Missouri

The Beech 200 was substantially damaged during an aborted landing. The winds were gusting in excess of the airplane's maximum demonstrated crosswind component. A witness reported finding landing gear strut pieces on the runway after the Beech 200's landing attempt. The flight then aborted the landing and continued on to its originating airport where the airplane veered off the runway and damaged airport property during its landing.

Prior to takeoff from Lambert Field/St. Louis International Airport, St. Louis, Missouri, the pilot contacted the operations manager at M. Graham Clark Airport, Point Lookout, Missouri, and asked about the current weather conditions there. The operations manager told the pilot that the weather was "pretty poor." The airplane took off from St. Louis, at 1411 cst. At 1447:12 cst, the pilot checked in with Springfield Approach Control. The pilot was told to expect the ILS approach to runway 2 at the Springfield-Branson Regional Airport. At 1501:01 cst, the pilot requested to go to Point Lookout and shoot the GPS to runway 11. Springfield Approach instructed the pilot to descend to 3,000 feet msl and cleared him for the approach. At 1507:08 cst, Springfield radar showed the airplane crossing the initial waypoint at 3,000 feet msl, and turn to 116 degrees approach heading. At 1507:17 cst, the airplane descended to 2,500 feet msl. At 1508:51 cst, Springfield Approach cleared the pilot to change to advisory frequency. "Call me back with your cancellation or your miss." The pilot responded, "Okay we're, we're RAWBE inbound and we will call you on the miss or cancellation." The operations manager at M. Graham Clark Airport said that he heard the pilot on the airport's common frequency radio say, "Citation 525KL is RAWBE inbound on the GPS 11 approach." At 1509:01 cst, Springfield radar showed the airplane begin a descent out of 2,500 feet msl. The last radar contact was at 1509:48 cst. The airplane was five nautical miles from the airport on a 296 degree radial, at 2,100 feet msl. At 1530 cst, the operations manager heard Springfield approach trying to contact the airplane. The operations manager initiated a search for the airplane. At 1430 cst, the weather observation at the M. Graham Clark Airport was 300 feet overcast, rain and mist, 3/4 miles visibility, temperature 53 degrees F, winds variable at 3 knots, altimeter 29.92 inches HG. Approach minimum weather for the GPS RWY11 straight in approach to Point Lookout are a minimum ceiling of 600 feet and visibility of 1 mile for a category B aircraft. An examination of the airplane wreckage revealed no anomalies. The results of FAA toxicology testing of specimens from the pilot revealed concentrations of Doxepin in kidney and liver. The Physicians' Desk Reference states that "... drowsiness may occur with the use of this drug, patients should be warned of the possibility and cautioned against driving a car or operating dangerous machinery while taking the drug." The physician who prescribed the Doxepin to the pilot said that he was using it to treat the pilot's "irritable bowel" condition. According to his wife, the pilot had not slept well for several nights, up to the day of the accident, due to problems he was having with the FAA. A friend, who spoke with the pilot just before the accident flight, confirmed the pilot saying "I haven't slept for three days." The friend stated further that the pilot "wasn't himself that day."

The airplane impacted the ground in a nose low, inverted attitude. The pilot reported, 'Jeff Tower, N34TM, I've just lost power on the right engine, eh, left engine.' The airplane's altitude was approximately 200 to 400 feet when the airplane's wings wobbled back and forth. The airplane's wings banked approximately 90 degrees to the left, and then the airplane nosed over and impacted the ground. White smoke was seen coming from the belly of the airplane for 1 to 2 seconds about 20 seconds prior to it impacting the ground. The terrain was a flat, hard packed field used for growing grass sod. Both the left and right propellers were found 12 to 18 inches under the hard packed soil. Rotational paint transfer patterns from the propeller blades onto the hard packed soil were evident. The left and right propeller blades exhibited chordwise scratching and leading edge polishing. The #2 cylinder piston was broken and the piston pin was still attached to the piston rod. The NTSB Materials Laboratory examination revealed the fracture face of the #2 exhaust valve stem was consistent with a bending fatigue separation. Both #2 and #6 exhaust valve guides showed heavy wear that ovalized the bores. The annual inspection conducted on March 15, 1999, indicated the compression on the left engine was 80/64, 50, 67, 70, 69, and 62.

The pilot and passengers departed the Spirit of St. Louis Airport and flew to Springfield Regional Airport, a 50 to 60 minute flight. The fuel on board was about 25 to 30 gallons in the left wing tanks, and 75 to 80 gallons in the right wing tanks. Each engine burned about 25 to 30 gallons per hour. The airplane was not fueled prior to the return flight. About five minutes after takeoff, the airplane had reached 4,300 feet msl (3,033 feet agl) and began a 402 fpm descent. The airplane continued the descent away from the airport for about 7 nm before turning 180 degrees to the left. The airplane had descended to 2,200 feet msl (933 feet agl) and was 10 miles from the airport. The pilot reported to the controller that he had a '...partial engine failure on the left side.' The airplane impacted the ground in an inverted, vertical nose down attitude. The landing gear were down at impact. Neither propeller was feathered. The right wing, right engine, fuselage, and empennage received extensive fire damage. The left wing was consumed by fire between the nacelle and the wing root. The remaining left wing, left nacelle, and engine were not destroyed by fire. Examination of the engines and airframe did not reveal any pre-existing anomalies that prevented normal operation. The Airplane Flight Manual did not contain procedures which explained fuel cross feeding procedures in case of fuel exhaustion to a wing's fuel tanks.

The airplane crashed immediately after liftoff during a three-engine takeoff. Flightcrew had shortened rest break; rest periods not required for ferry flights. Flight crew fatigue from lack of rest, sleep, and disruption of circadian rhythms. Flightcrew did not have adequate, realistic training in three-engine takeoff techniques or procedures. Flight crew did not adequately understand three-engine takeoff procedures, including significance of vmcg. Flight engineer improperly determined vmcg speed, resulting in value 9 knots too low. During first takeoff attempt, captain applied power to asymmetrical engine too soon, was unable to maintain directional control, and rejected the takeoff. Captain agreed to modify procedure by allowing flight engineer to advance throttle, a deviation of prescribed procedure. FAA oversight of operator was inadequate because the poi and geographic inspectors were unable to effectively monitor domestic crew training and international operations. Existing far part 121 flight time limits & rest requirements that pertained to the flights that the flightcrew flew prior to the ferry flights did not apply to the ferry flights flown under far part 91. Current one-engine inoperative takeoff procedures do not provide adequate rudder availability for correcting directional deviations during the takeoff roll compatible with the achievement of maximum asymmetric thrust at an appropriate speed greater than ground minimum control speed. All three crew members were killed.

During arrival at night in fog and drizzle, the pilot was cleared for an ILS runway 1l approach. While on the approach, she reported encountering moderate rime ice. Radar data showed that the airplane continued inbound on the localizer until it neared the middle marker, then it deviated about 20° left and collided with the ground, about 300 feet short and 300 feet left of the threshold. According to witnesses, the airplane stopped its descent and slowed down, shortly before entering a steep descent and a spin. An on-scene investigation revealed no preimpact airframe, control system, or powerplant anomalies. The wings had 1/4 inch of ice on the leading edge and a 1/2 inch high ridge of ice, parallel to the deicing boots, about 3 inches aft of the boots. The cockpit and windshield heating system were found in the 'off' position. The pilot's logbook was not available for inspection. Company records showed she had passed a 14 cfr part 135 checkride on may 20, 1994. The faa checkride form was administered and signed by the chief pilot. However, other records/information showed the chief pilot would not have been able to have given the checkride on that date.

During the takeoff roll on runway 30R, the MD-82, N954U, collided with the Cessna 441, N441KM, which was positioned on the runway waiting for takeoff clearance. The pilot of the Cessna acted on an apparently preconceived idea that he would use his arrival runway, runway 30R, for departure. After receiving taxi clearance to back-taxi into position and hold on runway 31, the pilot taxied into a position at an intersection on runway 30R, which was the assigned departure runway for the MD-82. The ATIS current at the time the Cessna pilot was operating in the Lambert-St. Louis area listed runways 30R and 30L as the active runways for arrivals and departures; there was no mention of the occasional use of runway 31. Air traffic control personnel were not able to maintain visual contact with the Cessna after it taxied from the well lighted ramp area into the runway/taxiway environment of the northeast portion of the airport. An operational ASDE-3, particularly ASDE-3 enhanced with AMASS, could be used to supplement visual scan of the northeast portion of the airport.

After taking off on an IFR flight, the airplane was observed to climb into a low overcast. The pilot contacted departure control and reported climbing through 2,200 feet for an assigned altitude of 5,000 feet msl. Shortly thereafter, radar and radio contact were lost, and the airplane crashed in a steep dive. During an investigation, no preimpact part failure or malfunction was found, though the airplane was extensively damaged during impact. The pilot's logbook indicated that he had flown three instrument approaches on 3/3/94 and that he had flown 3.1 hours in actual instrument conditions since that date.

Two foreign pilots took off VFR to remain in the vicinity of an airport on the outskirts of a metropolitan area. No record was found to show the airplane had been fueled either before or after the preceding flight. The flight crew contacted an area approach control and requested an ILS approach to test their ILS equipment without specifying an airport. Approach control issued and the flight crew accepted vectors to another airport for which the pilots had no approach plate or airport information. Vectors took the airplane about 25 miles from the departure airport. The flight crew requested to proceed back to the departure airport. A short time later, the flight crew declared an emergency due to low fuel, then radar contact was lost. Witnesses at a landfill heard an intermittent sound from the engine(s). The airplane came into their view with one engine running, then the engine sound ceased. They indicated the airplane went out of control and crashed, but one engine accelerated just before impact. A small fire was confined to the left wing. Both occupants were killed.