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Crash of a Cessna 500 Citation in San Luis Obispo: 4 killed

Date & Time: Sep 24, 1990 at 0702 LT
Type of aircraft:
Registration:
N79DD
Flight Type:
Survivors:
No
Schedule:
Van Nuys - San Luis Obispo
MSN:
500-0254
YOM:
1975
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
1021
Captain / Total hours on type:
95.00
Aircraft flight hours:
4197
Circumstances:
The flight was cleared for a loc runway 11 approach. About 3 minutes later, the 2nd-in-command (sic) reported '. . . We don't get the localizer can you see if we're on course.' The LAX ARTCC R-15 controller confirmed the flight was right of course and below the required altitude. The aircraft's mode C indicated an altitude of 1,400 feet; the controller advised the flight crew to maintain at least 2,300 feet until past the final approach fix (faf). The crew then replied that they were in VMC. Radar svc was terminated and a frequency change to tower was approved. Shortly thereafter, the aircraft hit a eucalyptus tree at about 90 feet agl, 2.05 miles from the approach end of the runway and about 195 feet right of the loc. Elevation of the crash site was 101 feet; minimum descent altitude (MDA) for the approach was 640 feet. The 0645 pdt weather was, in part: indefinite ceiling, 100 feet obscured, vis 1/8 mile with fog, wind from 220° at 4 kts. No preimpact part failure or malfunction of the aircraft was found. All four occupants were killed.
Probable cause:
The pilot's improper IFR (instrument) procedure, and his failure to maintain the minimum descent altitude (MDA) for the approach. The adverse weather was a related factor.
Final Report:

Crash of a BAe 146-200 near San Luis Obispo: 43 killed

Date & Time: Dec 7, 1987 at 1616 LT
Type of aircraft:
Operator:
Registration:
N350PS
Flight Phase:
Survivors:
No
Schedule:
Los Angeles – San Francisco
MSN:
E2027
YOM:
1984
Flight number:
PS1771
Crew on board:
5
Crew fatalities:
Pax on board:
38
Pax fatalities:
Other fatalities:
Total fatalities:
43
Captain / Total flying hours:
11600
Captain / Total hours on type:
1600.00
Aircraft flight hours:
8571
Circumstances:
A recently discharged USAir employee boarded PSA flight 1771 after having left a goodbye message with friends. He bypassed security and carried aboard a borrowed 44 caliber pistol. A note written by this passenger, found in the wreckage, threatened his former supervisor at USAir, who was aboard the flight. At 1613, the pilot reported to Oakland ARTCC that he had an emergency and that gunshots had been fired in the airplane. Within 25 seconds, Oakland control controllers observed that PSA 1771 had begun a rapid descent from which it did not recover. Witnesses on the ground said the airplane was intact and there was no evidence of fire before the airplane struck the ground in a steep nose-down attitude. The cover tape revealed the sounds of a scuffle and several shots which were apparently fired in or near the cockpit. The pistol was found in the wreckage with 6 expended rounds. FAA rules permitted airline employees to bypass security checkpoints. All 43 occupants were killed.
Probable cause:
Occurrence #1: loss of control - in flight
Phase of operation: cruise - normal
Findings
1. (f) security - inadequate - company/operator management
2. (f) procedure inadequate - company/operator management
3. (f) insuff standards/requirements, operation/operator - faa (organization)
4. (c) control interference - intentional - passenger
5. (c) sabotage - intentional - passenger
6. (c) emotional reaction - passenger
7. Incapacitation - pilot in command
8. Incapacitation - copilot/second pilot
9. Suicide - intentional - passenger
----------
Occurrence #2: in flight collision with terrain/water
Phase of operation: descent - uncontrolled
Final Report:

Crash of a Beechcraft C99 Airliner near San Luis Obispo: 15 killed

Date & Time: Aug 24, 1984 at 1118 LT
Type of aircraft:
Operator:
Registration:
N6399U
Flight Phase:
Survivors:
No
Schedule:
Los Angeles – Santa Maria – San Luis Obispo – San Francisco
MSN:
U-187
YOM:
1982
Flight number:
RM628
Crew on board:
2
Crew fatalities:
Pax on board:
13
Pax fatalities:
Other fatalities:
Total fatalities:
15
Captain / Total flying hours:
4110
Captain / Total hours on type:
873.00
Copilot / Total flying hours:
6194
Copilot / Total hours on type:
62
Circumstances:
Wings West Airlines Flight 628, a commuter flight, departed Los Angeles for San Francisco, with scheduled en route stops at Santa Maria and San Luis Obispo. At 11:10, Flight 628 left the gate at San Luis Obispo. The weather at the time was essentially clear and the visibility was 15 miles. At 11:16, after taking off from runway 29, Flight 628 called the Los Angeles ARTCC and reported that it was climbing through 2,700 feet 'IFR to San Francisco.' At 11:17:23, the Los Angeles ARTCC’s radar controller cleared Flight 628 to the San Francisco airport, as filed, to climb and maintain 7,000 feet. At 11:17:38 the aircraft collided head-on with Rockwell Commander N112SM at 3,400 feet. This single-engined aircraft had departed Paso Robles Airport on a training flight with two pilots on board. Nll2SM was flying in visual meteorological conditions and under VFR in the vicinity of the San Luis Obispo Airport just before the collision.
Probable cause:
The failure of the pilots of both aircraft to follow the recommended communications and traffic advisory practices for uncontrolled airports contained in the Airman’s Information Manual to alert each other to their presence and to enhance the controller’s ability to provide timely traffic advisories. Underlying the accident were the physiological limitations of human vision and reaction time. Also underlying the accident was the short time available to the controller to detect and appraise radar data and to issue a safety advisory. Contributing to the accident was the Wings West Airlines policy which required its pilots to tune one radio to the company frequency at all times.
Final Report:

Crash of a Rockwell Aero Commander 520 near Agoura Hills: 3 killed

Date & Time: Sep 26, 1982 at 1308 LT
Operator:
Registration:
N2622B
Flight Phase:
Survivors:
No
Site:
Schedule:
Hawthorne - San Luis Obispo
MSN:
520-134
YOM:
1954
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Aircraft flight hours:
5198
Circumstances:
During departure, the pilot climbed in IFR conditions to 6,000 feet. After leveling, a frequency change was made and he was cleared to 8,000 feet, which he acknowledged. About 2 minutes later, the controller radioed to the pilot that he was about 4 miles north of the airway, but there was no reply from the pilot. Shortly after that radar contact was lost and the plane crashed in mountainous terrain. Several residents in the area reported hearing extremely loud engine noises followed by complete silence. An investigation revealed that both wings had separated outboard of their respective engine nacelle assemblies. An examination of the fractures revealed the wings had separated from positive overload. The leading edges of both wings had ballooned upward, indicative of extreme airspeed. The empennage had separated in a yaw and from right torsional overload. Parts of the aircraft were found within a 1 mile arc, north of the main impact area. The pilot's recent instrument experience could not be verified. All three occupants were killed. Turbulence was forecasted below 8,000 feet.
Probable cause:
Occurrence #1: loss of control - in flight
Phase of operation: climb - to cruise
Findings
1. (f) weather condition - clouds
2. (f) weather condition - turbulence in clouds
3. (c) aircraft handling - not maintained - pilot in command
4. (c) spatial disorientation - pilot in command
----------
Occurrence #2: airframe/component/system failure/malfunction
Phase of operation: descent - uncontrolled
Findings
5. Wing,spar - overload
6. (c) design stress limits of aircraft - exceeded - pilot in command
7. Wing - separation
8. Stabilizer - overload
9. Stabilizer - separation
----------
Occurrence #3: in flight collision with terrain/water
Phase of operation: descent - uncontrolled
Final Report:

Crash of a Waco UIC in San Luis Obispo: 4 killed

Date & Time: Apr 27, 1968 at 1314 LT
Type of aircraft:
Operator:
Registration:
N13066
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
San Luis Obispo - San Luis Obispo
MSN:
3716
YOM:
1933
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
4
Circumstances:
After completing touch-and-go, the pilot increased engine power and elected to takeoff. While climbing, the airplane stalled and crashed, killing all four occupants.
Probable cause:
The pilot failed to obtain/maintain flying speed and the aircraft entered an abnormally steep climb after touch-and-go and crashed.
Final Report:

Crash of a Grumman HU-16E Albatross near San Luis Obispo: 3 killed

Date & Time: Aug 7, 1967
Operator:
Registration:
2128
Flight Phase:
Survivors:
Yes
Site:
MSN:
G-355
YOM:
1953
Crew on board:
8
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
3
Circumstances:
The crew was searching for an overdue vessel along the California coastline in marginal weather. While cruising in limited visibility due to fog, the seaplane struck a mountain slope and crashed north of San Luis Obispo. Three crew members were killed while five others were rescued.
Those killed were:
LTJG Francis J. Charles,
AD3 William E. Prowitt,
AD3 John G. Medek.