Crash of a Piper PA-46-350P Malibu Mirage near Saint George: 1 killed

Date & Time: Jun 30, 2009 at 0708 LT
Registration:
N927GL
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
North Las Vegas – Cedar City
MSN:
46-36400
YOM:
2006
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
782
Circumstances:
Radar data indicated that the airplane departed for a cross-country flight, climbed to a cruise altitude of 9,700 feet msl, and maintained a northeasterly course of 050 degrees magnetic direct to its destination. About 11 minutes after takeoff, the airplane entered a 1,000 foot-per-minute descent. The airplane continued to descend at this rate until it impacted terrain at an elevation of 4,734 feet. Examination of the accident site revealed that the airplane was still on its northeasterly course towards the destination at impact. Ground scars at the initial point of impact were consistent with the airplane being wings level in a slight nose-down pitch attitude. No mechanical anomalies with the airplane or engine were identified during the airplane wreckage examination. A postimpact fire destroyed all cockpit instrumentation, and no recorded or stored flight data could be recovered. Weather conditions at the time were clear, and light winds. The pilot had some moderate heart disease that was noted during the autopsy. He also had a history of stress and insomnia, which was documented in his FAA medical records. Toxicology findings noted the use of a sedating and impairing over-the-counter medication (chlorpheniramine) that was taken at some undetermined time prior to the accident. The investigation could not conclusively determine whether the pilot’s conditions or medication use were related to the accident. The reason for the airplane’s descent to ground impact could not be determined.
Probable cause:
The pilot's failure to maintain terrain clearance during descent for undetermined reasons.
Final Report:

Crash of a Lockheed P2V-7 near Stockton: 3 killed

Date & Time: Apr 25, 2009 at 1004 LT
Type of aircraft:
Operator:
Registration:
N442NA
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Missoula - Alamogordo
MSN:
726-7286
YOM:
1958
Flight number:
Tanker 42
Location:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
7334
Captain / Total hours on type:
916.00
Copilot / Total flying hours:
15075
Copilot / Total hours on type:
350
Aircraft flight hours:
3554
Circumstances:
The multi-engine fire bomber, which was not carrying retardant, was established at its cruise altitude while en route to a fire base where it would be used as part of the effort to fight a local fire. While en route, the flight crew encountered a forecast area of instrument meteorological conditions, whereupon they began a series of descents to lower altitudes in order to stay in visual flight rules (VFR) conditions beneath the clouds. During the last few minutes of their flight, the flight crew had descended to an altitude that was less than 1,300 feet above ground level (agl) over nearly level terrain. As they approached rapidly rising terrain at the end of the broad open valley they had been flying over, they inadvertently entered instrument meteorological conditions (IMC). Soon thereafter, while still in a nearly wings-level attitude, the airplane impacted a ridge about 240 feet below its top. The First Officer, who was flying at the time, had asked the Captain about ten minutes prior to the impact if their altitude was high enough to clear the upcoming terrain, but the Captain did not respond, and the First Officer did not challenge the Captain about the issue. Witnesses in the area reported low clouds with ceilings about 200 feet above ground level with a visibility of one-quarter mile or less, with rain and fog. One of the witnesses reported momentarily viewing the airplane flying "very low," while the others reported only being able to hear the airplane.
Probable cause:
The flight crew's failure to maintain terrain clearance during low altitude flight in low ceiling and visibility conditions. Contributing to the accident was the flight crew's failure to adequately monitor their location with respect to the rising terrain environment ahead, and, their lack of crew resource management communication as a crew.
Final Report:

Crash of a Beechcraft A100 King Air in Moab: 10 killed

Date & Time: Aug 22, 2008 at 1750 LT
Type of aircraft:
Registration:
N601PC
Flight Phase:
Survivors:
No
Schedule:
Moab - Cedar City
MSN:
B-225
YOM:
1975
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
10
Captain / Total flying hours:
1818
Captain / Total hours on type:
698.00
Aircraft flight hours:
9263
Circumstances:
The twin engine aircraft, owned by the Red Canyon Aesthetics & Medical Spa, a dermatology clinic headquartered in Cedar City, was returning to its base when shortly after take off, the pilot elected to make an emergency landing due to technical problem. The aircraft hit the ground, skidded for 300 meters and came to rest in flames in the desert, near the Arches National Park. All 10 occupants, among them some cancer specialist who had traveled to Moab early that day to provide cancer screening, cancer treatment, and other medical services to citizens in Moab, were killed.
Probable cause:
The pilot’s failure to maintain terrain clearance during takeoff for undetermined reasons.
Final Report:

Crash of a Spectrum FJ33 in Spanish Fork: 2 killed

Date & Time: Jul 25, 2006 at 1606 LT
Type of aircraft:
Operator:
Registration:
N322LA
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Spanish Fork - Spanish Fork
MSN:
01
YOM:
2006
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
2300
Captain / Total hours on type:
22.00
Copilot / Total flying hours:
3100
Copilot / Total hours on type:
16
Aircraft flight hours:
44
Aircraft flight cycles:
47
Circumstances:
The proto-type experimental light jet airplane was departing on a local maintenance test flight. Witnesses reported that the airplane entered a right roll almost immediately after liftoff. The roll continued to about 90 degrees right wing down at which point the right wingtip impacted the ground. During examination of the wreckage, the aileron control system was found connected such that the airplane rolled in the opposite direction to that commanded in the cockpit. The maintenance performed on the airplane before the accident flight included removal of the main landing gear (MLG) in order to stiffen the MLG struts. Interviews with the mechanics who performed the maintenance revealed that during re-installation and system testing of the MLG, it was discovered that the changes to the MLG struts impacted the Vbracket holding the aileron control system's upper torque tube. The V-bracket was removed and a redesigned V-bracket was installed in its place. This work required the disconnection of a portion of the aileron control system, including the removal of the aft upper torque tube bell crank from the torque tube. The mechanic who reinstalled the aft upper torque tube bell crank was under the incorrect assumption that there was only one way to install the bell crank on the torque tube. However, there are actually two positions in which the bell crank could be installed. The incorrect installation is accomplished by rotating the bell crank 180° about the axis of the torque tube and flipping it front to back, and this is the way the bell crank was found installed. With the bell crank installed incorrectly and the rest of the system installed as designed, there is binding in the system. This binding was noticed on the accident airplane during the inspection after initial installation. However, the mechanic did not recognize that the bell crank was improperly installed on the torque tube. Instead of fixing the problem by removing and correctly reinstalling the bell crank, he fixed the problem by disconnecting the necessary tie rods and rotating the upper torque tube so that the arm of the bell crank pointed up and to the left. This action reversed the movement of the ailerons. According to all of the personnel interviewed, there was no maintenance documentation to instruct mechanics how to perform the work since this was a proof-of-concept airplane. None of the mechanics who performed the work could recall if the position of the ailerons in relation to the position of the control stick was checked. Such a position check, if it had been performed by either the mechanics after the maintenance or by the flight crew during the preflight checks, would assuredly have indicated that the system was installed incorrectly.
Probable cause:
Incorrect installation by company maintenance personnel of the aft upper torque tube bell crank resulting in roll control that was opposite to that commanded in the cockpit. Contributing factors were the lack of maintenance documentation detailing the installation of the bell crank, the installing mechanic's incorrect assumption that the bell crank could only be installed in one position, and the failure of maintenance personnel and the flight crew to check the position of the control stick relative to the ailerons after the maintenance and during the preflight checks.
Final Report:

Crash of a Gulfstream GII in Logan

Date & Time: Jan 19, 2005 at 2030 LT
Type of aircraft:
Operator:
Registration:
N74RQ
Survivors:
Yes
Schedule:
Kansas City – Logan
MSN:
113
YOM:
1972
Crew on board:
2
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
5320
Captain / Total hours on type:
1253.00
Copilot / Total flying hours:
8000
Copilot / Total hours on type:
3000
Aircraft flight hours:
12011
Circumstances:
The captain stated they had flown the GPS approach to runway 35. When they did not see the runway or runway environment they initiated a missed approach. During the missed approach, they were able to see the first 4 to 5 thousand feet on the approach end of runway 17. They "elected to circle to the north west to set up for a visual approach to runway 17." The captain stated that the approach was "slightly high and as a result, the flare was a bit higher than normal." The airplane entered the fog layer just prior to touchdown. The captain stated that during the landing flare the airplane had drifted to the left and "the aircraft settled onto the runway to the left of centerline and shortly thereafter the left main gear impacted a snow berm." The airplane turned hard to the left and departed the runway. The nose gear separated, the radome was crushed and the cockpit pressure bulkhead was broken open. The routine aviation weather report (METAR) at LGU reported the weather as follows: wind, calm; visibility, 1/4 statute mile in freezing fog; sky condition, vertical visibility 100 feet agl; temperature, minus 7 degrees Celsius (C), dewpoint, minus 7 degrees C; altimeter, 30.45 inches.
Probable cause:
The pilot's improper IFR operation by which he failed to comply to the missed approach procedure, and his improper evaluation of the weather resulting in an encounter with fog and his loss of visual contact with the runway during the landing.
Final Report:

Crash of a Cessna T207A Turbo Stationair 7 II in Kanab

Date & Time: May 27, 2001 at 1400 LT
Operator:
Registration:
N6427H
Flight Type:
Survivors:
Yes
Schedule:
Marble Canyon – Kanab
MSN:
207-0522
YOM:
1979
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
940
Captain / Total hours on type:
34.00
Aircraft flight hours:
7485
Circumstances:
The pilot departed for the cross-country flight with 10 gallons of fuel in the left tank and 17 gallons of fuel in the right tank. He leveled off and reduced to cruise power. He said he was "preparing to make switch from left to right tank....just before I could make the switch, the engine lost power." He attempted to switch tanks and restart the engine, but could not get a restart. He performed a forced landing to a dirt road. During the landing roll, the left wing struck a tree and the airplane rotated 180 degrees. The engine was torn from the mount, both wing spars were bent, and the empennage sustained substantial damage. A salvage team member noted, during the airplanes recovery, that there were approximately 10 to 15 gallons of fuel in the left tank; he said the right fuel tank was empty.
Probable cause:
The pilot's inadequate fuel consumption planning, and the subsequent fuel starvation, which resulted in a loss of engine power.
Final Report:

Crash of a Beechcraft 65-A90 King Air in Tooele Valley: 9 killed

Date & Time: Jan 14, 2001 at 1729 LT
Type of aircraft:
Registration:
N616F
Flight Type:
Survivors:
No
Schedule:
Mesquite – Tooele Valley
MSN:
LJ-165
YOM:
1966
Crew on board:
1
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
9
Captain / Total flying hours:
5149
Captain / Total hours on type:
321.00
Aircraft flight hours:
9725
Circumstances:
The pilot and eight parachutists were returning from a skydive meet. The pilot had obtained a weather briefing, which advised of instrument meteorological conditions at the destination, and filed a VFR flight plan, but it was never activated. Witnesses heard, but could not see, a twin engine turboprop pass over the airport, heading north out over the Great Salt Lake. They described the weather conditions as being a low ceiling with 1/4-mile visibility, light snow, haze, and fog. They said it was almost dark. The airplane impacted the water approximately 1/2-mile off shore. It had been stripped of all avionics except for one transceiver and a handheld GPS receiver. One member of the skydive club, who had flown with the pilot, said he had previously encountered poor weather conditions and descended over the Great Salt Lake until he could see the ground, then proceeded to the airport. Another member related a similar experience, but said they descended over the Great Salt Lake in the vicinity of the accident site. The pilot was able to navigate in deteriorating weather conditions to Tooele Airport, using various landmarks. Examination of the airframe, engines, and propellers did not reveal evidence of any anomalies that would have precluded normal operation.
Probable cause:
The pilot's exercise of poor judgment and his failure to maintain a safe altitude/clearance above the water. Contributing factors were the weather conditions that included low ceiling and visibility obscured by snow and mist, an inadequately equipped airplane for flying in instrument meteorological conditions, and the pilot's overconfidence in his personal ability in that he had reportedly done this on two previous occasions.
Final Report:

Crash of a Beechcraft 65-A90 King Air in West Jordan

Date & Time: Apr 19, 1997 at 1320 LT
Type of aircraft:
Operator:
Registration:
N616AS
Survivors:
Yes
Schedule:
West Jordan - West Jordan
MSN:
LJ-160
YOM:
1966
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
2000
Captain / Total hours on type:
15.00
Aircraft flight hours:
1101
Circumstances:
The pilot stated that after parachutists egressed from the airplane, he returned to the airport and found that he did not have a green down-and-locked indication for the left main landing gear. He stated that he executed emergency procedures and did two fly-bys over the runway. Ground personnel stated that the landing gear appeared to be down-and-locked. During the landing roll, the airplane began to slide side-ways, and the right main landing gear began to collapse and eventually separated from the airplane. The left main gear also collapsed as the airplane slid to a stop. After the accident, the upper torque knee on the left main landing gear was found broken. The failure mode of the upper torque knee was not determined.
Probable cause:
Landing gear collapsed for undetermined reasons.
Final Report:

Crash of a Beechcraft 200 Super King Air in Salt Lake City: 1 killed

Date & Time: Mar 2, 1997 at 1913 LT
Registration:
N117WM
Survivors:
Yes
Schedule:
Las Vegas - Salt Lake City
MSN:
BB-662
YOM:
1980
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
8172
Captain / Total hours on type:
1841.00
Aircraft flight hours:
4692
Circumstances:
The flight was on a coupled instrument landing system (ILS) approach with 1/2 mile visibility in snow showers. Three successive fixes on the localizer are defined by distance measuring equipment (DME) paired with the ILS; prior to the ILS DME commissioning 6 months before the accident, the DME fixes were defined by a VORTAC 4.7 nautical miles past the ILS DME. The aircraft was 800 feet high at the first fix and 1,500 feet high at the second, but approximately on altitude 4.7 nautical miles past the first and second fixes, respectively. It passed the outer marker 900 feet high and captured the glide slope from above about 1.8 nautical miles from the threshold, 500 feet above decision height (DH) and 700 feet above touchdown. The aircraft was on glide slope for 28 seconds, during which time its speed decayed to stall speed; it then dropped below glide slope and crashed 1.3 nautical miles short of the threshold. The pilot's FLT DIR DME-1/ DME-2 switch, which control the DME display on the pilot's horizontal situation indicator (HSI), was found set to DME-2; the NAV-2 radio was set to the VORTAC frequency. Up to 800 feet may be required for stall recovery.
Probable cause:
The pilot's failure to maintain adequate airspeed on the ILS approach, resulting in a stall. Factors included: low visibility; the pilot's selection of the improper DME for the approach; his resulting failure to attain the proper descent profile for the approach; and insufficient altitude available for stall recovery.
Final Report:

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

Date & Time: Feb 9, 1995 at 1821 LT
Operator:
Registration:
N57NW
Flight Type:
Survivors:
No
Site:
Schedule:
Pueblo – Tremonton
MSN:
61-0775-8063388
YOM:
1980
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
4300
Aircraft flight hours:
2100
Circumstances:
The instrument-rated private pilot intended to land at an uncontrolled airport at night. The airport had no instrument approaches. The airplane was flying on an instrument flight rules (IFR) flight plan above an overcast layer of clouds. The pilot informed air traffic control (ATC) that he was going to try to find a 'hole' in the overcast and attempt a visual approach into the uncontrolled airport. The pilot then stated that he could not find a hole; he requested and received an IFR clearance to a larger controlled airport. On his way to the controlled airport, he stated that he found a 'hole' and attempted a visual approach to the uncontrolled airport. He received a cruise clearance from atc for 12,000 feet msl, and then descended at 2,280 feet per minute before impacting mountainous terrain at an elevation of 6,200 feet msl. Instrument meteorological conditions prevailed near the accident site. No distress calls from the airplane were recorded. An examination of the wreckage did not reveal any evidence of preimpact mechanical malfunctions. Both occupants were killed.
Probable cause:
The pilot's attempt to conduct visual flight into instrument meteorological conditions, and his failure to maintain altitude/clearance with the mountainous terrain. Factors were the clouds, and the dark night.
Final Report: