Crash of a Beechcraft A60 Duke in Santa Rosa: 2 killed

Date & Time: May 5, 2019 at 1600 LT
Type of aircraft:
Operator:
Registration:
N102SN
Flight Type:
Survivors:
No
Schedule:
Arlington - Santa Fe
MSN:
P-217
YOM:
1973
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
4100
Circumstances:
The pilot was performing a personal cross-country flight. While en route to the intended destination, the pilot contacted air traffic control to report that the airplane was having a fuel pump issue and requested to divert to the nearest airport. The pilot stated that the request was only precautionary and did not declare an emergency during the flight; he provided no further information about the fuel pump. As the airplane approached the diversion airport, witnesses observed the airplane flying low and rolling to the left just before impacting terrain, after which a postcrash fire ensued. An examination of the airframe revealed no preimpact mechanical malfunctions or failures that would have precluded normal operation. A postaccident examination and review of recorded data indicated that the left engine was secured and in the feather position, and that the right engine was operating at a high RPM setting. The left engine-driven fuel pump was found fractured. Further examination of the fuel pump revealed fatigue failure of the pressure relief valve. The fatigue failure initiated in upward bending on one side of the valve disk and progressed around both sides of the valve stem. As the cracks grew, the stem separated from the disk on one side and began to tilt in relation to the disk and the valve guide due to the non-symmetric support, which caused the lower end of the stem to rub against the valve guide, creating wear marks. The increasing stem tilt would have impinged against the valve guide, and the valve might have begun to stick in the closed position. If the valve were stuck in the closed position, it would not be able to open, and the outlet fuel pressure could rise above the set point pressure. Because the pump was driven by the engine, there would not be a way for the pilot to shut it off, disconnect it, or bypass it. Instead, the fuel pressure would continue to rise until the valve were to unstick. Thus, the pilot was likely experiencing variable fuel pressure as the valve became stuck and unstuck. Examination of the spring seat and the diaphragm plate, which were in contact with each other in the fuel pump assembly, revealed wear marks on the surface of each component, with one mark on the diaphragm plate and two wear marks on the spring seat. The two wear marks on the spring seat were distinct features separated by material with no wear indications in between. The only way that these wear marks could have occurred were if the spring seat was separated from the diaphragm plate and reinstalled in a different orientation. Thus, it is likely that the pilot had encountered a fuel pump problem before the accident flight and that someone tried to troubleshoot the problem. The last radar data point indicated that the airplane was traveling at a groundspeed of about 98 knots, and had passed north of the airport, traveling to the southwest. The minimum control speed for the airplane with single-engine operation was 88 knots. However, it is likely that if the pilot initiated a left turn back toward the airport, that the right engine torque and the 14 knot wind with gusts to 24 knots would have necessitated a higher speed. Because appropriate control inputs and airspeed were not maintained, the airplane rolled in the direction of the feathered engine (due to the left fuel pump problem), resulting in a loss of control. The pilot's toxicology report was positive for cetirizine, sumatriptan, gabapentin, topiramate, and duloxetine. All of these drugs act in the central nervous system and can be impairing alone or in combination. Although this investigation could not determine the reason(s) for the pilot's use of these drugs, they are commonly used to treat chronic pain syndromes or seizures. It is likely that the pilot was experiencing some impairment because of multiple impairing medications and was unable to successfully respond to the in-flight urgent situation and safely land the airplane.
Probable cause:
The pilot's loss of airplane control due to his failure to maintain appropriate control inputs and airspeed after shutting down an engine because of a progressive failure of the pressure relief valve in the fuel pump, which resulted in variable fuel pressure in the engine. Contributing to the loss of control was the pilot's use of multiple impairing medications.
Final Report:

Crash of a Pilatus PC-12 in Santa Fe: 1 killed

Date & Time: Sep 29, 2008 at 2216 LT
Type of aircraft:
Registration:
N606SL
Flight Type:
Survivors:
No
Schedule:
New York - Lubbock - Santa Fe
MSN:
1020
YOM:
2008
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
2437
Captain / Total hours on type:
86.00
Aircraft flight hours:
130
Circumstances:
The pilot was approaching his home airport under dark night conditions. He reported that he was five miles from the airport and adjusted the airport lighting several times. He made no further radio calls, though his normal practice was to report his position several times as he proceeded in the landing pattern. The airplane approached the airport from the southeast in a descent, continued past the airport, and adjusted its course slightly to the left. One witness reported observing the airplane enter a left turn, then pitch down, and descend at a steep angle. The airplane impacted terrain in a steep left bank and cart wheeled. An examination of the airframe, airplane systems, and engine revealed no pre-impact anomalies. Flight control continuity was confirmed. The pilot had flown eight hours and 30 minutes on the day of the accident, crossing two time zones, and had been awake for no less than 17 hours when the accident occurred. The accident occurred at a time of day after midnight in the pilot's departure time zone. Post-accident toxicology testing revealed doxylamine and amphetamine in the pilot's tissues. The pilot had been diagnosed with attention deficit hyperactivity disorder (ADHD) almost five years prior to the accident and had taken prescription amphetamines for the disorder since that diagnosis. The FAA does not medically certify pilots who require medication for the control of ADHD. At the time of the accident, the pilot's blood level of amphetamines may have been falling, and he may have been increasingly fatigued and distracted. The use of doxylamine (an over-the-counter antihistamine, often used as a sleep aid) could suggest that the pilot was having difficulty sleeping.
Probable cause:
The pilot's incapacitation due to fatigue resulting in an in-flight collision with terrain.
Final Report:

Crash of a Piper PA-61 Aerostar (Ted Smith 601) in Scottsdale: 2 killed

Date & Time: Jan 26, 2003 at 2023 LT
Registration:
N3636Q
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Scottsdale – Santa Fe
MSN:
61-0785-8063398
YOM:
1980
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
1450
Captain / Total hours on type:
160.00
Aircraft flight hours:
2574
Circumstances:
The airplane collided with mountainous terrain 5 miles from the departure airport during a dark night takeoff. Review of recorded radar data found a secondary beacon code 7267 (the code assigned to the airplane's earlier inbound arrival ) on the runway at 2021:08, with a mode C report consistent with the airport elevation. Two more secondary beacon returns were noted on/over the runway at 2021:12 and 2021:19, reporting mode C altitudes of 1,600 and 1,700 feet, respectively. Between 2021:08 and 2021:38, the secondary beacon target (still on code 7267) proceeded on a northeasterly heading of 035 degrees (runway heading) as the mode C reported altitude climbed to 2,000 feet and the computed ground speed increased to 120 knots. Between 2021:38 and 2021:52, the heading changed from an average 035 to 055 degrees as the mode C reports continued to climb at a mathematically derived 1,300 feet per minute and the ground speed increased to average of 170 knots. At 2022:23, the code 7267 target disappeared and was replaced by a 1200 code target. The mode C reports continued to climb at a mathematically derived rate of 1,200 feet per minute as the ground speed increased to the 180- knot average range. The computed average heading of 055 degrees was maintained until the last target return at 2022:53, which showed a mode C reported altitude of 3,500 feet. The accident site elevation was 3,710 feet and was 0.1 miles from the last target return. The direct point to point magnetic course between Scottsdale and Santa Fe was found to be 055 degrees. Numerous ground witnesses living at the base of the mountain where the accident occurred reported hearing the airplane and observing the aircraft's lights. The witnesses reported observations consistent with the airplane beginning a right turn when a large fireball erupted coincident with the airplane's collision with the mountain. No preimpact mechanical malfunctions or failures were found during an examination of the wreckage. The radar data establishes that the pilot changed the transponder code from his arrival IFR assignment to the VFR code 30 seconds before impact and this may have been a distraction.
Probable cause:
The pilot's failure to maintain an adequate altitude clearance from mountainous terrain. Contributing factors were dark night conditions, mountainous terrain, and the pilot's diverted attention.
Final Report:

Crash of a Mitsubishi MU-2B-20 Marquise in Cerrillos: 2 killed

Date & Time: Jun 10, 2001 at 1221 LT
Type of aircraft:
Operator:
Registration:
N187AF
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Peoria – Santa Fe
MSN:
187
YOM:
1970
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
800
Captain / Total hours on type:
4.00
Aircraft flight hours:
6500
Circumstances:
The pilot was maneuvering the airplane south of the airport preparing to make a VFR approach. Witnesses observed the airplane in a right spin. NTAP data showed the airplane to be well above stall speed before disappearing from radar. Examination of the radar data revealed that in 6 seconds, ground speed dropped 31 knots, from 200 knots to 169 knots, and altitude dropped 440 feet, from 11,760 feet to 11,320 feet (4,400 feet per minute). In the next 6 seconds, ground speed dropped another 31 knots, from 169 knots to 138 knots, and altitude dropped 1,020 feet, from 11,320 feet to 10,300 feet (10,200 feet per minute). According to the manufacturer, if the throttles were to be brought back into Beta (flat pitch) range, it is possible that one propeller could go into Beta an instant before the other propeller. If this were to happen, the airplane would instantly snap roll and enter a spiral. The pilot had received an estimated 4 hours of dual instruction in the airplane.
Probable cause:
The pilot's loss of aircraft control inflight for reasons undetermined. Contributing factors were the pilot's inadequate transition/upgrade training and his total lack of experience in aircraft make/model.
Final Report:

Crash of a Piper PA-31T Cheyenne I in Santa Fe

Date & Time: Dec 16, 1999 at 1515 LT
Type of aircraft:
Registration:
N919RD
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Santa Fe - Olathe
MSN:
31-8104037
YOM:
1981
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
1098
Captain / Total hours on type:
401.00
Aircraft flight hours:
3558
Circumstances:
On takeoff during the initiation of a cross-country flight, the pilot raised the landing gear following liftoff and the aircraft settled back onto the ground off the end of the runway. According to the pilot and the FAA inspector who examined the aircraft, both engines were producing normal power. The elevator trim was set at 12 degrees nose up vice 3-6 degrees required, and the aircraft was within weight and balance limits. The pilot lowered the landing gear prior to impact. According to information provided by the aircraft manufacturer, induced drag increases during landing gear retraction and extension due to the landing gear doors being extended into the air stream as the landing gear cycles.
Probable cause:
The pilot initiating lift off at an airspeed insufficient to maintain flight and retracting the landing gear prematurely resulting in a stall mush. A factor was the pilot incorrectly setting the elevator trim.
Final Report:

Crash of a Learjet 25D on Mt Rowe: 7 killed

Date & Time: Sep 5, 1993 at 1715 LT
Type of aircraft:
Registration:
N999BH
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Houston - Santa Fe
MSN:
25-318
YOM:
1980
Crew on board:
2
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
7
Captain / Total flying hours:
17000
Captain / Total hours on type:
4000.00
Aircraft flight hours:
4973
Circumstances:
While descending to his destination the pilot in command (pic) canceled his IFR clearance and declined VFR flight following. Witnesses observed the aircraft maneuvering at low altitude in the area where the accident occurred, approximately 25 miles from the destination airport. The aircraft impacted rising terrain at 7,300 feet msl. Toxicological testing revealed that the pic and two passengers had cocaine and alcohol in tissue samples. At an unknown time the pic left the cockpit. Based on cockpit voice recorder analysis, he was called back to the cockpit approximately 11 minutes prior to the accident by the copilot. The copilot had no previous Lear experience. Toxicological test results indicated that the pic 'used cocaine in the very recent past, probably while in-flight' and concluded that he 'was impaired by multiple drug use of cocaine and alcohol.' The investigation did not reveal any structural or system failure or malfunction. All seven occupants were killed.
Probable cause:
Physical impairment of the pilot in command from alcohol and drugs. A factor was the first officer's lack of experience in the Learjet.
Final Report:

Crash of a Swearingen SA226T Merlin III in Santa Fe: 4 killed

Date & Time: May 25, 1993 at 2114 LT
Type of aircraft:
Registration:
N241DT
Flight Type:
Survivors:
No
Schedule:
Albuquerque - Santa Fe
MSN:
T-242
YOM:
1973
Crew on board:
3
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
7125
Captain / Total hours on type:
3550.00
Aircraft flight hours:
3677
Circumstances:
The purpose of the training flight was to conduct part 135 checkrides for a pilot-in-command and a second-in-command upon completion of the crew's training. The checkride was being observed by an FAA inspector seated in the cabin. After completing an ILS approach to runway 02, the flight was cleared to circle to land on runway 15. The airplane was observed overflying runway 15 and lined up for runway 20. The tower advised the pilot that he was lined up for runway 20, and was given the option to land on either runway 15 or runway 20. The pilot opted for runway 15 and was cleared to a right downwind. The airplane impacted a hill at the 6,870-feet level near the crest, approximately 5 miles west of the airport. The published circling MDA for the ILS runway 02 approach is 6,860 feet. The airport is located about 9 miles from the city, and several local pilots reported a total lack of visual reference in that segment. All four occupants were killed.
Probable cause:
The pilot's poorly planned circling approach, and his failure to maintain an adequate altitude. Factors which contributed to the accident were: the dark night and a lack of visual reference.
Final Report:

Crash of a Swearingen SA227AC Metro III near Pueblo: 2 killed

Date & Time: Dec 7, 1982 at 1907 LT
Type of aircraft:
Operator:
Registration:
N30093
Flight Type:
Survivors:
No
Schedule:
Santa Fe - Pueblo
MSN:
AC-449
YOM:
1981
Location:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
8534
Captain / Total hours on type:
945.00
Aircraft flight hours:
2269
Circumstances:
At 1906 the flight was cleared to descend and maintain 7,500 feet, turn right to a heading 040 for an ASR approach to Pueblo Memorial Airport, and that the MDA is 5,200 feet. The flight read back "left to one forty five two zero zero." Approach control advised the flight that the heading was 040 and the flight acknowledged. There were no further communications with the flight. The aircraft was travelling in excess of an estimated 200 mph when it struck tundra in level flight on a heading of about 040. The copilot's autopsy revealed that the trachae, bronchi, and lungs contained aspirated gastric contents, including skeletal muscle fibers. Another company pilot reported that the copilot had vomited during a flight on November 14, 1982.
Probable cause:
Occurrence #1: in flight collision with terrain/water
Phase of operation: descent
Findings
1. (f) light condition - dark night
2. (c) altitude - inattentive - pilot in command
3. (f) diverted attention - pilot in command
4. (f) physical impairment - copilot/second pilot
Final Report:

Crash of a Rockwell Aero Commander 500 near Santa Fe: 1 killed

Date & Time: Dec 22, 1979 at 1319 LT
Operator:
Registration:
N6194X
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Albuquerque - Denver
MSN:
500-1055-44
YOM:
1961
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
1340
Captain / Total hours on type:
71.00
Circumstances:
While flying in marginal weather conditions, the pilot failed to realize his altitude was insufficient when the twin engine airplane struck trees and crashed in a mountain shrouded in clouds. The pilot, sole on board, was killed.
Probable cause:
Collision with trees and subsequent crash in normal cruise due to improper IFR operation on part of the pilot. The following contributing factors were reported:
- Traffic control personnel issued improper or conflicting instructions,
- Santa Fe weather observation reported mountain tops obscured,
- The controller was not familiar with high terrain in area or MVA.
Final Report:

Crash of a Cessna 411A near Santa Fe: 6 killed

Date & Time: Mar 26, 1978 at 1946 LT
Type of aircraft:
Registration:
N417DR
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Sierra Vista - Lamar
MSN:
411-0265
YOM:
1967
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
6
Captain / Total flying hours:
2700
Circumstances:
While flying by night at an altitude of 11,700 feet, the twin engine airplane struck the slope of a mountain located in the region of Santa Fe. The wreckage and all six dead bodies were found a week later, on April 2.
Probable cause:
Controlled flight into terrain caused by inadequate preflight preparation and improper in-flight decisions.
Final Report: