Total flying hours:
2019
Copilot / Total hours on type:
65
Aircraft flight hours:
17156
Aircraft flight cycles:
21593
Circumstances:
While on a localizer back course approach the airplane collided with trees and the terrain approximately 3 miles from the runway threshold. The captain delayed the start of the descent that subsequently required an excessive descent rate to reach the FAF and MDH. The captain's actions led to distractions during critical phases of the approach. The flightcrew lost altitude awareness and allowed the airplane to descend below mandatory level off points. The captain's record raised questions about his airmanship and behavior that suggested a lack of crew coordination during flight operations, including intimidation of first officers. Company management did not address these matters adequately. The airline's flight operations management failed to implement provisions to adequately oversee the training of their flight crews and the operation of their aircraft. FAA guidance to their inspectors concerning implementation of ops bulletins is inadequate and has failed to transmit valuable safety information as intended to airlines. The aircraft was totally destroyed and all 18 occupants were killed.
Probable cause:
The captain's actions that led to a breakdown in crew coordination and the loss of altitude awareness by the flight crew during an unstabilized approach in night instrument meteorological conditions. Contributing to the accident were: the failure of the company management to adequately address the previously identified deficiencies in airmanship and crew resource management of the captain; the failure of the company to identify and correct a widespread, unapproved practice during instrument approach procedures; and the Federal Aviation Administration's inadequate surveillance and oversight of the air carrier.
Final Report:

Crash of a Beechcraft E18S in Lone Rock: 1 killed

Date & Time: May 4, 1993 at 0140 LT
Type of aircraft:
Operator:
Registration:
N80CB
Flight Type:
Survivors:
No
Schedule:
Aurora - Minneapolis
MSN:
BA-257
YOM:
1957
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
4492
Captain / Total hours on type:
310.00
Aircraft flight hours:
15027
Circumstances:
The pilot of a twin-engine cargo airplane shut down the left engine and feathered the propeller due to a loss of engine oil. The FAA ARTCC handling the flight vectored the airplane toward a VOR. Due to the airplane's altitude and distance from the center's radar, the pilot of the airplane had to perform a full instrument approach procedure. The airplane maintained its enroute assigned altitude until passing the VOR outbound. Ntap readouts show the airplane descending throughout the procedure turn and inbound leg of the approach. The airplane's last radar contact was 300 feet below the inbound altitude for the approach while outside the final approach fix. The airplane collided with trees and terrain approximately 2 1/4 miles from the airport. The VOR is 5.5 miles from the airport. The on-scene investigation revealed the left engine's propeller had been feathered, its number nine cylinder mounting studs on the engine's case were crushed downward or were broken off at the case's surface, and the landing gear had been extended. The pilot, sole on board, was killed.
Probable cause:
The National Transportation Safety Board determines the probable cause(s) of this accident to be: was a pre-mature extension of the landing gear by the pilot which resulted in the inability of
the pilot to maintain the minimum descent altitude. Factors related to the accident were the loose cylinder and loss of oil.
Final Report:

Crash of a Saab 340A in Hibbing

Date & Time: Jan 2, 1993 at 1942 LT
Type of aircraft:
Registration:
N342PX
Survivors:
Yes
Schedule:
Minneapolis - Hibbing
MSN:
147
YOM:
1989
Crew on board:
3
Crew fatalities:
Pax on board:
28
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
6500
Captain / Total hours on type:
2800.00
Circumstances:
During the approach, the 1st officer (FO) asked the captain if he wanted to '...pop the boots?' to remove ice off the wings. The capt responded '...it's going to the hangar. I'll run'em on the ground...' The FO retarded power over the threshold and the sink rate increased; the capt observed 900 fpm. The FO applied additional back pressure on the yoke, but it was inadequate to arrest the high sink rate. Additional back pressure was applied, and the stall horn sounded followed shortly thereafter by the captain stating 'I got it.' During the hard landing the right main landing gear broke, the fuel tank ruptured, and the right wing rear spar bent upward. Aprx 18 hrs after the accident, 3/16 inch of rime mixed with clear ice was observed on the leading edges of the wing, horizontal stab, and vertical stab. The ice had finger-like protrusions positioned vertically to the wing surfaces. The company's line ops manual does not discuss flight characteristics or landing techniques specific to wing ice. Neither pilot had received company's current crm training.
Probable cause:
The first officer's failure to maintain a proper descent rate during the landing, and the captain's inadequate supervision by not taking timely action to ensure a safe landing. Factors which contributed to the accident were: the company's failure to provide adequate training on the airplane's flight characteristics and/or handling techniques under conditions of wing ice contamination, the company's failure to assure that both pilots had received the current crew resource management (crm) training, and the existing weather conditions which resulted in an accumulation of ice on the airplane's wing.
Final Report:

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

Date & Time: Jan 4, 1992 at 1606 LT
Operator:
Registration:
N1974G
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Steamboat Springs - Minneapolis
MSN:
421B-0862
YOM:
1974
Crew on board:
1
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
4000
Aircraft flight hours:
2916
Circumstances:
While initiating a cross country flight, the eight place aircraft with nine persons aboard, impacted terrain shortly after takeoff. Ice had been seen on the wings and horizontal stabilizer, and icing conditions were present. The aircraft was over maximum gross weight by a minimum of 258 pounds, and the pilot held an expired student pilot certificate dated august 17, 1984. A copy of a private pilot certificate designating multiengine land and instrument was found in the pilot's personal belongings. Faa officials concluded that it was not a valid certificate. An application for a medical certificate dated may 30, 1991, indicated the pilot had 4,000 hours of flight time. This figure could not be verified. Just prior to takeoff the pilot was observed brushing snow off the wings. Following the accident granular ice was found on the aerodynamic surfaces. The pilot and two passengers were killed while six other occupants were injured.
Probable cause:
Airframe ice and the pilot's failure to remove it. Factors were: aircraft weight exceeded and lack of pilot certification.
Final Report:

Crash of a Piper PA-31P Pressurized Navajo in Mosinee: 1 killed

Date & Time: Jan 2, 1992 at 1305 LT
Type of aircraft:
Operator:
Registration:
N500BH
Survivors:
No
Schedule:
Minneapolis - Mosinee
MSN:
31-7530024
YOM:
1975
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
8150
Captain / Total hours on type:
1500.00
Aircraft flight hours:
3520
Circumstances:
Pilot was cleared for an ILS approach at his destination, and requested to report altitude of 3,000 feet on the approach. This was the last radio transmission received from the pilot. Aircraft was found in soft field six miles from the airport. Landing gear was up, flaps were down. Fisherman nearby reported hearing the aircraft maneuvering at low altitude. He reported that the engines sounded fine, but the sound was changing in pitch and intensity. He reported that got quiet just a few seconds before he heard the impact. The investigation revealed that there was evidence of a fire in the nose baggage compartment. The cabin heater is located in the nose baggage compartment, and had a recent history of discrepancies. The pilot, sole on board, was killed.
Probable cause:
An inflight fire with the cabin heater as the origin, and unsuitable terrain in which to make a forced landing. A factor related to the accident was the soft terrain.
Final Report:

Crash of a Learjet 35A in Rochester: 3 killed

Date & Time: Dec 8, 1985 at 1339 LT
Type of aircraft:
Operator:
Registration:
N15TW
Flight Type:
Survivors:
No
Schedule:
Minneapolis - Rochester
MSN:
35-106
YOM:
1977
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
4986
Circumstances:
The aircraft had just successfully completed a series of practice approaches to a full stop. The training flight was being conducted to give refresher training to the pilot who had not flown a Lear Jet in over a year and had never flown a lear model 35. The flight instructor requested a practice approach with a missed approach and was cleared for the option. Witnesses stated that the aircraft rolled right and then rolled left to an inverted position. Colliding with the ground shortly thereafter. All three occupants were killed.
Probable cause:
Occurrence #1: loss of control - in flight
Phase of operation: go-around (vfr)
Findings
1. (c) directional control - not corrected - pilot in command (cfi)
2. (f) overconfidence in personal ability - pilot in command (cfi)
3. (c) remedial action - not performed - pilot in command (cfi)
4. (f) lack of recent experience in type of aircraft - dual student
----------
Occurrence #2: in flight collision with terrain/water
Phase of operation: descent - uncontrolled
Final Report:

Crash of a Cessna 207 Skywagon in Golden Valley

Date & Time: May 18, 1985 at 0656 LT
Registration:
N91043
Flight Phase:
Flight Type:
Survivors:
Yes
Site:
Schedule:
Minneapolis - Crystal
MSN:
207-0030
YOM:
1969
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
1800
Captain / Total hours on type:
607.00
Aircraft flight hours:
4002
Circumstances:
Shortly after takeoff, on the last leg on it's flight, the engine of the air cargo aircraft started to sputter. The pilot turned the fuel selector handler from the left tank to another position and turned on the boost pump. The engine stopped running and the pilot elected to land in a public park. The left wing was torn off the aircraft during the emergency landing. Investigation revealed that the fuel selector had been turned to the 'off' position, a check of the fuel quantity in each tank showed less than five gallons in the left tank and about twelve gallons in the right tank. Sole on board, the pilot was slightly injured.
Probable cause:
Occurrence #1: loss of engine power (total) - nonmechanical
Phase of operation: cruise - normal
Findings
1. (f) fluid, fuel - starvation
2. (f) preflight planning/preparation - inadequate - pilot in command
3. (c) fuel tank selector position - improper - pilot in command
4. (c) in-flight planning/decision - inadequate - pilot in command
5. (f) procedures/directives - misjudged - pilot in command
6. (f) diverted attention - pilot in command
----------
Occurrence #2: forced landing
Phase of operation: descent - emergency
----------
Occurrence #3: in flight collision with terrain/water
Phase of operation: descent - emergency
Findings
7. (f) object - tree(s)
8. Wing - separation
Final Report:

Crash of a Lockheed L-188C Electra in Reno: 70 killed

Date & Time: Jan 21, 1985 at 0104 LT
Type of aircraft:
Operator:
Registration:
N5532
Survivors:
Yes
Schedule:
Reno - Minneapolis
MSN:
1121
YOM:
1960
Flight number:
GX203
Crew on board:
6
Crew fatalities:
Pax on board:
65
Pax fatalities:
Other fatalities:
Total fatalities:
70
Captain / Total flying hours:
14500
Captain / Total hours on type:
5600.00
Copilot / Total flying hours:
5000
Copilot / Total hours on type:
172
Aircraft flight hours:
34148
Aircraft flight cycles:
33285
Circumstances:
A Galaxy Airlines Lockheed L-188A Electra, registration N5532, was scheduled operate flights from Seattle (SEA) to Oakland as Flight 201, from Oakland to Reno (RNO) as Flight 202, from Reno (RNO) to Minneapolis (MSP) as Flight 203 and finally returning to Seattle using flight number 204. Scheduled departure time for Flight 201 had been 15:30, but had been delayed and the airplane departed Seattle at 20:19 on a ferry flight to Oakland, where it arrived at 22:25. Sixty-five passengers boarded the plane for the flight to Reno. Following ground servicing the ground handler supervisor signalled to the crew that they could commence engine starting. However, after engines one and four were started, he noticed that the other ground handler was unable to disconnect the air start hose. It was stretched taut from the power cart to the airplane’s air start access panel, located on the underside of the right wing leading edge, close to the fillet area. The supervisor gave the flightcrew an emergency stop signal, left his position, and disconnected the hose. None of the two ground crew members remembered closing the air start access door. At approximately 00:59 the first officer requested taxi instructions Reno tower almost immediately thereafter cleared Galaxy 203 to taxi to runway 16R. The aircraft taxied to the runway and at 01:01:32 the first officer requested takeoff clearance. Four seconds later Galaxy 203 was given clearance to take off from runway 16R. While accelerating through V1 speed, a "thunking" type sound was heard, followed by another one just after V2. Heavy airframe vibration started after liftoff. The captain reacted to the airplane’s vibration by reducing power significantly in all four engines, indicating that he believed the vibration was caused by the powerplants or propellers. The airplane reached an altitude of about 200-250 feet and started a right hand turn to return to the airport. The Electra then entered an aerodynamic stall buffet because of insufficient engine power to maintain flight. The Electra crashed into a field, bounced, slid into some mobile homes and burst into flames. Of the 71 occupants, three initially survived the crash. One died on January 29, while the second died of injuries on February 4. The sole survivor, a 17-year-old male, was thrown clear of the airplane onto the adjacent highway.
Probable cause:
The captain's failure to control and the co-pilot's failure to monitor the flight path and airspeed of the aircraft. This breakdown in crew coordination followed the onset of unexpected vibration shortly after takeoff. Contributing to the accident was the failure of ground handlers to properly close an air start access door, which led to the vibration.
Final Report: