Crash of a Piper PA-31T Cheyenne II near McKinleyville: 4 killed

Date & Time: Jul 29, 2016 at 0105 LT
Type of aircraft:
Operator:
Registration:
N661TC
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Crescent City – Oakland
MSN:
31-8120022
YOM:
1981
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
7300
Captain / Total hours on type:
125.00
Aircraft flight hours:
7309
Circumstances:
About 13 minutes after takeoff for a medical transport flight, while climbing through about 14,900 ft mean sea level (msl), the pilot reported to air traffic control (ATC) that he was smelling smoke in the cockpit and would be returning to the originating airport. The flight was cleared to return with a descent at pilot's discretion to 9,000 ft msl. The pilot replied, "okay," and said that it looked like he was going to lose some power shortly. The pilot then stated that he had smoke in the cockpit, declared an emergency, and requested that ATC contact the fire department. About 1 minute 15 seconds after the initial report of smelling smoke, the pilot made the last radio transmission of the flight stating that he had three people on board. The wreckage was located about 9 hours later in an area of brush and heavily forested terrain. Portions of the burned and fragmented wreckage were scattered along a debris path that measured about 2,400 ft in length, which is consistent with an inflight breakup. The center fuselage and cockpit areas were largely intact and displayed no evidence of fire; however, there was an area of thermal damage to the forward fuselage consistent with an inflight fire. The thermal damage was primarily limited to the floor area between the two forward seats near the main bus tie circuit breaker panel and extended to the forward edge of the wing spar. All exposed surfaces were heavily sooted. Some localized melting and thermal-related tearing of the aluminum structure was present. The primer paint on the floor panels under the right aft corner of the pilot seat and the left aft corner of the co-pilot seat was discolored dark brown. An aluminum stringer in this location exhibited broomstrawing indicating that the stringer material was heated to near its melting point prior to impact. A single wire located in the area exhibited notching consistent with mechanical rubbing. The main bus tie circuit breakers were partially missing. The remaining breakers were heavily sooted on their aft ends, and one breaker was thermally discolored. Areas of charring were on the backside of the panel. Examination of the wiring in this area showed evidence of electrical arcing damage. Four hydraulic lines servicing the landing gear system were located in this area, and all the lines exhibited signs of thermal exposure with melting and missing sections of material. Six exemplar airplanes of the same make and model as the accident airplane were examined, and instances of unsafe conditions in which electrical lines and hydraulic lines in the area of the main bus tie circuit breaker panel were in direct contact were found on all six airplanes. Some of the wires in the exemplar airplanes showed chafing between hydraulic lines and the electrical wires, which, if left uncorrected, could have led to electrical arcing and subsequent fire. Based on the unsafe conditions found during examination of the exemplar airplanes and the thermal damage to the area near the main bus tie circuit breaker panel on the accident airplane, including broomstrawing of the aluminum structure, electrical arcing damage to the wiring, and melting of the hydraulic lines, it is likely that an electrical wire near the tie bus circuit breakers chafed on a hydraulic line and/or airplane structure, which resulted in arcing and a subsequent in-flight fire that was fed by the hydraulic fluid.
Probable cause:
An inflight fire in the floor area near the main bus tie circuit breaker panel that resulted from chafing between an electrical wire and a hydraulic line and/or airplane structure.
Final Report:

Crash of a Piper PA-31-325 Navajo C/R in Kahului

Date & Time: Feb 18, 2004 at 1352 LT
Type of aircraft:
Registration:
C-GPTE
Flight Type:
Survivors:
Yes
Schedule:
Honolulu – Oakland – Brooks
MSN:
31-7712059
YOM:
1977
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Aircraft flight hours:
7923
Circumstances:
The airplane collided with terrain 200 yards short of the runway during an emergency landing following a loss of engine power. The pilot was on an intermediate leg of a ferry trip. Approximately 300 miles from land, the fuel flow and boost pump lights illuminated. Then, the right engine failed. The pilot flew back to the nearest airport; however, approximately 200 yards from the runway, the airplane stalled and the right wing dropped and collided with the ground. The fuel system had been modified a few months prior to the accident to allow for a ferry fuel tank installation. Post accident examination of the airplane could not find a reason for the power loss.
Probable cause:
The pilot's failure to maintain an adequate airspeed while maneuvering for landing on one engine, which resulted in an inadvertent stall. The loss of power in one engine for undetermined reasons was a factor.
Final Report:

Crash of a PAC 750XL in the Pacific Ocean: 1 killed

Date & Time: Dec 26, 2003 at 0601 LT
Operator:
Registration:
ZK-UAC
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Hamilton – Pago Pago – Christmas Island – Kiribati – Hilo – Oakland
MSN:
103
YOM:
2003
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
16564
Captain / Total hours on type:
180.00
Aircraft flight hours:
65
Circumstances:
The pilot was ferrying the aircraft from Hamilton, New Zealand to Davis, California, via Pago Pago, American Samoa; Christmas Island, Kiribati; and Hilo, Hawaii. On the final leg, following a position report 858 nm from San Francisco, he reported a problem with his fuel system, indicating a probable ditching. Under the observation of a US Coast Guard HC-130 crew, the pilot ditched the aircraft at 1701 UTC, 341 nm from San Francisco, the aircraft nosing over on to its back as it touched down. The pilot did not emerge as expected and was later found by rescue swimmers, deceased, still in the cockpit. His body could not be recovered and was lost with the aircraft.
Probable cause:
The following findings were reported:
- The pilot was appropriately licensed, rated and experienced for the series of flights undertaken.
- The aeroplane had a valid airworthiness certificate and had been released to service.
- There was nothing (other than the item in 3.5) to suggest that the aeroplane was operating abnormally on the final flight.
- The aeroplane was being operated at 14 000 feet pressure altitude without supplementary oxygen as required by CAR 91.209 and 91.533.
- The left front fuel filler orifice was observed to be leaking fuel before departure.
- There was no attempt made to further investigate or correct this fuel leak and the pilot stated that it would stop once he departed.
- On most other aircraft this would be true, once the fuel level dropped away from the filler orifice and was no longer affected by aerodynamic suction.
- On the 750XL, the fuel system design was such that the front tanks were continuously topped up.
- The fuel loss would continue until all fuel in the rear tanks and the ferry system was consumed.
- The front fuel caps are thus critical items to be checked before flight.
- The fuel quantity uplifted at Hilo indicated that the problem had existed on the previous leg with a loss rate of up to 125 litres (33.2 US gallons) per hour.
- A comparison of the uplift figure with the expected consumption on the previous leg should have provided sufficient warning to the pilot that a problem existed.
- The existence of the problem could have been detected on the final flight by the shortened top-up intervals and by comparing fuel used by the engine with fuel remaining.
- Cumulative delays, especially including the longer than normal final refuelling time, probably influenced the pilot’s decision to depart without further checking the reason for the fuel leak or the apparent discrepancy between fuel figures.
- Cumulative fatigue, circadian rhythm and hypoxia were probably significant factors in the pilot’s failure to detect the fuel problem in flight, in time to make a safe return.
- By the time the pilot announced that he had a fuel problem, the only course of action open to him was ditching the aeroplane.
- The search and rescue facilities were activated appropriately, and had the potential to effect a successful rescue.
- The water entry impact on ditching was reasonably severe and probably incapacitated the pilot before he could vacate the cockpit.
Final Report:

Crash of a Douglas DC-10-10 in Memphis

Date & Time: Dec 18, 2003 at 1226 LT
Type of aircraft:
Operator:
Registration:
N364FE
Flight Type:
Survivors:
Yes
Schedule:
Oakland – Memphis
MSN:
46600
YOM:
1971
Flight number:
FDX647
Crew on board:
2
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
21000
Captain / Total hours on type:
2602.00
Copilot / Total flying hours:
15000
Copilot / Total hours on type:
1918
Aircraft flight hours:
65375
Aircraft flight cycles:
26163
Circumstances:
On December 18, 2003, about 1226 central standard time, Federal Express Corporation (FedEx) flight 647, a Boeing MD-10-10F (MD-10), N364FE, crashed while landing at Memphis International Airport (MEM), Memphis, Tennessee. The right main landing gear collapsed after touchdown on runway 36R, and the airplane veered off the right side of the runway. After the gear collapsed, a fire developed on the right side of the airplane. Of the two flight crewmembers and five non revenue FedEx pilots on board the airplane, the first officer and one non revenue pilot received minor injuries during the evacuation. The post crash fire destroyed the airplaneís right wing and portions of the right side of the fuselage. Flight 647 departed from Metropolitan Oakland International Airport (OAK), Oakland, California, about 0832 (0632 Pacific standard time) and was operating under the provisions of 14 Code of Federal Regulations (CFR) Part 121 on an instrument flight rules flight plan.
Probable cause:
The National Transportation Safety Board determines that the probable causes of the accident were:
1) the first officerís failure to properly apply crosswind landing techniques to align the airplane with the runway centerline and to properly arrest the airplaneís descent rate (flare) before the airplane touched down; and
2) the captain's failure to adequately monitor the first officerís performance and command or initiate corrective action during the final approach and landing.
Final Report:

Crash of a Rockwell Grand Commander 690A in Bishop: 4 killed

Date & Time: Aug 11, 2002 at 0123 LT
Operator:
Registration:
N690TB
Flight Type:
Survivors:
No
Schedule:
Oakland - Bishop
MSN:
690-11109
YOM:
1973
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
3802
Captain / Total hours on type:
52.00
Aircraft flight hours:
3782
Circumstances:
The pilot entered the left-hand traffic pattern at an uncontrolled airport on a dark moonless night. Witnesses reported observing the airplane in a left descending turn. As the airplane turned onto the base leg, its left bank angle suddenly became steep. The airplane rapidly descended until colliding with level desert terrain 1.63 nm from runway 30's threshold. There were no ground reference lights in the accident site area. An examination of the airplane structure, control systems, engines, and propellers did not reveal any evidence of preimpact malfunctions or failures. Signatures consistent with engine power were found in both the engines and the propellers. The wreckage examination revealed that the airplane descended into the terrain in a left wing and nose low attitude. Fragmentation evidence, consisting of the left navigation light lens and left propeller spinner, was found near the initial point of impact. The wreckage was found principally distributed along a 307- to 310-degree bearing, over a 617- foot-long path. The bearing between the initial point of impact and the runway threshold was 319 degrees. The pilot's total logged experience in the accident airplane was 52 hours, of which only 1.6 hours were at night. The pilot was familiar with the area, but he had made only two nighttime landings within the preceding 90 days. Review of the recorded ATC communications tapes did not reveal any evidence of pilot impairment during voice communications with the pilot.
Probable cause:
The pilot's failure to maintain an appropriate terrain clearance altitude while maneuvering in the traffic pattern due to the sensory and visual illusions created by a lack of ground reference lights and/or terrain conspicuity, and the dark nighttime conditions.
Final Report:

Crash of a Piper PA-31-350 Navajo Chieftain near Novato: 1 killed

Date & Time: Mar 5, 1998 at 1905 LT
Operator:
Registration:
N257NW
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Santa Rosa - Oakland
MSN:
31-7952014
YOM:
1979
Flight number:
APC263
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
4300
Aircraft flight hours:
6881
Circumstances:
The airplane was on a VFR dusk cross-country flight when it collided with the 1,500-foot level of a hill. Radar data showed the aircraft in a descent from 2,000 feet until radar contact was lost about 1,500 feet msl, with a final ground speed of 194 knots. The route taken by the pilot was about 5 miles west of the route that the company pilots routinely flew, but while crossing higher terrain, it was a more direct route to the destination. A company pilot flying a few minutes ahead of the accident flight reported it was necessary to descend to between 1,200 and 1,500 feet msl in order to maintain VFR. A low-pressure system approaching the area from the west had resulted in low stratus, rain, and fog. At the time of the accident, a nearby weather reporting facility reported a 1,300-foot broken ceiling with 5- to 6-mile visibility in light rain and mist. On the evening of the accident, the pilot was scheduled to give a speech as her final examination in an evening college course. She had informed the instructor that she might be late, but had been told that he could not hold the class past its scheduled dismissal time to accommodate her late arrival.
Probable cause:
The pilot's failure to maintain adequate terrain clearance after initiating a descent over mountainous terrain at night and under marginal VFR conditions. The pilot's self-induced pressure to arrive at class with enough time remaining to take the final examination was a factor in the accident.
Final Report:

Crash of a De Havilland DHC-6 Twin Otter 300 in the Pacific Ocean

Date & Time: Apr 12, 1997 at 2204 LT
Operator:
Registration:
N242CA
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Oakland - Honolulu
MSN:
342
YOM:
1972
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
25000
Captain / Total hours on type:
1000.00
Aircraft flight hours:
9873
Circumstances:
On a ferry flight from Oakland, California, to Honolulu, Hawaii, the pilot declared a low fuel emergency and diverted toward Hilo, Hawaii. Approximately 2.5 hours later, the aircraft was ditched in the Pacific ocean. The pilot evacuated the aircraft before it sank and was rescued by the U.S. Coast Guard. He stated that, under flight planned conditions, the aircraft departed Oakland with sufficient fuel onboard to reach the intended destination with a 2-hour fuel reserve. However, the winds at flight altitude, which were reported as light and variable at the preflight weather briefing, developed into a significant headwind during the flight. At a point 7 hours and 10 minutes into the flight, the pilot determined that his fuel remaining was 8 hours and 40 minutes, with 7 hours and 40 minutes remaining to destination. Three hours later, the pilot determined that his 2-hour reserve was gone. He declared an emergency and diverted toward the closest airport, which was Hilo. Prior to fuel system exhaustion, the pilot elected to ditch the aircraft with power.
Probable cause:
The pilot's inadequate en route fuel consumption calculations, which led to his failure to recognize a deteriorating fuel duration versus time-to-go situation in a more timely way.
Final Report:

Crash of a Piper PA-31-350 Navajo Chieftain in San Jose: 2 killed

Date & Time: Dec 23, 1995 at 0019 LT
Operator:
Registration:
N27954
Flight Type:
Survivors:
No
Site:
Schedule:
Oakland - San Jose
MSN:
31-7952062
YOM:
1979
Flight number:
AMF041
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
4659
Captain / Total hours on type:
914.00
Aircraft flight hours:
9840
Aircraft flight cycles:
10966
Circumstances:
The aircraft impacted mountainous terrain in controlled flight during hours of darkness and marginal VFR conditions. The flight was being vectored for an instrument approach during the pilot's 14 CFR Part 135 instrument competency check flight. The flight was instructed by approach control to maintain VFR conditions, and was assigned a heading and altitude to fly which caused the aircraft to fly into another airspace sector below the minimum vectoring altitude (MVA). FAA Order 7110.65, Section 5-6-1, requires that if a VFR aircraft is assigned both a heading and altitude simultaneously, the altitude must be at or above the MVA. The controller did not issue a safety alert, and in an interview, said he was not concerned when the flight approached an area of higher minimum vectoring altitudes (MVA's) because the flight was VFR and 'pilots fly VFR below the MVA every day.' At the time of the accident, the controller was working six arrival sectors and experienced a surge of arriving aircraft. The approach control facility supervisor was monitoring the controller and did not detect and correct the vector below the MVA.
Probable cause:
The failure of the air traffic controller to comply with instructions contained in the Air Traffic Control Handbook, FAA Order 7110.65, which resulted in the flight being vectored at an altitude below the minimum vectoring altitude (MVA) and failure to issue a safety advisory. In addition, the controller's supervisor monitoring the controller's actions failed to detect and correct the vector below the MVA. A factor in the accident was the flightcrew's failure to maintain situational awareness of nearby terrain and failure to challenge the controller's instructions.
Final Report:

Crash of a De Havilland DHC-6 Twin Otter 200 in the Pacific Ocean

Date & Time: Mar 16, 1995 at 0515 LT
Operator:
Registration:
N37ST
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Oakland – Honolulu – Majuro – Suva – Auckland
MSN:
207
YOM:
1969
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
1100
Captain / Total hours on type:
200.00
Circumstances:
The aircraft departed overweight for a 17-hour ferry flight. Early in the flight the crew experienced some fuel problems and decided to continue when they resolved the problem. The crew indicated the en route winds were close to forecast. The ferry fuel system is a simple 5- tank gravity fuel feed into the fore and aft main tanks. About 6 hours from destination, they realized the ferry tanks were not flowing into the main tanks as planned. They began manually transferring fuel from the rear ferry tank to the forward ferry tank, and shut down the right engine to reduce fuel consumption. This did not stop the negative fuel flow from the main tanks. At the time of ditching, the crew estimated the fuel remaining in the ferry tanks was about 170 gallons, most of which was in the 3 aft ferry tanks. An aero engineer calculated that the aircraft was at least 10 inches behind the maximum aft cg at the time of ditching, and suggested that the ferry fuel system was not managed to maintain the cg within the allowable limits, a task made more difficult with the rear fuselage cargo.
Probable cause:
Intentional ditching due to the flightcrew's failure to properly manage the fuel system, and operation of the airplane in an excessively overweight condition.
Final Report:

Crash of a Cessna 208B Super Cargomaster in Pleasanton: 1 killed

Date & Time: Jan 12, 1995 at 1747 LT
Type of aircraft:
Operator:
Registration:
N754FE
Flight Type:
Survivors:
No
Site:
Schedule:
Visalia - Oakland
MSN:
208B-0249
YOM:
1991
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
25500
Captain / Total hours on type:
516.00
Aircraft flight hours:
2073
Circumstances:
A Cessna 208B struck a ridge line about 14 miles from the destination airport. The pilot reported to atc he had the airport in sight from 7,000 feet msl more than 30 miles away. A weather reporting station located 5 miles east of the accident site was reporting two cloud layers; a scattered layer at 1,500 feet agl, and a broken layer at 5,000 feet agl. The airplane was descending after the pilot was cleared for a visual approach. The airplane collided with a tree and the ground in a wings level attitude at an elevation of 1,500 feet msl. There was no evidence of mechanical failure or malfunction found with the airplane.
Probable cause:
Failure of the pilot-in-command to maintain visual contact with terrain and sufficient altitude for terrain clearance. Factors in the accident were the pilot's decision to initiate a descent 14 miles from the airport, and weather, specifically cloud conditions and darkness.
Final Report: