Metro Liner

National Transportation Safety BoardWashington, DC 20594

Brief of Accident

Adopted 1/15/1983

NYC82FA021File No. 657 1/15/1982 JAMAICA, NY Aircraft Reg No. N341PL Time (Local): 09:09 EST

Make/Model: SWEARINGEN / SA 226-TCEngine Make/Model: AIRESEARCH / TP-331

Aircraft Damage: SubstantialNumber of Engines: 2

Operating Certificate(s): Commuter Air CarrierName of Carrier: POCONO AIRLINES

Type of Flight Operation: Scheduled; Passenger Only; DomesticReg. Flight Conducted Under: Part 135: Air Taxi & Commuter

Fatal Serious Minor/NoneCrew 0 0 2Pass 0 1 12

Last Depart. Point: Same as AccidentDestination: SCRANTON, PA

Airport Proximity: On AirportAirport Name: JOHN F. KENNEDY INT'L

Runway Identification: 31LRunway Length/Width (Ft): 14572 / 150

Runway Surface: MacadamRunway Surface Condition: Snow--compacted

Condition of Light: DayWeather Info Src: Unk/Nr

Basic Weather: Visual Meteorological CondLowest Ceiling: Unk/Nr

Visibility: < 1 SMWind Dir/Speed: 300 / 018 Kts

Temperature (°C): 22Obstr to Vision: Blowing Snow

Precipitation: None

Pilot-in-Command Age: 40

Certificate(s)/Rating(s)Airline Transport; Multi-engine Land; Single-engine Land

Instrument RatingsAirplane

Flight Time (Hours)

Total All Aircraft: 11434Last 90 Days: 241

Total Make/Model: 1328Total Instrument Time: 1255

BEFORE N341PL STARTED TAKEOFF ON RUNWAY 31L, A BOEING 747 WAS CLEARED TO TAXI SOUTHEAST DOWN THE OUTER/PARALLEL TAXIWAY.THE TAXIWAY WAS 375 FTRIGHT OF THE RUNWAY CENTERLINE. THE 747 STOPPED MOMENTARILY, THEN TURNED 90 DEG LEFT ONTO TAXI- WAY KK. MEANWHILE, N341PL WAS CLEARED FOR AND BEGANTAKING OFF. THE PILOT STATED HE SAW LIGHT SNOW BEHIND THE 747, BUT WAS NOT CONCERNED SINCE THE 747 HAD STOPPED. THE TOWER CONTROLLER AND ANOTHERWITNESS REPORTED AN INCREASING AMOUNT OF SNOW BEHIND THE 747 AS IT TURNED OFF THE OUTER TAXIWAY. AFTER LIFT-OFF THE PILOT REMAINED IN GROUND EFFECTWHILE ACCELERATING TO CLIMB SPEED. HE STATED HE WAS TRAINED TO USE THIS PROCEDURE ON ALL TAKEOFFS. THE PILOT STATED THAT AFTERHE CALLED FOR GEARRETRACTION, HE ENTERED A WHITEOUT CONDITION, LEVELED HIS WINGS FROM A ROLL, AND ENCOUNTERED A DOWN- DRAFT. THE PLANE EMERGED FROM THE SNOW CLOUDAND STRUCK THE RUNWAY ABOUT 1100 FT BEFORE PASSING BEHIND THE 747. FLIGHT SAFETY INTL STATED THAT DURING GROUND/SIMULATOR TRAINING THEY RECOMMEND APOSITIVE RATE OF CLIMB IN IMC AND AT NIGHT.

Brief of Accident (Continued)

NYC82FA021File No. 657 1/15/1982 JAMAICA, NY Aircraft Reg No. N341PL Time (Local): 09:09 EST

Occurrence #1: IN FLIGHT ENCOUNTER WITH WEATHERPhase of Operation: TAKEOFF - INITIAL CLIMB

Findings 1. (F) TERRAIN CONDITION - SNOW COVERED 2. (F) WEATHER CONDITION - SNOW 3. (F) WEATHER CONDITION - WHITEOUT

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Occurrence #2: IN FLIGHT COLLISION WITH TERRAIN/WATERPhase of Operation: TAKEOFF - INITIAL CLIMB

Findings 4. (C) PROPER CLIMB RATE - NOT PERFORMED - PILOT IN COMMAND

Findings Legend: (C) = Cause, (F) = Factor

The National Transportation Safety Board determines the probable cause(s) of this accident as follows.There is no causal narrative file for this case.

Printed on 11/5/2003


Brief of Accident

Adopted 1/19/1983

DCA82AA012AFile No. 2657 1/19/1982 ROCKPORT, TX Aircraft Reg No. N336SA Time (Local): 13:23 CST

Make/Model: SWEARINGEN / SA226-T(B)Engine Make/Model: AIRESEARCH / TPE 331-10A

Aircraft Damage: DestroyedNumber of Engines: 2

Operating Certificate(s): Unk/NrType of Flight Operation: Executive/Corporate

Reg. Flight Conducted Under: Part 91: General Aviation


Last Depart. Point: CORPUS CHRISTI, TXDestination: Same as Accident

Airport Proximity: Off Airport/Airstrip


Basic Weather: Instrument Meteorological CondLowest Ceiling: 500 Ft. AGL, Overcast

Visibility: 2.00 SMWind Dir/Speed: 150 / 006 Kts

Temperature (°C): Unk/NrObstr to Vision: Fog

Precipitation: None




Flight Time (Hours)

Total All Aircraft: 3800Last 90 Days: Unk/Nr

Total Make/Model: Unk/NrTotal Instrument Time: Unk/Nr

PRIOR TO THE FAF DURING A VOR/DME APPROACH, THE MERLIN WAS CLEARED TO CHANGE TO THE UNICOM FREQ. THE PLT OF THE MERLIN CONTACTED UNICOM &REQUESTED AN ARPT ADVISORY. THE UNICOM OPERATOR REPLIED THAT THERE WAS A PIREP OF 500 FT OVER THE FIELD WITH 2 MI VISIBILITY BUT "ZILCH" OVER THE WATER.SHORTLY AFTER THIS CONTACT THE PLT OF THE AA5A CALLED ON UNICOM TURNING FINAL. THE PLT OF THE AA5A WAS GIVEN THE SAME ADVISORY AS GIVEN TO THE MERLIN& FURTHER ADVISED THAT ANOTHER ACFT WAS INBOUND FOR RWY 14. THE ACFT COLLIDED LESS THAN 1 MI NW OF THE APPROACH END OF RWY 14. AIM 157 RECOMMENDSTHAT VFR INBOUND FLTS BROADCAST ENTERING DOWNWIND & FINAL. AIM 363(C) RECOMMENDS THAT, WHEN MAKING AN IFR APPROACH TO AN ARPTNOT SERVED BY A TOWEROR FSS & AFTER ATC ADVISES TO CHANGE TO ADVISORY FREQ, TO BROADCAST INTENTIONS, INCLUDING TYPE APPROACH, POSITION & WHEN OVER FAF INBOUND.


DCA82AA012AFile No. 2657 1/19/1982 ROCKPORT, TX Aircraft Reg No. N336SA Time (Local): 13:23 CST

Occurrence #1: MIDAIR COLLISIONPhase of Operation: CIRCLING (IFR)

Findings 1. (F) CONTROL TOWER - UNAVAILABLE 2. (F) RADAR,APPROACH/DEPARTURE - UNAVAILABLE 3. (F) WEATHER CONDITION - LOW CEILING 4. (F) WEATHER CONDITION - FOG 5. (F) AIR/GROUND COMMUNICATIONS - INADEQUATE - PILOT IN COMMAND 6. (F) AIR/GROUND COMMUNICATIONS - INADEQUATE - PILOT OF OTHER AIRCRAFT 7. (C) VISUAL LOOKOUT - INADEQUATE - PILOT IN COMMAND 8. (C) VISUAL LOOKOUT - INADEQUATE - PILOT OF OTHER AIRCRAFT





Brief of Incident

Adopted 2/24/1983

CHI82IA072File No. 5070 2/24/1982 CHICAGO, IL Aircraft Reg No. N192MA Time (Local): 20:15 CST

Make/Model: SWEARINGEN / SA-227Engine Make/Model: AIRESEARCH / TPE33111U061G

Aircraft Damage: NoneNumber of Engines: 2

Operating Certificate(s): Commuter Air CarrierName of Carrier: MIDSTATE AIRLINES



Last Depart. Point: MKEDestination: ORD

Airport Proximity: On AirportAirport Name: O'HARE

Runway Identification: 27Runway Length/Width (Ft): 7400 / 150

Runway Surface: AsphaltRunway Surface Condition: Dry

Condition of Light: Night/DarkWeather Info Src: Unk/Nr



Temperature (°C): Unk/NrObstr to Vision: Unk/Nr

Precipitation: None




Flight Time (Hours)


Total Make/Model: 1873Total Instrument Time: Unk/Nr

THE PILOT STATED THAT AT THE DEPARTURE AIRPORT, THE RUNWAY WAS SLIPPERY AND THE TURN ONTO THE RUNWAY WAS DIFFICULT. THE NOSEWHEEL STEERING WASACTIVATED MOMENTARILY TO STRAIGHTEN THE NOSE, BUT WAS TURNED OFF PRIOR TO THE TAKEOFF ROLL. AT THE DESTINED AIRPORT THE AIRCRAFT WAS LANDED ATAPPROXIMATELY 115 KTS, AS SOON AS THE NOSEWHEEL TOUCHED, THE AIRCRAFT VEERED TO THE RIGHT. FULL LEFT BRAKE AND RUDDER DID NOT CORRECT THE SWERVE.THE NOSE GEAR STEERING ACTUATOR WAS EXAMINED AND NO EVIDENCE OF MALFUNCTION WAS REVEALED. ACCORDING TO THE COMPANY SAFETY BULLETIN AND AIRCRAFTMANUFACTURE BULLETIN, THE NOSE WHEEL STEERING SWITCH MUST BE OFF AND VERIFY THE NOSE WHEEL WILL CASTER (BY DISPLACING THE NOSE OF AIRCRAFT LEFT ORRIGHT USING BRAKES AND/OR ASYMETRIC ENGINE POWER) PRIOR TO TAKEOFF. THIS PROCEDURE IS TO BE PERFORMED BEFORE EVERY TAKEOFF WHILE TURNING ONTO THERUNWAY. THE NOSE WHEEL STEERING MUST NOT BE ARMED UNTIL THE SUBSEQUENT LANDING IS COMPLETED AND AIRCRAFT SPEED IS REDUCED BELOW 10 KTS.

Brief of Incident (Continued)

CHI82IA072File No. 5070 2/24/1982 CHICAGO, IL Aircraft Reg No. N192MA Time (Local): 20:15 CST

Occurrence #1: LOSS OF CONTROL - ON GROUND/WATERPhase of Operation: LANDING - FLARE/TOUCHDOWN

Findings 1. (C) PROCEDURES/DIRECTIVES - IMPROPER USE OF - PILOT IN COMMAND 2. (F) DIRECTIONAL CONTROL - INADVERTENT - COPILOT/SECOND PILOT


The National Transportation Safety Board determines the probable cause(s) of this incident as follows.There is no causal narrative file for this case.



Brief of Incident

Adopted 3/30/1983

CHI82IA108File No. 5100 3/30/1982 CHICAGO, IL Aircraft Reg No. N62Z Time (Local): 21:05 CST

Make/Model: SWEARINGEN / SA226TCEngine Make/Model: GARRETT / TPE-331-3U3-O

Aircraft Damage: MinorNumber of Engines: 2

Operating Certificate(s): Commuter Air CarrierName of Carrier: BRITT AIRWAYS, INC.



Last Depart. Point: Same as IncidentDestination: URBANA, IL

Airport Proximity: On AirportAirport Name: O'HARE INTERNATIONAL


Runway Surface: Asphalt; ConcreteRunway Surface Condition: Dry




Temperature (°C): 60Obstr to Vision: None

Precipitation: None


Certificate(s)/Rating(s)Airline Transport; Multi-engine Land


Flight Time (Hours)



THE AIRCRAFT VEERED LEFT AT SLOW SPEED BUT THE VEER WAS CORRECTED. AT 60 KTS THE AIRCRAFT VEERED AGAIN AND WAS NOT CORRECTED. AIRCRAFT LEFT RUNWAYAND DAMAGED PROPS. SERVICE BULLETIN SA-226 NO. 103 DATED 01/20/82 STATES THAT LIMITS BE PLACED ON USE OF NOSE WHEEL STEERING AND PRE-TAKEOFF CHECK TOINSURE STEERING IS IN CASTOR MODE PRIOR TO TAKEOFF.


CHI82IA108File No. 5100 3/30/1982 CHICAGO, IL Aircraft Reg No. N62Z Time (Local): 21:05 CST

Occurrence #1: LOSS OF CONTROL - ON GROUND/WATERPhase of Operation: TAKEOFF - ROLL/RUN

Findings 1. (C) LANDING GEAR,STEERING SYSTEM - IMPROPER 2. (F) GROUND LOOP/SWERVE - INADVERTENT - PILOT IN COMMAND 3. (C) PROCEDURES/DIRECTIVES - NOT FOLLOWED - PILOT IN COMMAND

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Occurrence #2: ON GROUND/WATER ENCOUNTER WITH TERRAIN/WATERPhase of Operation: TAKEOFF - ROLL/RUN

Findings 4. (F) TERRAIN CONDITION - SOFT





Brief of Accident

Adopted 4/5/1983

CHI82DA115File No. 1014 4/5/1982 FORT WAYNE, IN Aircraft Reg No. N639S Time (Local): 21:38 EST

Make/Model: SWEARINGEN / SA226TCEngine Make/Model: AIRESEARCH / 331-3UW-303G


Operating Certificate(s): Unk/NrType of Flight Operation: Ferry



Last Depart. Point: CLEVELAND, OHDestination: FORT WAYNE, TX

Airport Proximity: On AirportAirport Name: BAER FIELD


Runway Surface: AsphaltRunway Surface Condition: Snow--wet


Basic Weather: Instrument Meteorological CondLowest Ceiling: 200 Ft. AGL, Obscured



Precipitation: None


Certificate(s)/Rating(s)Airline Transport; Multi-engine Land; Single-engine Land; Single-engine Sea


Flight Time (Hours)



PRIOR TO LANDING THE CREW WAS ADVISED BY FORT WAYNE ATC THAT THE 150 FOOT WIDE RUNWAY HAD BEEN PLOWED 140 FEET WIDE WITH 18 INCH WINDROWS ON EACHSIDE OF THE RUNWAY. THE RUNWAY WAS REPORTED TO BE 40 PERCENT COVERED WITH FINGER DRIFTS. THE WIND WAS FROM 010 DEGREES AT 15 KNOTS AND GUSTING. THEPILOT STATED THAT AFTER TOUCHDOWN THE AIRCRAFT BEGAN TO DRIFT TO THE RIGHT AND CONTINUED TO DRIFT TO THE RIGHT UNTIL THE RIGHT MAIN LANDING GEARMADE CONTACT WITH A SNOW WINDROW. THE NOSE GEAR COLLAPSED AND THE AIRCRAFT VEERED ACROSS THE RUNWAY AND CAME TO REST OFF THE LEFT SIDE OFRUNWAY 04.


CHI82DA115File No. 1014 4/5/1982 FORT WAYNE, IN Aircraft Reg No. N639S Time (Local): 21:38 EST

Occurrence #1: LOSS OF CONTROL - ON GROUND/WATERPhase of Operation: LANDING - ROLL

Findings 1. (F) AIRPORT FACILITIES,RUNWAY/LANDING AREA CONDITION - SNOW COVERED 2. (F) WEATHER CONDITION - HIGH WIND 3. (F) WEATHER CONDITION - GUSTS 4. (F) LIGHT CONDITION - DARK NIGHT 5. (F) VISUAL/AURAL PERCEPTION - PILOT IN COMMAND 6. (C) DIRECTIONAL CONTROL - NOT MAINTAINED - PILOT IN COMMAND 7. (F) GROUND LOOP/SWERVE - INADVERTENT - PILOT IN COMMAND

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Occurrence #2: NOSE GEAR COLLAPSEDPhase of Operation: LANDING - ROLL

Findings 8. (F) LANDING GEAR,NOSE GEAR - OVERLOAD





Brief of Accident

Adopted 5/28/1983

LAX82DUG12File No. 1339 5/28/1982 PALM SPRINGS, CA Aircraft Reg No. N1009R Time (Local): 20:40 PDT

Make/Model: SWEARINGEN / SA226-TCEngine Make/Model: Unk/Nr


Operating Certificate(s): Commuter Air CarrierName of Carrier: SUNAIRE


Fatal Serious Minor/NoneCrew 0 0 2Pass 0 0 3Other 0 1 0

Last Depart. Point: Same as AccidentDestination: YUMA, AZ

Airport Proximity: On AirportAirport Name: PALM SPRINGS





Visibility: 20.00 SMWind Dir/Speed: Calm

Temperature (°C): Unk/NrObstr to Vision: None

Precipitation: None




Flight Time (Hours)



AFTER STARTING THE ENGINES AT NIGHT, A SIGNAL WAS GIVEN TO A LINE SERVICE EMPLOYEE TO DISCONNECT THE APU. WHILE ATTEMPTING TO DISCONNECT THE APU, THELINE SERVICE EMPLOYEE MOVED INTO THE PATH OF THE RIGHT PROPELLER AND WAS SERIOUSLY INJURED.


LAX82DUG12File No. 1339 5/28/1982 PALM SPRINGS, CA Aircraft Reg No. N1009R Time (Local): 20:40 PDT

Occurrence #1: PROPELLER/ROTOR CONTACT TO PERSONPhase of Operation: STANDING - ENGINE(S) OPERATING

Findings 1. (C) UNSAFE/HAZARDOUS CONDITION - INATTENTIVE - GROUND PERSONNEL





Brief of Accident

Adopted 8/20/1983

MKC82FA149File No. 1739 8/20/1982 KANSAS CITY, MO Aircraft Reg No. N237AM Time (Local): 14:43 CDT

Make/Model: SWEARINGEN / SA226TCEngine Make/Model: GARRETT / TPE331


Operating Certificate(s): Commuter Air CarrierName of Carrier: AIR MIDWEST

Type of Flight Operation: Scheduled; Passenger/Cargo; DomesticReg. Flight Conducted Under: Part 135: Air Taxi & Commuter


Last Depart. Point: WICHITA, KSDestination: TOPEKA, KS

Airport Proximity: On AirportAirport Name: DOWNTOWN





Visibility: 6.00 SMWind Dir/Speed: Unk/Nr

Temperature (°C): Unk/NrObstr to Vision: Haze

Precipitation: None




Flight Time (Hours)



DURING THE APPROACH TO TOPEKA THE CREW WAS UNABLE TO EXTEND THE LEFT GEAR. THE CREW DIVERTED TO KANSAS CITY, AND AFTER MANY UNSUCCESSFULATTEMPTS TO LOWER THE LEFT GEAR ELECTED TO LAND WHEELS-UP. THE LEFT MAIN GEAR WAS JAMMED INTO THE GEARDOORS. THE AFT HINGE BOLT WAS MISSING FROMTHE LEFT INBOARD GEAR DOOR, ALLOWING THE GEAR DOOR TO SHIFT JUST ENOUGH TO JAM THE GEAR AS IT STARTED TO EXTEND. 17 DAYS PRIOR TO THE ACCIDENT THELOOSE AFT HINGE WAS NOTED DURING PREFLIGHT. COMPANY MAINTENANCE WAS UNABLE TO RETORQUE THE BOLT DUE TO THE NUTPLATE ATTACHMENT RIVETS BEINGSTRIPPED. THIS ITEM WAS BEING CARRIED AS A DELAYED DISCREPANCY. THESE PARTS CAN ONLY BE LUBRICATED BEFORE INSTALLATION. THE ENTIRE ASSEMBLY IS ALMOSTIMPOSSIBLE TO INSPECT, REMOVE, LUBRICATE, INSTALL, TORQUE & SAFETY REPLACEMENT OF THE NUTPLATE IS CONSIDERED A MAJOR UNDERTAKING THE MANFACTURERSTATED THAT "SHORT CYCLING" THE GEAR AS MANY AS 18 TIMES WOULD EVENTUALLY BREAK OPEN THE GEAR DOORS. THIS EMERGENCY METHOD OF EXTENDING THE GEARHAD NOT BEEN DISSEMINATED TO ALL OPERATORS.


MKC82FA149File No. 1739 8/20/1982 KANSAS CITY, MO Aircraft Reg No. N237AM Time (Local): 14:43 CDT

Occurrence #1: AIRFRAME/COMPONENT/SYSTEM FAILURE/MALFUNCTIONPhase of Operation: APPROACH

Findings 1. (C) LANDING GEAR,NORMAL RETRACTION/EXTENSION ASSEMBLY - JAMMED 2. (C) LANDING GEAR,MAIN GEAR - MOVEMENT RESTRICTED 3. (C) DOOR,LANDING GEAR - ASSEMBLY 4. (C) DOOR,LANDING GEAR - LOOSE 5. (C) DOOR,LANDING GEAR - DISCONNECTED 6. (C) MAINTENANCE,REPLACEMENT - NOT PERFORMED - COMPANY MAINTENANCE PERSONNEL 7. (F) ACFT/EQUIP,INADEQUATE AIRFRAME - MANUFACTURER

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Occurrence #2: IN FLIGHT COLLISION WITH TERRAIN/WATERPhase of Operation: LANDING - FLARE/TOUCHDOWN

Findings 8. GEAR EXTENSION - ATTEMPTED - PILOT IN COMMAND 9. (F) INFORMATION INSUFFICIENT - MANUFACTURER10. WHEELS UP LANDING - PERFORMED - PILOT IN COMMAND





Brief of Incident

Adopted 9/1/1983

CHI82IA331File No. 5052 9/1/1982 APPLETON, WI Aircraft Reg No. N261S Time (Local): 19:03 CDT

Make/Model: SWEARINGEN / SA-226TCEngine Make/Model: AIRESEARCH / TPE-331


Operating Certificate(s): Commuter Air CarrierType of Flight Operation: Unk/Nr



Last Depart. Point: Same as IncidentDestination: Local

Airport Proximity: On AirportAirport Name: OUTAGAMIE CO. A/P


Runway Surface: ConcreteRunway Surface Condition: Dry





Precipitation: None


Certificate(s)/Rating(s)Airline Transport; Flight Instructor; Multi-engine Land; Single-engine Land


Flight Time (Hours)



THE RIGHT MAIN GEAR "IN TRANSIT" LIGHT REMAINED ON AFTER GEAR RETRACTION ON A TRAINING FLIGHT. VARIOUS METHODS OF REMEDIAL ACTION DID NOT CURE THEPROBLEM. A LANDING ON RUNWAY 21 WAS EXECUTED WITH THE NOSE AND LEFT MAIN GEAR IN THE DOWN POSITION. THE RIGHT GEAR REMAINED IN TRANSIT. DIRECTIONALCONTROL WAS MAINTAINED NEARLY THROUGHOUT THE LANDING ROLL. PRIOR TO THIS FLIGHT, COMPANY MAINTENANCE PERSONNEL HAD INSPECTED THE GEAR INCOMPLIANCE WITH A TELEGRAPHIC MESSAGE FROM THE MANUFACTURER. THE INSPECTION WAS INITIATED BY ONE MAINTENANCE SHIFT AND COMPLETED BY ANOTHER.INSUFFICIENT INFORMATION WAS PASSED BETWEEN THE SHIFTS TO ENSURE THAT GEAR DOOR WAS PROPERLY RE-RIGGED. DURING GEAR EXTENSION, THE DOOR JAMMEDPREVENTING COMPLETE EXTENSION OF THE GEAR.


CHI82IA331File No. 5052 9/1/1982 APPLETON, WI Aircraft Reg No. N261S Time (Local): 19:03 CDT

Occurrence #1: AIRFRAME/COMPONENT/SYSTEM FAILURE/MALFUNCTIONPhase of Operation: TAKEOFF - INITIAL CLIMB

Findings 1. (C) DOOR,LANDING GEAR - MOVEMENT RESTRICTED 2. (C) MAINTENANCE,ADJUSTMENT - IMPROPER - COMPANY MAINTENANCE PERSONNEL 3. (C) LANDING GEAR,NORMAL RETRACTION/EXTENSION ASSEMBLY - JAMMED 4. (C) LANDING GEAR,MAIN GEAR - JAMMED

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Findings 5. DIRECTIONAL CONTROL - NOT POSSIBLE - PILOT IN COMMAND 6. GROUND LOOP/SWERVE - UNCONTROLLED - PILOT IN COMMAND





Brief of Incident

Adopted 9/13/1983

DEN82IA192File No. 5073 9/13/1982 DENVER, CO Aircraft Reg No. N5471M Time (Local): 05:20 MDT

Make/Model: FAIRCHILD/SWEARINGEN / SA226TCEngine Make/Model: AIRESEARCH / TPE33134W303G



Type of Flight Operation: Non-scheduled; ; DomesticReg. Flight Conducted Under: Part 135: Air Taxi & Commuter


Last Depart. Point: Same as IncidentDestination: WICHITA, KS

Airport Proximity: On AirportAirport Name: STAPLETON INTERNATIONAL


Runway Surface: Asphalt; ConcreteRunway Surface Condition: Wet





Precipitation: None


Certificate(s)/Rating(s)Airline Transport; Commercial; Multi-engine Land; Single-engine Land


Flight Time (Hours)



DURING TAKEOFF ON A MAINTENANCE FERRY FLIGHT, WITH A MECHANIC FLYING FROM THE RIGHT SEAT, THE AIRCRAFT WOULD NOT ACCELERATE ABOVE V1 AND WOULD NOTROTATE EVEN WITH FULL AFT YOKE. THE CAPTAIN ABORTED THE TAKEOFF AND THE AIRCRAFT WAS STOPPED AT THE END OF THE RUNWAY WITH THE RIGHT GEAR ON THEOVERRUN AREA. AFTER THE AIRCRAFT STOPPED, CREWMEMBERS EXTINGUISHED TWO SMALL FIRES IN THE MAIN GEAR BRAKES. INVESTIGATION DID NOT REVEAL THEREASON THE AIRCRAFT WOULD NOT ACCELERATE, HOWEVER IT WAS NOTED THAT BOTH MAIN BRAKE ASSEMBLIES HAD BEEN SUBJECTED TO EXTREME HEAT AND RAPIDCOOLING. IN ADDITION, ALL OF THE BRAKE PUCKS WERE WORN THIN. THIS DAMAGE WAS CONSISTENT WITH TAKING OFF WITH THE PARKING BRAKE ENGAGED ORINADVERTENT APPLICATION OF THE TOE BRAKES DURING TAKEOFF ROLL.


DEN82IA192File No. 5073 9/13/1982 DENVER, CO Aircraft Reg No. N5471M Time (Local): 05:20 MDT

Occurrence #1: OVERRUNPhase of Operation: OTHER

Findings 1. (C) LANDING GEAR,NORMAL BRAKE SYSTEM - ENGAGED 2. REASON FOR OCCURRENCE UNDETERMINED





Brief of Accident

Adopted 10/15/1983

LAX83FA002File No. 2077 10/15/1982 PALM SPRINGS, CA Aircraft Reg No. N63SA Time (Local): 19:57 PDT

Make/Model: SWEARINGEN / SA-226TCEngine Make/Model: GARRETT / TPE-331


Operating Certificate(s): Commuter Air CarrierName of Carrier: BORREGO SPRINGS AIRLINE



Last Depart. Point: PALM SPRINGS, CADestination: LOS ANGELES, CA

Airport Proximity: On AirportAirport Name: PALM SPRINGS


Runway Surface: Unk/NrRunway Surface Condition: Unk/Nr





Precipitation: None




Flight Time (Hours)



WHILE AT THE GATE WITH THE PASSENGERS SEATED & THE ENGINES RUNNING, THE COPILOT ATTEMPTED TO TURN UP HIS PANEL LIGHTS WITH THE RHEOSTAT LOCATED ONTHE FAR RIGHT FORWARD PORTION OF THE SIDE ELECTRICAL PANEL. AT THAT INSTANT SMOKE BEGAN TO ERUPT AT HIS RIGHT KNEE POSITION. THE PASSENGERS WEREEVACUATED & THE COCKPIT FIRE WAS PUT OUT BY THE GROUND CREW. THE RHEOSTAT WAS FOUND TO BE CONTAMINATED WITH HYDRAULIC FLUID, & HEAVY ARCING WASFOUND ON THE RHEOSTAT AT THE FULL HIGH POSITION. THREE HYDRAULIC LINES WERE FOUND TO BE BURNED IN HALF FORWARD & UNDER THE CIRCUIT BREAKER PANELACCESS DOOR. EXAMINATION OF THE HYDRAULIC BRAKE LINE REVEALED STRESS CRACKS DUE TO CHEMICAL CONTAMINATION OR FATIGUE, PERMITTING BRAKE FLUID TOESCAPE INTO THE SURROUNDING AREA. THE BRAKE FLUID WAS IGNITED BY THE ARCING COPILOT'S RHEOSTAT, & THE FIRE REACHED AN OXYGEN LINE WITHIN SECONDSCAUSING A BLOW-OUT HOLE THRU THE FUSELAGE.


LAX83FA002File No. 2077 10/15/1982 PALM SPRINGS, CA Aircraft Reg No. N63SA Time (Local): 19:57 PDT

Occurrence #1: FIRE/EXPLOSIONPhase of Operation: STANDING - ENGINE(S) OPERATING

Findings 1. LIGHT CONDITION - DARK NIGHT 2. (C) INSTRUMENT LIGHT(S) - CONTAMINATION 3. (C) INSTRUMENT LIGHT(S) - ARCING 4. (C) HYDRAULIC SYSTEM,LINE - CONTAMINATION 5. (C) HYDRAULIC SYSTEM,LINE - DUMPED 6. (C) HYDRAULIC SYSTEM,LINE - FAILURE,PARTIAL 7. (C) HYDRAULIC SYSTEM,LINE - LEAK 8. (C) HYDRAULIC SYSTEM,LINE - BURNED 9. (C) FUSELAGE,INSTRUMENT/ELECTRICAL PANEL - BURNED10. (C) OXYGEN SYSTEM,CREW - EXPLODED





Brief of Accident

Adopted 10/17/1983

CHI83LA021File No. 2516 10/17/1982 INDIANAPOLIS, IN Aircraft Reg No. N173MA Time (Local): 15:30 EST

Make/Model: SWEARINGEN / SA227-ACEngine Make/Model: AIRESEARCH / TPE-331


Operating Certificate(s): Commuter Air CarrierName of Carrier: MIOSTATES AIRLINES



Last Depart. Point: MILWAUKEE, WIDestination: Same as Accident

Airport Proximity: On AirportAirport Name: INDIANAPOLIS INT'L. APRT.




Basic Weather: Visual Meteorological CondLowest Ceiling: 25000 Ft. AGL, Overcast



Precipitation: None




Flight Time (Hours)



THE LEFT WING STRUCK A BUILDING DURING TAXI INTO THE PASSENGER GATE. GROUND PERSONNEL WERE STATIONED ON EACH SIDE OF THE AIRCRAFT.


CHI83LA021File No. 2516 10/17/1982 INDIANAPOLIS, IN Aircraft Reg No. N173MA Time (Local): 15:30 EST

Occurrence #1: ON GROUND/WATER COLLISION WITH OBJECTPhase of Operation: TAXI - FROM LANDING

Findings 1. (F) OBJECT - BUILDING(NONRESIDENTIAL) 2. (C) PROPER ASSISTANCE - INADEQUATE - GROUND PERSONNEL





Brief of Accident

Adopted 11/5/1983

LAX83LA026File No. 2577 11/5/1982 SAN FRANCISCO, CA Aircraft Reg No. N65SA Time (Local): 18:01 PST

Make/Model: SWEARINGEN / SA-226TCEngine Make/Model: AIRESEARCH / 3313UV303G


Operating Certificate(s): Commuter Air CarrierName of Carrier: NEVADA NATIONAL LEASING CO.



Last Depart. Point: Same as AccidentDestination: SACRAMENTO, CA

Airport Proximity: On AirportAirport Name: SAN FRANCISCO INTERN.


Runway Surface: AsphaltRunway Surface Condition: Unk/Nr





Precipitation: None




Flight Time (Hours)



FLIGHT 238, WAS CLEARED FOR TAKEOFF FROM RUNWAY 28L AT SAN FRANCISCO INTL AIRPORT. WHILE ACCELERATING THROUGH V2 WITH THE GEAR IN UPWARD TRANSIT ATAPPROXIMATELY 50 FEET AGL, THE RED LEFT ENGINE FIRE WARNING LIGHT ILLUMINATED. THE FLIGHT CREW ELECTED TO ABORT AND THE AIRCRAFT WAS LANDED STRAIGHTAHEAD ON THE RUNWAY. THE LANDING GEAR DID NOT EXTEND IN TIME AND THE AIRCRAFT IMPACTED THE RUNWAY.


LAX83LA026File No. 2577 11/5/1982 SAN FRANCISCO, CA Aircraft Reg No. N65SA Time (Local): 18:01 PST


Findings 1. (F) ENGINE INSTRUMENTS,EGT/TOT GAGE - FALSE INDICATION 2. (C) REASON FOR OCCURRENCE UNDETERMINED 3. ABORTED TAKEOFF - PERFORMED - PILOT IN COMMAND

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Occurrence #2: COMPLETE GEAR COLLAPSEDPhase of Operation: TAKEOFF

Findings 4. GEAR EXTENSION - NOT OBTAINED - PILOT IN COMMAND 5. EMERGENCY PROCEDURE - PERFORMED - PILOT IN COMMAND





Brief of Accident

Adopted 12/7/1983

DCA83AA009File No. 1202 12/7/1982 CHANTILLY, VA Aircraft Reg No. N126AV Time (Local): 17:00 EST

Make/Model: SWEARINGEN / SA-226TCEngine Make/Model: AIRESEARCH / TPE-331


Operating Certificate(s): Commuter Air CarrierName of Carrier: FLT AMERICA, INC



Last Depart. Point: NORFOLK, VADestination: Same as Accident

Airport Proximity: On AirportAirport Name: DULLES INTL



Condition of Light: DuskWeather Info Src: Unk/Nr

Basic Weather: Visual Meteorological CondLowest Ceiling: 4900 Ft. AGL, Broken



Precipitation: None




Flight Time (Hours)



APPROACHING THE ARPT THE FLT WAS GIVEN VECTORS TO RWY 01L & CLEARED TO DESCEND TO 2,000 FT. THE CONTROLLER REQUESTED THAT THE PLT EXPEDITE THEDESCENT THROUGH 3,000 FT. THE FIRST OFFICER, WHO WAS FLYING THE ACFT, REQUESTED THE GEAR DOWN.THE CAPTAIN STATED THAT HE DID NOT SPECIFICALLYREMEMBER PLACING THE GEAR HANDLE DOWN BUT THOUGHT HE DID. THE FIRST OFFICER STATED THAT HE DID NOT LOOK AT THE GEAR HANDLE OR INDICATORS. THE ACFTLANDED GEAR UP. THE CAPTAIN STATED THAT WHEN THE PROPELLERS BEGAN CONTACTING THE RWY HE CHECKED THE GEAR HANDLE TO CONFIRM IT WAS DOWN, & MAYHAVE PUT IT DOWN AT THAT TIME. AT NO TIME DID EITHER CREW MEMBER HEAR THE GEAR UNSAFE WARNING HORN. THE CAPTAIN STATED THAT BECAUSE MANY OF THEIRAPPROACHES WERE STEEP & FAST WITH POWER LEVERS AT IDLE, MANY CREWS FLEW WITH THE WARNING HORN CIRCUIT BREAKER PULLED.


DCA83AA009File No. 1202 12/7/1982 CHANTILLY, VA Aircraft Reg No. N126AV Time (Local): 17:00 EST


Findings 1. (F) LANDING GEAR,GEAR WARNING SYSTEM - DISABLED 2. (C) GEAR EXTENSION - NOT PERFORMED - PILOT IN COMMAND 3. WHEELS UP LANDING - INADVERTENT - PILOT IN COMMAND





Brief of Accident

Adopted 12/7/1983

DEN83AA032File No. 3285 12/7/1982 PUEBLO, CO Aircraft Reg No. N30093 Time (Local): 19:07 MST

Make/Model: SWEARINGEN / SA-227ACEngine Make/Model: GARRETT / TPE331


Operating Certificate(s): Commuter Air CarrierName of Carrier: PIONEER AIRLINES

Type of Flight Operation: Scheduled; Cargo; DomesticReg. Flight Conducted Under: Part 135: Air Taxi & Commuter


Last Depart. Point: SANTA FE, NMDestination: PUEBLO, CO



Basic Weather: Instrument Meteorological CondLowest Ceiling: Unk/Nr


Temperature (°C): 24Obstr to Vision: Unk/Nr

Precipitation: Snow




Flight Time (Hours)



AT 1906 THE FLT WAS CLEARED TO DESCEND & MAINTAIN 7,500 FT, TURN RIGHT TO A HEADING 040 FOR AN ASR APCH TO PUEBLO MEMORIAL ARPT, & THAT THE MDA IS 5,200.THE FLT READ BACK "LEFT TO ONE FORTY FIVE TWO ZERO ZERO." APPROACH CONTROL ADVISED THE FLT THAT THE HEADING WAS 040 & THE FLT ACKNOWLEDGED. THEREWERE NO FURTHER COMMUNICATIONS WITH THE FLT. THE ACFT WAS TRAVELLING IN EXCESS OF AN ESTIMATED 200 MPH WHEN IT STRUCK TUNDRA IN LEVEL FLIGHT ON AHEADING OF ABOUT 040. THE COPLT'S AUTOPSY REVEALED THAT THE TRACHAE, BRONCHI, & LUNGS CONTAINED ASPIRATED GASTRIC CONTENTS, INCLUDING SKELETALMUSCLE FIBERS. ANOTHER COMPANY PLT REPORTED THAT THE COPLT HAD VOMITED DURING A FLT ON 11/14/82.


DEN83AA032File No. 3285 12/7/1982 PUEBLO, CO Aircraft Reg No. N30093 Time (Local): 19:07 MST

Occurrence #1: IN FLIGHT COLLISION WITH TERRAIN/WATERPhase 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





Brief of Accident

Adopted 12/7/1983

LAX83FVM04File No. 3053 12/7/1982 SAN FRANCISCO, CA Aircraft Reg No. N4273X Time (Local): 11:56 PST

Make/Model: SWEARINGEN / SA226-TEngine Make/Model: AIRESEARCH / TPE-3313U303G


Operating Certificate(s): Unk/NrType of Flight Operation: Executive/Corporate



Last Depart. Point: FRESNO, CADestination: Same as Accident

Airport Proximity: On AirportAirport Name: SAN FRANCISCO INTL.

Runway Identification: 28RRunway Length/Width (Ft): 11870 / 200






Precipitation: None


Certificate(s)/Rating(s)Airline Transport; Flight Instructor; Commercial; Multi-engine Land; Single-engine Land; Helicopter


Flight Time (Hours)



DURING ARRIVAL, THE WINDS WERE REPORTED FROM 350 TO 360 DEG AT 20 GUSTING 25 KTS, AND WHILE LANDING, THEY WERE FROM 360 DEG AT 21 KTS. THE ACFT'S MAXDEMO X-WIND CAPABILITY WAS 22 KTS. THE PLT REPORTED THAT DURING THE LANDING, THE POWER LEVERS WERE RETARDED TO IDLE, THEN TO REVERSE. WHILE ENTERINGREVERSE, THE ACFT SWERVED TO THE LEFT, AWAY FROM THE X-WIND. THE PLT THEN ADVANCED THE THROTTLES OUT OF REVERSE TO LESS THAN FLT IDLE. AT THAT TIME,THE ACFT SWERVED TO THE RIGHT. THE POWER LEVERS WERE AGAIN REVERSED & BRAKES WERE APPLIED. HOWEVER, THE ACFT VEERED OFF THE RIGHT SIDE OF THE RWY.IT CONTINUED INTO MUD, THE NOSE GEAR COLLAPSED & BOTH PROPS WERE DAMAGED. THE PLT DID NOT FEATHER THE ENGS UNTIL AFTER BOTH PROPS HAD STOPPEDTURNING. THE RIGHT PROP WAS FOUND IN THE FULL FEATHERED POSITION, THE LEFT PROP HAD NOT FEATHERED. REMOVAL OF THE RIGHT PROP DOME REVEALED NOAPPARENT ABNORMALITIES OR INTERNAL DAMAGE. THERE WAS EVIDENCE THAT THE LEFT PROP HAD GONE BEYOND FULL REVERSE ON IMPACT. NO PREIMPACT FAILURE WASFOUND.


LAX83FVM04File No. 3053 12/7/1982 SAN FRANCISCO, CA Aircraft Reg No. N4273X Time (Local): 11:56 PST


Findings 1. (C) REASON FOR OCCURRENCE UNDETERMINED 2. (F) WEATHER CONDITION - CROSSWIND 3. DIRECTIONAL CONTROL - NOT MAINTAINED 4. GROUND LOOP/SWERVE - UNCONTROLLED

----------


Findings 5. (F) TERRAIN CONDITION - SOFT 6. (F) TERRAIN CONDITION - WET 7. LANDING GEAR,NOSE GEAR - OVERLOAD





Brief of Accident

Adopted 12/20/1983

DEN83LA036File No. 3289 12/20/1982 GILLETTE, WY Aircraft Reg No. N2671V Time (Local): 20:15 MST

Make/Model: SWEARINGEN / SA-227ACEngine Make/Model: GARRETT / TPE331


Operating Certificate(s): Commuter Air CarrierName of Carrier: PIONEER AIRLINES



Last Depart. Point: DENVER, WYDestination: GILLETTE, WY

Airport Proximity: On AirportAirport Name: GILLETTE CAMPBELLL COUNTY


Runway Surface: AsphaltRunway Surface Condition: Unk/Nr





Precipitation: None




Flight Time (Hours)



DIRECTIONAL CONTROL WAS LOST IN THE EARLY STAGE OF THE TAKEOFF ROLL. THE ACFT DEPARTED THE RWY 400 FT DOWN THE RWY & TRAVELLED 85 FT OFF THE SIDE OFTHE RWY. ONE RWY LIGHT WAS DESTROYED. THE ACFT HAD COME FROM THE FACTORY EQUIPPED WITH AN ANTI-SKID BRAKE SYSTEM. THE SYSTEM WAS REPLACED WITH ASTANDARD BRAKING SYSTEM PRIOR TO THE ACFT'S FIRST PASSENGER FLT. DURING THIS PROCESS HYDRAULIC LINES ATTACHED TO THE PARKING BRAKE SHUTTLE VALVEUNDER THE INSTRUMENT PANEL AREA WERE INADVERTENTLY REVERSED, ALLOWING BRAKING ACTION TO TAKE PLACE ON THE OPPOSITE LANDING GEAR OF THE BRAKEPEDAL BEING DEPRESSED. THE FLT CREW WAS UNAWARE OF THIS CONDITION SINCE THEY HAD BEEN USING ASYMMETRICAL THRUST FOR DIRECTIONAL CONTROL UNTIL THISTAKEOFF.


DEN83LA036File No. 3289 12/20/1982 GILLETTE, WY Aircraft Reg No. N2671V Time (Local): 20:15 MST


Findings 1. (C) LANDING GEAR,NORMAL BRAKE SYSTEM - INCORRECT 2. (C) MAINTENANCE,REPLACEMENT - IMPROPER - COMPANY MAINTENANCE PERSONNEL 3. (C) LANDING GEAR,NORMAL BRAKE SYSTEM - ASYMMETRICAL 4. DIRECTIONAL CONTROL - NOT POSSIBLE - PILOT IN COMMAND 5. GROUND LOOP/SWERVE - UNCONTROLLED - PILOT IN COMMAND

----------

Occurrence #2: IN FLIGHT COLLISION WITH TERRAIN/WATERPhase of Operation: TAKEOFF

Findings 6. ABORTED TAKEOFF - PERFORMED - PILOT IN COMMAND





Brief of Incident

Adopted 12/22/1983

SEA83IA034File No. 5077 12/22/1982 KLAMATH FALLS, OR Aircraft Reg No. N5475M Time (Local): 17:49 PST

Make/Model: SWEARINGEN / SA-226TCEngine Make/Model: GARRETT / TPG331-3


Operating Certificate(s): Commuter Air CarrierName of Carrier: GATX THIRD AIRCRAFT CORP.



Last Depart. Point: Same as IncidentDestination: MEDFORD, OR

Airport Proximity: On AirportAirport Name: KINGSLEY FIELD


Runway Surface: Asphalt; ConcreteRunway Surface Condition: Snow--dry


Basic Weather: Instrument Meteorological CondLowest Ceiling: Unk/Nr



Precipitation: Snow




Flight Time (Hours)



DURING TAKEOFF ON RUNWAY 14 WITH THE WINDS FROM 310 DEG AT 17 KNOTS, SATISFACTORY ACCELERATION OCCURRED THROUGH 70 KNOTS FOLLOWED BY A SLOWINGRATE OF ACCELERATION AT 80 KNOTS. THE CAPTAIN THEN REDUCED POWER AND SHORTLY THEREAFTER FELT THE LEFT MAIN TIRES STRIKE SOMETHING AND THE AIRCRAFTBEGAN A LEFT YAW. ATTEMPTS TO REGAIN DIRECTIONAL CONTROL WERE UNSUCCESSFUL AN N5475M ROLLED OFF THE EAST SIDE OF THE RUNWAY AND STRUCK ASNOWBANK. THE CREW SHUT DOWN THE ENGINES AND EVACUATED THE PASSENGERS. THE DOWNWIND TAKEOFF WAS NECESSITATED BY VISIBILITY REQUIREMENTS FOR THEDEPARTURE.


SEA83IA034File No. 5077 12/22/1982 KLAMATH FALLS, OR Aircraft Reg No. N5475M Time (Local): 17:49 PST


Findings 1. (F) AIRCRAFT PERFORMANCE,TAKEOFF CAPABILITY - DETERIORATED 2. ABORTED TAKEOFF - PERFORMED - PILOT IN COMMAND 3. (C) TERRAIN CONDITION - SNOW COVERED 4. (C) WEATHER CONDITION - UNFAVORABLE WIND 5. (C) DIRECTIONAL CONTROL - NOT MAINTAINED - PILOT IN COMMAND

----------

Occurrence #2: ON GROUND/WATER COLLISION WITH OBJECTPhase of Operation: OTHER

Findings 6. (F) TERRAIN CONDITION - SNOWBANK





Brief of Accident

ATL83LA080File No. 462 1/2/1983 LAUREL, MS Aircraft Reg No. N5291M Time (Local): 03:44 CST

Make/Model: SWEARINGEN / SA-226TCEngine Make/Model: AIRESEARCH / TPE3313UW303G


Operating Certificate(s): Unk/NrType of Flight Operation: Personal



Last Depart. Point: BATON ROUGE, LADestination: CHAMBLEE, GA

Airport Proximity: On AirportAirport Name: PINE BELT REGIONAL


Runway Surface: AsphaltRunway Surface Condition: Wet

Condition of Light: Night/DarkWeather Info Src: Pilot



Temperature (°C): 13Obstr to Vision: Fog

Precipitation: Rain




Flight Time (Hours)



AT 11,000 FT MSL DURING CRUISE A PROP SEPARATED FROM THE LEFT ENG. THE ENG WAS FEATHERED & THE PLT OBSERVED THE ENG DISPLACED INBOARD & DOWNWARD.AN EMERGENCY LANDING WAS MADE & UPON LANDING THE LEFT MAIN GEAR WAS FOUND TO BE RETRACTED.THE ACFT SLID TO A STOP COMING TO REST ON THE ADJACENTTAXIWAY. METALLURGICAL EXAMINATION REVEALED THAT THE BLADE FAILED FROM FATIGUE INITIATING AT CORROSION PITS ON THE INTERIOR OF THE FAILED BLADEBALANCE HOLE. THE PAINT IN THE BALANCE HOLE WAS DISCONTINUOUS & NON-UNIFORM. THERE WAS NO EVIDENCE OF THE HOLE HAVING BEEN SHOTPEENED. OVERHAULINSTRUCTIONS REQUIRE SHOTPEENING OF THE BALANCE HOLE. TSO WAS CALCULATED AS 1565.8 HRS.


ATL83LA080File No. 462 1/2/1983 LAUREL, MS Aircraft Reg No. N5291M Time (Local): 03:44 CST

Occurrence #1: AIRFRAME/COMPONENT/SYSTEM FAILURE/MALFUNCTIONPhase of Operation: CRUISE - NORMAL

Findings 1. (C) PROPELLER SYSTEM/ACCESSORIES,BLADE - CORRODED 2. (C) PROPELLER SYSTEM/ACCESSORIES,BLADE - FATIGUE 3. (C) PROPELLER SYSTEM/ACCESSORIES,BLADE - FAILURE,TOTAL 4. (C) MAINTENANCE,OVERHAUL - INADEQUATE - OTHER MAINTENANCE PERSONNEL 5. (F) PROPELLER SYSTEM/ACCESSORIES,BLADE - SEPARATION

----------


Findings 6. (C) LANDING GEAR,NORMAL RETRACTION/EXTENSION ASSEMBLY - INOPERATIVE 7. (C) GEAR EXTENSION - NOT POSSIBLE - PILOT IN COMMAND 8. (C) DIRECTIONAL CONTROL - NOT POSSIBLE - PILOT IN COMMAND 9. (F) GROUND LOOP/SWERVE - UNCONTROLLED - PILOT IN COMMAND





Brief of Accident

MKC83FA072File No. 973 2/24/1983 ST. LOUIS, MO Aircraft Reg No. N237AM Time (Local): 19:16 CST

Make/Model: SWEARINGEN / SA 226TCEngine Make/Model: AIRESEARCH / 331-3UW-30-3G





Last Depart. Point: COLUMBIA, MODestination: Same as Accident

Airport Proximity: On AirportAirport Name: LAMBERT-ST. LOUIS INTL.

Runway Identification: 00Runway Length/Width (Ft): Unk/Nr


Condition of Light: Night/DarkWeather Info Src: Weather Observation Facility




Precipitation: None




Flight Time (Hours)



ROTATING RIGHT PROP STRUCK A FEMALE CHILD PASSENGER WHO HAD RUN DOWN THE ACFT AIRSTAIR TO RETRIEVE A DOLL SHE HAD DROPPED WHILE CLIMBING THEAIRSTAIR TO BOARD FOR THE FLT. A COMPANY ATTENDANT WAS STATIONED AT THE LEFT (STOPPED) PROP, BUT NOT ON OR NEAR THE AIRSTAIR, TO ASSIST THEPASSENGERS. THE OPERATOR HAD NO PROCEDURES GOVERNING THE OPERATION OF ENGINES DURING ENPLANING & DEPLANING. BOARDING PROCEDURES WERE SKETCHY,BUT HAVE BEEN CHANGED SINCE THE ACCIDENT TO REQUIRE A CREWMEMBER BE ON THE BOARDING STAIRS PRIOR TO BOARDING PASSENGERS.


MKC83FA072File No. 973 2/24/1983 ST. LOUIS, MO Aircraft Reg No. N237AM Time (Local): 19:16 CST


Findings 1. (F) LIGHT CONDITION - DARK NIGHT 2. (C) SUPERVISION - INADEQUATE - COMPANY/OPERATOR MANAGEMENT 3. (C) CONDITION(S)/STEP(S) NOT LISTED - COMPANY/OPERATOR MANAGEMENT





Brief of Accident

NYC83FA074File No. 287 3/12/1983 ALBANY, NY Aircraft Reg No. N1011N Time (Local): 19:00 EST

Make/Model: SWEARINGEN / SA226TCEngine Make/Model: Airesearch / TPE 331


Operating Certificate(s): On-demand Air TaxiName of Carrier: EAST COAST AIRWAYS

Type of Flight Operation: Non-scheduled; Passenger Only; DomesticReg. Flight Conducted Under: Part 135: Air Taxi & Commuter


Last Depart. Point: WESTFIELD, MADestination: ALBANY, NY

Airport Proximity: On AirportAirport Name: ALBANY


Runway Surface: AsphaltRunway Surface Condition: Snow-crusted





Precipitation: Snow


Certificate(s)/Rating(s)Airline Transport; Single-engine Land


Flight Time (Hours)



THE PLT REPORTED THAT DURING ARRIVAL, HE FOLLOWED THE ILS GLIDE SLOPE TO TOUCHDOWN ABOUT 1000 FT DOWN THE RWY. HE REPORTED THE LANDING WAS SMOOTH,AND WHEN THE ACFT WAS APRX 100 FT FROM THE INTERSECTION OF RWYS 1/19 AND 10/28, HE SAW A RIDGE OF SNOW AND ICE ACROSS THE RWY. SINCE THE ACFT SAW STILLTRAVELING AT APRX 50 KTS, THE AIRCREW COULD NOT AVOID THE ICE AND SNOW. AS THE ACFT CROSSED THE INTERSECTION, A LOUD NOISE WAS HEARD. THE LANDINGGEAR AURAL WARNING HORN ACTIVATED AND THE RED LIGHT ON THE NOSE GEAR INDICATOR ILLUMINATED. AFTER STOPPING, AN INSPECTION REVEALED THE NOSE GEARWAS BENT AFT AND THE FUSELAGE WAS WRINKLED. ALSO, THE SPACE BETWEEN THE NOSEWHEEL TIRES WAS FOUND PACKED WITH ICE. A FURTHER INVESTIGATIONREVEALED THAT SNOWPLOW OPERATORS HAD BEEN PLOWING SNOW ON RWY 10/28 AND TURN-AROUNDS HAD BEEN MADE ON RWY 1/19 BEFORE SWEARINGEN, N1011N, HADLANDED.


NYC83FA074File No. 287 3/12/1983 ALBANY, NY Aircraft Reg No. N1011N Time (Local): 19:00 EST

Occurrence #1: ON GROUND/WATER COLLISION WITH OBJECTPhase of Operation: LANDING - ROLL

Findings 1. (F) LIGHT CONDITION - DARK NIGHT 2. (F) WEATHER CONDITION - LOW CEILING 3. (F) WEATHER CONDITION - FOG 4. (F) WEATHER CONDITION - SNOW 5. (C) AIRPORT SNOW REMOVAL - IMPROPER - AIRPORT PERSONNEL





Brief of Incident

MKC83IA102File No. 5012 5/6/1983 LINCOLN, NE Aircraft Reg No. N779M Time (Local): 12:45 CDT

Make/Model: FAIRCHILD SWEARINGEN / SA226TEngine Make/Model: GARRETT / TPE-3311


Operating Certificate(s): Unk/NrType of Flight Operation: Instructional



Last Depart. Point: OMAHA, NEDestination: Same as Incident

Airport Proximity: Unk/Nr

Condition of Light: DayWeather Info Src: Pilot

Basic Weather: Visual Meteorological CondLowest Ceiling: None



Precipitation: None




Flight Time (Hours)



DURING LANDING ROLL THE ACFT VEERED LEFT. THE PARKING BRAKE VALVE WAS SUSPECTED TO HAVE FAILED & WAS REPLACED AS A PRECAUTIONARY MEASURE.


MKC83IA102File No. 5012 5/6/1983 LINCOLN, NE Aircraft Reg No. N779M Time (Local): 12:45 CDT


Findings 1. (C) OTHER SYSTEM - BLOCKED(PARTIAL)





Brief of Accident

DCA83AA037File No. 2216 8/27/1983 HOT SPRINGS, AR Aircraft Reg No. N503SS Time (Local): 20:03 CDT

Make/Model: SWEARINGEN / SA226TCEngine Make/Model: AIRESEARCH / TPE-331


Operating Certificate(s): Commuter Air CarrierName of Carrier: SCHEDULED SKYWAYS INC.



Last Depart. Point: DALLAS, TXDestination: LITTLE ROCK, AR

Airport Proximity: On AirportAirport Name: MEMORIAL FIELD



Condition of Light: DuskWeather Info Src: Unk/Nr




Precipitation: None




Flight Time (Hours)



TURNING ONTO THE RWY THE COPLT OBSERVED A FLASH BEHIND HIS INST PANEL. HE THEN RECEIVED AN ELECT SHOCK TO HIS RIGHT ARM FROM THE RIGHT CONSOLE. AFIRE THEN ERUPTED AT THE LOWER RIGHT HAND CORNER OF HIS INST PANEL. THE CREW & PAX EVACUATED THE ACFT. THE INTERIOR OF THE ACFT WAS CONSUMED BY FIREAS WELL AS MOST OF THE UPPER HALF OF THE FUSELAGE. EXAM OF THE RIGHT SIDE WIRE BUNDLE REVEALED NUMEROUS INDICATIONS OF ARCING BETWEEN WIRES & FROMWIRES TO GROUND. ONE WIRE WAS ARCED AT A POINT IN LINE WITH A PLASTIC OXYGEN LINE. THERE WAS ALSO AN OILY RESIDUE INSIDE THE WIRE BUNDLE. A SMALLSECTION OFTHE RIGHT BRAKE PRESSURE LINE EXHIBITED SIGNS OF ELECT ARCING. THE HYDRAULIC SYST PRESS GAGE COPPER LINE ALSO SHOWED SIGNS OF ARCING. THEPLASTIC OXYGEN LINES FROM THE THE COCKPIT SIDE OF THE FORWARD PRESSURE BULKHEAD TO THE COCKPIT OUTLETS HAD BEEN CONSUMED BY FIRE & THE OXYGENSUPPLY WAS DEPLEATED.


DCA83AA037File No. 2216 8/27/1983 HOT SPRINGS, AR Aircraft Reg No. N503SS Time (Local): 20:03 CDT

Occurrence #1: FIREPhase of Operation: TAXI - TO TAKEOFF

Findings 1. (C) FUSELAGE,INSTRUMENT/ELECTRICAL PANEL - SHORTED 2. (C) FUSELAGE,INSTRUMENT/ELECTRICAL PANEL - ARCING 3. (C) ELECTRICAL SYSTEM,ELECTRIC WIRING - ARCING 4. (C) ELECTRICAL SYSTEM,ELECTRIC WIRING - CONTAMINATION 5. (C) ELECTRICAL SYSTEM,ELECTRIC WIRING - FIRE 6. (C) OXYGEN SYSTEM,CREW - BURST 7. (C) FUSELAGE,INSTRUMENT/ELECTRICAL PANEL - FIRE 8. (C) FUSELAGE - FIRE





Brief of Incident

DEN84IA070File No. 5022 1/14/1984 DURANGO, CO Aircraft Reg No. N31088 Time (Local): 21:05 MST

Make/Model: SWEARINGEN / SA227-ACEngine Make/Model: GARRETT / TPE 331-11


Operating Certificate(s): Commuter Air CarrierName of Carrier: TRANS COLORADO AIRLINE



Last Depart. Point: ALBUQUERQUE, NMDestination: Same as Incident

Airport Proximity: On AirportAirport Name: LA PLATA COUNTY


Runway Surface: AsphaltRunway Surface Condition: Ice Covered; Snow--dry




Temperature (°C): -4Obstr to Vision: None

Precipitation: Rain; Snow




Flight Time (Hours)



ACCORDING TO THE CAPTAIN, THE COPLT WAS MAKING THE LANDING & CROSSED THE THRESHOLD AT 50 TO 60 FT AGL AT 110 TO 115 KTS. HE SAID A SLIGHTLY HIGHERAIRSPEED WAS USED TO COMPENSATE FOR A SMALL ABOUNT OF ICE THAT REMAINED ON THE LEADING EDGE OF THE WINGS. IN THE FLARE, THE ACFT YAWED LEFT &REPORTEDLY TOUCHED DOWN WITH THE NOSE ABOUT 15 DEGS TO THE LEFT. THE LEFT MAIN WHEEL TOUCHED DOWN ABOUT 21 FT FROM THE EDGE OF THE 150 FT WIDERWY. THE CAPT TOOK CONTROL & APPLIED CORRECTIVE ACTION, BUT THE ACFT WENT OFF THE RWY, HIT A SNOW BANK & MUD, THEN THE NOSE GEAR COLLAPSED.THENORMAL APCH SPEED WAS 103 KTS FOR THE ACFT'S WEIGHT. ACCORDING TO THE FLT MANUAL, THE APCH SPEED SHOULD HAVE BEEN INCREASED BY 19 KTS IF THERE WASICE ON THE FLYING SURFACES.


DEN84IA070File No. 5022 1/14/1984 DURANGO, CO Aircraft Reg No. N31088 Time (Local): 21:05 MST

Occurrence #1: IN FLIGHT ENCOUNTER WITH WEATHERPhase of Operation: OTHER

Findings 1. (F) WEATHER CONDITION - ICING CONDITIONS 2. (F) WING - ICE

----------

Occurrence #2: LOSS OF CONTROL - ON GROUND/WATERPhase of Operation: LANDING - FLARE/TOUCHDOWN

Findings 3. (C) AIRSPEED - INADEQUATE - COPILOT/SECOND PILOT 4. (C) SUPERVISION - INADEQUATE - PILOT IN COMMAND 5. (C) DIRECTIONAL CONTROL - NOT MAINTAINED 6. GROUND LOOP/SWERVE - INADVERTENT

----------

Occurrence #3: NOSE GEAR COLLAPSEDPhase of Operation: LANDING

Findings 7. (F) AIRPORT FACILITIES,RUNWAY/LANDING AREA CONDITION - ICY 8. (F) TERRAIN CONDITION - SNOWBANK 9. (F) TERRAIN CONDITION - SOFT10. (F) TERRAIN CONDITION - WET





Brief of Accident

NYC84LA079File No. 59 1/29/1984 PHILADELPHIA, PA Aircraft Reg No. N99JW Time (Local): 18:20 EST

Make/Model: SWEARINGEN / SA-226TEngine Make/Model: AIRESEARCH / TPE-331


Operating Certificate(s): NoneType of Flight Operation: Business



Last Depart. Point: BURLINGTON, VTDestination: PHILADELPHIA, PA

Airport Proximity: On AirportAirport Name: PHILADELPHIA



Condition of Light: DuskWeather Info Src: Pilot

Basic Weather: UnknownLowest Ceiling: 1000 Ft. AGL, Overcast


Temperature (°C): -1Obstr to Vision: Fog

Precipitation: Rain; Snow


Certificate(s)/Rating(s)Airline Transport; Multi-engine Land; Single-engine Land; Glider


Flight Time (Hours)



THE PLT BROKE OUT OF THE OVERCAST AT 1000 FT LOWERED FLAPS AND LANDED THE ACFT WITH THE GEAR RETRACTED. THE PLT SAID HE HAD LOWERED THE GEAR. THEGEAR WARNING HORN REPORTEDLY DID NOT SOUND.


NYC84LA079File No. 59 1/29/1984 PHILADELPHIA, PA Aircraft Reg No. N99JW Time (Local): 18:20 EST

Occurrence #1: COMPLETE GEAR COLLAPSEDPhase of Operation: LANDING - FLARE/TOUCHDOWN

Findings 1. (F) LANDING GEAR,GEAR INDICATING SYSTEM - UNDETERMINED 2. (C) WHEELS UP LANDING - INADVERTENT - PILOT IN COMMAND 3. (C) CHECKLIST - NOT FOLLOWED - PILOT IN COMMAND





Brief of Accident

DCA84AA015File No. 3316 1/30/1984 TERRE HAUTE, IN Aircraft Reg No. N63Z Time (Local): 06:30 EST

Make/Model: SWEARINGEN / SA226TCEngine Make/Model: GARRETT / TPE-331


Operating Certificate(s): Commuter Air CarrierType of Flight Operation: Positioning



Last Depart. Point: Same as AccidentDestination: EVANSVILLE, IN


Condition of Light: DawnWeather Info Src: Weather Observation Facility




Precipitation: Drizzle




Flight Time (Hours)



AFTER TAKING OFF FROM RWY 23, THE ACFT CRASHED SSW OF THE ARPT ABOUT 6300 FT FROM THE DEPARTURE END OF THE RWY & ABOUT 1800 FT TO THE LEFT OF THE RWYCENTERLINE. IMPACT OCCURRED WHILE THE ACFT WAS IN A STEEP DESCENT. THE WRECKAGE PATH WAS SCATTERED ALONG A HEADING OF 035 DEG FROM THE INITIALIMPACT POINT. THE ACFT WAS DEMOLISHED BY IMPACT & FIRE & NO PREIMPACT PART FAILURE OR MALFUNCTION WAS FOUND THAT WOULD HAVE CAUSED THE ACCIDENT.


DCA84AA015File No. 3316 1/30/1984 TERRE HAUTE, IN Aircraft Reg No. N63Z Time (Local): 06:30 EST

Occurrence #1: LOSS OF CONTROL - IN FLIGHTPhase of Operation: TAKEOFF

Findings 1. (C) REASON FOR OCCURRENCE UNDETERMINED 2. LIGHT CONDITION - DAWN 3. WEATHER CONDITION - RAIN 4. WEATHER CONDITION - FOG

----------






Brief of Incident

CHI84IA155File No. 5082 4/16/1984 MILWAUKEE, WI Aircraft Reg No. N163MA Time (Local): 17:57 CST

Make/Model: SWEARINGEN / SA226TCEngine Make/Model: AIRESEARCH / TPE 331


Operating Certificate(s): Commuter Air CarrierName of Carrier: MIDSTATE AIRLINES, INC.



Last Depart. Point: INDIANAPOLIS, INDestination: MILWAUKEE, WI

Airport Proximity: On AirportAirport Name: GENERAL MITCHELL







Precipitation: Rain




Flight Time (Hours)



A GEAR UP LANDING WAS PERFORMED AFTER THE CREW WAS UNABLE TO EXTEND THE RGT MAIN GEAR THRU NORMAL & EMERG PROCEDURES. AN EXAM OF THE ACFTDISCLOSED THE RGT MAIN GEAR DOOR AFT HINGE BOLT WAS SLIGHTLY BENT & DIFFICULT TO ROTATE IN ITS BUSHING. THE BUSHING & BOLT WERE DRY & HAD NOT BEENLUBRICATED RECENTLY. THE HYDRAULIC CYLINDER WAS NOT CAPABLE OF SUPPLYING ENOUGH PRESSURE TO OVERCOME THE BINDING DOOR. THE BUSHING HAD NOTRECENTLY BEEN INSPECTED OR LUBRICATED BY MAINTENANCE PERSONNEL BECAUSE OF ITS LOCATION BEING DIFFICULT TO ACCESS.


CHI84IA155File No. 5082 4/16/1984 MILWAUKEE, WI Aircraft Reg No. N163MA Time (Local): 17:57 CST

Occurrence #1: AIRFRAME/COMPONENT/SYSTEM FAILURE/MALFUNCTIONPhase of Operation: DESCENT

Findings 1. (C) DOOR,LANDING GEAR - BINDING(MECHANICAL) 2. (C) MAINTENANCE,LUBRICATION - INADEQUATE - COMPANY MAINTENANCE PERSONNEL 3. (C) LANDING GEAR,MAIN GEAR - MOVEMENT RESTRICTED

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Findings 4. WHEELS UP LANDING - PERFORMED - PILOT IN COMMAND





Brief of Incident

DEN84IA157File No. 5056 5/24/1984 ALBUQUERQUE, NM Aircraft Reg No. N237AM Time (Local): 08:00 MDT



Operating Certificate(s): Commuter Air CarrierName of Carrier: AIR MIDWEST AIRLINES, INC.



Last Depart. Point: ROSWELL, NMDestination: Same as Incident

Airport Proximity: On AirportAirport Name: ALBUQUERQUE INT'L ARPT.



Condition of Light: DayWeather Info Src: Weather Observation Facility




Precipitation: Unk/Nr




Flight Time (Hours)



WHEN GEAR WAS LOWERED FOR LANDING RT MAIN GEAR WOULD NOT EXTEND ALTHOUGH PERSONS ON THE GROUND STATED THE GEAR DOORS APPEARED OPEN. REMEDIALACTION BY THE FLT CREW DID NOT RECTIFY THE SITUATION AND A GEAR UP LANDING WAS PERFORMED. WHEN ACFT WAS RAISED FROM RWY AND RT MAIN GEAR DOORSFORCED OPEN, A MECHANICS TOOL, CALLED AN AWL, FELL OUT OF WHEEL WELL. EXAMINATION OF MARKS ON THE AWL AND IN THE WHEEL WELL INDICATED THE AWL BECAMELODGED BTW THE KEELSON WEB AND THE DOOR HINGE. THIS WOULD HAVE BLOCKED THE DOORS FROM OPENING PAST THE HALF WAY POSITION THUS PREVENTING GEAREXTENSION. A MECHANIC HAD PERFORMED A ROUTINE GEAR INSPECTION USING AN AWL TO ALIGN SOME SCREW HOLES ON THE EVENING PRECEEDING THE INCIDENT.


DEN84IA157File No. 5056 5/24/1984 ALBUQUERQUE, NM Aircraft Reg No. N237AM Time (Local): 08:00 MDT


Findings 1. (C) DOOR,LANDING GEAR - FOREIGN OBJECT 2. (C) MAINTENANCE - IMPROPER - COMPANY MAINTENANCE PERSONNEL 3. (F) COMPLACENCY - COMPANY MAINTENANCE PERSONNEL 4. (C) DOOR,LANDING GEAR - JAMMED 5. GEAR EXTENSION - NOT POSSIBLE

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Findings 6. WHEELS UP LANDING





Brief of Incident

CHI84IA252File No. 5109 6/13/1984 PONTIAC, MI Aircraft Reg No. N2GL Time (Local): 11:20 EDT

Make/Model: FAIRCHILD / SA-227-TTEngine Make/Model: AIRESEARCH / TPE 331


Operating Certificate(s): NoneType of Flight Operation: Executive/Corporate



Last Depart. Point: JANESVILLE, WIDestination: Same as Incident






Precipitation: None




Flight Time (Hours)



THE AIRCREW NOTICED A 'NOSE UP' PITCH CHANGE DURING DESCENT AT ABOUT THE TIME THEY WERE LEVELING TO SLOW FOR THE ARPT PATTERN & TRAFFIC. THE PLTREPORTED THAT FULL FORWARD YOKE PRESSURE WAS REQUIRED TO STOP THE NOSE UP CONDITION. THE ACFT WAS LANDED WITHOUT FURTHER INCIDENT. ANINVESTIGATION REVEALED THAT THE OCCURRENCE WAS CAUSED BY A WORN HORIZONTAL STABILIZER TRIM ACTUATOR, P/N DL5040M2-4.


CHI84IA252File No. 5109 6/13/1984 PONTIAC, MI Aircraft Reg No. N2GL Time (Local): 11:20 EDT

Occurrence #1: AIRFRAME/COMPONENT/SYSTEM FAILURE/MALFUNCTIONPhase of Operation: DESCENT - NORMAL

Findings 1. (C) FLT CONTROL SYST,HORIZ STAB DRIVE - WORN





Brief of Incident

MKC84IA185File No. 5106 6/27/1984 JOPLIN, MO Aircraft Reg No. N233AM Time (Local): 07:32 CDT

Make/Model: SWEARINGEN / SA226TCEngine Make/Model: AIRESEARCH / TPE 331-3UW


Operating Certificate(s): Commuter Air CarrierName of Carrier: AIR MIDWEST (AMWA)



Last Depart. Point: TULSA, OKDestination: Same as Incident

Airport Proximity: On AirportAirport Name: JOPLIN MUNI







Precipitation: None




Flight Time (Hours)



WHILE TAXIING TO TAKEOFF & ON THE TAKEOFF ROLL, THE LEFT BRAKE OVERHEATED. TEN TO FIFTEEN MINS AFTER DEPARTURE BOTH TIRES ON THE LEFT MAIN LANDINGGEAR EXPLODED. THE BEARINGS AND BRAKES ALSO SEIZED DUE TO THE HIGH TEMPERATURES. UPON ARRIVAL AT THE DEST, THE NORMAL GEAR EXTENSION SYSTEM WASINOPERATIVE AND THE EMERGENCY EXTENSION SYSTEM WAS UTILIZED. NO FURTHER DAMAGE WAS INCURRED DURING THE LANDING.INVESTIGATORS DISCOVERED ASTICKING VALVE IN THE LEFT PARKING BRAKE. MAINTENANCE RECORDS REVEALED THAT ON JUNE 19 AND 22, DIFFICULTY WAS REPORTED IN RELEASING THE PARKINGBRAKES; MAINTENANCE PERSONNEL COULD NOT DUPLICATE THE DISCREPANCY AND RETURNED THE ACFT TO SERVICE.


MKC84IA185File No. 5106 6/27/1984 JOPLIN, MO Aircraft Reg No. N233AM Time (Local): 07:32 CDT

Occurrence #1: AIRFRAME/COMPONENT/SYSTEM FAILURE/MALFUNCTIONPhase of Operation: TAKEOFF - ROLL/RUN

Findings 1. (C) LANDING GEAR,NORMAL BRAKE SYSTEM - BINDING(MECHANICAL) 2. PARKING BRAKES - NOT SELECTED 3. (C) MAINTENANCE - INADEQUATE - COMPANY MAINTENANCE PERSONNEL 4. (C) LANDING GEAR,NORMAL BRAKE SYSTEM - OVERTEMPERATURE

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Findings 5. LANDING GEAR,TIRE - BURST 6. LANDING GEAR,NORMAL RETRACTION/EXTENSION ASSEMBLY - DISABLED 7. LANDING GEAR,EMERGENCY EXTENSION ASSEMBLY - ENGAGED 8. EMERGENCY PROCEDURE - PERFORMED - PILOT IN COMMAND





Brief of Incident

MKC84IA184File No. 5039 6/29/1984 GRAND ISLAND, NE Aircraft Reg No. N1014P Time (Local): 16:37 CDT

Make/Model: SWEARINGEN / SA227-ACEngine Make/Model: GARRETT / TPE 331


Operating Certificate(s): Commuter Air CarrierName of Carrier: PIONEER AIRWAYS,INC.(PIOA)



Last Depart. Point: GRAND ISLAND, NEDestination: KEARNEY, NE

Airport Proximity: On AirportAirport Name: HALL COUNTY REGINAL







Precipitation: None




Flight Time (Hours)



THE CAPT STARTED THE RT ENG AT THE GATE & THE LT ENG WHILE TAXIING FOR TAKEOFF. AT THIS TIME THE F/O WAS BRIEFING THE PASSENGERS ON TAKEOFF & EN ROUTEPROCEDURES. THE F/O THEN INITIATED THE TAKEOFF ROLL & THE ACFT PROCEEDED TO THE LT, STRIKING A RWY LIGHT. DURING THE INVESTIGATION THE LT PROPELLER WASFOUND ON THE START LOCKS.


MKC84IA184File No. 5039 6/29/1984 GRAND ISLAND, NE Aircraft Reg No. N1014P Time (Local): 16:37 CDT


Findings 1. (C) STARTING PROCEDURE - IMPROPER - PILOT IN COMMAND 2. PROPELLER SYSTEM/ACCESSORIES - LOCKED 3. CHECKLIST - NOT FOLLOWED 4. (F) DIRECTIONAL CONTROL - NOT MAINTAINED - COPILOT/SECOND PILOT

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Occurrence #2: ON GROUND/WATER COLLISION WITH OBJECTPhase of Operation: TAKEOFF - ROLL/RUN

Findings 5. (F) OBJECT - RUNWAY LIGHT





Brief of Incident

ATL84IA255File No. 5091 8/13/1984 MEMPHIS, TN Aircraft Reg No. N501SS Time (Local): 15:40 CDT



Operating Certificate(s): Commuter Air CarrierName of Carrier: SCHEDULED SKYWAYS, INC.



Last Depart. Point: MEMPHIS, TNDestination: FT. SMITH, AR





Temperature (°C): 32Obstr to Vision: Haze

Precipitation: None




Flight Time (Hours)



DURING LEVEL OFF AT 16,000 FT WITH A SEA LEVEL CABIN PRESSURE (6 PSI DIFFERENTIAL PRESSURE), THE CREW HEARD A 'POP', THEN THE COPLT'S WINDOW BLEW OUT.DEBRIS, INCLUDING THE GLARESHIELD, EXITED THE COCKPIT & INJURED THE COPILOT. THE WINDOW WAS A SINGLE THICKNESS ACRYLIC, MANUFACTURED BY PPG (PN 26-2L383-006). THE WINDOW WAS IN SERVICE 12,158 HRS SINCE NEW IN 1979. FATIGUE ORIGINATED NEAR THE LOWER REAR CORNER UNDER THE EDGE OF THE WINDOW RETAINERSTRIP. CAUSE OF THE FATIGUE WAS NOT DETERMINED. WHITE PAINT & SEALANT MATERIAL WERE AT THE FATIGUE ORIGIN. A SCRIBE LINE WAS IN CLOSE PROXIMITY TO THEORIGIN.


ATL84IA255File No. 5091 8/13/1984 MEMPHIS, TN Aircraft Reg No. N501SS Time (Local): 15:40 CDT

Occurrence #1: AIRFRAME/COMPONENT/SYSTEM FAILURE/MALFUNCTIONPhase of Operation: CRUISE

Findings 1. (C) WINDOW,FLIGHT COMPARTMENT WINDOW/WINDSHIELD - FATIGUE 2. WINDOW,FLIGHT COMPARTMENT WINDOW/WINDSHIELD - SEPARATION





Brief of Incident

FTW85IA028File No. 5078 10/26/1984 TULSA, OK Aircraft Reg No. N5115S Time (Local): 08:24 CDT



Operating Certificate(s): Commuter Air CarrierName of Carrier: SCHEDULED SKYWAYS



Last Depart. Point: Same as IncidentDestination: FAYETTEVILLE, AR

Airport Proximity: On AirportAirport Name: TULSA INTL'







Precipitation: None


Certificate(s)/Rating(s)Airline Transport; Flight Instructor; Commercial; Multi-engine Land; Single-engine Land


Flight Time (Hours)



DURING CRUISE, THE CREW EXPERIENCED A LOSS OF HYDRAULIC PRESSURE & SMOKE IN THE COCKPIT, THEN DONNED THEIR OXYGEN MASKS.THEY USED THE EMERG GEAREXTENSION SYSTEM & MADE A SAFE EMERG LANDING. AN EXAM REVEALED A CRACKED 2000 PSI ALUMINUM HYDRAULIC LINE HAD SPRAYED FLUID IN THE COCKPIT. ARECENTLY ISSUED SERVICE BULLETIN RECOMMENDED REPLACEMENT OF THAT LINE, BUT PARTS WERE REPORTEDLY NOT AVAILABLE. LONGITUDINAL SCRATCHES WEREFOUND ALONG THE LENGTH OF THE LINE. FAILURE HAD OCCURRED AT A LONGITUDINAL SCRATCH AT A BEND IN THE LINE.


FTW85IA028File No. 5078 10/26/1984 TULSA, OK Aircraft Reg No. N5115S Time (Local): 08:24 CDT


Findings 1. (C) HYDRAULIC SYSTEM,LINE - FATIGUE 2. (C) HYDRAULIC SYSTEM,LINE - BURST 3. (F) MAINTENANCE,SERVICE BULLETIN/LETTER - NOT FOLLOWED





Brief of Incident

MIA85IA031File No. 5066 11/14/1984 TALLAHASSEE, FL Aircraft Reg No. N31264 Time (Local): 01:30 EST

Make/Model: SWEARINGEN / SA-226ATEngine Make/Model: AIRESEARCH / TPE 331


Operating Certificate(s): On-demand Air TaxiName of Carrier: PLANES INC

Type of Flight Operation: Non-scheduled; Cargo; DomesticReg. Flight Conducted Under: Part 135: Air Taxi & Commuter


Last Depart. Point: ATLANTA, GADestination: Same as Incident

Airport Proximity: On AirportAirport Name: TALLASSEE MUNI







Precipitation: None




Flight Time (Hours)



N31264 CRASHED INTENTIONALLY GEAR UP ON RWY 18 AT TALLAHASSEE, FL, WHILE ON A NIGHT, ALL CARGO 14 CFR 135 FLT. THE CREW ATTEMPTED EMERGENCY GEAREXTENSION PROCEDURES & A FLY-BY. INVESTIGATION REVEALED A BROKEN WIRE, TS-70, WHERE IT CONNECTS WITH TERMINAL 6. TS-70 WAS INSTALLED ON THE ACFT WHENSERVICE BULLETIN #32-037 WAS COMPLIED WITH. SERVICE BULLETIN 32-017 WHICH CHANGES GEAR MICRO-SWITCHES FROM PARALLEL TO SERIES WAS NOT COMPLIED WITH.


MIA85IA031File No. 5066 11/14/1984 TALLAHASSEE, FL Aircraft Reg No. N31264 Time (Local): 01:30 EST

Occurrence #1: AIRFRAME/COMPONENT/SYSTEM FAILURE/MALFUNCTIONPhase of Operation: APPROACH - VFR PATTERN - DOWNWIND

Findings 1. (C) ELECTRICAL SYSTEM,ELECTRIC WIRING - DISCONNECTED

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Occurrence #2: GEAR COLLAPSEDPhase of Operation: LANDING - FLARE/TOUCHDOWN





Brief of Incident

Adopted 9/30/1994

SEA85IA024File No. 5064 11/29/1984 PULLMAN, WA Aircraft Reg No. N1014T Time (Local): 19:05 PST

Make/Model: Fairchild Swearingen / SA 227Engine Make/Model: GARRETT / TPE 331


Operating Certificate(s): Commuter Air CarrierName of Carrier: CASCADE AIRWAYS



Last Depart. Point: Same as IncidentDestination: LEWISTON, ID

Airport Proximity: On AirportAirport Name: PULLMAN-MOSCOW







Precipitation: Snow




Flight Time (Hours)



THE AIRCRAFT'S LANDING GEAR COLLAPSED AFTER THE PLANE WENT OFF THE RIGHT SIDE OF RUNWAY 23 DURING TAKEOFF. REPORTEDLY, THE AIRCRAFT DRIFTED TO THERIGHT OF CENTERLINE ON A FAIRLY CONSTANT ARC UNTIL CONTACTING A SNOW BERM AT A TAXIWAY INTERSECTION. AN INVESTIGATION REVEALED THAT THE TAKEOFF WASBEING CONDUCTED AT NIGHT WITH A PARTIALLY OBSCURED WINDSHIELD. VISIBILITY WAS ONE MILE WITH FOG AND FALLING SNOW, AND THE WIND WAS FROM 150 DEGREESAT 11 KNOTS. THE RUNWAY WAS COVERED WITH ABOUT 1/4 INCH OF SNOW. THE COPILOT'S DUTIES REQUIRED HIM TO SCAN 'INSIDE' THE COCKPIT, WHILE HE 'FINE TUNED'THE POWER SETTINGS AND CHECKED ENGINE INSTRUMENTS DURING THE TAKEOFF ROLL. NO PRE-ACCIDENT PART FAILURE OR MALFUNCTION OF THE AIRCRAFT WAS FOUNDDURING THE INVESTIGATION.


SEA85IA024File No. 5064 11/29/1984 PULLMAN, WA Aircraft Reg No. N1014T Time (Local): 19:05 PST

Occurrence #1: ON GROUND/WATER ENCOUNTER WITH TERRAIN/WATERPhase of Operation: TAKEOFF

Findings 1. (C) PLANNING/DECISION - IMPROPER - PILOT IN COMMAND 2. (F) VISUAL/AURAL PERCEPTION - PILOT IN COMMAND 3. (F) LIGHT CONDITION - DARK NIGHT 4. (F) AIRPORT FACILITIES,RUNWAY/LANDING AREA CONDITION - SNOW COVERED 5. (F) WEATHER CONDITION - SNOW 6. (F) WEATHER CONDITION - FOG 7. (F) WEATHER CONDITION - CROSSWIND 8. (F) TERRAIN CONDITION - SNOWBANK 9. (C) PROPER ALIGNMENT - NOT MAINTAINED - PILOT IN COMMAND





Brief of Accident

MKC85FA032File No. 2753 12/7/1984 HARRISON, AR Aircraft Reg No. N511SS Time (Local): 14:10 CST

Make/Model: SWEARINGEN / SA226TCEngine Make/Model: GARRETT / TPE331-10VA


Operating Certificate(s): Commuter Air CarrierName of Carrier: SCHEDULED SKYWAYS,INC.



Last Depart. Point: FAYETTEVILLE, ARDestination: Same as Accident

Airport Proximity: On AirportAirport Name: BOONE COUNTY



Condition of Light: DayWeather Info Src: Witness




Precipitation: None




Flight Time (Hours)



THE ACFT WAS BEING OPERATED AS SKYWAYS FLT 488. THE FIRST OFFICER WAS FLYING THE ACFT. THE ACFT TOUCHED DOWN ON THE RWY APRX 1584 FEET FROM THEAPPROACH END AND AFTER A SHORT ROLL, THE LANDING GEAR WARNING HORN SOUNDED AND THE LEFT WING SETTLED TO THE GROUND. THE CREW ATTEMPTED TO RAISETHE WING AND THE ACFT SETTLED TO THE GROUND AND SLID 2190 FEET. POST CRASH EXAM REVEALED NO EVIDENCE OF A MECHANICAL MALFUNCTION OR FAILURE OF THELANDING GEAR PRIOR TO THE ACCIDENT. BOTH FLIGHT CREW MEMBERS STATED THAT THE GEAR HANDLE WAS IN THE DOWN POSITION AND THAT THE GEAR SAFE INDICATORWAS ILLUMINATED AT THE TIME OF LANDING.


MKC85FA032File No. 2753 12/7/1984 HARRISON, AR Aircraft Reg No. N511SS Time (Local): 14:10 CST

Occurrence #1: GEAR COLLAPSEDPhase of Operation: LANDING - ROLL

Findings 1. (C) LANDING GEAR - UNDETERMINED





Brief of Incident

MKC85IA045File No. 5021 1/4/1985 ST. LOUIS, MO Aircraft Reg No. N322BA Time (Local): 16:10 CST

Make/Model: SWEARINGEN / SA226TCEngine Make/Model: Airesearch / TPE3313UW303G


Operating Certificate(s): Commuter Air CarrierName of Carrier: BRITT AIRWAYS



Last Depart. Point: ST. LOUIS, MODestination: EVANSVILLE, IN






Precipitation: None




Flight Time (Hours)

Total All Aircraft: Unk/NrLast 90 Days: Unk/Nr


AFTER DEPARTING ST LOUIS AND REACHING CRUISE FLT THE CREW EXPERIENCED A CONTINUAL TRIM PITCH-UP WHICH HAD TO BE RELIEVED BY A REDUCED AIRSPEED. NOAURAL INDICATION WAS NOTED BY THE CREW. THE RETURN TO THE AIRPORT WAS UNEVENTFUL. FOLLOW-UP INSPECTION OF THE TRIM SYSTEM REVEALED A OUT OFTOLERANCE TRIM ACTUATOR WITH 355 OPERATIONAL HOURS SINCE O-TIME OVERHAUL. NORMAL LIFE FOR A TRIM ACTUATOR IS ABT 2000 HOURS. THIS UNIT WAS CERTIFIEDAS O-TIME BY AN FAA CERTIFIED SHOP. A TEARDOWN INSPECTION OF THE TRIM ACTUATOR UNIT REVEALED THAT THE UNIT WAS NOT OVERHAULED TO SPECIFICATIONS OFTHE UNIT MANUFACTURER. THE TRIM ACTUATOR WAS INADEQUATE FOR OPERATION AS OVERHAULED.


MKC85IA045File No. 5021 1/4/1985 ST. LOUIS, MO Aircraft Reg No. N322BA Time (Local): 16:10 CST


Findings 1. FLT CONTROL SYST,ELEVATOR TRIM/TAB CONTROL - ERRATIC 2. (C) MAINTENANCE,OVERHAUL - INADEQUATE - OTHER MAINTENANCE PERSONNEL 3. (F) INADEQUATE SURVEILLANCE OF OPERATION - FAA(ORGANIZATION)





Brief of Incident

CHI85IA084File No. 5000 1/8/1985 COVINGTON, KY Aircraft Reg No. N3110J Time (Local): 08:55 EST

Make/Model: SWEARINGEN / SA-227-ACEngine Make/Model: AIRESEARCH / TPE-331-11U


Operating Certificate(s): Commuter Air CarrierName of Carrier: COMAIR



Last Depart. Point: LEXINGTON, KYDestination: CINCINNATI, OH






Precipitation: None


Certificate(s)/Rating(s)Airline Transport; Commercial; Multi-engine Land; Single-engine Land; Single-engine Sea


Flight Time (Hours)



THE AIRCREW REPORTED THAT DURING FLT AT 6000 FT MSL, THEY ENCOUNTERED ICING CONDITIONS & USED THE DE-ICE & ANTI-ICE EQUIPMENT. AFTER THEY DESCENDED &WERE CLEAR OF ICING, THEY DEACTIVATED THE DE-ICE & ANTI-ICE EQUIPMENT.THE CAPT SAID HECHECKED THE PROP SPINNERS & NOTED A SMALL BUILDUP OF ICE, WHICHHE CONSIDERED AS MINIMAL, & TURNED OFF THE CONTINUOUS IGNITION. SHORTLY THEREAFTER WHILE ON FINAL APCH AT APRX 1000 FT AGL & 1 TO 1.5 MI FROM THE ARPT,THE R ENG LOST POWER WITHOUT WARNING. THE COPLT FEATHERED THE R PROP & THE APCH WAS CONTINUED. HOWEVER, AT ABOUT 200 FT AGL THE OTHER ENG ALSOLOST POWER. THE ACFT WAS LANDED WITHOUT FURTHER INCIDENT. DURING AN INVESTIGATION, ICE WAS FOUND ON THE GROUND UNDER THE WINGS. NO MECHANICALPROBLEMS OR FUEL CONTAMINATION WERE FND. THE ACFT HAD A HISTORY OF FLAMEOUTS DUE TO ICE BUILDUP & RELEASE FROM THE SPINNERS. IGNITION SW LABELED'NORM', 'CONT' & 'OVRD.' TO OBTAIN CONTINUOUS IGNITION IN FLT, THE SWITCH MUST HAVE BEEN IN 'OVRD.' NO SPECIFIC WARNING IN FLT MANUAL TO USE CONTINUOUSIGNITION (OVRD) IN ICING COND.


CHI85IA084File No. 5000 1/8/1985 COVINGTON, KY Aircraft Reg No. N3110J Time (Local): 08:55 EST

Occurrence #1: LOSS OF ENGINE POWER(PARTIAL) - NONMECHANICALPhase of Operation: APPROACH - VFR PATTERN - FINAL APPROACH

Findings 1. (F) WEATHER CONDITION - ICING CONDITIONS 2. IGNITION SYSTEM,IGNITION SWITCH - OTHER 3. ACFT/EQUIP,INADEQUATE STANDARD/REQUIREMENT - MANUFACTURER 4. SAFETY SYSTEM(OTHER) - NOT ENGAGED 5. EMERGENCY EQUIPMENT - NOT USED - PILOT IN COMMAND 6. (C) PROCEDURE INADEQUATE - MANUFACTURER 7. (F) ACFT/EQUIP,INADEQUATE AIRCRAFT MANUALS - MANUFACTURER 8. IGNITION SYSTEM - NOT ENGAGED 9. (C) PROPELLER SYSTEM/ACCESSORIES,SPINNER - ICE10. PROPELLER FEATHERING - PERFORMED - PILOT IN COMMAND

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Occurrence #2: LOSS OF ENGINE POWER(TOTAL) - NONMECHANICALPhase of Operation: APPROACH - VFR PATTERN - FINAL APPROACH

Findings11. PROPELLER SYSTEM/ACCESSORIES,SPINNER - ICE12. AIRCRAFT PERFORMANCE,TWO OR MORE ENGINES - INOPERATIVE

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Occurrence #3: FORCED LANDINGPhase of Operation: LANDING





Brief of Accident

CHI85MA100File No. 1911 1/31/1985 LONDON, KY Aircraft Reg No. N568UP Time (Local): 05:47 CST

Make/Model: SWEARINGEN / SA-227Engine Make/Model: AIRESEARCH / TPE-331


Operating Certificate(s): CargoName of Carrier: SAT-AIR, INC.



Last Depart. Point: LOUISVILLE, KYDestination: Same as Accident

Airport Proximity: On AirportAirport Name: LONDON-CORBIN











Flight Time (Hours)



DRG ARRIVAL, AT 0540:31, THE CAPT WAS CLRD FOR AN RNAV RWY 5 APCH & WAS TOLD TO CONTACT LONDON FSS ON 121.6 MHZ, 'NOW.' HOWEVER, HE DID NOT MAKE THERADIO CALL UNTIL APRX 3 MIN LATER. THE ACFT BROKE OUT OF THE WX AT ABOUT 1000' & 1 MI FM THE ARPT (BEFORE THE RADIO CALL). AT THAT TIME, THE RWY LIGHTS WERENOT ON. THE CAPT THEN ADVISED THE FSS TO TURN ON THE RWY LIGHTS & HE MADE A LEFT PATTERN TO CIRCLE BACK & LAND. DRG THE NEXT APCH, THE ACFT WAS HI &FAST ON FINAL APCH & TOUCHED DOWN LONG. THE 1ST OFFICER RECOMMENDED THAT THE CAPT MAKE A GO-AROUND, BUT THE CAPT ELECTED TO CONT THE LNDG. WHENTHE CAPT REALIZED THAT HE WOULD NOT BE ABLE TO STOP ON THE REMAINING RWY, HE RETRACTED THE GEAR. THE ACFT THEN SLIDOFF THE END OF THE RWY, WENT OVRAN EMBANKMENT, BECAME AIRBORNE FOR ABOUT 140', THEN IMPACTED IN A LARGE RAVINE AREA. THE WEIGHT MANIFEST WAS FND TO BE IN ERROR. AFTER ALLOWING FOR A500 LB FUEL BURN-OFF, THE LANDING WEIGHT WAS ESTIMATED TO BE 14,668 LBS. THE MAX GROSS WT LIMIT WAS 14,500 LBS.


CHI85MA100File No. 1911 1/31/1985 LONDON, KY Aircraft Reg No. N568UP Time (Local): 05:47 CST

Occurrence #1: MISCELLANEOUS/OTHERPhase of Operation: APPROACH - FAF/OUTER MARKER TO THRESHOLD (IFR)

Findings 1. (F) AIRCRAFT WEIGHT AND BALANCE - EXCEEDED 2. (F) WEATHER CONDITION - LOW CEILING 3. (F) WEATHER CONDITION - FOG 4. (F) WEATHER CONDITION - RAIN 5. (F) WEATHER CONDITION - DARK NIGHT 6. (F) RADIO COMMUNICATIONS - DELAYED - PILOT IN COMMAND 7. (F) AIRPORT FACILITIES,RUNWAY EDGE LIGHTS - NOT OPERATING 8. MISSED APPROACH

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Occurrence #2: OVERRUNPhase of Operation: LANDING - ROLL

Findings 9. PLANNED APPROACH - INITIATED10. (C) PROPER TOUCHDOWN POINT - NOT ATTAINED - PILOT IN COMMAND11. (C) AIRSPEED - EXCESSIVE - PILOT IN COMMAND12. (F) AIRPORT FACILITIES,RUNWAY/LANDING AREA CONDITION - WET13. (C) GO-AROUND - NOT PERFORMED - PILOT IN COMMAND

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Occurrence #3: GEAR COLLAPSEDPhase of Operation: LANDING

Findings14. GEAR RETRACTION - INTENTIONAL - PILOT IN COMMAND15. (F) TERRAIN CONDITION - ROUGH/UNEVEN





Brief of Accident

FTW85LA110File No. 1410 2/2/1985 SHREVEPORT, LA Aircraft Reg No. N20QN Time (Local): 15:40 CST

Make/Model: SWEARINGEN / SA-226TEngine Make/Model: AIRESEARCH / PTE331-3U-303





Last Depart. Point: CHATTANOOGA, TNDestination: ED DORADO, AR

Airport Proximity: On AirportAirport Name: SHREVEPORT REGIONAL


Runway Surface: ConcreteRunway Surface Condition: Snow--wet





Precipitation: None




Flight Time (Hours)



THE PLT LANDED ON RWY 05 WHICH WAS ICY AND COVERED WITH A BLANKET OF FRESH SNOW. HE STATED THE WIND WAS FROM 360 DEGS AT 10 KTS. HE HAD BEENINFORMED OF POOR BRAKING CONDITIONS ON THE RWY. THE PLT USED MAIN WHEEL BRAKES AND REVERSE THRUST. THE ACFT DRIFTED OFF THE RIGHT SIDE OF THE RWY,WHEN THE THROTTLES WERE NEUTRALIZED, INTO THE SOFT SOD SURFACE WHERE THE NOSE GEAR COLLAPSED AND THE NOSE SECTION IMPACTED THE GROUND. THE PLTSTATED SNOW COVERED A LAYER OF ICE ON THE RWY.


FTW85LA110File No. 1410 2/2/1985 SHREVEPORT, LA Aircraft Reg No. N20QN Time (Local): 15:40 CST


Findings 1. (F) TERRAIN CONDITION - ICY 2. (F) TERRAIN CONDITION - SNOW COVERED 3. (F) WEATHER CONDITION - CROSSWIND 4. (F) WEATHER CONDITION - UNFAVORABLE WIND 5. (C) COMPENSATION FOR WIND CONDITIONS - INADEQUATE - PILOT IN COMMAND

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Occurrence #2: ON GROUND/WATER ENCOUNTER WITH TERRAIN/WATERPhase of Operation: LANDING - ROLL

Findings 6. TERRAIN CONDITION - SOFT

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Findings 7. (F) DESIGN STRESS LIMITS OF AIRCRAFT - EXCEEDED 8. (C) LANDING GEAR,NOSE GEAR - OVERLOAD





Brief of Incident

MKC85IA057File No. 5001 2/13/1985 BERKELEY, MO Aircraft Reg No. N328BA Time (Local): 20:40 CST

Make/Model: SWEARINGEN / SA-226-TCEngine Make/Model: GARRETT / 331-10UA-SHG





Last Depart. Point: SPRINGFIELD, ILDestination: Same as Incident

Airport Proximity: On AirportAirport Name: LAMBERT-ST.LOUIS INT'L



Condition of Light: Night/BrightWeather Info Src: Weather Observation Facility




Precipitation: None




Flight Time (Hours)



CREW ACCOMPLISHED DESCENT CHECKLIST. CHECKLIST WAS APPROVED MANUFACTURER'S CHECKLIST. DESCENT WAS MADE THROUGH 2500 FOOTTHICK CLOUDS WITH OATBELOW FREEZING WITHOUT AUTO-IGNITION SWITCH ON AUTO/CONTINUOUS POSITION. BOTH ENGINES QUIT ON FINAL APPROACH. AIRPLANE WAS LANDED WITHOUT DAMAGE.COMPANY CONCLUDED THAT FLAMEOUTS CAUSED BY ICE INGESTION.


MKC85IA057File No. 5001 2/13/1985 BERKELEY, MO Aircraft Reg No. N328BA Time (Local): 20:40 CST

Occurrence #1: LOSS OF ENGINE POWER(TOTAL) - NONMECHANICALPhase of Operation: APPROACH - FAF/OUTER MARKER TO THRESHOLD (IFR)

Findings 1. (F) WEATHER CONDITION - ICING CONDITIONS 2. (F) CHECKLIST - PERFORMED - PILOT IN COMMAND 3. (C) CHECKLIST - INADEQUATE - MANUFACTURER





Brief of Accident

SEA85LA070File No. 689 3/8/1985 HAILEY, ID Aircraft Reg No. N3115U Time (Local): 18:43 MST

Make/Model: FAIRCHILD / SA-227ACEngine Make/Model: GARRETT / TPE33111U611G


Operating Certificate(s): Flag Carrier/DomesticName of Carrier: HORIZON AIRLINES, INC.



Last Depart. Point: SALT LAKE CITY, UTDestination: Same as Accident

Airport Proximity: On AirportAirport Name: FRIEDMAN MEMORIAL



Condition of Light: DuskWeather Info Src: Weather Observation Facility




Precipitation: None




Flight Time (Hours)



ON LDG THE EXPERIENCED CAPTN ENCOUNTERED A RIGHT DRIFT ON THE DRY RWY WITH NEGLIGIBLE WINDS. RUDDER/PWR/NOSEWHEEL STEERING INPUTS WEREINSUFFICIENT TO REGAIN DIRECTIONAL CONTROL. RIGHT DRIFT TRANSLATED INTO A STRONG RIGHT SWERVE WITH CONTINUED APPLICATION OF FULL LEFT NOSEWHEELSTEERING AND SIMULTANEOUS BRAKING. ACFT DEPARTED RIGHT SIDE OF RWY AND NOSEWHEEL OBSERVED TRACKING STRAIGHT INTO SNOW & NO NOSEWHEEL SKID MARKSOBSERVED. TESTING REVEALED REDUCED NOSEWHEEL STEERING EFFECTIVENESS WITH DECREASING NOSE STRUT COMPRESSION DUE TO ENGAGEMENT OF CENTERINGCAM. CAPTN REPORTED 'NOSE HIGH' TAXI ATTITUDE AND 'PITCH SENSITIVE' FLT. CAPTN/OTHER PLTS REPORTED DIFFICULTY ACHIEVING EQUAL BRAKING DURING CONDITIONSOF LARGE RUDDER PEDAL DISPLACEMENT. THIS CONDITION IS NOT ADDRESSED IN PLT/OPS MANUALS. CHECK OF BRAKE/NOSEWHEEL STEERING SYSTEMS REVEALED NOMECHANICAL MALFUNCTION.


SEA85LA070File No. 689 3/8/1985 HAILEY, ID Aircraft Reg No. N3115U Time (Local): 18:43 MST


Findings 1. (C) DIRECTIONAL CONTROL - INADEQUATE - PILOT IN COMMAND 2. (F) ACFT/EQUIP,INADEQUATE CONTROL LOCATION - MANUFACTURER 3. (F) ACFT/EQUIP,INADEQUATE AIRCRAFT MANUALS - MANUFACTURER 4. (F) LANDING GEAR,STEERING SYSTEM - INADEQUATE

----------


Findings 5. TERRAIN CONDITION - SNOWBANK





Brief of Accident

LAX85FA185File No. 6000 3/22/1985 LOS ANGELES, CA Aircraft Reg No. CGYRD Time (Local): 20:26 PST

Make/Model: SWEARINGEN / SA 226TCEngine Make/Model: AIRESEARCH / TPE-331


Operating Certificate(s): Commuter Air CarrierName of Carrier: SUN AIRE LINES



Last Depart. Point: IMPERIAL, CADestination: Same as Accident

Airport Proximity: On AirportAirport Name: LOS ANGELES INTL







Precipitation: None


Certificate(s)/Rating(s)Airline Transport; Flight Instructor; Commercial; Multi-engine Land; Single-engine Land; Single-engine Sea


Flight Time (Hours)



ON THIS LEG OF THE FLT, THE 1ST OFFICER (FO) WAS FLYING THE ACFT WHILE THE CAPTAIN (CAPT) WAS MONITORING & CONDUCTING ATC COMMUNICATIONS. REPORTEDLY,THE AIRCREW HAD FOLLOWED THE CHECKLIST DURING ARRIVAL; HOWEVER, THE ACFT WAS LANDED WITHTHE GEAR RETRACTED. WHEN THE ACFT TOUCHED DOWN, PIECESOF THE R PROP BLADES BROKE OFF & ENTERED THE RIGHT SIDE OF THE FUSELAGE, BETWEEN & BELOW THE 1ST & 2ND WINDOWS. FIVE PIECES PENETRATED THEPASSENGER COMPARTMENT & SERIOUSLY INJURED A PASSENGER IN THE 1ST ROW. THE OTHER 1ST ROW PASSENGER RECEIVED MINOR INJURIES. THE CAPT STATED HE HADPUT THE GEAR HANDLE IN THE DOWN POSITION. THE FO REMEMBERED CALLING FOR GEAR EXTENSION, BUT DID NOT RECALL ACTUALLY NOTICING THE GEARBEING LOWERED.DAMAGES INDICATED THE GEAR DOORS WERE CLOSED DURING TOUCHDOWN. THE GEAR & WARNING SYSTEMS WERE CHECKED & THEY FUNCTIONED NORMALLY. THE FO HADPULLED THE GEAR WARNING CIRCUIT BREAKER (CB) ON THE PREV FLT, BUT HAD RESET IT. HE SPECULATED THE CB MAY NOT HAVE BEEN ALL THE WAY IN (NOT FULLY RESET);THUS, DEACTIVATING THE GEAR WARNING SYSTEM.


LAX85FA185File No. 6000 3/22/1985 LOS ANGELES, CA Aircraft Reg No. CGYRD Time (Local): 20:26 PST


Findings 1. (F) ELECTRICAL SYSTEM,CIRCUIT BREAKER - NOT ENGAGED 2. LANDING GEAR,GEAR WARNING SYSTEM - INOPERATIVE 3. (C) GEAR EXTENSION - NOT ATTAINED - PILOT IN COMMAND 4. (C) GEAR EXTENSION - NOT IDENTIFIED - COPILOT/SECOND PILOT 5. (C) WHEELS UP LANDING - INADVERTENT





Brief of Accident

MKC85FA076File No. 197 3/23/1985 HOT SPRINGS, AR Aircraft Reg No. N508SS Time (Local): 10:45 CST

Make/Model: SWEARINGEN / SA226TCEngine Make/Model: GARRETT / TPE331 SERIES


Operating Certificate(s): Commuter Air CarrierName of Carrier: AIR MIDWEST SKYWAYS, INC.



Last Depart. Point: LITTLE ROCK, ARDestination: Same as Accident

Airport Proximity: On AirportAirport Name: HOT SPRING MEM







Precipitation: None


Certificate(s)/Rating(s)Airline Transport; Single-engine Land


Flight Time (Hours)



THE FIRST OFFICER WAS MAKING THE LANDING AND THE ACFT BOUNCED DURING TOUCHDOWN. THE CAPTAIN'S RIGHT HAND, WHICH HAD BEENNEAR THE FLOOR TO THERIGHT OF HIS SEAT, BUMPED THE LANDING GEAR SELECTOR TO THE UP POSITION AS THE CAPTAIN REACHED FOR THE YOKE. THE AIRCRAFT THEN LANDED WITH THE GEARRETRACTED. ALTHOUGH THE LANDING GEAR SELECTOR HANDLE LATCH MECHANISM OPERATED AS DESIGNED, TESTS SHOWED THE MECHANISM OFFERED LITTLERESISTANCE TO INADVERTENT MOVEMENT TO THE UP POSITION.


MKC85FA076File No. 197 3/23/1985 HOT SPRINGS, AR Aircraft Reg No. N508SS Time (Local): 10:45 CST

Occurrence #1: COMPLETE GEAR COLLAPSEDPhase of Operation: LANDING - FLARE/TOUCHDOWN

Findings 1. FLARE - INADEQUATE - COPILOT/SECOND PILOT 2. (F) LANDING GEAR,GEAR SWITCH - INADEQUATE 3. (F) ACFT/EQUIP,INADEQUATE DESIGN - PRODUCTION/DESIGN PERSONNEL 4. (C) GEAR RETRACTION - INADVERTENT - PILOT IN COMMAND





Brief of Accident

DEN85FA113File No. 1944 4/7/1985 WILLISTON, ND Aircraft Reg No. N3005J Time (Local): 13:50 MST

Make/Model: SWEARINGEN / SA-227-ACEngine Make/Model: GARRETT / TPE-331


Operating Certificate(s): Commuter Air CarrierName of Carrier: PIONEER AIRLINES, INC.



Last Depart. Point: RAPID CITY, SDDestination: Same as Accident

Airport Proximity: On AirportAirport Name: SLOULIN FIELD INT'L











Flight Time (Hours)



THE FLT CREW STATED AFTER THE ACCIDENT THAT THE FLT WAS UNEVENTFUL FROM RAP TO INS. THE FIRST OFFICER WAS FLYING THE ACFT WHEN THE ACCIDENTOCCURRED. ACCORDING TO THE FLT CREW ALL CHECKLIST ITEMS HAD BEEN PERFORMED PRIOR TO THE LANDING. THE ACFT MADE GND CONTACT WITH THE LANDING GEARIN THE /UP' POSITION. THE CPT TOOK CONTROLL AND EXECUTED A GO-AROUND. THE LANDING GEAR WAS LOWERED MANUALLY AND THE RT ENG SHUTDOWN FOLLOWED BYAN UNEVENTFUL LANDING. THREE WITNESSES STATED THAT THE LANDING GEAR WAS IN THE UP POSITION THROUGHOUT THE APPROACH AND LANDING PHASES. NOEVIDENCE OF A MECHANICAL MALFUNCTION OR FAILURE WAS FOUND WITH LANDING GEAR COMPONENTS OR SYSTEM.


DEN85FA113File No. 1944 4/7/1985 WILLISTON, ND Aircraft Reg No. N3005J Time (Local): 13:50 MST


Findings 1. (C) CHECKLIST - MISJUDGED - PILOT IN COMMAND 2. (C) COMPLACENCY - PILOT IN COMMAND 3. (C) GEAR EXTENSION - NOT PERFORMED - PILOT IN COMMAND 4. (C) GEAR EXTENSION - NOT IDENTIFIED - COPILOT/SECOND PILOT 5. (C) COMPLACENCY - COPILOT/SECOND PILOT 6. (C) GO-AROUND - PERFORMED - PILOT IN COMMAND





Brief of Incident

CHI85IA160File No. 5018 4/10/1985 DAYTON, OH Aircraft Reg No. N163MA Time (Local): 13:30 EST

Make/Model: SWEARINGEN / SA226TCEngine Make/Model: GARRETT / TPE3313UUW303


Operating Certificate(s): Commuter Air CarrierName of Carrier: MIDSTATE AIRLINES, INC.



Last Depart. Point: MILWAUKEE, WIDestination: Same as Incident






Precipitation: None




Flight Time (Hours)



ON SHORT FINAL AT AN AIRSPEED BET 120 AND 125 KTS FULL FLAPS WERE LOWERED FOR LANDING. WHEN THE FLAPS REACHED THE FULL DOWN POSITION, THE STALLWARNING HORN CAME ON AND THE STICK PUSHER ON THE ROSEMONT STALL AVOIDANCE SYSTEM ACTIVATED. THE CAPTAIN DISENGAGED THE SAS CLUTCH AND A NORMALLANDING WAS MADE. THE STALL WARNING REMAINED ON UNTIL TOUCHDOWN. A CALIBRATION CHECK AND BENCH TEST OF THE SYSTEMS COMPONENTS DID NOT REVEALEDTHE CAUSE OF THE MALFUNCTION.


CHI85IA160File No. 5018 4/10/1985 DAYTON, OH Aircraft Reg No. N163MA Time (Local): 13:30 EST

Occurrence #1: AIRFRAME/COMPONENT/SYSTEM FAILURE/MALFUNCTIONPhase of Operation: APPROACH - VFR PATTERN - FINAL APPROACH

Findings 1. WARNING SYSTEM(OTHER) - ENGAGED 2. (C) WARNING SYSTEM(OTHER) - UNDETERMINED 3. SAFETY SYSTEM(OTHER) - ENGAGED 4. (C) SAFETY SYSTEM(OTHER) - UNDETERMINED 5. REMEDIAL ACTION - PERFORMED - PILOT IN COMMAND





Brief of Accident

NYC85LA105File No. 878 4/12/1985 UTICA, NY Aircraft Reg No. N101UR Time (Local): 21:10 EST

Make/Model: SWEARINGEN / SA-226TCEngine Make/Model: GARRETT / TPE-331UW304G


Operating Certificate(s): Commuter Air CarrierType of Flight Operation: Instructional



Last Depart. Point: UTICA, NYDestination: Local

Airport Proximity: On AirportAirport Name: ONEIDA COUNTY



Condition of Light: Night/BrightWeather Info Src: Witness




Precipitation: None




Flight Time (Hours)



THE ACCIDENT OCCURRED DURING A TRAINING FLT FOR EMPIRE AIRLINES. A LEFT ENG FAILURE WAS SIMULATED PAST THE FAF WHEN APRX 300 FT ABOVE MDA. THE STUDENTCOMPLETED THE EMERG CHECKLIST WHICH INCLUDED RETRACTING THE LANDING GEAR. THE FLT THEN CONTINUED VISUALLY TO THE RWY. THE CFI REPORTED THE FINALLANDING CHECKLIST WAS COMPLETED ONCE A SAFE LANDING WAS ASSURED. UPON TOUCHDOWN, A NOISE WAS HEARD WHICH WAS BELIEVED TO HAVE BEEN FROM THENOSE GEAR. THE CFI INITIATED A GO-AROUND AND RETURNED FOR ANOTHER LANDING WHICH WAS ACCOMPLISHED WITHOUT INCIDENT. INVESTIGATION REVEALED THEPROPS ON BOTH ENGINES HAD CONTACTED THE RWY AS THE LANDING GEAR WAS NOT DOWN AND LOCKED WHEN THE FIRST TOUCHDOWN WAS ATTEMPTED.


NYC85LA105File No. 878 4/12/1985 UTICA, NY Aircraft Reg No. N101UR Time (Local): 21:10 EST


Findings 1. (C) GEAR EXTENSION - IMPROPER - COPILOT/SECOND PILOT 2. (F) SUPERVISION - INADEQUATE - PILOT IN COMMAND(CFI)





Brief of Accident

LAX85LA236File No. 1863 5/3/1985 LIVERMORE, CA Aircraft Reg No. N444LM Time (Local): 21:42 PDT

Make/Model: FAIRCHILD / SA226TEngine Make/Model: GARRETT / TPE-33134303G





Last Depart. Point: THERMAL, CADestination: Same as Accident

Airport Proximity: On AirportAirport Name: LIVERMORE







Precipitation: None




Flight Time (Hours)



THE ACFT LANDED HARD AND SHORT OF THE RUNWAY. THE IMPACT COLLAPSED THE RIGHT MAIN LANDING GEAR AND THE ACFT WAS DESTROYED BY THE POST CRASH FIRE.THE PLT REPORTED THAT ON SHORT FINAL A MUFFLED 'POP' WAS HEARD AND THE ACFT YAWED TO THE RIGHT. DIRECTIONAL CONTROL WAS REGAINED AND THE ACFTLANDED HARD. POST ACCIDENT INSPECTION FAILED TO DISCLOSE ANY PRE-IMPACT FAILURE/MALFUNCTION OF THE ACFT OR ENGS. RIGHT ENG PROP SLASH MARKS IN THERWY INDICATE PWR WAS BEING PRODUCED ON THE ENG AT TOUCHDOWN.


LAX85LA236File No. 1863 5/3/1985 LIVERMORE, CA Aircraft Reg No. N444LM Time (Local): 21:42 PDT

Occurrence #1: IN FLIGHT COLLISION WITH TERRAIN/WATERPhase of Operation: APPROACH - VFR PATTERN - FINAL APPROACH

Findings 1. (C) DESCENT - IMPROPER - PILOT IN COMMAND 2. PULL-UP - DELAYED - PILOT IN COMMAND 3. (C) AIRSPEED - NOT MAINTAINED - PILOT IN COMMAND

----------

Occurrence #2: MAIN GEAR COLLAPSEDPhase of Operation: LANDING - FLARE/TOUCHDOWN

Findings 4. LANDING GEAR,MAIN GEAR - OVERLOAD





Brief of Incident

ATL85IA180File No. 5032 6/5/1985 CHERRY POINT, NC Aircraft Reg No. N1007W Time (Local): 15:16 EDT

Make/Model: Fairchild Swearingen / SA226TCEngine Make/Model: Garrett / TPE-331-3


Operating Certificate(s): Commuter Air CarrierName of Carrier: GOLDEN GATE ASSOCIATES



Last Depart. Point: ROCKY MOUNTAIN, NCDestination: NEW BERN, NC

Airport Proximity: On AirportAirport Name: MCAS CHERRY POINT







Precipitation: None

Pilot-in-Command Age: Unk/Nr



Flight Time (Hours)



DURING AN APPCH FOR LDG AT NEW BERN NC, THE CREW WAS UNABLE TO GET THE RIGHT MAIN LDG GEAR TO EXTEND. GROUND OBSERVERS REPORTED THAT THE RIGHTGEAR DOOR WAS PARTIALLY OPEN. THE CREW ELECTED TO DIVERT THE COMMUTER AIR CARRIER FLT. TO MCAS CHERRY POINT WHERE CFR EQUIPMENT WAS AVAILABLE. ASUCCESSFUL WHEELS UP LDG WAS COMPLETED WITH MINOR DAMAGE AND NO INJURIES TO THE CREW OR PASSENGERS. MAIN. HAD BEEN PERFORMED ON THE RIGHT MAINGEAR DOORS THE PREV. DAY.


ATL85IA180File No. 5032 6/5/1985 CHERRY POINT, NC Aircraft Reg No. N1007W Time (Local): 15:16 EDT

Occurrence #1: AIRFRAME/COMPONENT/SYSTEM FAILURE/MALFUNCTIONPhase of Operation: APPROACH - FAF/OUTER MARKER TO THRESHOLD (IFR)

Findings 1. (C) DOOR,LANDING GEAR - JAMMED 2. GEAR EXTENSION - ATTEMPTED - PILOT IN COMMAND 3. (C) LANDING GEAR - LOCKED 4. (C) GEAR EXTENSION - NOT POSSIBLE - COMPANY MAINTENANCE PERSONNEL 5. (C) MAINTENANCE - INADEQUATE - COMPANY MAINTENANCE PERSONNEL 6. (C) MAINTENANCE,ADJUSTMENT - IMPROPER - COMPANY MAINTENANCE PERSONNEL 7. (F) MAINTENANCE,ADJUSTMENT - POOR - MANUFACTURER





Brief of Accident

FTW85FA308File No. 2921 8/7/1985 DALLAS, TX Aircraft Reg No. N5356M Time (Local): 18:50 CDT

Make/Model: Fairchild Swearingen / SA226TCEngine Make/Model: ALLISON / TPE331-3UW303


Operating Certificate(s): Commuter Air CarrierName of Carrier: AIR MIDWEST INC.



Last Depart. Point: FAYETTEVILLE, ARDestination: Same as Accident

Airport Proximity: On AirportAirport Name: LOVE FIELD







Precipitation: None




Flight Time (Hours)



THE AIRCRAFT SUSTAINED SUBSTANTIAL DAMAGE WHEN IT LANDED WITH THE GEAR UP. THE PILOTS REPORTED LOWERING THE GEAR, BUT DID NOT CONFIRM THE GEARPOSITION. THE TOWER TRANSMITTED A WARNING, BUT THE CREW DID NOT RESPOND. SUBSEQUENT INVESTIGATION REVEALED A MALFUNCTION IN THE VOLTAGEREGULATORS ON BOTH GENERATORS. THE BATTERY VOLTAGE AVAILABLE WAS NOT SUFFICIENT TO INITIATE GEAR EXTENSION. MANUAL GEAR EXTENSION WAS AVAILABLE.


FTW85FA308File No. 2921 8/7/1985 DALLAS, TX Aircraft Reg No. N5356M Time (Local): 18:50 CDT


Findings 1. (C) ELECTRICAL SYSTEM,VOLTAGE REGULATOR - FAILURE,TOTAL 2. MAINTENANCE,SERVICE OF AIRCRAFT/EQUIPMENT - INADEQUATE - COMPANY MAINTENANCE PERSONNEL 3. (C) LANDING GEAR,NORMAL RETRACTION/EXTENSION ASSEMBLY - INOPERATIVE 4. BATTERY - INADVERTENT USE - PILOT IN COMMAND 5. IMPROPER TRAINING(EMERGENCY PROCEDURE(S)) - CHECK PILOT

----------

Occurrence #2: GEAR COLLAPSEDPhase of Operation: LANDING - ROLL

Findings 6. (C) WHEELS UP LANDING - INADVERTENT - PILOT IN COMMAND 7. ANXIETY/APPREHENSION - PILOT IN COMMAND 8. (C) CHECKLIST - IMPROPER USE OF - PILOT IN COMMAND





Brief of Accident

LAX85FA373File No. 2726 8/27/1985 FRESNO, CA Aircraft Reg No. N139WW Time (Local): 10:28 PDT

Make/Model: SWEARINGEN / SA226TC METRO IIEngine Make/Model: AIRESEARCH / TPE331-1QUA


Operating Certificate(s): Commuter Air CarrierName of Carrier: WINGS WEST, INC.



Last Depart. Point: LOS ANGELES, CADestination: MERCED, CA






Precipitation: None



Instrument RatingsHelicopter

Flight Time (Hours)



WHILE IN CRUISE FLIGHT AT 16,000 FEET ONE OF THE THREE PROPELLER BLADES SEPARATED AT THE SHANK. THE UNBALANCED CONDITION TWISTED THE ENG FROM ITSMOUNTS AND INTO THE FUSELAGE. THE CABIN WAS PUNCTURED AND RAPID DECOMPRESSION FOLLOWED. THE CREW WAS ABLE TO CONTROL THE ACFT AND LAND WITHOUTFURTHER DAMAGE.


LAX85FA373File No. 2726 8/27/1985 FRESNO, CA Aircraft Reg No. N139WW Time (Local): 10:28 PDT


Findings 1. (C) PROPELLER SYSTEM/ACCESSORIES,BLADE - BINDING(MECHANICAL) 2. (C) MAINTENANCE,INSPECTION - NOT PERFORMED - CHECK PILOT 3. (C) PROPELLER SYSTEM/ACCESSORIES,BLADE - FATIGUE





Brief of Accident

FTW85LAMS2File No. 1649 9/17/1985 MISSING, GM Aircraft Reg No. N3RB Time (Local): 12:55 CDT

Make/Model: SWEARINGEN / SA-226TEngine Make/Model: GARRETT / TPE3313U303G





Last Depart. Point: BELIZE, CADestination: NEW ORLEANS, LA






Precipitation: None




Flight Time (Hours)



A DISTRESS MESSAGE WAS RECEIVED FROM THE PILOT STATING HE WAS 100 MILES SOUTH OF GRAND ISLE, LA, AND HAD LOST AN ENG ANDWAS UNABLE TO MAINTAINALTITUDE. A SECOND MESSAGE WAS RECEIVED SHORTLY AFTERWARDS STATING THAT THE AIRCRAFT WAS AT 1500 FEET AND THE PILOT WAS PREPARING TO DITCH THEAIRCRAFT. NO FURTHER CONTACTS AND NO ELT SIGNALS WERE HEARD. THE ACFT WRECKAGE HAS NOT BEEN LOCATED.


FTW85LAMS2File No. 1649 9/17/1985 MISSING, GM Aircraft Reg No. N3RB Time (Local): 12:55 CDT

Occurrence #1: MISSING AIRCRAFTPhase of Operation: UNKNOWN

Findings 1. (C) REASON FOR OCCURRENCE UNDETERMINED





Brief of Accident

CHI86LA051File No. 2359 12/20/1985 CLEVELAND, OH Aircraft Reg No. N334BA Time (Local): 17:30 EST

Make/Model: FAIRCHILD / SA226TCEngine Make/Model: GARRETT / TPE331-3U





Last Depart. Point: DAYTON, OHDestination: Same as Accident

Airport Proximity: On AirportAirport Name: CLEVELAND-HOPKINS


Runway Surface: AsphaltRunway Surface Condition: Snow--compacted; Wet





Precipitation: Snow




Flight Time (Hours)



THE CREW OBTAINED VISUAL CONTACT WITH THE RW EVIRONMENT 100 FT ABOVE DH. DURING THE LANDING ROLL THE A/C TRAVELED ALONG THE LEFT EDGE OF THE RUNWAYUNTIL IT COLLIDED WITH A SNOW BANK. THE RUNWAY WAS COVERED WITH PATCHES OF ICE AND PACKED SNOW.


CHI86LA051File No. 2359 12/20/1985 CLEVELAND, OH Aircraft Reg No. N334BA Time (Local): 17:30 EST


Findings 1. (F) TERRAIN CONDITION - ICY 2. (C) DIRECTIONAL CONTROL - NOT OBTAINED - PILOT IN COMMAND 3. WEATHER CONDITION - LOW CEILING 4. LIGHT CONDITION - DUSK

----------


Findings 5. (C) DIRECTIONAL CONTROL - NOT CORRECTED - PILOT IN COMMAND 6. TERRAIN CONDITION - SNOWBANK





Brief of Accident

MKC86FA059File No. 1271 2/14/1986 KANSAS CITY, MO Aircraft Reg No. N252AM Time (Local): 20:33 CST



Operating Certificate(s): Commuter Air CarrierName of Carrier: AIR MIDWEST INC.



Last Depart. Point: KANSAS CITY, MODestination: MOLINE, IL






Precipitation: None




Flight Time (Hours)



DURING A CLIMB TO CRUISE, THE PILOT-IN-COMMAND DECLARED AN EMERGENCY & REQUESTED TO DSCND & RETURN TO THE ARPT. THE LANDING WAS UNEVENTFUL. ANEXAM OF THE LEFT PROP REVEALED THAT 1 OF ITS 3 BLADES HAD FAILED AT THE BUTT END & HAD SEPARATED. SUBSEQUENTLY, THE LEFT ENG ATTACH MOUNTS HAD FAILED& THE ENG HAD BECOME COCKED OUTBOARD FROM ITS ORIGINAL POSITION. A METALLURGICAL EXAM OF THE BLADE REVEALED FATIGUE CRACKING, EMINATING FM WITHINTHE PILOT HOLE OF THE BLADE BUTT. NUMEROUS SCRATCHES WERE VISIBLE IN THE PILOT HOLE AND THE CRACK HAD ITS INITIATION AT ONE OF THE SCRATCH MARKS NRTHE BEARING WASHER. THE WASHER IS USED TO PULL THE BEARING OUT OF THE PILOT HOLE FOR MAINTENANCE AND/OR INSPECTION.


MKC86FA059File No. 1271 2/14/1986 KANSAS CITY, MO Aircraft Reg No. N252AM Time (Local): 20:33 CST

Occurrence #1: AIRFRAME/COMPONENT/SYSTEM FAILURE/MALFUNCTIONPhase of Operation: CLIMB - TO CRUISE

Findings 1. (C) PROPELLER SYSTEM/ACCESSORIES,BLADE - FATIGUE 2. (C) MAINTENANCE - IMPROPER - OTHER MAINTENANCE PERSONNEL 3. PROPELLER SYSTEM/ACCESSORIES,BLADE - SEPARATION 4. ENGINE ASSEMBLY - VIBRATION 5. ENGINE ASSEMBLY,MOUNT - OVERLOAD





Brief of Accident

DEN86FA128File No. 943 5/7/1986 BILLINGS, MT Aircraft Reg No. N577KA Time (Local): 23:45 MDT

Make/Model: SWEARINGEN / SA226ATEngine Make/Model: GARRETT / TPE331-3U303G


Operating Certificate(s): On-demand Air TaxiName of Carrier: LESTER C. BARCKLEY



Last Depart. Point: HELENA, MTDestination: BILLINGS, MT






Precipitation: None




Flight Time (Hours)



WHILE ON AN IFR FLT PLAN IN IMC, THE PLT EXECUTED A MISSED APPROACH AFTER FLYING A LOCALIZER BACK COURSE 27 APPROACH. DURING A SUBSEQUENT ILS RWY 09LAPPROACH, RADIO AND RADAR CONTACT WITH THE ACFT WAS LOST LOST. THE ACFT WRECKAGE WAS LOCATED ON THE INBOUND APPROACH COURSE 1/2 MILE EAST OF THESAIGE LOCATOR OUTER MARKER. THE ACFT WAS DESTROYED BY IMPACT FORCES AND A POST IMPACT FIRE. THE AUTOPSY AND MEDICAL HISTORY OF THE PLT LED TO ACONCLUSION THAT HE WAS INCAPACITATED AT THE TIME OF IMPACT. THE PLTS FLT TIME WAS NOT REPORTED AND HIS LOGS WERE NOT LOCATED.


DEN86FA128File No. 943 5/7/1986 BILLINGS, MT Aircraft Reg No. N577KA Time (Local): 23:45 MDT

Occurrence #1: LOSS OF CONTROL - IN FLIGHTPhase of Operation: APPROACH - FAF/OUTER MARKER TO THRESHOLD (IFR)----------

Occurrence #2: IN FLIGHT COLLISION WITH TERRAIN/WATERPhase of Operation: APPROACH - FAF/OUTER MARKER TO THRESHOLD (IFR)

Findings 1. (C) PHYSICAL IMPAIRMENT(OTHER CARDIOVASCULAR) - PILOT IN COMMAND





Brief of Accident

MKC86FA113File No. 1272 5/20/1986 HUTCHINSON, KS Aircraft Reg No. N514SS Time (Local): 16:30 CDT

Make/Model: SWEARINGEN / SA226Engine Make/Model: AIRESEARCH / TPE-331


Operating Certificate(s): Commuter Air CarrierName of Carrier: AIR MIDWEST, INC.



Last Depart. Point: WICHITA, KSDestination: Same as Accident

Airport Proximity: On AirstripAirport Name: HUTCHINSON







Precipitation: None




Flight Time (Hours)



THE CAPT RPRTD THAT DURING ARRIVAL, THE APCH SEEMED NORMAL UNTIL HE FLARED TO LAND ON RWY 17. AT THAT TIME, HE HEARD A LOUD 'POP' AS THE LANDING GEARCONTACTED THE RWY SURFACE. SUBSEQUENTLY, THE LEFT MAIN GEAR COLLAPSED & THE ACFT VEERED OFF THE RWY. AN EXAM REVEALED THAT THE LEFT MAIN GEAR HADFAILED WHEN IT HIT A 6 INCH LIP AT THE APCH END OF THE ASPHALT RWY DURING TOUCHDOWN. ACCORDING TO 14 CFR 139.43, THE RWY LIP SHOULD NOT EXCEED 3 INCHES.


MKC86FA113File No. 1272 5/20/1986 HUTCHINSON, KS Aircraft Reg No. N514SS Time (Local): 16:30 CDT

Occurrence #1: UNDERSHOOTPhase of Operation: APPROACH - VFR PATTERN - FINAL APPROACH

Findings 1. (C) PROPER GLIDEPATH - NOT ATTAINED - PILOT IN COMMAND 2. (C) PROPER TOUCHDOWN POINT - MISJUDGED - PILOT IN COMMAND

----------


Findings 3. (F) AIRPORT FACILITIES,RUNWAY/LANDING AREA CONDITION - ROUGH/UNEVEN 4. (F) RUNWAY MAINTENANCE - INADEQUATE - AIRPORT PERSONNEL

----------


Findings 5. LANDING GEAR,MAIN GEAR - OVERLOAD





Brief of Accident

FTW86LA120BFile No. 628 6/23/1986 OKLAHOMA CITY, OK Aircraft Reg No. N516SS Time (Local): 22:10 CDT



Operating Certificate(s): On-demand Air TaxiName of Carrier: MARTINAIRE



Last Depart. Point: EL PASO, TXDestination: Same as Accident

Airport Proximity: On AirportAirport Name: WILL ROGERS WORLD







Precipitation: None


Certificate(s)/Rating(s)Commercial; Multi-engine Land; Single-engine Land


Flight Time (Hours)



A SWEARINGEN SA-226TC, N516SS, WAS LNDD AT NGT ON RWY 17L. AFTER LNDG, THE FLT CREW EXITED ONTO TAXIWAY-E3 (TWY-E3), WHERE THEY WERE INSTRUCTED BYTOWER TO HOLD. A BEECH E18S, N2001C, WAS THEN LNDD ON THE SAME RWY (RWY 17L) & ITS PLT ALSO EXITED ONTO TWY-E3. THE BEECH PLT RPRTD THAT HE DID NOT SEETHE SWEARINGEN IN THE DARKNESS UNTIL AFTER ENTERING THE TWY. BEFORE HE COULD STOP, THE RIGHT WING OF THE BEECH COLLIDED WITH THE LEFT WING OF THESWEARINGEN.


FTW86LA120BFile No. 628 6/23/1986 OKLAHOMA CITY, OK Aircraft Reg No. N516SS Time (Local): 22:10 CDT


Findings 1. (F) LIGHT CONDITION - DARK NIGHT 2. (F) OBJECT - AIRCRAFT MOVING ON GROUND 3. (C) VISUAL LOOKOUT - INADEQUATE - PILOT OF OTHER AIRCRAFT 4. (F) VISUAL/AURAL DETECTION - PILOT OF OTHER AIRCRAFT





Brief of Accident

MKC86LA136File No. 918 7/1/1986 LINCOLN, NE Aircraft Reg No. N243DH Time (Local): 08:13 CDT

Make/Model: FAIRCHILD / SA-227Engine Make/Model: GARRETT / TPE 331-11U


Operating Certificate(s): CargoName of Carrier: DHL AIR INC.



Last Depart. Point: OMAHA, NEDestination: Same as Accident

Airport Proximity: On AirportAirport Name: LINCOLN







Precipitation: None




Flight Time (Hours)



FLARE FOR TOUCHDOWN ENDED SHORT OF THE ACTIVE RWY AT LINCOLN, NEBRASKA. THE PIC RPTD WINDSHEAR ON FINAL BUT WIND CONDITIONS WERE RPTD AS BEING 340DEGREES AT 15 KTS, A HEADWIND FOR THIS LANDING. NO MECHANICAL CONTROL PBLM WAS REPORTEDLY EXPERIENCED DURING THIS SEQUENCE AND NO THUNDERSTORMACTIVITY WAS PRESENT. THE RWY LENGTH FOR RWY 35R WAS 5500 FEET, WELL WITHIN THE CAPABILITY OF THIS ACFT. THERE WERE NO RPTS FM ANY OTHER ACFTEXPERIENCING A SIMILAR DIFFICULTY.


MKC86LA136File No. 918 7/1/1986 LINCOLN, NE Aircraft Reg No. N243DH Time (Local): 08:13 CDT

Occurrence #1: UNDERSHOOTPhase of Operation: LANDING - FLARE/TOUCHDOWN

Findings 1. (C) PROPER GLIDEPATH - NOT MAINTAINED - PILOT IN COMMAND





Brief of Incident

MKC87IA007File No. 5031 10/16/1986 SPRINGFIELD, MO Aircraft Reg No. N251AM Time (Local): 21:18 CDT

Make/Model: SWEARINGEN / SA-226-TCEngine Make/Model: GARRETT / TPE-331-10UA


Operating Certificate(s): Commuter Air CarrierName of Carrier: AIR MIDWEST, INC.



Last Depart. Point: ST.LOUIS, MODestination: FT.LEONARD WOOD, MO

Airport Proximity: On AirportAirport Name: REGIONAL







Precipitation: None




Flight Time (Hours)



DURING THE APPROACH, THE RIGHT MAIN LANDING GEAR WOULD NOT EXTEND BY NORMAL OR EMERGENCY MEANS. AIRPLANE WAS INTENTIONALLY LANDED WITH ALLLANDING GEAR RETRACTED. INSPECTION INDICATED GEAR DOORS PULLED CLOSED FARTHER THAN NORMAL DUE TO RIGHT MAIN LANDING GEAR ROLLER BEING STUCKBELOW THE ROLLER FOLLOWER ARM. GEARS DOORS WERE STUCK CLOSED WHICH IN TURN EFFECTIVELY LOCKED GEAR INSIDE GEAR DOORS.


MKC87IA007File No. 5031 10/16/1986 SPRINGFIELD, MO Aircraft Reg No. N251AM Time (Local): 21:18 CDT


Findings 1. (C) LANDING GEAR,NORMAL RETRACTION/EXTENSION ASSEMBLY - JAMMED 2. (C) GEAR EXTENSION - NOT POSSIBLE - PILOT IN COMMAND

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Findings 3. (F) WHEELS UP LANDING - PERFORMED - PILOT IN COMMAND





Brief of Accident

Adopted 8/11/1988

LAX87FA028File No. 2760 10/30/1986 SANTA BARBARA, CA Aircraft Reg No. N137WW Time (Local): 19:35 PST

Make/Model: FAIRCHILD SWEARINGEN / SA-226TCEngine Make/Model: GARRETT / TPE331-10-VA


Operating Certificate(s): Commuter Air CarrierName of Carrier: WINGS WEST AIRLINES, INC.



Last Depart. Point: LOS ANGELES, CADestination: Same as Accident

Airport Proximity: On AirportAirport Name: SANTA BARBARA







Precipitation: None




Flight Time (Hours)



ON A DARK NIGHT, IN CAVU WEATHER, THE CAPTAIN DIRECTED THE FIRST OFFICER (WHO WAS FLYING) TO DISARM THE LANDING GEAR WARNING HORN SYSTEM BY PULLINGITS CIRCUIT BREAKER. THE F/O COMPLIED & DID NOT CHALLENGE THE CAPTAIN. ON FINAL APPROACH THE F/O FAILED TO CHECK THAT HIS 'GEAR DOWN' COMMAND WASCOMPLIED WITH & THE CAPTAIN FORGOT TO LOWER THE GEAR. AS THE ACFT SLID TO A STOP ON ITS BELLY THE RIGHT ENGINE'S 3 PROP BLADES FRAGMENTED & PUNCTUREDTHE PASSENGER COMPARTMENT. THE 2 PAX WHO WERE SEATED IN ROW 2 ABEAM THE BLADES' PLANE OF ROTATION WERE STRUCK BY FRAGMENTS & RECEIVED SERIOUSLEG & MINOR FACIAL LACERATIONS.


LAX87FA028File No. 2760 10/30/1986 SANTA BARBARA, CA Aircraft Reg No. N137WW Time (Local): 19:35 PST


Findings 1. (C) WARNING SYSTEM(OTHER) - DISABLED 2. (C) CHECKLIST - NOT FOLLOWED - PILOT IN COMMAND 3. (C) CHECKLIST - INATTENTIVE - COPILOT/SECOND PILOT 4. (F) LACK OF TOTAL EXPERIENCE IN KIND OF AIRCRAFT - COPILOT/SECOND PILOT 5. (C) GEAR EXTENSION - NOT PERFORMED - PILOT IN COMMAND 6. (C) WHEELS UP LANDING - INADVERTENT - COPILOT/SECOND PILOT 7. (C) SUPERVISION - INADEQUATE - PILOT IN COMMAND





Brief of Incident

CHI87IA047File No. 5055 12/11/1986 PADUCAH, KY Aircraft Reg No. N323BA Time (Local): 14:35 CST

Make/Model: FAIRCHILD / SA226TCEngine Make/Model: GARRETT / 331-3UW-303G



Reg. Flight Conducted Under: Part 91F: Special Flt Ops.


Last Depart. Point: ST. LOUIS, MIDestination: PADUCAH, KY






Precipitation: None




Flight Time (Hours)



JUST AFTER THE BEGINNING OF A DESCENT FOR LANDING A RUDDER CABLE FAILED COMPLETELY, RENDERING THE RUDDER INOPERATIVE. THE AIRCRAFT LANDEDUNEVENTFULLY. METALLURGICAL ANALYSIS REVEALED THAT THE CABLE WORE SEVERELY UNTIL IT FAILED. FOLLOWING AN EXAMINATION OF TWO OPERATOR'S SA-226 FLEETSMANY OTHER WORN CONTROL CABLES WERE FOUND. LATER, THE FAA: 1. PUBLISHED A CABLE INSPECTION AIRWORTHINESS DIRECTIVE 2. RECOMMENDED THAT THEMANUFACTURER CLARIFY ITS PUBLISHED CABLE INSPECTION PROCEDURES AND 3. RECOMMENDED THAT AVIATION MAINTENANCE TECHNICIAN SCHOOLS REVIEW THEIRCABLE INSPECTION TEACHING THOROUGHNESS.


CHI87IA047File No. 5055 12/11/1986 PADUCAH, KY Aircraft Reg No. N323BA Time (Local): 14:35 CST


Findings 1. (F) FLT CONTROL SYST,RUDDER CONTROL - WORN 2. (C) MAINTENANCE,AAIP/PROGRESSIVE PROGRAM - INADEQUATE - MANUFACTURER 3. (C) INSUFFICIENT STANDARDS/REQUIREMENTS - MANUFACTURER 4. (F) FLT CONTROL SYST,RUDDER CONTROL - FAILURE,TOTAL 5. (C) MAINTENANCE,INSPECTION - INATTENTIVE - COMPANY MAINTENANCE PERSONNEL 6. (C) INADEQUATE SUBSTANTIATION PROCESS - COMPANY/OPERATOR MGMT 7. (F) FLIGHT CONTROL,ELEVATOR TAB - DISABLED 8. (C) UNSAFE/HAZARDOUS CONDITION - NOT IDENTIFIED - FAA(OTHER/ORGANIZATION) 9. (C) INADEQUATE SURVEILLANCE OF OPERATION - FAA(ORGANIZATION)





Brief of Accident

SEA87FA036File No. 2068 12/15/1986 SALT LAKE CITY, UT Aircraft Reg No. N164SW Time (Local): 19:27 MST

Make/Model: SWEARINGEN / SA227ACEngine Make/Model: GARRETT / TPE-331


Operating Certificate(s): Commuter Air CarrierName of Carrier: SKYWEST AIRLINES, INC.



Last Depart. Point: IDAHO FALLS, IDDestination: SALT LAKE CITY, UT




Visibility: < 1 SMWind Dir/Speed: Calm


Precipitation: Snow Grains




Flight Time (Hours)



THE F/O WAS AT THE CONTROLS FOR THE ILS APCH TO SLC. FOG SEEDING WAS IN PROGRESS, PRODUCING VARIABLE VISIBILITIES. THE APCH COMMENCED WITH RVR WELLABOVE CAT I MINS. AT DECISION HEIGHT(DH), THE CAPT CALLED 'LIGHTS IN SITE'. THE F/O CONTINUED THE APCH DESCENT THRU DH. THE ACFT THEN REENTERED IMC ANDTHE CAPT CALLED FOR MISSED APCH. THE F/O ADDED PWR AND ESTABLISHED A WINGS LEVEL, 10 DEG NOSE-UP ATTITUDE ON THE GYRO HORIZON AS THE CAPT EXECUTEDCHECK LIST ITEMS. THE CAPT THEN NOTED THE ACFT WAS HEADING 20 DEGS RIGHT OF COURSE AND THE RIGHT WING DOWN ATTITUDE ON HIS GYRO HORIZON AT WHICHTIME HE CALLED 'TURN LEFT AND PULL UP.' THE ACFT LEFT MAIN LANDING GEAR CONTACTED A 45 FT HIGH ILS ANTENNA STACK 1049 FT DOWN THE RWY, 400 FT RIGHT OFCENTERLINE. THIS SEPARATED THE LEFT MAIN GEAR. THE ACFT DIVERETED TO PIH WHERE ADDITIONAL DAMAGE WAS SUSTAINED DURING LANDING. TESTS SHOWED THE F/OGRYO HORIZON HAD BAD BEARINGS AND THE 'OFF' FLAG WAS INOP. THE F/O'S ALTIMETER ALSO READ 100 FT HIGH.


SEA87FA036File No. 2068 12/15/1986 SALT LAKE CITY, UT Aircraft Reg No. N164SW Time (Local): 19:27 MST

Occurrence #1: IN FLIGHT ENCOUNTER WITH WEATHERPhase of Operation: APPROACH - FAF/OUTER MARKER TO THRESHOLD (IFR)

Findings 1. (F) WEATHER CONDITION - FOG 2. (F) WEATHER CONDITION - OBSCURATION 3. (F) WEATHER CONDITION - BELOW APPROACH/LANDING MINIMUMS 4. MISSED APPROACH - ATTEMPTED - COPILOT/SECOND PILOT

----------

Occurrence #2: IN FLIGHT COLLISION WITH OBJECTPhase of Operation: MISSED APPROACH (IFR)

Findings 5. (F) FLIGHT/NAV INSTRUMENTS,ALTIMETER - INCORRECT 6. (C) MINIMUM DESCENT ALTITUDE - NOT IDENTIFIED - COPILOT/SECOND PILOT 7. (F) FLIGHT/NAV INSTRUMENTS,ATTITUDE INDICATOR - FALSE INDICATION 8. (C) PROPER ALIGNMENT - NOT MAINTAINED - COPILOT/SECOND PILOT 9. (C) SUPERVISION - INADEQUATE - PILOT IN COMMAND10. (F) DIVERTED ATTENTION - PILOT IN COMMAND11. (F) EXPECTANCY - PILOT IN COMMAND12. (F) OBJECT - APPROACH LIGHT/NAVAID

----------

Occurrence #3: IN FLIGHT COLLISION WITH TERRAIN/WATERPhase of Operation: MISSED APPROACH (IFR)

Findings13. (C) LANDING GEAR,MAIN GEAR - PREVIOUS DAMAGE





Brief of Incident

DEN87IA032File No. 5057 12/19/1986 BILLINGS, MT Aircraft Reg No. N124AV Time (Local): 21:10 MST

Make/Model: SWEARINGEN / SA226TCEngine Make/Model: GARRETT / TPE331-3U303G


Operating Certificate(s): Commuter Air CarrierName of Carrier: BIG SKY AIRLINES



Last Depart. Point: HELENA, MTDestination: Same as Incident

Airport Proximity: On AirportAirport Name: BILLINGS LOGAN INT'L.







Precipitation: None


Certificate(s)/Rating(s)Airline Transport; Commercial; Multi-engine Land; Multi-engine Sea; Single-engine Land; Single-engine Sea; Helicopter


Flight Time (Hours)



N124AV WAS OPERATING AS BIG SKY AIRLINES FLT 3857, SCHEDULED SERVICE FROM HELENA TO BILLINGS. THE FLT PROCEEDED UNEVENTFULLY UNTIL THE APCH INTOBILLINGS. THE FLT CREW STATED AFTER THE INCIDENT THAT WHEN THE LANDING GEAR WAS EXTENDED, THE LEFT MAIN GEAR LIGHTS DID NOT ILLUMINATE, VERIFYING THE'DOWN AND LOCKED POSITION..' AFTER NUMEROUS ATTEMPTS TO ILLUMINATE THE LIGHTS AND CONFIRM THE POSITION OF THE LANDING GEAR, THE CREW EXECUTED ANINTENTIONAL GEAR UP LANDING. POST INCIDENT INSPECTION OF THE LANDING GEAR SYSTEM REVEALED IT WAS CAPABLE OF NORMAL OPERATION. THE MALFUNCTIONINGCOCKPIT INDICATOR LIGHT WAS TRACED BACK TO AN INOPERATIVE OUTBOARD DOWNLOCK MICROSWITCH.


DEN87IA032File No. 5057 12/19/1986 BILLINGS, MT Aircraft Reg No. N124AV Time (Local): 21:10 MST


Findings 1. (F) LANDING GEAR,GEAR INDICATING SYSTEM - FAILURE,PARTIAL 2. (C) REMEDIAL ACTION - IMPROPER - PILOT IN COMMAND

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Findings 3. AIRPORT FACILITIES,RUNWAY/LANDING AREA CONDITION - RUNWAY 4. (C) WHEELS UP LANDING - INTENTIONAL - PILOT IN COMMAND





Brief of Accident

Adopted 12/27/1988

LAX87LA086File No. 1919 1/10/1987 YUMA, AZ Aircraft Reg No. N165SW Time (Local): 00:30 MST

Make/Model: SWEARINGEN / SA227-ACEngine Make/Model: GARRETT / TPE-331-11461


Operating Certificate(s): Commuter Air CarrierName of Carrier: SKY WEST AIRLINES



Last Depart. Point: IMPERIAL, CADestination: Same as Accident

Airport Proximity: On AirportAirport Name: YUMA INT'L







Precipitation: None




Flight Time (Hours)



THE LEFT MAIN LANDING GEAR RETRACTED AFTER A NORMAL LANDING AND THE AIRCRAFT SWERVED OFF THE LEFT SIDE OF THE RUNWAY INTO THE DIRT. CREWMEMBERSSTATED THAT THEY OBSERVED THREE GREEN LANDING GEAR POSITION LIGHTS PRIOR TO TOUCH DOWN AND THAT, AFTER THE AIRCRAFT CAME TO A STOP, THE LEFT GEARIN TRANSIT LIGHT HAD COME ON AND THE GREEN LIGHT WAS OFF. INSPECTION REVEALED NO MALFUNCTION OR PRE-ACCIDENT DEFECT OF THE LANDING GEAR SYSTEM.


LAX87LA086File No. 1919 1/10/1987 YUMA, AZ Aircraft Reg No. N165SW Time (Local): 00:30 MST

Occurrence #1: MAIN GEAR COLLAPSEDPhase of Operation: LANDING - ROLL

Findings 1. LANDING GEAR,GEAR LOCKING MECHANISM - UNLOCKED 2. (C) REASON FOR OCCURRENCE UNDETERMINED





Brief of Accident

Adopted 12/12/1988

DCA87MA018AFile No. 156 1/15/1987 KEARNS, UT Aircraft Reg No. N1635W Time (Local): 12:52 MST

Make/Model: SWEARINGEN / SA-226TCEngine Make/Model: GARRETT / TPE-331


Operating Certificate(s): Commuter Air CarrierName of Carrier: SKY WEST AIRLINES INC.



Last Depart. Point: POCATELLO, IDDestination: SALT LAKE CITY, UT






Precipitation: None




Flight Time (Hours)



THE TWO ACFT, A SWEARINGEN SA-226TC AND A MOONEY M-20, COLLIDED IN FLT AT APRX 7000 FT MSL IN THE SALT LAKE CITY ARPT (SLC) RADAR SERVICE AREA OVERKEARNS, UT. THE SA-226 WAS APPROACHING SLC FOR LNDG AND THE M-20 WAS CONDUCTING A LOCAL TRNG FLT WHEN THE COLLISION OCCURRED. THERE IS EVIDENCE THATTHE SA-226 INITIATED EVASIVE ACTION IN THE FINAL MOMENTS BEFORE THE COLLISION. THERE WAS ALSO AN EXCLAMATORY EXPLETIVE ON THE RADIO AT ABOUT THE TIMETHE RADAR TARGETS OF THE TWO ACFT MERGED. THE FINAL CONTROLLER SAW A RADAR TARGET EARLIER THAT WAS POSSIBLY THE M-20 BUT DID NOT SEE IT AT THE TIMEOF THE COLLISION. THE M-20 HAD NO MODE-C TRANSPONDER TO HELP IDENTIFY IT ON RADAR. THE M-20 SHOULD NOT HAVE BEEN WHERE IT WAS WITHOUT CLEARANCE. THEPLT OF THE SA-226 HAD BEEN ADVISED OF ANOTHER ACFT TO ITS LEFT AND ASKED TO REPORT SIGHTING IT. THE M-20 APPROACHED THE SA-226 FROM THE RIGHT SIDE.AFTER THE COLLISION BOTH OF THE ACFT DESCENDED TO AN UNCONTROLLED CRASH. THE WEATHER AT THE TIME OF THE COLLISION WAS VMC WITH VISIBILITY OF 30 MILES.


DCA87MA018AFile No. 156 1/15/1987 KEARNS, UT Aircraft Reg No. N1635W Time (Local): 12:52 MST

Occurrence #1: MIDAIR COLLISIONPhase of Operation: MANEUVERING

Findings 1. (C) PROCEDURES/DIRECTIVES - NOT FOLLOWED - PILOT OF OTHER AIRCRAFT 2. (C) BECAME LOST/DISORIENTED - INATTENTIVE - PILOT OF OTHER AIRCRAFT 3. VISUAL LOOKOUT - REDUCED - PILOT IN COMMAND 4. (F) RADAR,APPROACH/DEPARTURE - INADEQUATE 5. (F) IDENTIFICATION OF AIRCRAFT ON RADAR - INADEQUATE - ATC PERSONNEL(DEP/APCH) 6. TRAFFIC ADVISORY - NOT ISSUED - ATC PERSONNEL(DEP/APCH) 7. VISUAL LOOKOUT - INADEQUATE - PILOT OF OTHER AIRCRAFT

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Occurrence #2: IN FLIGHT COLLISION WITH TERRAIN/WATERPhase of Operation: DESCENT - UNCONTROLLED





Brief of Accident

Adopted 4/25/1988

ATL87LA070File No. 238 2/5/1987 FLORENCE, SC Aircraft Reg No. N1013G Time (Local): 19:15 EST

Make/Model: SWEARINGEN / SA-226TCEngine Make/Model: GARRETT / TPE-331-10


Operating Certificate(s): Flag Carrier/Domestic; Other Large AircraftName of Carrier: ATLANTIS LEASING, INC.



Last Depart. Point: MYRTLE BEACH, SCDestination: Same as Accident

Airport Proximity: On AirportAirport Name: FLORENCE







Precipitation: None




Flight Time (Hours)



DURING THE FINAL LEG OF A DOMESTIC SCHEDULED COMMUTER AIRLINE FLIGHT THE AIRCRAFT LANDED WITH THE LANDING GEAR IN THE RETRACTED POSITION. THE CAPTAINCOULD NOT RECALL PLACING THE GEAR SELECTOR HANDLE IN THE DOWN POSITION AND THE CO-PILOT COULD NOT REMEMBER CALLING FOR 'GEAR DOWN' DURING THE'BEFORE LANDING CHECKLIST'. THE CO-PILOT WAS FLYING THE LEG AND THE CAPTAIN WAS PERFORMING THE CO-PILOT FUNCTIONS. AS THE PROPELLERS CAME IN CONTACTWITH THE RUNWAY APPROX. 6 INCHES OF A RIGHT PROPELLER BLADE SEPARATED AND PENETRATED THE FUSELAGE AT ROW 2, SEAT 'B'. THERE WERE NO PASSENGERSSEATED IN THE AREA AT THAT TIME. NO MECHANICAL DISCREPANCIES WERE REPORTED BY THE CREW PRIOR TO THE ACCIDENT AND A LANDING GEAR SYSTEM CHECK AFTERTHE ACCIDENT DID NOT REVEAL ANY MECHANICAL DIFFICIENCIES.


ATL87LA070File No. 238 2/5/1987 FLORENCE, SC Aircraft Reg No. N1013G Time (Local): 19:15 EST


Findings 1. LIGHT CONDITION - DARK NIGHT 2. (C) CHECKLIST - NOT FOLLOWED - PILOT IN COMMAND 3. (F) COMPLACENCY - PILOT IN COMMAND 4. (F) CHECKLIST - NOT FOLLOWED - COPILOT/SECOND PILOT 5. (F) DIVERTED ATTENTION - PILOT IN COMMAND 6. (F) CREW/GROUP COORDINATION - POOR - PILOT IN COMMAND 7. (C) GEAR EXTENSION - NOT PERFORMED - PILOT IN COMMAND 8. (C) WHEELS UP LANDING - INADVERTENT - COPILOT/SECOND PILOT





Brief of Accident

Adopted 10/6/1988

NYC87LA104File No. 6029 3/10/1987 JAMAICA, NY Aircraft Reg No. CGJWW Time (Local): 01:02 EST

Make/Model: SWEARINGEN / SA-226ATEngine Make/Model: GARRETT / TPE-331-30303


Operating Certificate(s): On-demand Air TaxiName of Carrier: SOUNDAIR CORP.

Type of Flight Operation: Non-scheduled; Cargo; InternationalReg. Flight Conducted Under: Part 129: Foreign


Last Depart. Point: TORONTO, CDDestination: JAMAICA, NY

Airport Proximity: On AirportAirport Name: KENNEDY







Precipitation: None



Instrument RatingsNone

Flight Time (Hours)



THE FLIGHT LANDED AT KENNEDY INTERNATIONAL AIRPORT WITH THE LANDING GEARS RETRACTED DUE TO A FAILURE OF THE RIGHT MAIN LANDING GEAR EXTENSIONSYSTEM.


NYC87LA104File No. 6029 3/10/1987 JAMAICA, NY Aircraft Reg No. CGJWW Time (Local): 01:02 EST


Findings 1. WHEELS UP LANDING - PERFORMED - PILOT IN COMMAND 2. (C) LANDING GEAR,NORMAL RETRACTION/EXTENSION ASSEMBLY - FAILURE,PARTIAL





Brief of Accident

Adopted 5/2/1988

DEN87LA067BFile No. 275 3/18/1987 MISSOULA, MT Aircraft Reg No. N124AV Time (Local): 21:40 MST

Make/Model: SWEARINGEN / SA-226TCEngine Make/Model: GARRETT / TPE331-1OUA


Operating Certificate(s): Commuter Air CarrierName of Carrier: BIG SKY AIRLINES



Last Depart. Point: MISSOULA, MTDestination: GREAT FALLS, MT

Airport Proximity: On AirportAirport Name: MISSOULA







Precipitation: Snow




Flight Time (Hours)



THE PLT OF THE PIPER NAVAJO WAS TAXIING TO THE ACTIVE RWY FOR AN IFR DEPARTURE, DIRECTED HIS ATTENTION TO THE DEPARTURE PROCEDURE CHART IN THECOCKPIT, AND COLLIDED WITH THE TAIL OF A SWEARINGEN ACFT HOLDING SHORT OF THE RWY AWAITING TAKEOFF CLEARANCE.


DEN87LA067BFile No. 275 3/18/1987 MISSOULA, MT Aircraft Reg No. N124AV Time (Local): 21:40 MST

Occurrence #1: ON GROUND/WATER COLLISION WITH OBJECTPhase of Operation: STANDING - ENGINE(S) OPERATING

Findings 1. (C) VISUAL LOOKOUT - NOT MAINTAINED - PILOT OF OTHER AIRCRAFT 2. (C) CLEARANCE - NOT MAINTAINED - PILOT OF OTHER AIRCRAFT 3. OBJECT - AIRCRAFT MOVING ON GROUND





Brief of Accident

Adopted 12/27/1988

MKC87LA080File No. 1986 4/6/1987 COLUMBIA, MO Aircraft Reg No. N26863 Time (Local): 21:30 CDT

Make/Model: FAIRCHILD / SA-227Engine Make/Model: GARRETT / TPE-331


Operating Certificate(s): Commuter Air CarrierName of Carrier: RESORT AIR,INC.



Last Depart. Point: PEORIA, ILDestination: Unk/Nr


Condition of Light: Not ReportedWeather Info Src: Unk/Nr


Visibility: < 1 SMWind Dir/Speed: Unk/Nr



Pilot-in-Command Age: Unk/Nr

Certificate(s)/Rating(s)

Instrument Ratings

Flight Time (Hours)



ON APRIL 6, 1987 A CREW OPERATING A METRO III, COMMUTER ACFT NOTICED DAMAGE ON BOTH ENG NACELLES DURING A PREFLT INSP. THE COMMUTER OPERATOR CHIEFPILOT WAS NOTIFIED AND AN ON SITE INSP WAS MADE. THE CREW ORIGINALLY RPTNG THE DAMAGE CLAIMED THEY WERE NOT AT FAULT AND HAD NO PREVIOUS FLTS THATRESULTED IN ANY HARD LNDGS. A SAMPLING OF PAX'S WERE QUESTIONED ABT LNDGS DURING THEIR FLTS. THE PAX'S WERE NOT ABLE TO CONFIRM THAT ANY HARD LNDGSHAD OCCURRED. ANOTHER CREW KNOWN TO HAVE OPERATED THE ACFT ON THE PREVIOUS DAY NOTIFIED THE CHF PILOT THAT THEY HAD A 'FIRM' LNDG AT SPRINGFLD, ILL.,BUT DISCOVERED NO DAMAGE DURING TWO SEPARATE POST FLT INSP'S. FLIGHT CREWS WHO OPERATED THE ACDNT ACFT AFTER THE 'FIRM' LNDG WHICH OCCURRED ONAPRIL 5, CLAIMED TO HAVE OPERATED THE ACDNT ACFT WITHIN NORMAL PARAMETERS OBSVRNG NO DAMAGE DURING POST FLT INSP'S.


MKC87LA080File No. 1986 4/6/1987 COLUMBIA, MO Aircraft Reg No. N26863 Time (Local): 21:30 CDT

Occurrence #1: UNDETERMINEDPhase of Operation: UNKNOWN

Findings 1. NACELLE/PYLON,SKIN - DISTORTED 2. (C) REASON FOR OCCURRENCE UNDETERMINED





Brief of Accident

Adopted 8/31/1988

ATL87FA123File No. 912 4/23/1987 WILMINGTON, NC Aircraft Reg No. N505LB Time (Local): 19:35 EDT

Make/Model: SWEARINGEN / SA-226TCEngine Make/Model: GARRETT / TPE 331-3UW


Operating Certificate(s): Commuter Air Carrier; On-demand Air TaxiName of Carrier: AIR-LIFT ASSOCIATES, INC.



Last Depart. Point: Same as AccidentDestination: LUMBERTON, NC






Precipitation: None




Flight Time (Hours)



THE RIGHT ENGINE FAILED DURING TAKEOFF IMMEDIATELY AFTER ROTATION 3000' DOWN THE 7,002' RWY 16. THE PLT CONTINUED THE FLT AND THE LANDING GEAR REMAINEDEXTENDED. THE UNAUTHORIZED PLT RATED PAX MADE XMISSIONS TO THE TOWER. WITNESSES RPTED THAT THE ACFT REACHED APPROX. 150' THEN DESCENDED INTO TREES20 DEGREES TO THE RIGHT OF RWY CENTERLINE AND 3,000' SOUTH OF THE ARPT. THE PRE- 1979 3RD STAGE STATOR ASSY IN THE RIGHT ENGINE DID NOT HAVE THE LATESTMANUFACTURE WELDING PROCESS/INSPECTION AND FAILED CAUSING THE UNCONTAINED TURBINE FAILURE. INSTRUMENTS IN THE WRECKAGE INDICATED THAT ANUNDETERMINABLE LOSS OF ELECTRICAL POWER OCCURRED AT THE TIME OF ENGINE FAILURE. PERFORMANCE DATA INDICATED THAT A SAFE LANDING COULD HAVE BEENMADE ON THE REMAINING RWY PAST THE POINT OF ENGINE FAILURE.


ATL87FA123File No. 912 4/23/1987 WILMINGTON, NC Aircraft Reg No. N505LB Time (Local): 19:35 EDT

Occurrence #1: LOSS OF ENGINE POWER(PARTIAL) - MECH FAILURE/MALFPhase of Operation: TAKEOFF - INITIAL CLIMB

Findings 1. (F) TURBINE ASSEMBLY,NOZZLE RETENTION - INADEQUATE 2. (F) ACFT/EQUIP,INADEQUATE DESIGN - MANUFACTURER 3. (F) TURBINE ASSEMBLY,TURBINE WHEEL - BURST 4. (F) ELECTRICAL SYSTEM - UNDETERMINED

----------

Occurrence #2: FORCED LANDINGPhase of Operation: DESCENT - EMERGENCY----------

Occurrence #3: IN FLIGHT COLLISION WITH OBJECTPhase of Operation: DESCENT - UNCONTROLLED

Findings 5. (F) OBJECT - TREE(S) 6. (C) IN-FLIGHT PLANNING/DECISION - POOR - PILOT IN COMMAND 7. (F) PRESSURE INDUCED BY OTHERS - PILOT IN COMMAND 8. (C) EMERGENCY PROCEDURE - NOT FOLLOWED - PILOT IN COMMAND 9. (C) ALL AVAILABLE RUNWAY - NOT USED - PILOT IN COMMAND

----------


Findings10. TERRAIN CONDITION - GROUND





Brief of Incident

Adopted 8/8/1989

ATL87IA191File No. 5026 6/26/1987 NASHVILLE, TN Aircraft Reg No. N256AM Time (Local): 07:55 CDT

Make/Model: SWEARINGEN / SA-226TCEngine Make/Model: AIRESEARCH / TPE-331-3





Last Depart. Point: PADUCAH, KYDestination: Same as Incident

Airport Proximity: On AirportAirport Name: NASHVILLE METRO







Precipitation: None




Flight Time (Hours)



THERE WAS HVY TRAFFIC AT THE NASHVILLE METRO ARPT WHEN AIR MIDWEST FLT 4530 (SWEARINGEN SA-226TC, N256AM) ARRIVED DRG A MORNING FLT. THE FLT CREWMADE AN ILS APCH TO RWY 31 AS ANOTHER ACFT (AMERICAN FLT 130) WAS ON AN APCH TO RWY 2L. THE 2 RWYS INTERSECTED NR THE MIDPOINT OF RWY 31. THE TWR CTLRCLRD FLT 4530 TO LND ON RWY 31, BUT INSTRUCTED THE FLT CREW TO HOLD SHORT OF RWY 2L. THE FLT REPLIED WITH AN UNINTELLIGIBLE COMMENT FLWD BY '. . . AIRMIDWEST 4530'S CLEARED TO LAND, 31.' THE TWR CTLR EXPECTED THE FLT TO HOLD SHORT OF RWY 2L. HOWEVER, AFTER LNDG, FLT 4530 CONTD ITS LNDG ROLL & CROSSEDRWY 2L. THE RWY INCURSION OCCURRED AS FLT 130 WAS LNDG ON RWY 2L. THE CAPT OF FLT 4530 WAS AWARE OF INTERSECT-ING RWY OPNS, BUT SAID THAT BOTH HE &THE 1ST OFFICER UNDERSTOOD THEIR CLNC INCLUDED THE USE OF THE FULL RWY. A CHECK OFTHE TWR TAPES VERIFIED THE CTLR HAD TOLD FLT 4530 TO HOLD SHORT OFRWY 2L; HOWEVER, THE FLT CREW DID NOT ACKNOWLEDGE THAT INSTRUCTION & THE TWR CTLR FAILED TO ASK FOR AN ACKNOWLEDGEMENT.


ATL87IA191File No. 5026 6/26/1987 NASHVILLE, TN Aircraft Reg No. N256AM Time (Local): 07:55 CDT

Occurrence #1: MISCELLANEOUS/OTHERPhase of Operation: LANDING - ROLL

Findings 1. (F) AIRPORT/FACILITIES - CONGESTED 2. (C) ATC CLEARANCE - NOT UNDERSTOOD - PILOT IN COMMAND 3. (C) CONTROL TOWER SERVICE - INADEQUATE





Brief of Accident

Adopted 12/12/1988

SEA87MA192File No. 1895 9/24/1987 TWIN FALLS, ID Aircraft Reg No. N2689E Time (Local): 23:25 MDT

Make/Model: FAIRCHILD / SA227-ACEngine Make/Model: GARRETT / TPE-331-11U


Operating Certificate(s): Commuter Air Carrier; Flag Carrier/DomesticType of Flight Operation: Instructional



Last Depart. Point: Same as AccidentDestination: Local

Airport Proximity: On AirportAirport Name: JOSLIN FIELD







Precipitation: None




Flight Time (Hours)



CHK PLT WAS CONDUCTING CAPT PROFICIENCY CHK ON ANOTHER COMPANY PLT (PIC) UNDER DARK NGT CONDTNS. SUBSEQUENT TO FULL STOP LDG ON RWY 25, TAKEOFFCHKLST WAS RECITED. PIC COMMENCED T/O ON RWY 07. CHK PLT SIMULATED VI ENG CUT AFTER LIFTOFF. PIC WAS UNABLE TO ACCEL TO V2, CLIMB, OR MAINTAIN DIRECTNLCONTRL. ACFT LEVELLED OFF, A/S BEGAN TO DECAY & ACFT DRIFTED TO THE RIGHT. CHK CAPT FAILED TO TAKE CNTRL OR TERMINATE ENG CUT SIMULATION AS EVOLUTIONDETERIORATED. ACFT COLLIDED WITH ILS GS TWR MARKED BY RED OBST LIGHTS. LOSS OF CNTRL FOLLOWED WHEN RGT WINGTIP/AILERON SEPARATED. ACFT THENIMPACTED GND AND SLID TO A STOP. TKOF FLAP POSITION SHOULD BE 1/4. BOTH FLAPS FOUND NEAR 1/2 FLAP EXTENDED POSITION. HANDLE FOUND IN 1/2 FLAP DETENT.PERFMNC CHARTS SHOW ACFT ABL TO REACH V2 AT 50 FT ALT IN 6500 FT ROLL, THEN +575 FPM CLIMB (VYSE) AT ACC WT.


SEA87MA192File No. 1895 9/24/1987 TWIN FALLS, ID Aircraft Reg No. N2689E Time (Local): 23:25 MDT

Occurrence #1: LOSS OF ENGINE POWERPhase of Operation: TAKEOFF - INITIAL CLIMB

Findings 1. (C) PREFLIGHT PLANNING/PREPARATION - INADEQUATE - PILOT IN COMMAND 2. (C) RAISING OF FLAPS - NOT PERFORMED 3. (C) CHECKLIST - INATTENTIVE - PILOT IN COMMAND 4. (F) EMERGENCY PROCEDURE - SIMULATED - CHECK PILOT 5. PROPER CLIMB RATE - NOT POSSIBLE 6. DIRECTIONAL CONTROL - NOT POSSIBLE 7. (C) SUPERVISION - INADEQUATE - CHECK PILOT

----------

Occurrence #2: LOSS OF CONTROL - IN FLIGHTPhase of Operation: TAKEOFF - INITIAL CLIMB

Findings 8. (F) OBJECT - TOWER(MARKED) 9. WING,WINGTIP - SEPARATION10. FLIGHT CONTROL,AILERON - LOSS,PARTIAL

----------






Brief of Accident

Adopted 10/5/1988

BFO88FA010File No. 2401 12/17/1987 CHANTILLY, VA Aircraft Reg No. N23AZ Time (Local): 19:36 EST

Make/Model: SWEARINGEN / SA-226Engine Make/Model: GARRETT / TPE331-I0UA-5


Operating Certificate(s): Commuter Air CarrierName of Carrier: AVAIR INCORPORATED



Last Depart. Point: NEWARK, NJDestination: CHANTILLY, VA






Precipitation: None




Flight Time (Hours)



THE ACFT HAD DESCENDED THROUGH A CLOUD LAYER ENROUTE FOR THE SCHEDULED LNDG AT IAD AND ACCORDING TO THE CREW HAD PICKED UP SOME TRACE RIME ICEON ITS WING SURFACES. ALTHOUGH PITOT AND SAS (STALL AVOIDANCE SYSTEM) HEAT WERE USED THE CAPTAIN ELECTED NOT TO USE ENGINE INLET ANTI-ICE. JUST INSIDETHE OUTER MARKER THE LEFT ENGINE LOST POWER FOLLOWED SHORTLY BY THE RIGHT ENGINE. THE CAPTAIN WAS ABLE TO SET THE ACFT DOWN IN AN OPEN FIELD WHERETHE GEAR COLLAPSED DURING THE LANDING ROLL. THE ENGINES WERE SUCCESSFULLY RUN-UP AT THE GARRETT FACILITY. THE FLT MANUAL CONTAINS A WARNING AND ANOTE STATING THAT ENGINE HEAT AND CONTINUOUS IGNITION MUST BE USED AFTER LEAVING ICING CONDITIONS UNTIL THE PLT IS CONFIDENT THAT ANY SIGNIFICANTRESIDUAL ICE WILL NOT BE INJESTED INTO THE ENGINES. ICE WAS FOUND LYING BENEATH THE RT WING WHICH MATCHED THE CURVATURE OF THE LEADING EDGE OF THEWING. A ROUND CONICAL SHAPED PIECE OF ICE WAS FOUND ALONG THE WRECKAGE PATH WHICH MATCHED THE NOSE OF THE PROPELLER SPINNER.


BFO88FA010File No. 2401 12/17/1987 CHANTILLY, VA Aircraft Reg No. N23AZ Time (Local): 19:36 EST

Occurrence #1: LOSS OF ENGINE POWER(TOTAL) - NONMECHANICALPhase of Operation: APPROACH - FAF/OUTER MARKER TO THRESHOLD (IFR)

Findings 1. ALL ENGINES 2. (F) WEATHER CONDITION - ICING CONDITIONS 3. (C) IN-FLIGHT PLANNING/DECISION - IMPROPER - PILOT IN COMMAND 4. (C) ANTI-ICE/DEICE SYSTEM - NOT USED - PILOT IN COMMAND 5. (C) INADEQUATE INITIAL TRAINING - CHECK PILOT 6. (C) INADEQUATE CERTIFICATION/APPROVAL,AIRMAN - COMPANY/OPERATOR MGMT 7. (F) WING,SKIN - ICE

----------


Findings 8. (F) TERRAIN CONDITION - OPEN FIELD 9. (F) TERRAIN CONDITION - DOWNHILL10. (F) LIGHT CONDITION - DARK NIGHT





Brief of Accident

Adopted 11/28/1989

CHI88FA041File No. 1548 1/10/1988 PONTIAC, MI Aircraft Reg No. N800AW Time (Local): 10:17 EST

Make/Model: FAIRCHILD / SA226TEngine Make/Model: GARRETT / TPE-331-100


Operating Certificate(s): NoneType of Flight Operation: Instructional



Last Depart. Point: Same as AccidentDestination: Unk/Nr

Airport Proximity: On AirportAirport Name: OAKLAND PONTIAC







Precipitation: None




Flight Time (Hours)



ACFT WAS SCHEDULED FOR AN INSTRUCTIONAL FLT. DURING THE WX BRIEFING, THE CFI TOLD THE FSS SPECIALIST THAT THE FLT WOULD INCLUDE ENG-OUT PRACTICE.WITNESS STATEMENTS INDICATE THAT THE ACFT ROLLED SHARPLY TO THE RT AND NOSED DOWN AFTER ATTAINING ABOUT 100 FT OF ALT DURING THE CLIMB AFTERTAKEOFF. THE ACFT STRUCK THE GROUND LEFT PROP AND LEFT WING TIP FIRST, IN AN INVERTED FLT ATTITUDE. DURING THE POST ACCIDENT INVESTIGATION, THE RT ENGPWR LEVER WAS SUBJECTED TO LAB EXAM AND IT WAS FOUND THAT THE LOWER AFT PART OF THE LIFT GATE DETENT WAS WORN. THIS CREATED A RAMPING EFFECTBETWEEN THE ROUNDED EDGE OF THE LIFT GATE AND THE FLT IDLE STOP. A WORN LIFT GATE DETENT WOULD ALLOW THE POWER LEVER TO INADVERTENTLY BE MOVEDINTO THE BETA RANGE, CAUSING ASYMMETRICAL DRAG AND DEGRADED AIRPLANE PERFORMANCE, PARTICULARLY IN CRITICAL PHASES OF FLIGHT.


CHI88FA041File No. 1548 1/10/1988 PONTIAC, MI Aircraft Reg No. N800AW Time (Local): 10:17 EST

Occurrence #1: LOSS OF ENGINE POWER(TOTAL) - MECH FAILURE/MALFPhase of Operation: TAKEOFF - INITIAL CLIMB

Findings 1. 1 ENGINE 2. (F) EMERGENCY PROCEDURE - SIMULATED - PILOT IN COMMAND(CFI) 3. (C) THROTTLE/POWER LEVER - WORN 4. (C) PROPELLER SYSTEM/ACCESSORIES,REVERSING SYSTEM - DEPLOYED INADVERTENTLY

----------

Occurrence #2: LOSS OF CONTROL - IN FLIGHTPhase of Operation: TAKEOFF - INITIAL CLIMB----------






Brief of Accident

Adopted 9/1/1989

DCA88MA017File No. 313 1/19/1988 BAYFIELD, CO Aircraft Reg No. N68TC Time (Local): 19:20 MST

Make/Model: FAIRCHILD / SA-227ACEngine Make/Model: GARRETT / TPE-331-114


Operating Certificate(s): Commuter Air CarrierName of Carrier: TRANS COLORADO AIRLINES



Last Depart. Point: DENVER, CODestination: Same as Accident






Precipitation: Snow Shower




Flight Time (Hours)



THE AIRCRAFT WAS OPERATING AS CONTINENTAL EXPRESS FLIGHT 2286. DURING THE APPROACH IN IFR CONDITIONS, THE AIRCRAFT WENT BELOW THE MINIMUM DESCENTALTITUDE THEN STRUCK THE TERRAIN AT 7180 FEET MSL. EXAM OF THE AIRCRAFT DID NOT DISCLOSE ANY PRE-IMPACT FAILURES OR SYSTEM MALFUNCTIONS. THE EVIDENCEINDICATED THAT THE COPILOT WAS FLYING THE AIRPLANE DURING THE APPROACH. EVALUATION OF THE RADAR DATA SHOWED AN EXCESSIVE RATE OF DESCENT BEFORETHE COLLISION WITH TERRAIN. POST- MORTEM TOXICOLOGICAL EXAMINATION SHOWED THAT THE CAPTAIN HAD USED COCAINE PRIOR TO THIS FLIGHT. THE SAFTEY BOARDCONCLUDED THAT THIS USE HAD ADVERSLY AFFECTED HIS ABILITY TO MONITOR THE UNSTABILIZED APPROACH FLOWN BY THE COPILOT. RECORDS OF BOTH CREWMEMBERSREVEALED PRIOR TRAFFIC VIOLATIONS AND ACCIDENTS, AND, IN THE CASE OF THE CAPTAIN, A PREVIOUS AIRCRAFT ACCIDENT. EVALUATION OF THE WEATHER CONDITIONSINDICATED THAT A 10 TO 15 KNOT TAILWIND CONDITION EXISTED THROUGHOUT THE APPROACH.


DCA88MA017File No. 313 1/19/1988 BAYFIELD, CO Aircraft Reg No. N68TC Time (Local): 19:20 MST

Occurrence #1: IN FLIGHT COLLISION WITH TERRAIN/WATERPhase of Operation: APPROACH - IAF TO FAF/OUTER MARKER (IFR)

Findings 1. WEATHER CONDITION - SNOW 2. WEATHER CONDITION - TAILWIND 3. (C) IFR PROCEDURE - IMPROPER - COPILOT/SECOND PILOT 4. (C) PROPER DESCENT RATE - EXCESSIVE - COPILOT/SECOND PILOT 5. (C) SUPERVISION - INADEQUATE - PILOT IN COMMAND 6. (F) IMPAIRMENT(DRUGS) - PILOT IN COMMAND





Brief of Incident

Adopted 1/25/1990

FTW88IA055File No. 5003 1/20/1988 COLLEGE STATION, TX Aircraft Reg No. N3107P Time (Local): 06:44 CST

Make/Model: SWEARINGEN / SA227-ACEngine Make/Model: GARRETT / TPE331-115-61


Operating Certificate(s): Commuter Air CarrierName of Carrier: TRANS COLORADO AIRLINES, INC.



Last Depart. Point: Same as IncidentDestination: HOUSTON, TX

Airport Proximity: On AirportAirport Name: EASTERWOOD FIELD







Precipitation: None


Certificate(s)/Rating(s)Airline Transport; Multi-engine Land; Single-engine Land; Helicopter


Flight Time (Hours)



THE AIRCRAFT'S NOSE GEAR STRUCK A DEER DURING THE TAKEOFF ROLL AND THE TAKEOFF WAS ABORTED. THE AIRCRAFT TAXIED BACK TO THE TERMINAL AND WASEXAMINED BY THE FLIGHT CREW. NO DAMAGE WAS FOUND. IT THEN DEPARTED ON ITS SCHEDULED FLIGHT. IT FLEW 18 FLIGHTS DURING THE NEXT TWO DAYS AND WAS THENPLACED IN THE SHOP FOR MAINTENANCE. AT THIS TIME DAMAGE WAS NOTED IN THE NOSE WHEEL AREA.


FTW88IA055File No. 5003 1/20/1988 COLLEGE STATION, TX Aircraft Reg No. N3107P Time (Local): 06:44 CST

Occurrence #1: ON GROUND/WATER COLLISION WITH OBJECTPhase of Operation: TAKEOFF - ROLL/RUN

Findings 1. (C) OBJECT - ANIMAL(S)





Brief of Incident

Adopted 6/11/1990

LAX88IA102File No. 5091 1/29/1988 S. LAKE TAHOE, CA Aircraft Reg No. N368AE Time (Local): 12:27 PST

Make/Model: FAIRCHILD / SA227ACEngine Make/Model: Airesearch / TPE331-11U


Operating Certificate(s): Commuter Air CarrierName of Carrier: WINGS WEST AIRLINE



Last Depart. Point: SAN FRANCISCO, CADestination: Same as Incident






Precipitation: None




Flight Time (Hours)



DURING THE DESCENT FOR LANDING THE AIRCRAFT ENTERED INSTRUMENT METEOROLOGICAL CONDITIONS AND ACCUMLUATED A SLIGHT COAT OF ICE. THE ENGINEANTI-ICE/DE-ICE HEATERS WERE NOT ON THROUGHOUT THE DESCENT AND LANDING. ON TOUCHDOWN BOTH ENGINES FLAMED OUT AND THE AIRCRAFT WAS TOWED TO THETERMINAL.


LAX88IA102File No. 5091 1/29/1988 S. LAKE TAHOE, CA Aircraft Reg No. N368AE Time (Local): 12:27 PST

Occurrence #1: LOSS OF ENGINE POWER(TOTAL) - NONMECHANICALPhase of Operation: LANDING - ROLL

Findings 1. (C) FLIGHT MANUALS - NOT FOLLOWED - PILOT IN COMMAND 2. (C) ANTI-ICE/DEICE SYSTEM - IMPROPER USE OF - PILOT IN COMMAND 3. (C) POWERPLANT - ICE


The National Transportation Safety Board determines the probable cause(s) of this incident as follows.CAPTAIN'S FAILURE TO FOLLOW FLIGHT MANUAL PROCEDURES IN THE OPERATION OF THE ANTI-ICE/DE-ICE SYSTEMS.



Brief of Accident

Adopted 4/4/1989

DCA88MA032File No. 399 2/19/1988 CARY, NC Aircraft Reg No. N622AV Time (Local): 21:27 EST

Make/Model: FAIRCHILD / SA227-ACEngine Make/Model: GARRETT / TPE-331-11U-6


Operating Certificate(s): Commuter Air CarrierName of Carrier: AVAIR, INC.



Last Depart. Point: RALEIGH, NCDestination: RICHMOND, VA










Flight Time (Hours)



THE AIRCRAFT DEPARTED DURING LOW CEILING, LOW VISIBILITY, AND NIGHT CONDITIONS. SHORTLY AFTER TAKEOFF THE AIRCRAFT IMPACTED A RESERVOIR. ANALYSIS OFRADAR DATA INDICATED THE ACFT WAS IN A 45 DEGREE DESCENDING TURN. EXAM OF THE ACFT TRIM SYSTEM SHOWED THAT THE ACFT WAS TRIMMED FOR LEVEL FLIGHT.THERE WAS NO VOICE OR FLIGHT DATA RECORDER ON BOARD. A REVIEW OF ATC COMMUNICATIONS INDICATED THAT THE CAPTAIN WAS COMMUNICATING WITH ATCALLOWING THE FIRST OFFICER TO ACCOMP-LISH THE FLYING DUTIES. EXAMINATION OF THE WRECKAGE REVEALED NO INDICATIONS OF POWERPLANT OR SYSTEM FAILURES.HOWEVER, THERE WAS EVIDENCE THAT THE SAS WARNING LIGHT WAS ILLUMINATED, THE SAS SWITCH WAS IN THE OFF POSITION, AND NO SAS SYSTEMMALFUNCTION COULDBE FOUND. WITNESSES STATED THAT BEFORE THE FLIGHT THE CAPTAIN HAD COMPLAINED OF ILLNESS BUT HE DECIDEDTO REPORT FOR DUTY. COMPANY RECORDS SHOWEDINSTANCES OF SUBSTANDARD PERFORMANCE BY THE FIRST OFFICER. THE INVESTIGATION FOUND COMPANY OVERSIGHT OF TRAINING, OPERATIONS, AND INADEQUATE FAASUPERVISION. (SEE NTSB/AAR-88/10)


DCA88MA032File No. 399 2/19/1988 CARY, NC Aircraft Reg No. N622AV Time (Local): 21:27 EST


Findings 1. WEATHER CONDITION - LOW CEILING 2. WEATHER CONDITION - FOG 3. LIGHT CONDITION - DARK NIGHT 4. (C) CLIMB - NOT MAINTAINED 5. (C) VISUAL/AURAL DETECTION - COPILOT/SECOND PILOT 6. (F) INADEQUATE SURVEILLANCE OF OPERATION - COMPANY/OPERATOR MGMT 7. (F) INADEQUATE SURVEILLANCE OF OPERATION - FAA(ORGANIZATION) 8. MENTAL PERFORMANCE OVERLOAD - COPILOT/SECOND PILOT 9. (C) MONITORING - INADEQUATE - PILOT IN COMMAND10. PHYSICAL IMPAIRMENT - PILOT IN COMMAND11. STALL WARNING SYSTEM - NOT ENGAGED12. PROCEDURES/DIRECTIVES - MISJUDGED - PILOT IN COMMAND13. (C) VISUAL/AURAL PERCEPTION

----------


Findings14. DESCENT - INADVERTENT - COPILOT/SECOND PILOT15. TERRAIN CONDITION - WATER





Brief of Incident

Adopted 6/18/1990

CHI88IA074AFile No. 5109 3/7/1988 CHICAGO, IL Aircraft Reg No. N600TA Time (Local): 17:42 CST

Make/Model: SWEARINGEN / SA226TEngine Make/Model: GARRETT / TPE-331





Last Depart. Point: MOLINE, ILDestination: Same as Incident





Temperature (°C): 6Obstr to Vision: Fog; Haze

Precipitation: None


Certificate(s)/Rating(s)Commercial; Multi-engine Land; Single-engine Land; Helicopter


Flight Time (Hours)



AS PIPER PA-31T, N484SC, WAS ON AN IFR DEPARTURE FROM RWY 18 AT MERRIL C MEIGS ARPT, SWEARINGEN SA226T, N600TA WAS ON AN IFR ARRIVAL. SUBSEQUENTLY, THE 2ACFT CONVERGED APRX 3 MI SOUTH OF THE ARPT. THE CREW OF N484SC SAW N600TA & TURNED TO MAINTAIN SEPARATION. THE PASSING DISTANCE WAS ESTIMATED TO BEABOUT 2000 FT. AN INVESTIGATION REVEALED THAT AS N600TA WAS ARRIVING, THE SOUTH SATELLITE SECTOR #1 CONTROLLER (CTLR) AT CHICAGO O'HARE TRACON HADCLRD THE CREW TO DSCND & MAINTAIN 2000 FT. WHEN THEY (N600TA) ADVISED THAT MEIGS WAS IN SIGHT, THE SECTOR #1 CTLR CLRD THEM FOR A VISUAL APCH & TOLDTHEM TO CONTACT MEIGS TOWER. AT ABOUT THAT TIME, THE SOUTH SATELLITE SECTOR #3 CTLR AT TRACON WAS IN CONTACT WITH MEIGS TOWER TO PROVIDE INFO ABOUTN600TA CONCERNING ANOTHER MATTER & HAD RELEASED N484SC FOR A SOUTH- BOUND DEPARTURE. WHEN THE SECTOR #3 CTLR PROVIDED THE RELEASE, HE WASUNAWARE N600TA HAD BEEN CLRD FOR A VISUAL APCH. WHEN N600TA CONTACTED MEIGS TOWER, THE MEIGS TOWER CTLR THOUGHT IT WAS ON A VFR ARRIVAL. VISRESTRICTED BY FOG & HAZE.


CHI88IA074AFile No. 5109 3/7/1988 CHICAGO, IL Aircraft Reg No. N600TA Time (Local): 17:42 CST

Occurrence #1: NEAR COLLISION BETWEEN AIRCRAFTPhase of Operation: APPROACH - VFR PATTERN - DOWNWIND

Findings 1. (C) IFR SEPARATION STANDARDS - NOT MAINTAINED - ATC PERSONNEL(DEP/APCH)


The National Transportation Safety Board determines the probable cause(s) of this incident as follows.THE TRACON SUPERVISOR FAILED TO COMPLY WITH THE ESTABLISHED VISUAL MINIMA CRITERIA AND HIS INCORRECT ISSUANCE OF VISUAL APPROACH TO AN ARRIVINGAIRCRAFT.



Brief of Accident

Adopted 3/13/1989

MIA88FA132AFile No. 325 3/29/1988 MIAMI, FL Aircraft Reg No. N30042 Time (Local): 10:40 EST

Make/Model: SWEARINGEN / SA-227-TTEngine Make/Model: Garrett / TPE-331


Operating Certificate(s): NoneType of Flight Operation: Ferry



Last Depart. Point: Same as AccidentDestination: KEY LARGO, FL

Airport Proximity: On AirportAirport Name: MIAMI INT'L







Precipitation: None




Flight Time (Hours)



THE PLT STATED THAT HE WAS AT THE END OF RUNWAY 9 LEFT, MONITORING THE TOWER FREQUENCY, AWAITING TAKEOFF CLEARANCE WHEN THE ACFT'S EMPENNAGE WASSTRUCK FROM BEHIND BY N92BL.


MIA88FA132AFile No. 325 3/29/1988 MIAMI, FL Aircraft Reg No. N30042 Time (Local): 10:40 EST

Occurrence #1: ON GROUND/WATER COLLISION WITH OBJECTPhase of Operation: STANDING

Findings 1. (C) CLEARANCE - MISJUDGED - PILOT OF OTHER AIRCRAFT 2. RADIO COMMUNICATIONS - NOT USED - PILOT OF OTHER AIRCRAFT





Brief of Incident

Adopted 6/11/1990

CHI88IA096File No. 5104 4/8/1988 FORT WAYNE, IN Aircraft Reg No. N448CA Time (Local): 01:15 EST

Make/Model: SWEARINGEN / SA-227ACEngine Make/Model: GARRETT / TPE-331-11U





Last Depart. Point: Same as IncidentDestination: Local

Airport Proximity: On AirportAirport Name: BAER FIELD







Precipitation: None


Certificate(s)/Rating(s)Airline Transport; Multi-engine Land; Helicopter


Flight Time (Hours)



THE AIRCRAFT WAS INVOLVED IN COMMUTER AIR CARRIER FLIGHT TRAINING OPERATIONS WHEN THE RIGHT MAIN LANDING GEAR COLLAPSED DURING A TOUCH AND GOLANDING. SUBSEQUENT INVESTIGATION REVEALED OVERLOAD AND MULTIPLE FATIGUE ORIGINS IN THE FAILED STRUT. THERE HAS BEEN A HISTORY OF FAILURES AND ASERVICE BULLETIN REQUIRING PERIODIC INSPECTIONS IN SERVICE. THE OPERATOR HAD COMPLIED WITH ALL RECOMMENDED INSPECTION CYCLES.


CHI88IA096File No. 5104 4/8/1988 FORT WAYNE, IN Aircraft Reg No. N448CA Time (Local): 01:15 EST


Findings 1. LANDING GEAR,MAIN GEAR SHOCK ABSORBING STRUT - FAILURE,TOTAL 2. (C) LANDING GEAR,MAIN GEAR SHOCK ABSORBING STRUT - FATIGUE 3. (C) LANDING GEAR,MAIN GEAR SHOCK ABSORBING STRUT - OVERLOAD


The National Transportation Safety Board determines the probable cause(s) of this incident as follows.INADEQUATE DESIGN OF THE STRUT FOR THE INTENDED SERVICE CONDITIONS IN COMMUTER AIR CARRIER OPERATIONS.



Brief of Incident

Adopted 6/11/1990

CHI88IA097File No. 5010 4/11/1988 BLOOMINGTON, IL Aircraft Reg No. N332BA Time (Local): 09:40 CDT

Make/Model: Fairchild / SA-226-TCEngine Make/Model: GARRETT / TPE-331





Last Depart. Point: SPRINGFIELD, ILDestination: CHICAGO, IL






Precipitation: None




Flight Time (Hours)



THE FIRST OFFICER ON THE SCHEDULED COMMUTER FLIGHT BECAME PHYSICALLY INCAPACITATED AND PASSED OUT DURING THE FLIGHT. THE CAPTAIN MADE ANEMERGENCY LANDING. THE FIRST OFFICER WAS TREATED AND DIAGNOSED AS SUFFERING FROM A VIRAL SYNDROME. THE PILOT INVOLVED STATED THAT THE SYMPTOMSSTARTED THE DAY BEFORE THE FLIGHT, BUT HE DID NOT WANT TO CALL IN SICK SINCE IT WAS ONLY HIS SECOND WEEK WITH THE COMPANY.


CHI88IA097File No. 5010 4/11/1988 BLOOMINGTON, IL Aircraft Reg No. N332BA Time (Local): 09:40 CDT

Occurrence #1: MISCELLANEOUS/OTHERPhase of Operation: CRUISE - NORMAL

Findings 1. (C) PROCEDURES/DIRECTIVES - NOT FOLLOWED - COPILOT/SECOND PILOT 2. INCAPACITATION(LOSS OF CONSCIOUSNESS) - COPILOT/SECOND PILOT 3. (C) INCAPACITATION(ORGANIC PROBLEM) - COPILOT/SECOND PILOT 4. (F) ANXIETY/APPREHENSION - COPILOT/SECOND PILOT 5. (F) SELF-INDUCED PRESSURE


The National Transportation Safety Board determines the probable cause(s) of this incident as follows.PHYSICAL INCAPACITATION DUE TO AN ORGANIC PATHOGEN. CONTRIBUTING FACTORS ARE ANXIETY AND SELF-INDUCED PRESSURE.



Brief of Accident

Adopted 10/2/1989

ATL88FA173File No. 1202 5/16/1988 ATLANTA, GA Aircraft Reg No. N1013G Time (Local): 11:23 EDT

Make/Model: SWEARINGEN / SA-226-TCEngine Make/Model: GARRETT / TPE-331-10UA


Operating Certificate(s): Commuter Air CarrierName of Carrier: ATLANTIS AIRLINES, INC.



Last Depart. Point: MYRTLE BEACH, SCDestination: Same as Accident

Airport Proximity: On AirportAirport Name: ATLANTA HARTSFIELD







Precipitation: None




Flight Time (Hours)



DURING A VISUAL APPROACH TO RUNWAY 27L, THE AIRPLANE WAS LANDED GEAR UP. BOTH THE CAPT AND F/O STATED THAT THE LANDING GEAR HAD BEEN LOWERED OVERTHE OUTER MARKER AND THAT THEY HAD OBSERVED THREE GREEN LIGHTS AND THAT THE WARNING HORN HAD NOT SOUNDED PRIOR TO TOUCHDOWN. THE AIRPLANE LEFTPROPELLER BLADE SIGNATURES ON THE RUNWAY AND WITNESSES ON THE GROUND STATED THAT THE LANDING GEAR WAS RETRACTED DURING THE APPROACH ANDTOUCHDOWN. AFTER MOVING THE AIRPLANE AND PLACING IT ON JACKS, RETRACTION AND EXTENSION TESTS REVEALED THAT THE LANDING GEAR OPERATION WAS NORMALAS WAS THE WARNING INDICATIONS. THE WARNING HORN FOR FLAPS DOWN/GEAR UP ALSO EXHIBITED NORMAL OPERATION.


ATL88FA173File No. 1202 5/16/1988 ATLANTA, GA Aircraft Reg No. N1013G Time (Local): 11:23 EDT

Occurrence #1: GEAR NOT EXTENDEDPhase of Operation: LANDING

Findings 1. (C) GEAR EXTENSION - NOT PERFORMED - PILOT IN COMMAND 2. (C) GEAR EXTENSION - NOT PERFORMED - COPILOT/SECOND PILOT 3. (C) CHECKLIST - NOT FOLLOWED - PILOT IN COMMAND 4. (C) WHEELS UP LANDING - INADVERTENT - PILOT IN COMMAND





Brief of Incident

Adopted 6/11/1990

CHI88IA141File No. 5097 6/22/1988 CHICAGO, IL Aircraft Reg No. N329BA Time (Local): 09:05 CDT

Make/Model: SWEARINGEN / SA226-TCEngine Make/Model: GARRETT / TPE-331-10UA





Last Depart. Point: Same as IncidentDestination: PEORIA, IL

Airport Proximity: On AirportAirport Name: O'HARE INTERNATIONAL







Precipitation: None




Flight Time (Hours)



THE PILOT REPORTED THAT HE FELT A VIBRATIOIN IN THE YOKE DURING THE TAKEOFF GROUND ROLL, AND ELECTED TO ABORT THE TAKEOFF. THE PILOT STATED THAT ASTHE AIRCRAFT RETURNED TO THE GATE, THE ELEVATOR CONTROLS 'SEIZED' COMPLETELY. POST-INCIDENT INVESTIGATION REVEALED THAT A BEARING IN THE SAS SERVOMOTOR ASSEMBLY HAD FAILED, ALLOWING THE MOTOR TO SEIZE, AND JAMMING THE ELEVATOR CONTROLS. THE SYSTEM IS DESIGNED WITH A SLIP CLUTCH TO ALLOW SASASSEMBLY OVERRIDE WITH A FORCED OF 70 TO 86 POUNDS APPLIED AT THE YOKE. AN OPERATIONAL TEST OF THE CLUTCH INDICATED THAT OVERRIDE WOULD HAVE BEENPOSSIBLE IF THE CIRCUMSTANCES HAD DEMANDED IT. THE MOST RECENT SCHEDULED INSPECTION OF THE SAS ASSEMBLY OCCURRED JUNE 5, 1988, WITH NO NOTEDDISCREPENCIES. AN OPERATIONAL FLIGHT TEST OF THE SAS SYSTEM WAS PERFORMED ON JUNE 15, 1988 WITH SATISFACTORY RESULTS.


CHI88IA141File No. 5097 6/22/1988 CHICAGO, IL Aircraft Reg No. N329BA Time (Local): 09:05 CDT


Findings 1. (C) SAFETY SYSTEM(OTHER) - FAILURE,TOTAL 2. (C) FLIGHT CONTROL,ELEVATOR - JAMMED 3. ABORTED TAKEOFF - PERFORMED - PILOT IN COMMAND


The National Transportation Safety Board determines the probable cause(s) of this incident as follows.FAILURE OF THE FRONT MOTOR BEARING IN THE SAS SERVO MOTOR ASSEMBLY, AND THE RESULTANT 'JAMMING' OF THE ELEVATOR CONTROL CABLES. THE PILOT ABORTEDTHE TAKEOFF AS A RESULT OF THE VIBRATION IN THE YOKE.



Brief of Accident

Adopted 9/19/1989

ANC88FA100File No. 1006 7/27/1988 ANCHORAGE, AK Aircraft Reg No. N482SA Time (Local): 18:17 ADT

Make/Model: FAIRCHILD / SA227-ATEngine Make/Model: GARRETT / TPE-331-1146


Operating Certificate(s): Commuter Air Carrier; On-demand Air TaxiName of Carrier: PENINSULA AIRWAYS



Last Depart. Point: Same as AccidentDestination: DILLINGHAM, AK

Airport Proximity: On AirportAirport Name: ANCHORAGE INT'L







Precipitation: None




Flight Time (Hours)



DURING THE TAXI TO THE RUNWAY, THE FLIGHT CREW NOTED A VIBRATION IN THE AIRPLANE AND STOPPED TO CHECK THE TIRES, THINKING THAT THEY WEREUNDERINFLATED. NO OBVIOUS PROBLEM WAS SEEN, AND THEY ELECTED TO TAKEOFF. SHORTLY AFTER TAKEOFF, A FIRE ERUPTED IN THE LEFT MAIN GEAR WHEELWELL. THEPILOT RETURNED TO THE AIRPORT AND LANDED SAFELY. HOWEVER, THE AIRPLANE SUSTAINED EXTENSIVE DAMAGE TO THE LEFT WING AND AILERON CONTROL SYSTEM.EXAMINATION OF THE BRAKES REVEALED A COCKED THERMAL INSULATOR IN THE PISTON BORE. THERE WAS EVIDENCE THAT THE BRAKES WERE WORN, HAD BEEN DRAGING,THEN OVERHEATED; AND THAT THE TIRES HAD EXPLODED PRIOR TO THE FIRE. THE FIRE DAMAGE INDICATED THAT THE FIRE HAD STARTED NEAR THE BRAKES. AN ALUMINUMFITTING WAS USED AS PART OF THE HYDRAULIC BRAKE SYSTEM ON THE STEEL BRAKE HOUSING. THE EXAM INDICATED THAT THE FITTING HAD BEEN INSTALLED BUT COULDNOT BE FOUND AFTER THE FIRE. THE CREW SAID THAT THEY DELAYED LOWERING THE GEAR, IN CONTRADICTION TO THE CHECKLIST REQUIREMENT WHEN THE WHEELWELLAND WING OVERHEAT LIGHT IS ON.


ANC88FA100File No. 1006 7/27/1988 ANCHORAGE, AK Aircraft Reg No. N482SA Time (Local): 18:17 ADT

Occurrence #1: AIRFRAME/COMPONENT/SYSTEM FAILURE/MALFUNCTIONPhase of Operation: TAXI - TO TAKEOFF

Findings 1. (C) LANDING GEAR,NORMAL BRAKE SYSTEM - BINDING(MECHANICAL) 2. (C) ACFT/EQUIP,INADEQUATE AIRCRAFT COMPONENT - MANUFACTURER 3. (C) PROPER ASSISTANCE - NOT OBTAINED - PILOT IN COMMAND

----------

Occurrence #2: FIREPhase of Operation: CLIMB

Findings 4. (C) LANDING GEAR,NORMAL BRAKE SYSTEM - OVERTEMPERATURE 5. (C) HYDRAULIC SYSTEM,FITTING - MELTED 6. (F) EMERGENCY PROCEDURE - NOT FOLLOWED - PILOT IN COMMAND





Brief of Accident

Adopted 10/16/1990

CHI88FA205File No. 2471 8/16/1988 CLEVELAND, OH Aircraft Reg No. N322BA Time (Local): 07:57 EDT

Make/Model: FAIRCHILD / SA-226-TCEngine Make/Model: GARRETT / TPE331-10UA





Last Depart. Point: Same as AccidentDestination: LONDON, CD

Airport Proximity: On AirportAirport Name: HOPKINS







Precipitation: None




Flight Time (Hours)



DURING TAKEOFF ROLL THE CAPTAIN OBSERVED FLUCTUATIONS IN THE RIGHT ENGINE AND MADE THE DECISION TO ABORT AT V1. REVERSE THRUST WAS NOT AVAILABLEDURING THE ATTEMPTED ABORT RESULTING IN THE AIRCRAFT YAWING LEFT DURING THE ABORT ATTEMPT. THE AIRCRAFT OVERRAN THE END OF THE 8,998 FOOT RUNWAY.THE COPILOT WAS ON THE BRAKES WITH THE CAPTAIN RESULTING IN REDUCED BRAKING EFFECTIVENESS. INSPECTION OF THE RIGHT ENGINE PROPELLER GOVERNORLINKAGE DETERMINED THAT THE CONTROL LINKAGE HAD COME LOOSE CAUSING THE RIGHT ENGINE POWER FLUCTUATIONS AND NO REVERSE THRUST DURING THE ABORT.


CHI88FA205File No. 2471 8/16/1988 CLEVELAND, OH Aircraft Reg No. N322BA Time (Local): 07:57 EDT


Findings 1. (C) PROPELLER GOVERNOR CONTROL,LINKAGE - DISCONNECTED 2. (C) PROPELLER GOVERNOR CONTROL,LINKAGE - PREVIOUS DAMAGE

----------

Occurrence #2: OVERRUNPhase of Operation: TAKEOFF - ABORTED

Findings 3. (C) ABORTED TAKEOFF - DELAYED - PILOT IN COMMAND

----------

Occurrence #3: MAIN GEAR COLLAPSEDPhase of Operation: TAKEOFF - ABORTED


The National Transportation Safety Board determines the probable cause(s) of this accident as follows.THE CAPTAIN'S LATE DECISION TO ABORT AFTER A PROPELLER LINKAGE FAILURE ON THE RIGHT ENGINE AND THE CO-PILOT'S FAILURE TO RELINQUISH ENGINE AND BRAKINGAUTHORITY TO THE CAPTAIN RESULTING IN CONFUSION AND INADEQUATE BRAKING TO STOP ON THE RUNWAY AFTER THE ABORT.



Brief of Accident

Adopted 1/16/1990

LAX88LA303File No. 2254 8/26/1988 SACRAMENTO, CA Aircraft Reg No. N2683B Time (Local): 08:06 PDT

Make/Model: FAIRCHILD / SA-227-ACEngine Make/Model: AIRESEARCH / TPE-331


Operating Certificate(s): Commuter Air CarrierName of Carrier: WINGS WEST



Last Depart. Point: SAN FRANCISCO, CADestination: SACRAMENTO, CA




Visibility: 30.00 SMWind Dir/Speed: Light and Variable


Precipitation: None




Flight Time (Hours)



THE CREW STATED THAT WHILE ON THE GROUND AT SAN FRANCISCO, OIL WAS ADDED TO THE RIGHT ENGINE BY A MECHANIC. THE CAPTAIN STATED HE SAW THE SIXLATCHES DOWN AND THE COWLING HALVES WERE FLUSH. THE FIRST OFFICER DID NOT GET OUT OF THE AIRPLANE AND CHECK THE COWLING SINCE THE CAPTAIN HAD BEENOUTSIDE WITH THE MECHANIC. DURING CRUISE FLIGHT, THE TOP HALF OF THE RIGHT ENGINE COWLING SEPARATED FROM THE AIRPLANE. DURING SEPARATION, IT HIT THECABIN WINDOW AT ROW 4 CAUSING IT TO BREAK & DEPRESSURIZE THE CABIN. A LADY SEATED AT 4C RECEIVED A CUT ON HER RIGHT FOREARM & HER PURSE WAS 'SUCKEDOUT' THE OPENING. AN EXAM OF THE FAILED PARTS OF THE NACELLE REVEALED NO EVIDENCE OF PREEXISTING CRACKS.


LAX88LA303File No. 2254 8/26/1988 SACRAMENTO, CA Aircraft Reg No. N2683B Time (Local): 08:06 PDT


Findings 1. (C) COOLING SYSTEM,COWLING - SEPARATION 2. (C) MAINTENANCE,SERVICE OF AIRCRAFT/EQUIPMENT - INADEQUATE - COMPANY MAINTENANCE PERSONNEL 3. (F) AIRCRAFT PREFLIGHT - INADEQUATE - COPILOT/SECOND PILOT 4. (F) SUPERVISION - INADEQUATE - PILOT IN COMMAND


The National Transportation Safety Board determines the probable cause(s) of this accident as follows.MECHANICS FAILURE TO PROPERLY SECURE THE RIGHT ENGINE COWLING AFTER MAINTENANCE.



Brief of Accident

Adopted 9/19/1989

MKC88LA167File No. 1194 9/1/1988 EMPORIA, KS Aircraft Reg No. N257AM Time (Local): 10:15 CDT

Make/Model: SWEARINGEN / SA-226Engine Make/Model: AIRESEARCH / TPE-331


Operating Certificate(s): Commuter Air Carrier; Other Large AircraftName of Carrier: AIR MIDWEST



Last Depart. Point: WICHITA, KSDestination: KANSAS CITY, MO






Precipitation: None


Certificate(s)/Rating(s)Airline Transport; Flight Instructor; Commercial; Multi-engine Land; Single-engine Land; Single-engine Sea


Flight Time (Hours)



WHILE CRUISING AT 17,000 FT, THE 1ST OFFICER'S RGT WINDOW PANEL FAILED & BLEW OUTWARD. A CABIN DECOMPRESSION OCCURRED & THE COPILOT WAS SERIOUSLYINJURED. THE CAPTAIN IMMEDIATELY DESCENDED TO 10,000 FT & CONTINUED TO THEIR DESTINATION WHERE AN OTHERWISE UNEVENTFUL LANDING WAS MADE.


MKC88LA167File No. 1194 9/1/1988 EMPORIA, KS Aircraft Reg No. N257AM Time (Local): 10:15 CDT


Findings 1. (C) WINDOW,FLIGHT COMPARTMENT WINDOW/WINDSHIELD - FAILURE,TOTAL

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Occurrence #2: DECOMPRESSIONPhase of Operation: CRUISE

Findings 2. FUSELAGE,CABIN - DECOMPRESSION 3. EMERGENCY PROCEDURE - PERFORMED 4. PRECAUTIONARY LANDING - PERFORMED





Brief of Accident

Adopted 1/16/1990

BFO89LA013File No. 2246 11/30/1988 WASHINGTON, DC Aircraft Reg No. N263CM Time (Local): 15:00 EST

Make/Model: SWEARINGEN / SA-226TEngine Make/Model: AIRESEARCH / TPE-331


Operating Certificate(s): NoneType of Flight Operation: Personal



Last Depart. Point: ASHLAND, VADestination: LEESBURG, VA

Airport Proximity: On AirportAirport Name: DULLES INTL







Precipitation: None




Flight Time (Hours)



THE PLT RPRTD HE WAS FLYING AN AUTOPILOT COUPLED ILS APCH WHEN THE YAW DAMPER & AUTOPILOT DISENGAGED. AFTER SOME DIFFICULTY, THE PLT WAS ABLE TOKEEP THE AUTOPILOT ENGAGED. HE SAID HE DISENGAGED THE AUTOPILOT ON FINAL APCH AT AN ALT OF APRX 250' AGL. HE LOWERED FULL FLAPS & SLOWED THE ACFT TO107 KTS. THE PLT STATED THAT AFTER THE ACFT TOUCHED DOWN & TRAVELED APRX 1000', ITS NOSE BEGAN TO RISE & OSCILLATE. HE ABORTED THE LNDG, BUT HE WASUNABLE TO GET AN UP & LOCKED INDICATION FOR THE NOSE GEAR, ALTHOUGH IT WOULD LOCK DOWN. AFTER MAKING A FLY-BY TO VERIFY THE GEAR POSITION, HE MADE A'SLOW' LNDG. THE PLT RPRTD THAT ALTHOUGH A SLIGHT OSCILLATION WAS NOTED DRG THE LNDG, HE FORCEFULLY HELD THE NOSE DOWN AS HE SLOWED THE ACFT.TESTING & EVALUATION OF THE AUTOPILOT SYSTEM FAILED TO DISCLOSE ANY DISCREPANCY WHICH WOULD HAVE RESULTED IN THE OSCILLATIONS.


BFO89LA013File No. 2246 11/30/1988 WASHINGTON, DC Aircraft Reg No. N263CM Time (Local): 15:00 EST

Occurrence #1: HARD LANDINGPhase of Operation: LANDING

Findings 1. (C) FLARE - IMPROPER - PILOT IN COMMAND 2. (C) PORPOISE/PILOT-INDUCED OSCILLATION - INADVERTENT - PILOT IN COMMAND


The National Transportation Safety Board determines the probable cause(s) of this accident as follows.PILOTS FAILURE TO MAINTAIN CONTROL OF THE AIRPLANE DURING A TOUCH AND GO LANDING.



Brief of Accident

Adopted 6/22/1992

LAX89FA086File No. 1865 1/17/1989 LOS ANGELES, CA Aircraft Reg No. N26895 Time (Local): 17:44 PST

Make/Model: FAIRCHILD / SA227ACEngine Make/Model: GARRETT / TPE 331-11


Operating Certificate(s): Commuter Air CarrierName of Carrier: SKYWEST AIRLINES



Last Depart. Point: ONTARIO, CADestination: Same as Accident



Runway Surface: Unk/NrRunway Surface Condition: Dry





Precipitation: None




Flight Time (Hours)



THE SA227 HAD LANDED & WAS TAXIING TO THE GATE WITH THE TAXI, LANDING, RECOGNITION & STROBE LIGHTS OFF. AS IT TAXIED NORTHBOUND TOWARD THE GATE, THEDRIVER OF AN EASTBOUND FUEL TANKER TRUCK FAILED TO STOP AT A POSTED 'STOP FOR ACFT' SIGN AT THE INTERSECTION OF THE VEHICLE SERVICE ROAD & THE TAXIWAY.THE TANKER TRUCK COLLIDE WITH, AND PARTIALLY SEVERED, THE ACFT'S LEFT WING. THE DRIVER OF THE TANKER TRUCK INDICATED THAT HE DID NOT OBSERVE THE ACFTUNTIL IT WAS RIGHT IN FRONT OF HIS TRUCK & THEN IT WAS TOO LATE TO STOP. THE TANKER TRUCK DRIVER'S 1:30-2:00 VIEW VIEW WAS PARTIALLY BLOCKED BY THE TRUCKSTRUCTURE; THE 2:00-3:00 VIEW CONSIDERABLY RESTRICTED BY THE TRUCK'S CAGE STRUCTURE & EQUIPMENT CONTAINED THEREIN. AIRPORT REGULATIONS REQUIRE THAT'LOW SILHOUTTE' AIRCRAFT TAXI WITH LANDING LIGHTS ON UNTIL CLEAR OF TAXIWAYS AND INTERSECTING VEHICLE ACCESS ROADS.


LAX89FA086File No. 1865 1/17/1989 LOS ANGELES, CA Aircraft Reg No. N26895 Time (Local): 17:44 PST


Findings 1. (F) LIGHT CONDITION - DUSK 2. LANDING LIGHTS - NOT USED - PILOT IN COMMAND 3. (C) VISUAL LOOKOUT - INADEQUATE - DRIVER OF VEHICLE 4. (F) ACFT/EQUIP INADEQUATE,VISUAL RESTRICTION - MANUFACTURER 5. OBJECT - VEHICLE


The National Transportation Safety Board determines the probable cause(s) of this accident as follows.THE FAILURE OF THE FUEL TANKER DRIVER TO SEE AND AVOID THE MOVING AIRCRAFT. FACTORS CONTRIBUTING TO THE ACCIDENT WERE THE DRIVER'S OBSTRUCTEDVISIBILITY THROUGH THE RIGHT SIDE OF THE VEHICLE'S CAB, AND THE DUSK LIGHT CONDITIONS.



Brief of Incident

Adopted 8/26/1992

SEA89IA042File No. 5010 1/23/1989 SEATTLE, WA Aircraft Reg No. N386PH Time (Local): 13:44 PST

Make/Model: FAIRCHILD / SA-227-ACEngine Make/Model: GARRETT / TPE-331


Operating Certificate(s): Commuter Air CarrierName of Carrier: HORIZON AIR



Last Depart. Point: Same as IncidentDestination: PORTLAND, OR

Airport Proximity: On AirportAirport Name: SEATAC







Precipitation: None




Flight Time (Hours)



WHILE ON TAKEOFF ROLL, THE CPT TURNED THE ELECTRIC NOSE WHEEL STEERING OFF. THE FIRST OFFICER, FLYING THE ACFT, ANNOUNCED AN UNCOMMANDED RIGHT YAW.THE CPT TOOK THE CONTROLS BUT WAS NOT ABLE TO BRING THE ACFT TO A HALT BEFORE DEPARTING THE SIDE OF THE RUNWAY. POST MISHAP TESTS REVEALED AMALFUNCTION OF THE NOSE WHEEL STEERING DUE TO IMPROPER REPLACEMENT OF VALVES IN THE HYDRAULIC STEERING ACTUATOR UNIT.


SEA89IA042File No. 5010 1/23/1989 SEATTLE, WA Aircraft Reg No. N386PH Time (Local): 13:44 PST


Findings 1. (C) LANDING GEAR,STEERING SYSTEM - INOPERATIVE 2. (C) MAINTENANCE,INSTALLATION - IMPROPER - COMPANY MAINTENANCE PERSONNEL 3. (F) ACFT/EQUIP,INADEQUATE AIRCRAFT MANUALS - MANUFACTURER

----------

Occurrence #2: LOSS OF CONTROL - ON GROUND/WATERPhase of Operation: TAKEOFF - ABORTED

Findings 4. (C) DIRECTIONAL CONTROL - NOT POSSIBLE


The National Transportation Safety Board determines the probable cause(s) of this incident as follows.INOPERATIVE NOSEWHEEL STEERING DUE TO IMPROPER MAINTENANCE. CONTRIBUTING TO THE INCIDENT WAS THE LACK OF ADEQUATE MAINTENANCE INFORMATIONAVAILABLE IN THE AIRCRAFT MANUALS.



Brief of Accident

Adopted 5/22/1990

DEN89FA070AFile No. 399 1/30/1989 SALT LAKE CITY, UT Aircraft Reg No. N169SW Time (Local): 15:25 MST

Make/Model: SWEARINGEN / SA-227-ACEngine Make/Model: GARRETT / TPE 331-11UA


Operating Certificate(s): Commuter Air CarrierName of Carrier: N



Last Depart. Point: Same as AccidentDestination: ROCK SPRINGS, WY

Airport Proximity: On AirportAirport Name: SALT LAKE CITY INTL







Precipitation: None




Flight Time (Hours)



THE CAPTAIN STATED THAT HE WAS CLEARED BY ATC GROUND CONTROL TO PROCEED IN A TAXI LINE OF 10 AIRCRAFT THAT WERE WAITING FOR TAKEOFF. PROGRESS WASSLOW AS THE AIRCRAFT MOVED AND THEN STOPPED AND MOVED AGAIN. AFTER ABOUT 20-30 MINUTES OF TAXIING, THE TWO SUBJECT AIRCRAFT CAME TO A STOP AGAIN. THECAPTAIN SAID THAT WITHOUT REALIZING IT, HIS AIRCRAFT BEGAN TO CREEP UP ON THE PRECEDING AIRCRAFT UNTIL THE RIGHT ENGINE PROPELLER STRUCK THE TAIL OFTHE PROCEDING AIRCRAFT CAUSING SUBSTANTIAL DAMAGE TO BOTH AIRCRAFT. THE CAPTAIN STATED THAT HE WAS AT THE CONTROLS AT THE TIME OF THE COLLISION ANDCOULD NOT RECALL WHAT WAS OCCUPYING HIS ATTENTION PRIOR TO THE COLLISION. POST ACCIDENT EXAMINATION FAILED TO REVEAL ANY MALFUNCTION OF THE BRAKESYSTEM.


DEN89FA070AFile No. 399 1/30/1989 SALT LAKE CITY, UT Aircraft Reg No. N169SW Time (Local): 15:25 MST

Occurrence #1: ON GROUND/WATER COLLISION WITH OBJECTPhase of Operation: TAXI - TO TAKEOFF

Findings 1. (C) VISUAL LOOKOUT - NOT MAINTAINED - PILOT IN COMMAND 2. (F) COMPLACENCY - PILOT IN COMMAND 3. OBJECT - AIRCRAFT PARKED/STANDING


The National Transportation Safety Board determines the probable cause(s) of this accident as follows.THE FAILURE OF THE CAPTAIN TO MAINTAIN A VISUAL LOOKOUT WHILE TAXIING HIS AIRCRAFT, INADVERTENTLY ALLOWING HIS AIRCRAFT TO CREEP INTO THE STATIONARYAIRCRAFT IN FRONT OF HIM.



Brief of Accident

Adopted 5/22/1990

DEN89FA070BFile No. 399 1/30/1989 SALT LAKE CITY, UT Aircraft Reg No. N2685L Time (Local): 15:25 MST

Make/Model: FAIRCHILD / SA-227-ACEngine Make/Model: GARRETT / TPE331 11UA


Operating Certificate(s): Commuter Air CarrierName of Carrier: N



Last Depart. Point: Same as AccidentDestination: JACKSON, WY

Airport Proximity: On AirportAirport Name: SALT LAKE CITY INTL







Precipitation: None




Flight Time (Hours)



WHILE WAITING IN LINE FOR THE AIRCRAFT IN FRONT TO MOVE TOWARD THE TAKEOFF AREA, THE AIRCRAFT WAS RUN INTO BY A COMPANY AIRCRAFT BEHIND IT. THE CAPTAINOF THE OTHER AIRCRAFT STATED THAT WITHOUT REALIZING IT, HIS AIRCRAFT BEGAN TO CREEP UP ON THE PRECEDING AIRCRAFT UNTIL THE RIGHT ENGINE PROPELLERSTRUCK THE TAIL OF THE PRECEDING AIRCRAFT CAUSING SUBSTANTIAL DAMAGE TO BOTH AIRCRAFT.


DEN89FA070BFile No. 399 1/30/1989 SALT LAKE CITY, UT Aircraft Reg No. N2685L Time (Local): 15:25 MST


Findings 1. (C) VISUAL LOOKOUT - NOT MAINTAINED - PILOT OF OTHER AIRCRAFT 2. (C) COMPLACENCY - PILOT OF OTHER AIRCRAFT 3. OBJECT - AIRCRAFT MOVING ON GROUND


The National Transportation Safety Board determines the probable cause(s) of this accident as follows.THE FAILURE OF CAPTAIN OF N169SW TO MAINTAIN A VISUAL LOOKOUT WHILE TAXIING HIS AIRCRAFT ALLOWING HIS AIRCRAF TO CREEP INTO THE STATIONARY AIRCRAFT INFRONT OF HIM.



Brief of Accident

Adopted 4/24/1990

DEN89FA076File No. 405 2/10/1989 SAINT GEORGE, UT Aircraft Reg No. N1010Z Time (Local): 17:25 MST






Last Depart. Point: Same as AccidentDestination: PALM SPRINGS, CA

Airport Proximity: On AirportAirport Name: SAINT GEORGE







Precipitation: None




Flight Time (Hours)



DRG THE TAKEOFF ROLL WITH THE COPLT AT THE CTLS, THE ACFT BEGAN TURNING TO THE LEFT. THE COPLT CORRECTED WITH RGT RUDDER, BUT AS THE TAKEOFF CONTD,THE ACFT VEERED UNCONTROLLABLY TO THE LEFT. THE TAKEOFF WAS ABORTED, BUT BEFORE STOPPING, THE ACFT TURNED FURTHER LEFT & HIT A CESSNA 172 & A UPSVEHICLE, BOTH OF WHICH WERE UNOCCUPIED. THIS WAS THE 1ST FLT AFTER MAINT ON THE NOSEWHEEL STEERING SYS. A SYS CHECK REVEALED THAT WHEN HYDRAULIC &ELECTRICAL PWR WERE APPLIED, THE NOSEWHEEL STEERING SYS WOULD DEFLECT TO THE LEFT AT A RATE OF ABOUT ONE DEGREE PER SECOND. INVESTIGATIONREVEALED THAT WHEN MAINT WAS PERFORMED, A ONE-PIECE ARMING/POPPET VLV WAS USED TO REPLACE A TWO-PIECE VLV, WHICH WAS PREVIOUSLY INSTALLED. DRG THEINSTLN, THE SMALL PART OF THE TWO-PIECE VLV (ABT THE SIZE OF A WASHER) WAS NOT REMOVED. WHEN THE ONE-PIECE VLV WAS INSTLD PROPERLY, THE SYS OPERDNORMALLY. MAINT INSTRNS & DRAWINGS DID NOT ADDRESS THE TW0- PIECE VLV & NO INSTRNS WERE FND TO INDC THE TWO PIECES OF THE OLD VLV SHOULD BE CHGD AS APACKAGE.


DEN89FA076File No. 405 2/10/1989 SAINT GEORGE, UT Aircraft Reg No. N1010Z Time (Local): 17:25 MST

Occurrence #1: AIRFRAME/COMPONENT/SYSTEM FAILURE/MALFUNCTIONPhase of Operation: TAKEOFF

Findings 1. (C) LANDING GEAR,STEERING SYSTEM - INCORRECT 2. (C) MAINTENANCE,REPLACEMENT - IMPROPER - COMPANY MAINTENANCE PERSONNEL 3. (C) PROCEDURE INADEQUATE - MANUFACTURER 4. CONDITION(S)/STEP(S) INSUFFICIENTLY DEFINED

----------


Findings 5. DIRECTIONAL CONTROL - NOT MAINTAINED 6. GROUND LOOP/SWERVE - UNCONTROLLED

----------

Occurrence #3: ON GROUND/WATER COLLISION WITH OBJECTPhase of Operation: TAKEOFF - ABORTED

Findings 7. OBJECT - AIRCRAFT PARKED/STANDING 8. OBJECT - VEHICLE


The National Transportation Safety Board determines the probable cause(s) of this accident as follows.MALFUNCTION OF THE NOSEWHEEL STEERING SYSTEM DUE TO IMPROPER INSTALLATION OF THE NOSEWHEEL STEERING POPPET VALVE & INADEQUATE MAINTENANCEINSTRUCTIONS.



Brief of Incident

Adopted 8/26/1992

NYC89IA123AFile No. 5062 4/23/1989 NEW YORK, NY Aircraft Reg No. N3044J Time (Local): 17:01 EDT

Make/Model: FAIRCHILD SWEARINGEN / SA-227ACEngine Make/Model: GARRETT / TPE-331-11U


Operating Certificate(s): Commuter Air CarrierName of Carrier: POCONO AIRLINES



Last Depart. Point: PROVIDENCE, RIDestination: Same as Incident






Precipitation: None




Flight Time (Hours)



TWO 747S WERE ON APPROACH FOR RWY 31R, FOLLOWED BY A SWEARINGEN SA 227AC MERLIN. THE MERLIN WAS GIVEN A VISUAL APPROACH WHICH THE PILOT ACCEPTEDAND TRAFFIC HE WAS TO FOLLOW WAS CALLED AS BEING AT THE 11 O'CLOCK POSITION. RADAR DATA SHOWED THE FIRST 747 ONLY 10 DEGREES TO THE LEFT OF THE NOSEOF THE MERLIN WHICH THE FLIGHT CREW IDENTIFIED AS THE TRAFFIC TO FOLLOW. THE SECOND 747 WHICH WAS THE ONE TO BE FOLLOWED WAS 45 DEGREES TO THE LEFTOF THE NOSE. THE MERLIN PASSED APPROXIMATELY 300 FT OVER THE TOP OF THE 2ND 747 IN THE VICINITY OF THE OUTER MARKER WHILE ON THE VISUAL APPROACH. NOEVASIVE ACTION WAS TAKEN. THE CAPTAIN OF THE MERLIN SAID HE NORMALLY FLYS 1 TO 1 1/2 DOTS HIGH ON THE GLIDE SLOPE FOR WAKE TURBULENCE. THE SUN WAS ATAN ANGLE THAT BACKLIGHTED BOTH 747S.


NYC89IA123AFile No. 5062 4/23/1989 NEW YORK, NY Aircraft Reg No. N3044J Time (Local): 17:01 EDT

Occurrence #1: NEAR COLLISION BETWEEN AIRCRAFTPhase of Operation: APPROACH - VFR PATTERN - FINAL APPROACH

Findings 1. (C) IDENTIFICATION OF AIRCRAFT VISUALLY - IMPROPER - PILOT IN COMMAND 2. (C) IDENTIFICATION OF AIRCRAFT VISUALLY - IMPROPER - COPILOT/SECOND PILOT


The National Transportation Safety Board determines the probable cause(s) of this incident as follows.THE FAILURE OF THE SWEARINGEN FLIGHT CREW TO PROPERLY IDENTIFY THE AIRPLANE THEY WERE TO FOLLOW, PRIOR TO ACCEPTING THE VISUAL APPROACH TO RUNWAY31R.



Brief of Accident

Adopted 8/22/1990

MIA89FA138File No. 707 4/26/1989 JACKSONVILLE, FL Aircraft Reg No. N39RD Time (Local): 21:45 EST

Make/Model: SWEARINGEN / SA-226-ATEngine Make/Model: GARRETT / TPE3313U303G


Operating Certificate(s): On-demand Air TaxiName of Carrier: CORPORATE AIRWAYS



Last Depart. Point: SAVANNAH, GADestination: Same as Accident

Airport Proximity: On AirportAirport Name: JACKSONVILLE







Precipitation: None




Flight Time (Hours)



THE PILOT IN COMMAND OF AN ON DEMAND SINGLE PILOT AIR-TAXI CARGO FLIGHT LANDED ON THE RUNWAY WITH THE LANDING GEAR IN THE UP POSITION AND ATTEMPTEDTO LOWER THE GEAR AFTER THE PROPELLERS HAD STRUCK THE GROUND.


MIA89FA138File No. 707 4/26/1989 JACKSONVILLE, FL Aircraft Reg No. N39RD Time (Local): 21:45 EST

Occurrence #1: GEAR NOT EXTENDEDPhase of Operation: LANDING - FLARE/TOUCHDOWN

Findings 1. (C) CHECKLIST - NOT PERFORMED - PILOT IN COMMAND 2. (F) COMPLACENCY - PILOT IN COMMAND 3. (C) GEAR EXTENSION - NOT PERFORMED - PILOT IN COMMAND 4. (C) WHEELS UP LANDING - PERFORMED - PILOT IN COMMAND


The National Transportation Safety Board determines the probable cause(s) of this accident as follows.THE FAILURE OF THE PILOT IN COMMAND TO USE THE AIRPLANE LANDING CHECKLIST AND ASSURE THAT THE LANDING GEAR WAS DOWN AND LOCKED PRIOR TO LANDING.



Brief of Accident

Adopted 6/30/1992

CHI89FA092File No. 2184 5/18/1989 MARION, IL Aircraft Reg No. N232AM Time (Local): 19:10 CDT






Last Depart. Point: ST LOUIS, MODestination: Same as Accident

Airport Proximity: On AirportAirport Name: WILLIAMSON CITY REGIONAL

Runway Identification: 20Runway Length/Width (Ft): 20






Precipitation: None




Flight Time (Hours)



THE PILOT-IN-COMMAND EXPERIENCED A SLIGHT RIGHT DRIFT DURING LANDING ROLL. HE ATTEMPTED TO CORRECT FOR THE DRIFT BY SELECTING BETA AND REVERSE ONTHE LEFT ENGINE. THE AIRCRAFT CONTINUED THE RIGHT DRIFT DESPITE APPLICATION OF LEFT BRAKES, AND DEPARTED THE RUNWAY. THE AIRCRAFT CONTINUED OFF THERUNWAY FOR 2,000 FEET, AND CAME TO A STOP WHEN IT HIT A DITCH. THE INVESTIGATION REVEALED A FAILURE OF THE PROPELLER GOVERNOR CONTROL LINKAGE WHICHPREVENTED THE PROPELLER FROM GOING INTO BETA/REVERSE. NEITHER THE PILOT-IN-COMMAND NOR THE COPILOT RECOGNIZED THE MALFUNCTION, AND PERSISTED INTRYING TO SELECT REVERSE ON THE LEFT ENGINE, WHICH AGGRAVATED THE SITUATION BECAUSE THE PROPELLER WAS IN POSITIVE PITCH. THE PILOT HAD OVER 5,000 FEETOF RUNWAY AVAILABLE AFTER TOUCHDOWN IN WHICH TO STOP THE AIRCRAFT.


CHI89FA092File No. 2184 5/18/1989 MARION, IL Aircraft Reg No. N232AM Time (Local): 19:10 CDT

Occurrence #1: AIRFRAME/COMPONENT/SYSTEM FAILURE/MALFUNCTIONPhase of Operation: LANDING - ROLL

Findings 1. PROPELLER GOVERNOR CONTROL,LINKAGE - STRIPPED THREAD 2. (F) MAINTENANCE,MODIFICATION - IMPROPER - COMPANY MAINTENANCE PERSONNEL

----------


Findings 3. (C) DIRECTIONAL CONTROL - NOT MAINTAINED - PILOT IN COMMAND 4. (F) REMEDIAL ACTION - NOT PERFORMED - PILOT IN COMMAND 5. (F) CREW/GROUP COORDINATION - INADEQUATE - PILOT IN COMMAND

----------


Findings 6. TERRAIN CONDITION - DITCH


The National Transportation Safety Board determines the probable cause(s) of this accident as follows.FAILURE OF THE PILOT TO MAINTAIN DIRECTIONAL CONTROL OF THE AIRCRAFT. CONTRIBUTING TO THE ACCIDENT WAS LACK OF CREW COORDINATION AND INAPPROPRIATEREMEDIAL ACTION ON THE PART OF THE AIRCREW, AND IMPROPER MAINTENANCE MODIFICATION BY THE OPERATOR.



Brief of Accident

Adopted 9/9/1992

LAX89FA303File No. 2375 9/6/1989 LOS ANGELES, CA Aircraft Reg No. N27283 Time (Local): 20:02 PDT

Make/Model: FAIRCHILD / SA227-ACEngine Make/Model: GARRETT / TPE-331-11





Last Depart. Point: Same as AccidentDestination: SANTA BARBARA, CA








Precipitation: None




Flight Time (Hours)



IN ACCORDANCE WITH ITS ATC CLEARANCE, A SKYWEST AIRLINES FAIRCHILD (METROLINER) WAS TAXIING FOR TAKEOFF FOR ITS SCHEDULED PASSENGER FLIGHT. THEAIRCRAFT WAS PROCEEDING W-BND ON INNER TAXIWAY KILO. A FULLY LOADED, 10,000 GAL JET-A FUEL TANKER TRUCK, BEING DRIVEN BY A TRAINEE DRIVER, WASPROCEEDING E-BND ON A SERVICE VEHICLE ACCESS ROAD SOUTH OF KILO. THE TRAINEE WAS FOLLOWING HIS TRAINER WHO WAS IN A SIMILAR SIZE TANKER TRUCK. THETRAINER TURNED LEFT (N-BND), CROSSED KILO NEAR TAXIWAY 47J, & PROCEEDED TOWARD THE BRADLEY INTL TERMINAL. THE TRAINEE WAS LEFT ALONE, SOUTH OF KILO.THE TRAINEE THEN TURNED LEFT & PROCEEDED N-BND IN AN EFFORT TO CROSS KILO. THE TRAINEE FAILED TO OBSERVE THAT KILO WAS OCCUPIED BY THE W-BNDFAIRCHILD, & THE VEHICLES COLLIDED. THE COLLISION BROKE THE ACFT'S LEFT WING, FUEL SPILLED & SPARKS WERE GENERATED. THERE WAS NO FIRE & ALL OCCUPANTSEVACUATED WITHOUT FURTHER MISHAP.


LAX89FA303File No. 2375 9/6/1989 LOS ANGELES, CA Aircraft Reg No. N27283 Time (Local): 20:02 PDT


Findings 1. LIGHT CONDITION - BRIGHT NIGHT 2. (C) AIRPORT OPERATIONS - IMPROPER - DRIVER OF VEHICLE 3. (F) DIVERTED ATTENTION - DRIVER OF VEHICLE 4. OBJECT - VEHICLE 5. (F) SUPERVISION - INADEQUATE - COMPANY/OPERATOR MANAGEMENT


The National Transportation Safety Board determines the probable cause(s) of this accident as follows.THE FUEL TRUCK DRIVER'S IMPROPER OPERATION OF THE VECHICLE ON THE AIRPORT. FACTORS WERE THE DRIVER'S DIVERTED ATTENTION AND THE INADEQUATESUPERVISION BY COMPANY MANAGEMENT.



Brief of Accident

Adopted 9/5/1991

DEN90FA042File No. 738 1/15/1990 ELKO, NV Aircraft Reg No. N2721M Time (Local): 10:28 PST

Make/Model: FAIRCHILD / SA227-ACEngine Make/Model: GARRETT / TPE-331





Last Depart. Point: SALT LAKE CITY, UTDestination: ELKO, NV





Temperature (°C): 1Obstr to Vision: Blowing Snow; Fog

Precipitation: Snow




Flight Time (Hours)



DURING ARRIVAL, THE FLT CREW OF SKYWEST AIRLINES FLT 5855 REQUESTED A VOR/DME-B APCH TO THE ELKO ARPT, WHICH WAS APPROVED. AS THE APCH CONTINUED, THEFLT CREW RPRTD OVER THE BULLION VOR. APRX 30 SEC LATER, THE ACFT CRASHED. IMPACT OCCURRED AT THE TOP OF A MOUNTAIN, ABOUT 100' BEFORE REACHING THEVOR STATION. ELEVATION OF THE CRASH SITE WAS ABOUT 6460 FT; MIN PUBLISHED CROSSING ALT AT THE VOR WAS 7000 FT. THE ARPT WAS 4.1 MI FROM THE VOR AT ANELEVATION OF 5135 FT.


DEN90FA042File No. 738 1/15/1990 ELKO, NV Aircraft Reg No. N2721M Time (Local): 10:28 PST

Occurrence #1: IN FLIGHT COLLISION WITH TERRAIN/WATERPhase of Operation: APPROACH - IAF TO FAF/OUTER MARKER (IFR)

Findings 1. (F) WEATHER CONDITION - CLOUDS 2. (F) WEATHER CONDITION - LOW CEILING 3. (F) WEATHER CONDITION - OBSCURATION 4. (C) IFR PROCEDURE - IMPROPER - PILOT IN COMMAND 5. (C) MONITORING - INADEQUATE - COPILOT/SECOND PILOT 6. (F) TERRAIN CONDITION - MOUNTAINOUS/HILLY 7. (C) PROPER ALTITUDE - NOT MAINTAINED


The National Transportation Safety Board determines the probable cause(s) of this accident as follows.IMPROPER IFR PROCEDURE BY THE CAPTAIN, AND INADEQUATE MONITORING OF THE APPROACH BY THE FIRST OFFICER, WHICH RESULTED IN A FAILURE TO MAINTAINPROPER ALTITUDE DURING THE APPROACH. FACTORS RELATED TO THE ACCIDENT WERE: THE TERRAIN AND WEATHER CONDITIONS AT THE ACCIDENT SITE.



Brief of Accident

Adopted 9/28/1992

ATL90LA054File No. 899 1/24/1990 MORRISVILLE, NC Aircraft Reg No. N396AV Time (Local): 17:42 EST

Make/Model: SWEARINGEN / SA 226TCEngine Make/Model: GARRETT / TPE 331-10


Operating Certificate(s): Commuter Air CarrierName of Carrier: AMR CORPORATION



Last Depart. Point: Same as AccidentDestination: FAYETTEVILLE, NC

Airport Proximity: On AirportAirport Name: RALEIGH-DURHAM





Visibility: 7.00 SMWind Dir/Speed: Light and Variable


Precipitation: None




Flight Time (Hours)



AFTER THE COMMUTER FLIGHT ARRIVED AT ITS DESTINATION THE RIGHT MAIN LANDING GEAR WOULD NOT EXTEND USING NORMAL AND ABNORMAL PROCEDURES. THEAIRPLANE WAS RETURNED TO THE DEPARTURE AIRPORT AND LANDED ON THE RWY WITH ALL WHEELS RETRACTED. SUBSEQUENT EXAMINATION OF THE LANDING GEAR BYTHE OPERATOR REVEALED THAT THE RIGHT MAIN GEAR DOOR ACTUATOR FORK ASSEMBLY HAD BEEN INCORRECTLY INSTALLED. AS A RESULT THE LANDING GEAR DOORWOULD NOT OPEN.


ATL90LA054File No. 899 1/24/1990 MORRISVILLE, NC Aircraft Reg No. N396AV Time (Local): 17:42 EST


Findings 1. (C) LANDING GEAR,NORMAL RETRACTION/EXTENSION ASSEMBLY - INOPERATIVE 2. (C) MAINTENANCE,ADJUSTMENT - IMPROPER - COMPANY MAINTENANCE PERSONNEL

----------

Occurrence #2: ON GROUND/WATER ENCOUNTER WITH TERRAIN/WATERPhase of Operation: LANDING

Findings 3. AIRPORT FACILITIES,RUNWAY/LANDING AREA CONDITION - RUNWAY


The National Transportation Safety Board determines the probable cause(s) of this accident as follows.IMPROPER INSTALLATION OF THE LANDING GEAR DOOR ACTUATOR FORK ASSEMBLY BY COMPANY MAINTENANCE PERSONNEL.



Brief of Accident

Adopted 9/30/1991

SEA90LA037File No. 238 1/30/1990 COEUR D'ALENE, ID Aircraft Reg No. N56EA Time (Local): 19:15 PST



Operating Certificate(s): Commuter Air CarrierName of Carrier: EMPIRE AIRLINES



Last Depart. Point: SEATTLE, WADestination: Same as Accident

Airport Proximity: On AirportAirport Name: COEUR D'ALENE


Runway Surface: Asphalt; SnowRunway Surface Condition: Snow--dry




Temperature (°C): -1Obstr to Vision: Blowing Snow

Precipitation: Snow




Flight Time (Hours)



THE PILOT REPORTED THAT AFTER REACHING THE AIRPORT, IMC PREVAILED AND LIGHT SNOW WAS FALLING. AT THE DECISION HEIGHT, THE APPROACH LIGHTS AND THERUNWAY LIGHTS WERE IN SIGHT. THE RUNWAY WAS COVERED WITH SNOW. DURING THE FLARE TO LAND, THE PILOT LOST DEPTH PERCEPTION AND RUNWAY ALIGNMENTFROM BLOWING SNOW. THE AIRPLANE TOUCHED DOWN AND THE PILOT BELIEVEDTHE PLANE WAS SLIGHTLY LEFT OF THE CENTERLINE. HE CORRECTED WITH RIGHT RUDDER;HOWEVER, THE AIRPLANE CONTINUED TO TRAVEL LEFT. SUBSEQUENTLY, IT WENT OFF THE RUNWAY AND CAME TO REST IN A SNOWBANK WITH DAMAGE.


SEA90LA037File No. 238 1/30/1990 COEUR D'ALENE, ID Aircraft Reg No. N56EA Time (Local): 19:15 PST

Occurrence #1: IN FLIGHT ENCOUNTER WITH WEATHERPhase of Operation: LANDING - FLARE/TOUCHDOWN

Findings 1. (F) LIGHT CONDITION - DARK NIGHT 2. (F) WEATHER CONDITION - SNOW 3. (C) WEATHER CONDITION - WHITEOUT 4. PROPER ALIGNMENT - NOT POSSIBLE 5. (C) VISUAL/AURAL PERCEPTION

----------


Findings 6. (F) TERRAIN CONDITION - SNOWBANK


The National Transportation Safety Board determines the probable cause(s) of this accident as follows.THE LOSS OF THE FLIGHT CREW'S VISUAL PERCEPTION, DUE TO AN UNFORESEEN WHITEOUT CONDITION. A RELATED FACTOR WAS THE SNOWBANK.



Brief of Accident

Adopted 12/14/1992

LAX90LA141File No. 1896 4/1/1990 PANOCHE, CA Aircraft Reg No. N27220 Time (Local): 08:00 PDT

Make/Model: FAIRCHILD / SA227ACEngine Make/Model: GARRETT / TPE 331-11





Last Depart. Point: SACRAMNETO, CADestination: SANTA BARBARA, CA






Precipitation: None


Certificate(s)/Rating(s)Airline Transport; Flight Instructor; Multi-engine Land; Single-engine Land; Helicopter


Flight Time (Hours)



THE COMMUTER AIR CARRIER CAPTAIN'S LAST SCHEDULED FLIGHT HAD TERMINATED IN SACRAMENTO ON 3/31. HE INFORMED HIS CARRIER THAT HE WOULD LIKE TO BELOCATED IN THE LOS ANGELES OR SANTA BARBARA AREA BY 4/1. THEY OFFERED THE AIRPLANE WHICH NEEDED TO BE REPOSITIONED TO SANTA BARBARA. HE HAD NEVERPILOTED THE AIRPLANE SOLO, BUT DID NOT WANT TO WAIT FOR A CO-PILOT. THE PILOT STATED HE CLIMBED TO 17,500 FT, TRIMMED THE AIRPLANE FOR CRUISE FLIGHT, AND'DOZED OFF' SEVERAL TIMES. WHEN HE LAST AWOKE THE AIRPLANE WAS DESCENDING AT OVER 300 KTS (VNE IS 246 KTS). HE WAS ONLY ABLE TO RECOVER USING ELECTRICTRIM. THE UPPER WING SKIN PANEL DAMAGE WAS LATER OBSERVED BY A PASSENGER ON A SUBSEQUENT FLIGHT. ACCORDING TO THE AIRPLANE'S MANUFACTURER, THEAIRPLANE WOULD HAVE HAD TO EXPERIENCE A CALCULATED LOAD FACTOR OF 7.8 G'S TO SUSTAIN THE OBSERVED DAMAGE TO THE WING SKIN PANELS, STRINGERS ANDMAIN SPARS. THE PILOT STATED HE HAD ONLY SLEPT 1-1/2 TO 2 HRS DURING THE PRECEDING 24-HR PERIOD.


LAX90LA141File No. 1896 4/1/1990 PANOCHE, CA Aircraft Reg No. N27220 Time (Local): 08:00 PDT

Occurrence #1: LOSS OF CONTROL - IN FLIGHTPhase of Operation: CRUISE

Findings 1. (C) JUDGMENT - POOR - PILOT IN COMMAND 2. (C) AIRCRAFT CONTROL - UNCONTROLLED - PILOT IN COMMAND 3. (F) FATIGUE(LACK OF SLEEP) - PILOT IN COMMAND 4. (C) AIRSPEED(VNE) - EXCEEDED - PILOT IN COMMAND

----------

Occurrence #2: ALTITUDE DEVIATION,UNCONTROLLEDPhase of Operation: DESCENT - UNCONTROLLED----------

Occurrence #3: ABRUPT MANEUVERPhase of Operation: DESCENT - UNCONTROLLED

Findings 5. (C) DESIGN STRESS LIMITS OF AIRCRAFT - EXCEEDED - PILOT IN COMMAND


The National Transportation Safety Board determines the probable cause(s) of this accident as follows.THE PILOT'S POOR JUDGMENT IN ATTEMPTING A FLIGHT WHILE BEING FATIGUED DUE TO THE LACK OF SLEEP WHICH RESULTED IN A LOSS OF CONTROL AND SUBSEQUENTOVERSTRESSING OF THE AIRPLANE.



Brief of Accident

Adopted 3/31/1993

SEA90FA080File No. 1595 5/20/1990 COEUR D'ALENE, ID Aircraft Reg No. N161RS Time (Local): 13:50 MDT

Make/Model: SWEARINGEN / SA226-T(B)Engine Make/Model: GARRETT / TPE-331





Last Depart. Point: Same as AccidentDestination: BONNERS FERRY, ID

Airport Proximity: On AirportAirport Name: COEUR D'ALENE







Precipitation: None


Certificate(s)/Rating(s)Commercial; Multi-engine Land; Single-engine Land; Glider; Helicopter


Flight Time (Hours)



THE ASSISTANCE OF A GROUND LINEMAN WAS OBTAINED TO CONNECT AN EXTERNAL POWER UNIT. AFTER THE ENGINES WERE STARTED, THE LINEMAN DISCONNECTED THEPOWER UNIT. THE PILOT NOTED THE DISCONNECT AND COMPLETED THE CHECKLIST. WHEN HE LOOKED UP TO FIND THE LINEMAN, HE SAW AN INDIVIDUAL WALKING AWAYFROM HIS AIRPLANE AND ASSUMED THAT IT WAS THE LINEMAN THAT HAD BEEN ASSISTING HIM. THE PILOT RELEASED THE BRAKES AND STARTED FORWARD MOVEMENT OFTHE AIRPLANE. THE LINEMAN, HOWEVER, WAS STILL NEXT TO THE AIRPLANE AT THE EXTERNAL POWER RECEPTACLE, WHICH WAS LOCATED ON THE RIGHT SIDE OF THE NOSEIN FRONT OF THE PROPELLER. THE LINEMAN AND POWER UNIT WERE STRUCK BY THE RIGHT PROPELLER. A TOXICOLOGY CHECK OF THE LINEMAN'S BLOOD SHOWED IT HADAN ALCOHOL LEVEL OF 0.037%.


SEA90FA080File No. 1595 5/20/1990 COEUR D'ALENE, ID Aircraft Reg No. N161RS Time (Local): 13:50 MDT

Occurrence #1: PROPELLER/ROTOR CONTACT TO PERSONPhase of Operation: TAXI

Findings 1. (C) CREW/GROUP COORDINATION - INADEQUATE - PILOT IN COMMAND 2. (C) CREW/GROUP COORDINATION - INADEQUATE - GROUND PERSONNEL 3. (F) IMPAIRMENT(ALCOHOL) - GROUND PERSONNEL

----------


Findings 4. OBJECT - VEHICLE


The National Transportation Safety Board determines the probable cause(s) of this accident as follows.INADEQUATE COORDINATION BETWEEN THE PILOT AND THE GROUND LINEMAN. A FACTOR RELATED TO THE ACCIDENT WAS: IMPAIRMENT OF THE GROUND LINEMAN FROMCONSUMPTION OF ALCOHOL.



Brief of Incident

Adopted 12/30/1992

SEA90IA085File No. 5009 5/23/1990 OLYMPIA, WA Aircraft Reg No. N27442 Time (Local): 08:30 PDT

Make/Model: FAIRCHILD / SA227Engine Make/Model: GARRETT / TPE311


Operating Certificate(s): Commuter Air CarrierName of Carrier: HORIZON AIRLINES



Last Depart. Point: PORTLAND, ORDestination: SEATTLE, WA



Basic Weather: UnknownLowest Ceiling: Unk/Nr



Precipitation: None




Flight Time (Hours)



WHILE DESCENDING FROM 14,000 FEET, THE SECOND ROW RIGHT SIDE CABIN WINDOW SUDDENLY BLEW OUT. AN EMERGENCY DESCENT WAS INITIATED TO THE AIRPORTWHERE THE AIRPLANE LANDED WITHOUT FURTHER INCIDENT. THE WINDOW AND FRAME WERE INSPECTED AND NOTED THAT THE FRAME AND CONNECTING BOLTS APPEAREDUNDAMAGED. TWO INDENTATIONS WERE NOTED ON THE FUSELAGE JUST FORWARD OF THE WINDOW AND AFT OF THE ICE PROTECTION PLATE. PASSENGERS REPORTEDTHAT PRIOR TO THE WINDOW BLOW OUT, LOUD BUMPS OR THUMPS WERE HEARD.


SEA90IA085File No. 5009 5/23/1990 OLYMPIA, WA Aircraft Reg No. N27442 Time (Local): 08:30 PDT


Findings 1. (F) WINDOW,CABIN - PENETRATED 2. (C) WEATHER CONDITION - ICING CONDITIONS


The National Transportation Safety Board determines the probable cause(s) of this incident as follows.DUE TO AN ICE BUILD-UP DEPARTING THE PROPELLER AND STRIKING THE CABIN WINDOW.



Brief of Incident

Adopted 12/14/1992

ATL90IA177File No. 5055 9/22/1990 MORRISVILLE, NC Aircraft Reg No. N619AV Time (Local): 14:46 EDT

Make/Model: FAIRCHILD / SA 227Engine Make/Model: GARRETT / TPE 331-11U


Operating Certificate(s): Commuter Air CarrierName of Carrier: AMR EAGLE, INC



Last Depart. Point: Same as IncidentDestination: RICHMOND, VA





Temperature (°C): -18Obstr to Vision: Haze





Flight Time (Hours)



DURING CRUISE FLIGHT AT 3000 FEET ALTITUDE, THE PILOT EXPERIENCED A COMPLETE LOSS OF RUDDER CONTROL FOR ABOUT 20 SECONDS. AFTERWARD HE COULD FEELCONTINUOUS MOTION IN THE RUDDER THROUGH THE PEDALS, THEREFORE THE PILOT REDUCED HIS AIRSPEED FROM 180 KNOTS TO AN AIRSPEED WHICH ALLOWED FOR LESSRUDDER VIBRATION. AN EMERGENCY WAS DECLARED AND THE FLIGHT LANDED SAFELY. SUBSEQUENT EXAMINATIONS DISCLOSED THAT THE RUDDER TRIM TAB CONTROL RODEND FAILED IN FATIGUE. ACCORDING TO FAA RECORDS, OTHER CONTROL FAILURES WERE REPORTED WHICH PROMPTED THE ISSUANCE OF AN EMERGENCY AIRWORTHINESSDIRECTIVE TO PREVENT THE POSSIBLE LOSS OF CONTROL OF THE AIRPLANE.


ATL90IA177File No. 5055 9/22/1990 MORRISVILLE, NC Aircraft Reg No. N619AV Time (Local): 14:46 EDT


Findings 1. (C) FLIGHT CONTROL,RUDDER TAB - FAILURE,TOTAL 2. (C) FLIGHT CONTROL,RUDDER TAB - FATIGUE


The National Transportation Safety Board determines the probable cause(s) of this incident as follows.THE FATIGUE FAILURE OF THE RUDDER TRIM CONTROL ROD END.



Brief of Accident

Adopted 9/28/1992

BFO91LA011File No. 824 11/8/1990 COVINGTON, KY Aircraft Reg No. N445AC Time (Local): 22:23 EST







Airport Proximity: On AirportAirport Name: GREATER CINNCINNATI INT'L







Precipitation: None




Flight Time (Hours)



THE PILOT, A COMPANY CHECK AIRMAN, AND AN FAA INSPECTOR WERE ON BOARD THE AIRCRAFT FOR A CHECKRIDE WHICH WAS INTENDED TO REASSESS THE PILOT'SCOMPETENCY. A MAINTENANCE TEST (AILERON RIGGING) WAS TO BE PERFORMED IN CONJUNCTION WITH THE CHECK RIDE. THE FIRST MANEUVER TO BE PERFORMED WAS ANO-FLAP LANDING. ALL THREE PILOTS STATED THAT THE PILOT HAD DIFFICULTY MANAGING THE AIRCRAFT WHILE IN THE TRAFFIC PATTERN; AIRSPEEDS WERE TOO SLOW,AND THE PILOT WAS CONSTANTLY MANIPULATING POWER. THE PILOT NEVER CALLED FOR THE BEFORE LANDING CHECKLIST, AND THE AIRCRAFT TOUCHED DOWN ON THERUNWAY WITH THE LANDING GEAR UP. THE CHECK PILOT STATED THAT THE LANDING GEAR WARNING HORN CAME ON BRIEFLY, BUT THE PILOT ADDED POWER AND SILENCEDTHE HORN. THE FAA INSPECTOR WAS SEATED IN A PASSENGER SEAT FOR TAKEOFF AND LANDING, AND WAS NOT AWARE THAT THE LANDING GEAR WAS NOT EXTENDED.


BFO91LA011File No. 824 11/8/1990 COVINGTON, KY Aircraft Reg No. N445AC Time (Local): 22:23 EST


Findings 1. PROCEDURES/DIRECTIVES - NOT FOLLOWED - PILOT IN COMMAND 2. (F) PRESSURE INDUCED BY OTHERS - PILOT IN COMMAND 3. (F) SUPERVISION - INADEQUATE - CHECK PILOT 4. (F) INATTENTIVE - CHECK PILOT 5. CHECKLIST - NOT PERFORMED - PILOT IN COMMAND 6. (F) INATTENTIVE - PILOT IN COMMAND 7. (C) GEAR EXTENSION - NOT PERFORMED - PILOT IN COMMAND


The National Transportation Safety Board determines the probable cause(s) of this accident as follows.THE PILOT-IN-COMMAND'S FAILURE TO EXTEND THE LANDING GEAR PRIOR TO TOUCHDOWN. CHECKRIDE-INDUCED PRESSURE WAS A CONTRIBUTING FACTOR, ANDINADEQUATE SUPERVISION BY THE CHECK PILOT WAS A FACTOR.



Brief of Accident

Adopted 11/9/1992

SEA91LA040File No. 1161 12/31/1990 KALISPELL, MT Aircraft Reg No. N385PH Time (Local): 10:30 MST

Make/Model: SWEARINGEN / SA-227Engine Make/Model: GARRETT / TPE-331-11U





Last Depart. Point: SPOKANE, WADestination: Same as Accident

Airport Proximity: On AirportAirport Name: GLACIER INT'L


Runway Surface: AsphaltRunway Surface Condition: Snow--dry





Precipitation: Snow




Flight Time (Hours)



THE CREW OF THE SA-227 COMMUTER AIRLINER LOST DIRCTIONAL CONTROL AFTER LANDING IN SNOW THAT WAS REPORTEDLY BETWEEN FIVE AND TEN INCHES DEEP. THECREW HAD REQUESTED A SNOW-DEPTH REPORT, WHICH WAS RELAYED TO THEM BY AN AIRPORT SNOWPLOW OPERATOR, THROUGH THE AIRLINE'S OPERATIONS PERSONNEL.THE SNOW DEPTH HAD BEEN REPORTED AS ONE INCH AT THAT TIME. THE AIRCRAFT DRIFTED OFF THE RIGHT SIDE OF THE RUNWAY, CAUSING SUBSTANTIAL DAMAGE TO THEFUSELAGE.


SEA91LA040File No. 1161 12/31/1990 KALISPELL, MT Aircraft Reg No. N385PH Time (Local): 10:30 MST


Findings 1. (F) TERRAIN CONDITION - SNOW COVERED 2. (C) DIRECTIONAL CONTROL - NOT MAINTAINED - PILOT IN COMMAND 3. (F) AIRPORT FACILITIES,RUNWAY/LANDING AREA CONDITION - NOT MAINTAINED 4. (F) AIRPORT SNOW REMOVAL - MISJUDGED - AIRPORT PERSONNEL 5. (C) PROCEDURE INADEQUATE - AIRPORT PERSONNEL


The National Transportation Safety Board determines the probable cause(s) of this accident as follows.THE FLIGHT CREW'S INABLITY TO MAINTAIN DIRECTIONAL CONTROL AFTER LANDING IN SNOW-DEPTH CONDITIONS THAT HAD BEEN ERRONEOUSLY REPORTED AS BEINGWITHIN OPERATING LIMITATIONS.



Brief of Accident

Adopted 8/5/1993

DCA91MA018BFile No. 47 2/1/1991 LOS ANGELES, CA Aircraft Reg No. N683AV Time (Local): 18:07 PST

Make/Model: FAIRCHILD / SA-227-ACEngine Make/Model: GARRETT / TPE-331





Last Depart. Point: Same as AccidentDestination: PALMDALE, CA

Airport Proximity: On AirportAirport Name: LOS ANGELES INTERNATIONAL







Precipitation: None




Flight Time (Hours)



SKW5569, N683AV, HAD BEEN CLEARED TO RWY 24L, AT INTERSECTION 45, TO POSITION AND HOLD. THE LOCAL CONTROLLER, BECAUSE OF HER PREOCCUPATION WITHANOTHER AIRPLANE, FORGOT SHE HAD PLACED SKW5569 ON THE RUNWAY AND SUBSEQUENTLY CLEARED USA1493, N388US, FOR LANDING. AFTER THE COLLISION, THE TWOAIRPLANES SLID OFF THE RUNWAY INTO AN UNOCCUPIED FIRE STATION. THE TOWER OPERATING PROCEDURES DID NOT REQUIRE FLIGHT PROGRESS STRIPS TO BEPROCESSED THROUGH THE LOCAL GROUND CONTROL POSITION. BECAUSE THIS STRIP WAS NOT PRESENT, THE LOCAL CONTROLLER MISIDENTIFIED AN AIRPLANE ANDISSUED A LANDING CLEARANCE. THE TECHNICAL APPRAISAL PROGRAM FOR AIR TRAFFIC CONTROLLERS IS NOT BEING FULLY UTILIZED BECAUSE OF A LACK OFUNDERSTANDING BY SUPERVISORS AND THE UNAVAILABILITY OF APPRAISAL HISTORIES.


DCA91MA018BFile No. 47 2/1/1991 LOS ANGELES, CA Aircraft Reg No. N683AV Time (Local): 18:07 PST

Occurrence #1: ON GROUND/WATER COLLISION WITH OBJECTPhase of Operation: STANDING

Findings 1. (C) SUPERVISION - INADEQUATE - ATC PERSONNEL(SUPERVISOR) 2. (F) INADEQUATE SUBSTANTIATION PROCESS - FAA(ORGANIZATION) 3. (C) ATC CLEARANCE - IMPROPER - ATC PERSONNEL(LCL/GND/CLNC) 4. OBJECT - AIRCRAFT MOVING ON GROUND


The National Transportation Safety Board determines the probable cause(s) of this accident as follows.THE FAILURE OF THE LOS ANGELES AIR TRAFFIC FACILITY MANAGEMENT TO IMPLEMENT PROCEDURES THAT PROVIDED REDUNDANCY COMPARABLE TO THE REQUIREMENTSCONTAINED IN THE NATIONAL OPERATIONAL POSITION STANDARDS AND THE FAILURE OF THE FAA AIR TRAFFIC SERVICE TO PROVIDE ADEQUATE POLICY DIRECTION ANDOVERSIGHT TO ITS AIR TRAFFIC CONTROL FACILITY MANAGERS. THESE FAILURES CREATED AN ENVIRONMENT IN THE LOS ANGELES AIR TRAFFIC CONTROL TOWER THATULTIMATELY LED TO THE FAILURE OF THE LOCAL CONTROLLER 2 (LC2) TO MAINTAIN AN AWARENESS OF THE TRAFFIC SITUATION, CULMINATING IN THE INAPPROPRIATECLEARANCES AND THE SUBSEQUENT COLLISION OF THE USAIR AND SKYWEST AIRCRAFT. CONTRIBUTING TO THE CAUSE OF THE ACCIDENT WAS THE FAILURE OF THE FAA TOPROVIDE EFFECTIVE QUALITY ASSURANCE OF THE ATC SYSTEM. (NTSB REPORT AAR-91/08)



Brief of Accident

Adopted 1/22/1993

LAX91LA277File No. 2067 6/11/1991 VISALIA, CA Aircraft Reg No. N348AE Time (Local): 03:45 PDT

Make/Model: FAIRCHILD / SA227-ACEngine Make/Model: GARRETT / TPE331-11






Airport Proximity: On AirportAirport Name: VISALIA







Precipitation: None




Flight Time (Hours)



THE CERTIFICATED AIRPLANE TRANSPORT PILOT, THE PILOT-IN-COMMAND AND INSTRUCTOR PILOT, WAS CONDUCTING COMPANY TRAINING WITH TWO CAPTAIN CANDIDATES.THE SECOND-IN-COMMAND, A DUAL STUDENT, WAS FLYING FROM THE LEFT SEAT. THE INSTRUCTOR REQUESTED A NO FLAP, SINGLE ENGINE CIRCLING APPROACH, WHICHREQUIRES THAT THE LANDING GEAR NOT BE EXTENDED UNTIL A SAFE LANDING IS ASSURED. THE LANDING GEAR WARNING HORN DID NOT SOUND DUE TO THE POSITION OFTHE FLAPS AND ENGINE POWER LEVERS. THE STUDENT MADE A CHECKLIST CALL OUT AT A TIME IN THE LANDING SEQUENCE THAT OCCURS AFTER THE LANDING GEAR ISLOWERED. NEITHER PILOT RECALLED CALLING FOR THE LANDING GEAR DOWN. THE INSTRUCTOR RECALLED NOTING THAT THE STUDENT DID NOT CALL FOR GEAR DOWN. HESTATED THAT HE WAS GIVING THE STUDENT AN OPPORTUNITY TO LOWER THE GEAR WITHOUT BEING PROMPTED TO DO SO. THE AIRPLANE CONTACTED THE RUNWAY WITHTHE LANDING GEAR UP, CAUSING SUBSTANTIAL DAMAGE. THE THREE PILOTS WERE NOT INJURED.


LAX91LA277File No. 2067 6/11/1991 VISALIA, CA Aircraft Reg No. N348AE Time (Local): 03:45 PDT

Occurrence #1: GEAR NOT EXTENDEDPhase of Operation: LANDING - FLARE/TOUCHDOWN

Findings 1. (F) WARNING SYSTEM(OTHER) - DISABLED 2. (C) SUPERVISION - INADEQUATE - PILOT IN COMMAND 3. (C) CHECKLIST - IMPROPER USE OF - COPILOT/SECOND PILOT 4. (C) CREW/GROUP COORDINATION - NOT MAINTAINED - PILOT IN COMMAND


The National Transportation Safety Board determines the probable cause(s) of this accident as follows.THE INSTRUCTOR/PILOT-IN-COMMAND'S FAILURE TO ADEQUATELY SUPERVISE THE FLIGHT AND THE SECOND PILOT'S IMPROPER USE OF THE CHECKLIST AND FAILURE TO

MAINTAIN CREW COORDINATION TO ENSURE THAT THE LANDING GEAR WAS EXTENDED. CONTRIBUTING TO THE ACCIDENT WAS THE SILENCING OF THE LANDING GEARWARNING HORN BY POSITIONING GO THE ENGINE POWER LEVERS.



Brief of Accident

Adopted 3/9/1993

MIA91LA167File No. 1093 6/23/1991 TUPELO, MS Aircraft Reg No. N13JV Time (Local): 17:22 CDT

Make/Model: SWEARINGEN / SA227-TTEngine Make/Model: GARRETT / TPE-331





Last Depart. Point: FT. PIERCE, FLDestination: Same as Accident

Airport Proximity: On AirportAirport Name: TUPELO MUNICIPAL







Precipitation: None


Certificate(s)/Rating(s)Airline Transport; Flight Instructor; Multi-engine Land; Single-engine Land; Glider


Flight Time (Hours)



ACFT MADE SHARP RIGHT TURN AND DEPARTED RUNWAY WHEN NOSE STEERING WAS ACTIVATED DURING LANDING ROLLOUT. POST ACCIDENT INVESTIGATION REVEALEDTHE NOSE STEERING ACTUATOR HAD MALFUNCTIONED. THE UNIT'S ARMING VALVE WAS BACKED OUT AND NOT SECURED BY A REQUIRED SET SCREW. THE SEATS FOR THEVALVE WERE THE INCORRECT SEATS. THESE TWO FINDINGS CAUSED THE ACTUATOR TO HAVE INTERNAL LEAKAGE WHICH RESULTED IN FAILURE OF THE ACTUATOR.LOGBOOK RECORDS INDICATED THE ARMING VALVE WAS CHANGED BY A MECHANIC IN THE FIELD IN SEPTEMBER 1988, 401 FLT HOURS BEFORE THE ACCIDENT. IN APRIL 1989,FAIRCHILD AIRCRAFT ISSUED A SERVICE BULLETIN THAT REQUIRED THE ACTUATOR BE RETURNED TO THE MANUFACTURER FOR REPLACEMENT OF THE ARMING VALVE.


MIA91LA167File No. 1093 6/23/1991 TUPELO, MS Aircraft Reg No. N13JV Time (Local): 17:22 CDT


Findings 1. (C) LANDING GEAR,STEERING SYSTEM - FAILURE,TOTAL 2. (C) MAINTENANCE,REPLACEMENT - IMPROPER - OTHER MAINTENANCE PERSONNEL

----------


Findings 3. TERRAIN CONDITION - SOFT


The National Transportation Safety Board determines the probable cause(s) of this accident as follows.THE IMPROPER INSTALLATION OF THE NOSE STEERING ACTUATOR ARMING VALVE BY A MECHANIC WHICH RESULTED IN FAILURE OF THE ACTUATOR AND ON GROUND LOSS

OF DIRECTIONAL CONTROL BY THE PILOT DURING LANDING ROLLOUT.



Brief of Accident

Adopted 3/31/1993

NYC92LA002File No. 1887 10/6/1991 AUGUSTA, ME Aircraft Reg No. N120FA Time (Local): 22:50 EDT

Make/Model: FAIRCHILD / SA-227ACEngine Make/Model: GARRETT / TPE-331-11U


Operating Certificate(s): Commuter Air CarrierName of Carrier: NORTHEAST EXPRESS



Last Depart. Point: BOSTON, MADestination: Same as Accident

Airport Proximity: On AirportAirport Name: AUGUSTA STATE







Precipitation: Rain


Certificate(s)/Rating(s)Airline Transport; Commercial; Single-engine Land; Single-engine Sea


Flight Time (Hours)



THE FIRST OFICER LANDED LONG WITH A TAILWIND ON A WET RUNWAY. THE AIRPLANE WAS UNABLE TO STOP ON THE REMAINING RUNWAY, WENT OFF THE DEPARTURE ENDAND DOWN AN EMBANKMENT. THE FLIGHT CREW RECEIVED TWO WEATHER ADVISORIES PRIOR TO LANDING TELLING THEM OF THE WINDS. THE CAPTAIN AND FIRST OFFICERBOTH HAD LESS THAN 100 HOURS IN MODEL. THE COMPANY OPERATIONS MANUAL REQUIRED THE CAPTAIN TO MAKE ALL TAKEOFFS AND LANDINGS WHEN HE HAD LESS THAN100 HOURS IN MODEL.


NYC92LA002File No. 1887 10/6/1991 AUGUSTA, ME Aircraft Reg No. N120FA Time (Local): 22:50 EDT

Occurrence #1: OVERRUNPhase of Operation: LANDING

Findings 1. AIRPORT FACILITIES,RUNWAY/LANDING AREA CONDITION - WET 2. WEATHER CONDITION - TAILWIND 3. (F) PROCEDURES/DIRECTIVES - NOT FOLLOWED - PILOT IN COMMAND 4. (F) LACK OF TOTAL EXPERIENCE IN TYPE OF AIRCRAFT - PILOT IN COMMAND 5. (C) PROPER TOUCHDOWN POINT - NOT ATTAINED - COPILOT/SECOND PILOT 6. (F) LACK OF TOTAL EXPERIENCE IN TYPE OF AIRCRAFT - COPILOT/SECOND PILOT


The National Transportation Safety Board determines the probable cause(s) of this accident as follows.THE COPILOT'S FAILURE TO ATTAIN A PROPER TOUCHDOWN POINT. FACTORS WERE THE CAPTAIN'S FAILURE TO FOLLOW COMPANY PROCEDURE AND BOTH PILOT'S LIMITEDEXPERIENCE.



Brief of Accident

Adopted 4/23/1993

SEA92LA025File No. 2081 12/1/1991 MISSOULA, MT Aircraft Reg No. N26932 Time (Local): 18:55 MST

Make/Model: SWEARINGEN / SA-227-ACEngine Make/Model: GARRETT / TPE 331-11U


Operating Certificate(s): Commuter Air Carrier; Flag Carrier/DomesticName of Carrier: HORIZON AIR



Last Depart. Point: Same as AccidentDestination: SPOKANE, WA

Airport Proximity: On AirportAirport Name: JOHNSON-BELL


Runway Surface: AsphaltRunway Surface Condition: Snow--compacted; Snow--dry

Condition of Light: Night/DarkWeather Info Src: Witness




Precipitation: Snow


Certificate(s)/Rating(s)Airline Transport; Commercial; Single-engine Land; Single-engine Sea


Flight Time (Hours)



THE PILOT WAS UNABLE TO MAINTAIN DIRECTIONAL CONTROL AS THE AIRCRAFT DRIFTED OFF THE LEFT SIDE OF THE DEPARTURE RUNWAY, WHICH HAD AN ACCUMULATIONOF SNOW. THE INABILITY TO MAINTAIN DIRECTIONAL CONTROL AT HIGH SPEED WAS CONSISTENT WITH AA DRAGGING BRAKE ON THE LEFT SIDE OF THE AIRCRAFT.


SEA92LA025File No. 2081 12/1/1991 MISSOULA, MT Aircraft Reg No. N26932 Time (Local): 18:55 MST

Occurrence #1: LOSS OF CONTROL - ON GROUND/WATERPhase of Operation: LANDING

Findings 1. AIRPORT FACILITIES,RUNWAY/LANDING AREA CONDITION - SNOW COVERED 2. (F) LANDING GEAR,NORMAL BRAKE SYSTEM - OTHER 3. (C) DIRECTIONAL CONTROL - NOT MAINTAINED - PILOT IN COMMAND

----------

Occurrence #2: ON GROUND/WATER ENCOUNTER WITH TERRAIN/WATERPhase of Operation: TAKEOFF - ABORTED

Findings 4. TERRAIN CONDITION - SNOWBANK


The National Transportation Safety Board determines the probable cause(s) of this accident as follows.THE PILOT'S INABILITY TO MAINTAIN DIRECTIONAL CONTROL DURING TAKEOFF. FACTORS INCLUDE A DRAGGING BRAKE.



Brief of Accident

Adopted 4/23/1993

CHI92LA038File No. 1916 12/3/1991 IOWA, IA Aircraft Reg No. N14TP Time (Local): 15:45 CST

Make/Model: SWEARINGEN / SA-226TEngine Make/Model: GARRETT / TPE3313U303G


Operating Certificate(s): On-demand Air TaxiName of Carrier: IOWA FLYING SERVICES, INC

Type of Flight Operation: Non-scheduled; Passenger/Cargo; DomesticReg. Flight Conducted Under: Part 135: Air Taxi & Commuter


Last Depart. Point: ST LOUIS, MODestination: Same as Accident

Airport Proximity: On AirportAirport Name: IOWA CITY


Runway Surface: AsphaltRunway Surface Condition: Snow--compacted




Temperature (°C): -12Obstr to Vision: Blowing Snow

Precipitation: Snow


Certificate(s)/Rating(s)Flight Instructor; Commercial; Multi-engine Land; Single-engine Land


Flight Time (Hours)



DURING THE SECOND LANDING ATTEMPT, THE PILOT FAILED TO LOWER THE LANDING GEAR. THE PILOT EXECUTED A GO-AROUND AFTER THE PROPELLERS CONTACTED THERUNWAY. THE AIRPLANE THEN RETURNED FOR AN UNEVENTFUL GEAR DOWN LANDING. POST ACCIDENT INSPECTION REVEALED THAT ABOUT ONE THIRD OF EACH BLADE ONTHE RIGHT PROPELLER HAD SEPARATED. PIECES OF THE SEPARATED BLADE(S) PUNCTURED A HOLE IN THE PRESSURIZED FUSELAGE.


CHI92LA038File No. 1916 12/3/1991 IOWA, IA Aircraft Reg No. N14TP Time (Local): 15:45 CST


Findings 1. (C) GEAR EXTENSION - NOT PERFORMED - PILOT IN COMMAND 2. PROPELLER SYSTEM/ACCESSORIES,BLADE - FRACTURED 3. (F) CHECKLIST - NOT FOLLOWED - PILOT IN COMMAND 4. FUSELAGE - RUPTURED 5. GO-AROUND - PERFORMED - PILOT IN COMMAND 6. WEATHER CONDITION - SNOW 7. WEATHER CONDITION - GUSTS

----------

Occurrence #2:Phase of Operation: LANDING


The National Transportation Safety Board determines the probable cause(s) of this accident as follows.THE PILOT'S FAILURE TO EXTEND THE LANDING GEAR WHICH RESULTED IN THE PROPELLER BLADES CONTACTING THE RUNWAY DURING THE LANDING. A FACTOR RELATED

TO THE ACCIDENT WAS THE PILOT'S FAILURE TO FOLLOW A CHECKLIST DURING THE APPROACH.



Brief of Accident

Adopted 10/15/1993

NYC92LA083File No. 147 4/17/1992 LEXINGTON, KY Aircraft Reg No. N27465 Time (Local): 22:25 EDT



Operating Certificate(s): Commuter Air CarrierName of Carrier: MESABA AIRLINES



Last Depart. Point: DETROIT, MIDestination: Same as Accident

Airport Proximity: On AirportAirport Name: BLUE GRASS







Precipitation: None




Flight Time (Hours)



THE AIRPLANE WAS TAXIING TO THE GATE AFTER LANDING WHEN THE FLIGHT CREW OBSERVED A VEHICLE APPROACHING THEM FROM AHEAD ON THE TAXIWAY. THEYSTOPPED THE AIRPLANE. THE VEHICLE STRUCK THE AIRPLANE, PASSING THROUGH THE RIGHT ENGINE PROPELLER ARC, BETWEEN THE FUSELAGE AND RIGHT ENGINE. THEDRIVER HAD GAINED ENTRY ONTO THE TAXIWAY BY DRIVING THROUGH A LOCKED GATE AND BREAKING THE FENCE. WHEN INTERVIEWED, THE VEHICLE DRIVER SAID HE HADBEEN DRINKING AND WANTED TO KILL HIMSELF.


NYC92LA083File No. 147 4/17/1992 LEXINGTON, KY Aircraft Reg No. N27465 Time (Local): 22:25 EDT


Findings 1. OBJECT - VEHICLE 2. (C) SUICIDE - ATTEMPTED - DRIVER OF VEHICLE 3. (C) PSYCHOLOGICAL CONDITION - DRIVER OF VEHICLE


The National Transportation Safety Board determines the probable cause(s) of this accident as follows.ATTEMPTED SUICIDE BY THE VEHICLE DRIVER.



Brief of Accident

Adopted 9/14/1993

NYC92LA128File No. 2703 6/25/1992 BOSTON, MA Aircraft Reg No. N2691W Time (Local): 14:00 EDT



Operating Certificate(s): Commuter Air CarrierName of Carrier: NORTHEAST EXPRESS AIRLINES



Last Depart. Point: BANGOR, MEDestination: Same as Accident

Airport Proximity: On AirportAirport Name: LOGAN INTERNATIONAL







Precipitation: None




Flight Time (Hours)



THE AIRPLANE WAS LANDING ON RUNWAY 22L. THE WIND WAS REPORTED FROM 286 DEGREES AT 16 GUSTING TO 21 KNOTS. THE PILOT SAID, '...ON LANDING...CORRECTEDFOR CROSSWIND WITH RIGHT SIDESLIP....I REDUCED POWER TO FLIGHT IDLE AND AIRCRAFT ROLLED TO THE LEFT. I THEN APPLIED POWER ON LEFT ENGINE TO MAINTAINDIRECTIONAL CONTROL, AIRCRAFT TOUCHED DOWN ON LEFT SIDE OF RUNWAY AND...VEERED LEFT OFF THE RUNWAY.' EXAMINATION REVEALED DAMAGE TO THE LEFT WINGTIP, THE RIGHT ENGINE PROPELLERS AND THE NOSE GEAR TRUNION. TESTING WAS ACCOMPLISHED ON THE PROPELLER BLADE ANGLES, ENGINE CONTROL CABLES, THESTALL WARNING SYSTEM AND THE FLIGHT CONTROLS. NO DISCREPANCIES WERE NOTED.


NYC92LA128File No. 2703 6/25/1992 BOSTON, MA Aircraft Reg No. N2691W Time (Local): 14:00 EDT

Occurrence #1: LOSS OF CONTROL - IN FLIGHTPhase of Operation: LANDING - FLARE/TOUCHDOWN

Findings 1. WEATHER CONDITION - UNFAVORABLE WIND 2. (C) COMPENSATION FOR WIND CONDITIONS - IMPROPER - PILOT IN COMMAND 3. PROPER ALIGNMENT - NOT MAINTAINED - PILOT IN COMMAND 4. (C) AIRCRAFT CONTROL - NOT MAINTAINED - PILOT IN COMMAND

----------

Occurrence #2: HARD LANDINGPhase of Operation: LANDING - FLARE/TOUCHDOWN----------


Findings 5. TERRAIN CONDITION - RUNWAY


The National Transportation Safety Board determines the probable cause(s) of this accident as follows.THE LOSS OF AIRPLANE CONTROL DURING A CROSSWIND LANDING RESULTING IN A HARD BOUNCED LANDING AND A COLLISION WITH THE RUNWAY.



Brief of Incident

Adopted 9/28/1993

ANC92IA100AFile No. 5051 6/26/1992 DILLINGHAM, AK Aircraft Reg No. N620PA Time (Local): 13:00 ADT

Make/Model: FAIRCHILD / SA227-ACEngine Make/Model: GARRETT / TPE-331-10


Operating Certificate(s): Commuter Air CarrierName of Carrier: PENINSULA AIRWAYS, INC.



Last Depart. Point: ANCHORAGE, AKDestination: Same as Incident










Flight Time (Hours)



PENAIR FLIGHT 4266 WAS CLEARED FOR A LOCALIZER DME APPROACH TO RUNWAY 19. THE AIRPLANE BROKE OUT OF THE CLOUDS AT 800 FEET MSL AT 4.8 DME FROM THEAIRPORT. THE CREW IMMEDIATELY SAW AN AIRPLANE DIRECTLY IN FRONT, AND AFTER EVASIVE ACTION THE AIRPLANES PASSED WITHIN 100 FEET OF EACH OTHER. THESPECIAL WEATHER OBSERVATION, TAKEN ONE MINUTE PRIOR TO THE NEAR MID AIR BUT NOT YET TRANSMITTED, SHOWED THE CONTROL ZONE BELOW VISUALMETEOROLOGICAL CONDITIONS. HOWEVER, THE PREVIOUS HOURLY OBSERVATION, AND THE MOST CURRENT TRANSMITTED OBSERVATION, SHOWED THAT THE CONTROLZONE WAS UNDER VISUAL METEOROLOGICAL CONDITIONS.


ANC92IA100AFile No. 5051 6/26/1992 DILLINGHAM, AK Aircraft Reg No. N620PA Time (Local): 13:00 ADT

Occurrence #1: NEAR COLLISION BETWEEN AIRCRAFTPhase of Operation: APPROACH - FAF/OUTER MARKER TO THRESHOLD (IFR)

Findings 1. (F) WEATHER CONDITION - DRIZZLE/MIST 2. (F) WEATHER CONDITION - FOG 3. (C) VISUAL LOOKOUT - NOT MAINTAINED - PILOT OF OTHER AIRCRAFT 4. (F) UPDATING OF RECORDED WEATHER INFORMATION - NOT POSSIBLE - ATC PERSONNEL(FSS)


The National Transportation Safety Board determines the probable cause(s) of this incident as follows.THE VISUAL LOOKOUT THAT WAS NOT MAINTAINED BY THE PILOT OF THE OTHER AIRPLANE. FACTORS WERE THE DRIZZLE AND FOG AND THE IMPOSSIBILITY OF UPDATING

THE RECORDED WEATHER INFORMATION BY ATC PERSONNEL.



Brief of Incident

Adopted 9/14/1993

LAX92IA307BFile No. 5035 7/17/1992 LOS ANGELES, CA Aircraft Reg No. N2725D Time (Local): 18:30 PDT






Last Depart. Point: Unk/NrDestination: INYOKERN, CA

Airport Proximity: On AirportAirport Name: LOS ANGELES



Condition of Light: Night/DarkWeather Info Src: Witness




Precipitation: None




Flight Time (Hours)



A FAIRCHILD SA-227 WAS POSITIONED BY GROUND PERSONNEL IN A PARKING SPOT ADJACENT TO ANOTHER OPERATORS ARRIVAL GATE. DUE TO OTHER AIRCRAFT IN THEPARKING AREA, THE TAIL OF THE FAIRCHILD ENCROACHED INTO THE SAFETY AREA OF THE NEXT GATE. AS AN ARRIVING LOCKHEED L-1011 WAS TAXIING INTO ITS GATE AREA,GROUND PERSONNEL NOTICED THAT THE AIRPLANE'S LEFT WING WAS GOING TO CONTACT THE VERTICAL STABILIZER OF THE FAIRCHILD. GROUND PERSONNEL DID NOTSIGNAL A STOP IN TIME TO AVOID THE COLLISION.


LAX92IA307BFile No. 5035 7/17/1992 LOS ANGELES, CA Aircraft Reg No. N2725D Time (Local): 18:30 PDT

Occurrence #1: ON GROUND/WATER COLLISION WITH OBJECTPhase of Operation: TAXI

Findings 1. OBJECT - AIRCRAFT PARKED/STANDING 2. (C) DISTANCE - MISJUDGED - GROUND PERSONNEL 3. (F) PROPER ASSISTANCE - NOT PERFORMED - GROUND PERSONNEL


The National Transportation Safety Board determines the probable cause(s) of this incident as follows.A FAILURE OF GROUND PERSONNEL TO ENSURE PROPER CLEARANCE BETWEEN A TAXIING AIRPLANE AND AN ADJACENT PARKED AIRPLANE. CONTRIBUTING TO THE

ACCIDENT WAS A FAILURE OF GROUND PERSONNEL TO PROPERLY POSITION A PARKED AIRPLANE TO ENSURE THAT IT DID NOT ENCROACH INTO AN ADJACENT SAFETY AREA.



Brief of Accident

Adopted 9/17/1993

FTW92FA218File No. 2579 8/25/1992 HOT SPRINGS, AR Aircraft Reg No. N342AE Time (Local): 05:15 CDT

Make/Model: FAIRCHILD / SA 227-ACEngine Make/Model: GARRETT / TPE-331-611


Operating Certificate(s): Commuter Air CarrierType of Flight Operation: Unk/Nr




Airport Proximity: On AirportAirport Name: HOT SPRINGS MEMORIAL



Condition of Light: DawnWeather Info Src: Witness




Precipitation: None




Flight Time (Hours)



THE MAINTENANCE TEST FLIGHT WAS BEING FLOWN FOLLOWING COMPLETION OF AIRWORTHINESS DIRECTIVE 87-02-02 REQUIRING THE MANDATORY REPLACEMENT OF ALLPRIMARY FLIGHT CONTROL CABLES. FOLLOWING LIFT-OFF, WITNESSES OBSERVED THE AIRPLANE START A RAPID ROLL TO THE RIGHT UNTIL INITIAL IMPACT WAS MADE WITHTHE GROUND BY THE RIGHT WING TIP. EXAMINATION OF THE WRECKAGE REVEALED THE A HALF TURN IN THE ROUTING OF THE REPLACED FLIGHT CONTROL CABLE WASINADVERTENTLY OMITTED ON BOTH CONTROL COLUMNS WHICH WOULD RESULT IN THE AILERONS OPERATING IN REVERSE OF THE COMMANDED INPUT. THE PASSENGER WASTHE QUALITY CONTROL INSPECTOR WHO HAD INSPECTED AND SIGNED OFF THE MAINTENANCE PERFORMED. ACCORDING TO OTHER COMPANY PERSONNEL, HE HAD BRIEFEDTHE CREW PRIOR TO THE FLIGHT ON THE PURPOSE OF THE TEST FLIGHT AND THE EXTENT OF THE MAINTENANCE THAT THE AIRPLANE HAD UNDERGONE.


FTW92FA218File No. 2579 8/25/1992 HOT SPRINGS, AR Aircraft Reg No. N342AE Time (Local): 05:15 CDT


Findings 1. (C) FLT CONTROL SYST,AILERON CONTROL - INCORRECT 2. (C) MAINTENANCE,INSPECTION - INADEQUATE - COMPANY MAINTENANCE PERSONNEL 3. (C) AIRCRAFT PREFLIGHT - INADEQUATE - PILOT IN COMMAND

----------

Occurrence #2: IN FLIGHT COLLISION WITH TERRAIN/WATERPhase of Operation: TAKEOFF - INITIAL CLIMB


The National Transportation Safety Board determines the probable cause(s) of this accident as follows.INADEQUATE MAINTENANCE AND INSPECTION BY THE OPERATOR'S MAINTENANCE PERSONNEL, AND THE FAILURE OF THE PILOT-IN-COMMAND TO ASSURE PROPER TRAVELDIRECTION OF THE AIRPLANE'S PRIMARY FLIGHT CONTROLS AFTER BEING MADE AWARE OF THE NATURE OF THE MAINTENANCE PERFORMED.



Brief of Accident

Adopted 9/14/1993

FTW92LA228File No. 2981 9/18/1992 SAN ANTONIO, TX Aircraft Reg No. N2183A Time (Local): 13:10 CDT

Make/Model: FAIRCHILD / SA-227-ACEngine Make/Model: GARRETT / TPE331-11U


Operating Certificate(s): NoneType of Flight Operation: Unk/Nr




Airport Proximity: On AirportAirport Name: SAN ANTONIO INTL.







Precipitation: None




Flight Time (Hours)



THE PILOT WAS CONDUCTING A FUNCTIONAL TEST FLIGHT AND QUALITATIVE ENGINEERING EVALUATION OF THE AIRPLANE'S LONGITUDINAL CONTROL DURING LANDING.DURING FINAL APPROACH TO RUNWAY 12L, HE REDUCED THE ENGINES TO THE FLIGHT IDLE POSITIONS AND ESTABLISHED 95 KIAS. HE WAS UNABLE TO RAISE THE NOSE OFTHE AIRPLANE DURING THE FLARE TO ARREST THE DESCENT RATE AND LANDED HARD ONTO THE RUNWAY. THE AIRPLANE WAS TAXIED TO THE RAMP AND SECURED. NOMECHANICAL FAILURE WAS FOUND OR REPORTED.


FTW92LA228File No. 2981 9/18/1992 SAN ANTONIO, TX Aircraft Reg No. N2183A Time (Local): 13:10 CDT

Occurrence #1: HARD LANDINGPhase of Operation: LANDING - FLARE/TOUCHDOWN

Findings 1. PROPER DESCENT RATE - EXCEEDED 2. (C) AIRCRAFT PERFORMANCE,LANDING CAPABILITY - EXCEEDED 3. (F) PERFORMANCE DATA - INADEQUATE - MANUFACTURER


The National Transportation Safety Board determines the probable cause(s) of this accident as follows.THE LANDING CAPABILITY OF THE AIRPLANE WAS EXCEEDED. THE LACK OF PERFORMANCE DATA WAS A FACTOR IN THE ACCIDENT.



Brief of Accident

Adopted 5/26/1993

SEA93LA027File No. 463 11/21/1992 BILLINGS, MT Aircraft Reg No. N139PA Time (Local): 01:29 MST

Make/Model: SWEARINGEN / SA-226TCEngine Make/Model: GARRETT / TPE-331-10UA


Operating Certificate(s): Commuter Air CarrierName of Carrier: BIG SKY TRANSPORTATION CO



Last Depart. Point: SIDNEY, MTDestination: WILLISTON, ND

Airport Proximity: On AirportAirport Name: BILLINGS LOGAN INTERNAT.







Precipitation: None




Flight Time (Hours)



AFTER GETTING A GEAR UNSAFE LIGHT ON THE RIGHT MAIN LANDING GEAR WHEN THE PILOTS ATTEMPTED TO EXTEND THE LANDING GEAR, THEY ELECTED TO FLY BACK TOTHEIR MAINTENANCE FACILITY. AFTER REPEATED ATTEMPTS TO RECTIFY THE PROBLEM, THEY SUCCESSFULLY ACCOMPLISHED A PRECAUTIONARY GEAR UP LANDING.INVESTIGATION REVEALED THAT THE RIGHT MAIN LANDING GEAR DOOR ROLLER WAS FRACTURED AND PREVENTED THE RIGHT MAIN GEAR FROM EXTENDING.


SEA93LA027File No. 463 11/21/1992 BILLINGS, MT Aircraft Reg No. N139PA Time (Local): 01:29 MST


Findings 1. (C) LANDING GEAR,NORMAL RETRACTION/EXTENSION ASSEMBLY - FAILURE,PARTIAL 2. (F) MAINTENANCE,LUBRICATION - INADEQUATE - OTHER MAINTENANCE PERSONNEL


The National Transportation Safety Board determines the probable cause(s) of this accident as follows.FAILURE OF A GEAR DOOR ROLLER, WHICH NECESSITATED A GEAR UP LANDING. FACTORS INCLUDE INADEQUATE LUBRICATION.



Brief of Accident

Adopted 10/13/1993

SEA93LA053File No. 72 1/16/1993 JOHN DAY, OR Aircraft Reg No. N161RS Time (Local): 08:45 PST

Make/Model: SWEARINGEN / SA-226T(B)Engine Make/Model: GARRETT / TPE-331-10





Last Depart. Point: ROSEBURG, ORDestination: Same as Accident

Airport Proximity: On AirportAirport Name: JOHN DAY


Runway Surface: AsphaltRunway Surface Condition: Snow--dry





Precipitation: None




Flight Time (Hours)



THE PILOT STATED THAT THE RUNWAY HAD NOT BEEN PLOWED RECENTLY. DURING APPROACH, HE COULD IDENTIFY THE RUNWAY BECAUSE OF AIRPORT RUNWAY LIGHTS.HE STATED THAT HE BELIEVED THAT SNOW WAS THROWN UP BY THE PROPELLER(S) AFTER TOUCHDOWN, RESTRICTING HIS VISIBILITY. HE ELECTED TO STAY ON THEGROUND AT THAT TIME RATHER THAN ATTEMPT A GO AROUND. THE AIRCRAFT DRIFTED OFF THE LEFT SIDE OF THE RUNWAY, AND THE RIGHT MAIN LANDING GEARCOLLAPSED DURING HIS ATTEMPT TO REGAIN CONTROL.


SEA93LA053File No. 72 1/16/1993 JOHN DAY, OR Aircraft Reg No. N161RS Time (Local): 08:45 PST


Findings 1. (F) AIRPORT FACILITIES,RUNWAY/LANDING AREA CONDITION - SNOW COVERED 2. (C) DIRECTIONAL CONTROL - NOT MAINTAINED - PILOT IN COMMAND

----------

Occurrence #2: MAIN GEAR COLLAPSEDPhase of Operation: LANDING - ROLL

Findings 3. LANDING GEAR - OVERLOAD


The National Transportation Safety Board determines the probable cause(s) of this accident as follows.THE PILOT'S FAILURE TO MAINTAIN DIRECTIONAL CONTROL. FACTORS INCLUDE A SNOW COVERED RUNWAY.



Brief of Accident

Adopted 3/16/1994

ATL93MA068File No. 470 4/1/1993 BLOUNTVILLE, TN Aircraft Reg No. N500AK Time (Local): 21:28 EST

Make/Model: Fairchild / SA227-TTEngine Make/Model: Garrett / TPE331-10U513





Last Depart. Point: KNOXVILLE, TNDestination: Same as Accident






Precipitation: None




Flight Time (Hours)



N500AK ENCOUNTERED ICING IN FLIGHT BEFORE START OF ILS APPROACH. RADAR DATA SHOWED THAT BEFORE REACHING OUTER MARKER, IT SLOWED IN A MANNER THATWAS CONSISTENT WITH A POWER REDUCTION (OR PARTIAL LOSS OF POWER), THEN IT ENTERED A STEEP DESCENT & CRASHED. EXAMINATION REVEALED ENGINES WERE NOTOPERATING AT IMPACT & THAT PROPELLERS HAD BEEN FEATHERED. NO PREIMPACT PART FAILURE OR MALFUNCTION OF ENGINES, PROPELLERS OR ANTI-ICE SYSTEM WASFOUND. THERE WAS EVIDENCE THAT ENGINE INLET ANTI-ICE ANNUNCIATOR LIGHTS & STABILITY AUGMENTATION SYSTEM (SAS) FAULT WARNING LIGHT WERE ILLUMINATEDDURING IMPACT. THE ENGINE MANUFACTURER REPORTED THAT FLAMEOUTS HAD OCCURRED IN OTHER AIRCRAFT, DURING OR FOLLOWING OPERATION IN ICING CONDITIONS,SOMETIMES AFTER DESCENT INTO WARMER AIR. FLIGHT MANUAL NOTED THAT IF ICING WAS ENCOUNTERED WITH ANTI-ICE SYSTEM OFF, SELECT CONTINUOUS IGNITION &THEN SELECT ENGINE & PROPELLER HEAT (1 ENGINE AT A TIME, ENSURING FIRST ENGINE WAS OPERATING SATISFACTORILY BEFORE SELECTING SECOND ENGINE) & ENGAGESAS HEAT.


ATL93MA068File No. 470 4/1/1993 BLOUNTVILLE, TN Aircraft Reg No. N500AK Time (Local): 21:28 EST

Occurrence #1: IN FLIGHT ENCOUNTER WITH WEATHERPhase of Operation: CRUISE

Findings 1. (F) LIGHT CONDITION - DARK NIGHT 2. (F) WEATHER CONDITION - ICING CONDITIONS 3. (F) NACELLE/PYLON - ICE

----------

Occurrence #2: LOSS OF ENGINE POWER(TOTAL) - NONMECHANICALPhase of Operation: APPROACH - IAF TO FAF/OUTER MARKER (IFR)

Findings 4. ALL ENGINES 5. (C) PROCEDURES/DIRECTIVES - NOT FOLLOWED - PILOT IN COMMAND 6. (C) ANTI-ICE/DEICE SYSTEM - IMPROPER USE OF - PILOT IN COMMAND

----------

Occurrence #3: LOSS OF CONTROL - IN FLIGHTPhase of Operation: DESCENT - EMERGENCY

Findings 7. (C) AIRSPEED - NOT MAINTAINED - PILOT IN COMMAND 8. (C) STALL - INADVERTENT - PILOT IN COMMAND

----------



The National Transportation Safety Board determines the probable cause(s) of this accident as follows.FAILURE OF THE PILOT TO FOLLOW PROCEDURES CONCERNING USE OF THE ENGINE INLET ANTI-ICE SYSTEM AND/OR CONTINUOUS IGNITION WHILE OPERATING IN ICINGCONDITIONS, WHICH RESULTED IN PROBABLE ICE INGESTION AND LOSS OF ENGINE POWER; AND THE PILOT'S FAILURE TO MAINTAIN SUFFICIENT AIRSPEED WHILE COPINGWITH THE ENGINE PROBLEM, WHICH RESULTED IN A STALL. FACTORS RELATED TO THE ACCIDENT WERE: DARKNESS, ICING CONDITIONS, AND ENGINE INLET (NACELLE) ICE.



Brief of Accident

Adopted 6/22/1994

FTW93FA165File No. 833 5/25/1993 SANTA FE, NM Aircraft Reg No. N241DT Time (Local): 21:14 MDT

Make/Model: FAIRCHILD / SA-226TEngine Make/Model: GARRETT / TPE331-3U


Operating Certificate(s): On-demand Air TaxiType of Flight Operation: Instructional



Last Depart. Point: ALBUQUERQUE, NMDestination: Same as Accident






Precipitation: None




Flight Time (Hours)



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 THECREW'S TRAINING. THE CHECKRIDE WAS BEING OBSERVED BY A FAA INSPECTOR SEATED IN THE CABIN. AFTER COMPLETING AN ILS APPROACH TO RWY 2, THE FLIGHT WASCLEARED TO CIRCLE TO LAND ON RWY 15. THE AIRPLANE WAS OBSERVED OVERFLYING RWY 15 AND LINED UP FOR RWY 20. THE TOWER ADVISED THE PILOT THAT HE WASLINED UP FOR RWY 20, AND WAS GIVEN THE OPTION TO LAND ON EITHER RWY 15 OR RWY 20. THE PILOT OPTED FOR RWY 15 AND WAS CLEARED TO A RIGHT DOWNWIND. THEAIRPLANE IMPACTED A HILL AT THE 6,870-FT LEVEL NEAR THE CREST, APROX 5 MI WEST OF THE AIRPORT. THE PUBLISHED CIRCLING MDA FOR THE ILS RWY 2 APCH IS 6,860 FT.THE AIRPORT IS LOCATED ABOUT 9 MI FROM THE CITY, AND SEVERAL LOCAL PILOTS REPORTED A TOTAL LACK OF VISUAL REFERENCE IN THAT SEGMENT.


FTW93FA165File No. 833 5/25/1993 SANTA FE, NM Aircraft Reg No. N241DT Time (Local): 21:14 MDT

Occurrence #1: IN FLIGHT COLLISION WITH TERRAIN/WATERPhase of Operation: APPROACH - VFR PATTERN - BASE TURN

Findings 1. (F) TERRAIN CONDITION - MOUNTAINOUS/HILLY 2. (F) LIGHT CONDITION - DARK NIGHT 3. (C) PLANNED APPROACH - POOR - PILOT IN COMMAND(CFI) 4. (C) ALTITUDE - INADEQUATE - PILOT IN COMMAND(CFI) 5. (F) VISUAL/AURAL PERCEPTION - PILOT IN COMMAND(CFI)


The National Transportation Safety Board determines the probable cause(s) of this accident as follows.THE PILOT'S POORLY PLANNED CIRCLING APPROACH, AND HIS FAILURE TO MAINTAIN AN ADEQUATE ALTITUDE. FACTORS WHICH CONTRIBUTED TO THE ACCIDENT WERE: THEDARK NIGHT AND A LACK OF VISUAL REFERENCE.



Brief of Accident

Adopted 9/20/1994

NYC93FA159File No. 1811 8/17/1993 HARTFORD, CT Aircraft Reg No. N220KC Time (Local): 02:25 EDT

Make/Model: SWEARINGEN / SA-226-TCEngine Make/Model: GARRETT / TPE-331-3U


Operating Certificate(s): On-demand Air TaxiType of Flight Operation: Positioning



Last Depart. Point: FARMINGDALE, NYDestination: Same as Accident



Basic Weather: Instrument Meteorological CondLowest Ceiling: 1500 Ft. AGL, Broken



Precipitation: None



Instrument RatingsAirplane; Helicopter

Flight Time (Hours)



ON AN APPROACH TO LAND AT THE DESTINATION, THE SECOND-IN-COMMAND (SIC) WAS FLYING THE AIRPLANE. THE PLANE TOUCHED DOWN WITH THE LANDING GEARRETRACTED, & THE PROPELLER BLADES CONTACTED THE RUNWAY. THE SIC INITIATED A GO-AROUND (ABORTED LANDING). WITNESSES SAW THE AIRPLANE IN A STEEP LEFTBANK JUST BEFORE IMPACT IN A RIVER NEXT TO THE AIRPORT. PROPELLER STRIKES ON THE RUNWAY EXTENDED 380', INDICATING A TOUCHDOWN SPEED OF 96 KTS. THELAST PROPELLER STRIKES ON THE RIGHT SIDE INDICATED A SPEED OF 86 KTS. THE LAST STRIKES ON THE LEFT SIDE INDICATED A SLOWING PROPELLER. PUBLISHED VMCFOR THE AIRPLANE WAS 94 KTS. THE CVR TAPE REVEALED THE CREW COMPLETED A DESCENT ARRIVAL CHECK, PERFORMED AN INCOMPLETE APPROACH BRIEFING, & DIDNOT PERFORM A BEFORE LANDING CHECK. THE CVR REVEALED NO SOUND OF A GEAR WARNING HORN. COMPANY PERSONNEL STATED THAT THE CIRCUIT BREAKER FOR THEWARNING HORN HAD BEEN FOUND PULLED AT THE COMPLETION OF PREVIOUS FLIGHTS BY OTHER CREW; THIS WAS TO PREVENT A WARNING HORN FROM SOUNDING DURINGA HIGH RATE OF DESCENT.


NYC93FA159File No. 1811 8/17/1993 HARTFORD, CT Aircraft Reg No. N220KC Time (Local): 02:25 EDT


Findings 1. LIGHT CONDITION - DARK NIGHT 2. (C) CHECKLIST - NOT FOLLOWED - COPILOT/SECOND PILOT 3. (C) GEAR EXTENSION - NOT PERFORMED - COPILOT/SECOND PILOT 4. (C) SUPERVISION - INADEQUATE - PILOT IN COMMAND

----------

Occurrence #2: AIRFRAME/COMPONENT/SYSTEM FAILURE/MALFUNCTIONPhase of Operation: LANDING - FLARE/TOUCHDOWN

Findings 5. PROPELLER SYSTEM/ACCESSORIES - OVERLOAD

----------

Occurrence #3: LOSS OF CONTROL - IN FLIGHTPhase of Operation: LANDING - ABORTED

Findings 6. ABORTED LANDING - INITIATED - COPILOT/SECOND PILOT 7. (C) AIRSPEED(VMC) - NOT MAINTAINED - COPILOT/SECOND PILOT 8. (C) REMEDIAL ACTION - INADEQUATE - PILOT IN COMMAND 9. (C) AIRCRAFT CONTROL - NOT MAINTAINED

----------


Findings10. TERRAIN CONDITION - WATER


The National Transportation Safety Board determines the probable cause(s) of this accident as follows.FAILURE OF THE COPILOT (SECOND-IN-COMMAND) TO FOLLOW THE CHECKLIST, ASSURE THE GEAR WAS EXTENDED FOR LANDING AND ATTAIN OR MAINTAIN ADEQUATEAIRSPEED (VMC); AND FAILURE OF THE PILOT-IN-COMMAND (PIC) TO PROPERLY SUPERVISE THE FLIGHT AND TAKE SUFFICIENT REMEDIAL ACTION.



Brief of Incident

Adopted 9/26/1994

CHI93IA382File No. 5049 8/30/1993 GRAND RAPIDS, MN Aircraft Reg No. N446MA Time (Local): 12:30 CDT

Make/Model: FAIRCHILD / SA-227-ACEngine Make/Model: GARRETT / TPE-331-11U


Operating Certificate(s): SupplementalType of Flight Operation: Business



Last Depart. Point: THIEF RVE FALLS, MNDestination: Same as Incident

Airport Proximity: On AirportAirport Name: GRAND RAPIDS







Precipitation: None




Flight Time (Hours)



THE FLIGHT CREW WAS ON A REPOSITIONING FLIGHT. THE CREW EXPERIENCED A RESTRICTION TO AILERON CONTROL WHILE MANEUVERING TO LAND. ON APPROACH TOLANDING THERE WAS LIMITED AILERON CONTROL TO THE LEFT, AND NO AILERON CONTROL TO THE RIGHT. THE AIRPLANE LANDED SUCCESSFULLY. SUBSEQUENTEXAMINATION OF THE AILERON CABLE DISCLOSED THAT IT WAS BROKEN. AN INDEPENDENT METALLURGICAL EXAMINATION OF THE CABLE REVEALED THAT THE FAILURE WASCONSISTENT WITH IT HAVING COME OFF THE PULLEY AND WEARING AGAINST A SMALL DIAMETER STEEL PIN. AFTER THE INCIDENT, A COMPLETE INSPECTION OF THEAIRLINE'S FLEET WAS CONDUCTED ON THE AILERON CONTROL CABLES AND NO SIMILAR DISCREPANCIES WERE FOUND.


CHI93IA382File No. 5049 8/30/1993 GRAND RAPIDS, MN Aircraft Reg No. N446MA Time (Local): 12:30 CDT

Occurrence #1: AIRFRAME/COMPONENT/SYSTEM FAILURE/MALFUNCTIONPhase of Operation: MANEUVERING

Findings 1. (C) FLT CONTROL SYST,AILERON CONTROL CABLE/ROD - FRACTURED 2. (C) MAINTENANCE,ADJUSTMENT - INADEQUATE - OTHER MAINTENANCE PERSONNEL


The National Transportation Safety Board determines the probable cause(s) of this incident as follows.the fractured aileron cable and other maintenance personnel's inadequate maintenance/adjustment.



Brief of Accident

Adopted 10/20/1994

BFO94LA002File No. 1938 11/5/1993 NEWARK, NJ Aircraft Reg No. N550TD Time (Local): 12:06 EST

Make/Model: FAIRCHILD / SA 227-ACEngine Make/Model: Garrett / TPE 331-11


Operating Certificate(s): Commuter Air CarrierName of Carrier: NORTHEAST EXPRESS AIRLINES INC



Last Depart. Point: Same as AccidentDestination: BOSTON, MA

Airport Proximity: On AirportAirport Name: NEWARK INTERNATIONAL APT.







Precipitation: Rain




Flight Time (Hours)



THE RAMP AGENT WAS SERVICING A FLIGHT THAT WAS 40 MINUTES BEHIND ITS SCHEDULED DEPARTURE TIME. AFTER BOTH ENGINES HAD BEEN STARTED, THE CAPTAINGAVE THE HAND SIGNAL TO DISCONNECT THE AIRPLANE FROM THE GROUND POWER UNIT (GPU). UPON RECEIVING THE SIGNAL, THE RAMP AGENT WALKED FROM THE FRONTOF THE AIRPLANE, AROUND THE RIGHT WING, AND TO THE REAR OF THE AIRPLANE. A SECOND RAMP AGENT THEN ARRIVED TO ASSIST. THE FIRST RAMP AGENTDISCONNECTED THE GPU, HANDED THE PLUG TO THE SECOND RAMP AGENT, DUCKED UNDER THE RIGHT WING, WALKED FORWARD INTO THE PROPELLER ARC, AND WASSTRUCK SEVERAL TIMES BY THE MOVING PROPELLER. THE RAMP AGENT RECIEVED TRAINING ON RAMP SAFETY AND WAS DESIGNATED AN INSTRUCTOR OF RAMP SAFETY.THREE AIRPLANES WERE AT THE GATE AREA AT THE TIME OF THE ACCIDENT. THE RAMP AREA DOES NOT HAVE ANY MARKINGS FOR AIRPLANE PARKING OR GROUNDOPERATIONS. THE MANUALS USED BY THE AGENT'S EMPLOYER DID NOT REFERENCE WALKING UNDER WINGS OR CLEARANCE FROM PROPELLER ARCS DURING RAMPOPERATIONS.


BFO94LA002File No. 1938 11/5/1993 NEWARK, NJ Aircraft Reg No. N550TD Time (Local): 12:06 EST


Findings 1. AIRPORT FACILITIES,RAMP FACILITIES - CONGESTED 2. (C) PROCEDURES/DIRECTIVES - NOT FOLLOWED - GROUND PERSONNEL 3. (C) INATTENTIVE - GROUND PERSONNEL 4. FACILITY,INADEQUATE WORKPLACE, DISTRACTION - COMPANY/OPERATOR MANAGEMENT 5. (F) PRESSURE - GROUND PERSONNEL 6. (F) FACILITY,INADEQUATE MANUALS/DIRECTIVES - COMPANY/OPERATOR MANAGEMENT


The National Transportation Safety Board determines the probable cause(s) of this accident as follows.1) THE FAILURE OF THE RAMP AGENT TO FOLLOW PROPER PROCEDURES DURING THE SERVICING OF THE AIRPLANE, AND 2) HER LACK OF ATTENTION TO THE HAZARDSSURROUNDING HER. FACTORS RELATED TO THE ACCIDENT ARE 1) THE PRESSURE PLACED ON THE RAMP AGENT TO RUSH THE SERVICING OF THE DELAYED FLIGHT, AND 2)THE INADEQUATE MANUALS PROVIDED BY THE OPERATOR CONCERNING RAMP SAFETY.



Brief of Incident

Adopted 9/13/1994

FTW94IA032File No. 5050 11/11/1993 SUGAR LAND, TX Aircraft Reg No. N688NE Time (Local): 14:10 CST



Operating Certificate(s): Commuter Air CarrierName of Carrier: CONQUEST AIRLINES CORPORATION



Last Depart. Point: AUSTIN, TXDestination: Same as Incident

Airport Proximity: On AirportAirport Name: SUGAR LAND MUNICIPAL







Precipitation: None


Certificate(s)/Rating(s)Airline Transport; Flight Instructor; Commercial; Flight Engineer; Multi-engine Land; Single-engine Land


Flight Time (Hours)



ON FINAL APPROACH, THE LANDING GEAR WAS EXTENDED, CHECKED DOWN AND LOCKED, AND THREE GREEN LIGHTS WERE NOTED. THIS WAS CORROBORATED BY THECOCKPIT VOICE RECORDER. WHEN THE AIRPLANE TOUCHED DOWN, THE LEFT MAIN LANDING GEAR EITHER COLLAPSED OR RETRACTED. THE LANDING GEAR ACTUATORRODS, ROD ENDS, DOWN LOCK ROLLERS, AND CAMS WERE UNDAMAGED. DURING POST-INCIDENT EXAMINATION, THE HYDRAULIC POWER PACK MADE A LOUD NOISE ANDHYDRAULIC PRESSURE FLUCTUATED BETWEEN 500 AND 1,200 PSI. NO DISCREPANCIES WERE NOTED WHEN THE HYDRAULIC POWER PACK WAS FUNCTIONALLY TESTED ANDINTERNALLY INSPECTED. PROCEDURAL ERRORS WERE MADE THAT MIGHT HAVE INVALIDATED THE TEST RESULTS.


FTW94IA032File No. 5050 11/11/1993 SUGAR LAND, TX Aircraft Reg No. N688NE Time (Local): 14:10 CST


Findings 1. (C) HYDRAULIC SYSTEM,PUMP - FAILURE,PARTIAL 2. (C) REASON FOR OCCURRENCE UNDETERMINED


The National Transportation Safety Board determines the probable cause(s) of this incident as follows.THE PARTIAL FAILURE OF THE HYDRAULIC PUMP (POWER PACK).



Brief of Incident

Adopted 9/26/1994

ANC94IA020File No. 5034 11/30/1993 KING SALMON, AK Aircraft Reg No. N630PA Time (Local): 18:58 AST

Make/Model: SWEARINGEN / SA227Engine Make/Model: GARRETT / TPE331-11


Operating Certificate(s): Commuter Air CarrierName of Carrier: PENAIR



Last Depart. Point: Same as IncidentDestination: ANCHORAGE, AK

Airport Proximity: On AirportAirport Name: KING SALMON







Precipitation: None


Certificate(s)/Rating(s)Airline Transport; Flight Instructor; Flight Engineer; Multi-engine Land; Single-engine Land


Flight Time (Hours)



THE AIRPLANE BEGAN TO DIVERGE TO THE RIGHT OF THE RUNWAY CENTERLINE DURING THE INITIAL TAKEOFF RUN AT A GROUND SPEED OF BETWEEN 20 AND 30 KNOTS. THEPILOT-IN-COMMAND (PIC) GLANCED AT THE ENGINE INSTRUMENTS AND OBSERVED AN ASYMMETRY IN TORQUE BETWEEN THE PLANE'S TWO ENGINES. THE PIC REPORTEDTHAT IN HIS HASTE TO ACCOMPLISH THE ABORT, HE WAS NOT ABLE TO GET THE LEFT POWER LEVER BACK TO THE GROUND IDLE POSITION PRIOR TO THE IMPACT WITH THENORTHWEST ARRESTING BARRIER PIT. THE PIC SAID THAT HE DEPRESSED THE NOSE WHEEL STEERING BUTTON BUT DID NOT PUSH THE BUTTON ON THE ENGINE POWERLEVER TO ENGAGE THE NOSE WHEEL STEERING. THE REASON FOR THE DELAYED OR DECREASED TORQUE FROM THE NO. 2 ENGINE COULD NOT BE CONCLUSIVELYDETERMINED.


ANC94IA020File No. 5034 11/30/1993 KING SALMON, AK Aircraft Reg No. N630PA Time (Local): 18:58 AST

Occurrence #1: ON GROUND/WATER COLLISION WITH OBJECTPhase of Operation: TAKEOFF - ABORTED

Findings 1. (F) POWERPLANT - UNDETERMINED 2. (C) AIRCRAFT CONTROL - NOT MAINTAINED - PILOT IN COMMAND 3. (C) PROCEDURES/DIRECTIVES - NOT PERFORMED - PILOT IN COMMAND


The National Transportation Safety Board determines the probable cause(s) of this incident as follows.THE PILOT-IN-COMMAND DID NOT MAINTAIN CONTROL OF THE AIRPLANE AND DID NOT PERFORM THE APPROPRIATE PROCEDURES FOR AN ABORTED TAKEOFF. A FACTOR INTHE INCIDENT WAS THE ASYMMETRY IN POWER BETWEEN THE PLANE'S TWO ENGINES FOR UNDETERMINED REASONS.



Brief of Accident

Adopted 11/18/1994

NYC94LA046File No. 375 1/3/1994 RICHMOND HEIGHT, OH Aircraft Reg No. N999MM Time (Local): 19:27 EST

Make/Model: SWEARINGEN / SA-226TEngine Make/Model: GARRETT / TPE-331





Last Depart. Point: ALLAIRE AIRPORT, NJDestination: Same as Accident

Airport Proximity: On AirportAirport Name: CUYAHOGA COUNTY AIRPORT


Runway Surface: AsphaltRunway Surface Condition: Ice Covered; Snow--wet





Precipitation: Snow




Flight Time (Hours)



THE PILOT INITIATED THE ILS APPROACH TO RUNWAY 05, WHICH WAS COVERED WITH ICE AND SNOW. HE STATED THAT 'EVERYTHING LOOKED GOOD TO ME AT TOUCHDOWN.'THE AIRPLANE VEERED TO THE LEFT. HE SAID THAT IT MAY HAVE 'YAWED FIRST THEN SLID NOT SURE...' HE TRIED TO STEER THE AIRPLANE BACK TO THE RUNWAYCENTERLINE, BUT HE WAS UNABLE TO CONTROL THE DIRECTION. THE AIRPLANE 'MADE A VERY SHARP LEFT TURN [AND] LEFT THE RUNWAY.' THE NOSE WHEEL COLLAPSEDWHEN IT ENCOUNTERED SOFT TERRAIN. THE PILOT REPORTED THE WIND WAS FROM 060 DEGREES AT 10 KNOTS.


NYC94LA046File No. 375 1/3/1994 RICHMOND HEIGHT, OH Aircraft Reg No. N999MM Time (Local): 19:27 EST


Findings 1. (F) AIRPORT FACILITIES,RUNWAY/LANDING AREA CONDITION - ICY 2. (C) DIRECTIONAL CONTROL - NOT MAINTAINED - PILOT IN COMMAND

----------


Findings 3. (C) TERRAIN CONDITION - SOFT


The National Transportation Safety Board determines the probable cause(s) of this accident as follows.THE PILOT'S LOSS OF DIRECTIONAL CONTROL DURING LANDING, RESULTING IN A DEPARTURE FROM THE RUNWAY AND THE SUBSEQUENT ENCOUNTER WITH SOFT TERRAINAND COLLAPSE OF THE NOSE GEAR. A FACTOR RELATED TO THE ACCIDENT WAS THE ICY RUNWAY CONDITIONS.



Brief of Incident

Adopted 3/27/1995

LAX94IA181File No. 5006 4/4/1994 ONTARIO, CA Aircraft Reg No. N174SW Time (Local): 18:15 PDT

Make/Model: FAIRCHILD / SA-227ACEngine Make/Model: GARRETT / TPE 331-11


Operating Certificate(s): Commuter Air CarrierName of Carrier: SKYWEST AIRLINES INC.



Last Depart. Point: LOS ANGELES, CADestination: YUMA, AZ





Temperature (°C): 17Obstr to Vision: Haze; Smoke

Precipitation: None




Flight Time (Hours)



The aircraft was climbing at 1,000 feet per minute to a cruising altitude of 21,000 feet. Passing 19,800 feet, a loud 'bang' was heard and the captain was partially sucked through the broken left sidewindow. After about 4 seconds, he was able to pull himself back into the aircraft unassisted. He declared an emergency and landed the aircraft without further incident. A review of the maintenancerecords revealed that an applicable airworthiness directive requiring an inspection of the windows was complied with within the last 143.8 flight hours. The technical representative for Fairchild statedthat maintenance personnel who conducted the AD inspection and service bulletin inspections may have failed to detect the crack, due to the subtle inspection procedures employed. The approvedinspection procedures allow for two methods: 1) removal of the outer frame retainer for direct viewing of the screw holes, and 2) using a 90-degree prism seated in mineral oil for an indirect view ofthe screw holes. The airline was using the second method.


LAX94IA181File No. 5006 4/4/1994 ONTARIO, CA Aircraft Reg No. N174SW Time (Local): 18:15 PDT

Occurrence #1: DECOMPRESSIONPhase of Operation: CLIMB - TO CRUISE

Findings 1. (C) WINDOW,FLIGHT COMPARTMENT WINDOW/WINDSHIELD - FRACTURED 2. (C) MAINTENANCE,INSPECTION - INADEQUATE - COMPANY MAINTENANCE PERSONNEL 3. (F) INADEQUATE SURVEILLANCE,INADEQUATE PROCEDURE - MANUFACTURER


The National Transportation Safety Board determines the probable cause(s) of this incident as follows.the failure of maintenance personnel to detect a crack in the windscreen which exceeded the operational limits for pressurized flight. A factor in the accident was the inadequacy of the inspectionmethod published by the manufacturer.



Brief of Incident

Adopted 4/12/1995

LAX94IA203File No. 5007 4/23/1994 SANTA MONICA, CA Aircraft Reg No. N27220 Time (Local): 09:09 PDT

Make/Model: FAIRCHILD / SA-227Engine Make/Model: GARRETT / TPE-331-11





Last Depart. Point: SANTA MARIA, CADestination: LOS ANGELES, CA










Flight Time (Hours)



WHILE DESCENDING INTO THE DOWNWIND LEG OF THE TRAFFIC PATTERN AT THE LOS ANGELES INTL AIRPORT, THE COMMUTER AIRPLANE ENCOUNTERED WAKE TURBULENCEFROM A PRECEDING BOEING 747-400, AND THE AIRPLANE ROLLED INVERTED. THE PILOT RECOVERED THE AIRPLANE, AND THE FLIGHT CONTINUED AND LANDED WITHOUTFURTHER INCIDENT. THE AIRPLANE SUSTAINED MINOR DAMAGE. RADAR DATA SHOWED THAT THE CUMMUTER WAS APPROX 5 MI FROM THE B-747 UP TO AND AT THE TIME ITENCOUNTERED THE TURBULENCE, WHICH MET CURRENT SEPARATION CRITERIA.


LAX94IA203File No. 5007 4/23/1994 SANTA MONICA, CA Aircraft Reg No. N27220 Time (Local): 09:09 PDT

Occurrence #1: VORTEX TURBULENCE ENCOUNTEREDPhase of Operation: DESCENT

Findings 1. (C) RADAR SEPARATION - INADEQUATE - FAA(OTHER/ORGANIZATION) 2. (C) INSUFFICIENT STANDARDS/REQUIREMENTS - FAA(ORGANIZATION) 3. WAKE TURBULENCE - ENCOUNTERED - PILOT IN COMMAND

----------

Occurrence #2: LOSS OF CONTROL - IN FLIGHTPhase of Operation: DESCENT


The National Transportation Safety Board determines the probable cause(s) of this incident as follows.FAA INADEQUATE SEPARATION STANDARDS BETWEEN LARGE AND HEAVY CATEGORY AIRCRAFT.



Brief of Incident

Adopted 10/13/1995

LAX95IA027File No. 5027 10/29/1994 OAKLAND, CA Aircraft Reg No. N191AF Time (Local): 07:45 PDT



Operating Certificate(s): On-demand Air TaxiName of Carrier: AMERIFLIGHT, INC



Last Depart. Point: Same as IncidentDestination: RENO, NV






Precipitation: None




Flight Time (Hours)



THE PILOT EXPERIENCED A LOSS OF AILERON CONTROL SHORTLY AFTER TAKEOFF. THE PILOT RETURNED TO THE AIRPORT AND LANDED WITHOUT FURTHER INCIDENT.EXAMINATION OF THE AIRPLANE REVEALED THE CABLE BROKE NEAR ITS 90-DEGREE ATTACH PULLEYS. THE SAFETY BOARD MATERIALS LABORATORY CONDUCTED AMETALLURGICAL EXAMINATION OF THE CABLE'S FRACTURED SURFACES. THE EXAMINATION REVEALED THE CABLE SEPARATED DUE TO HIGH-STRESS/LOW-CYCLE FATIGUECRACKING. MOST WIRE ENDS IN THE VICINITY OF THE SEPARATION WERE SEVERELY BENT. SUCH DAMAGE WOULD MOST LIKELY BE PRODUCED BY A KINK IN THE CABLE. ACABLE KINK CREATES VERY HIGH TENSILE STRESSES ALONG THE OUTSIDE OF THE KINK AND WOULD GENERATE PREMATURE HIGH-STRESS FATIGUE CRACKING. THE 15HOURS OF TIME SINCE INSTALLATION IS CONSISTENT WITH SOME SORT OF SEVERE CONDITION SUCH AS A KINK. THE MECHANIC MOST LIKELY INSTALLED THE CABLE WITHONE END TWISTED COMPARED WITH THE OTHER END.


LAX95IA027File No. 5027 10/29/1994 OAKLAND, CA Aircraft Reg No. N191AF Time (Local): 07:45 PDT


Findings 1. FLT CONTROL SYST,AILERON CONTROL CABLE/ROD - SEPARATION 2. FLT CONTROL SYST,AILERON CONTROL CABLE/ROD - FATIGUE 3. (C) MAINTENANCE,INSTALLATION - IMPROPER - COMPANY MAINTENANCE PERSONNEL


The National Transportation Safety Board determines the probable cause(s) of this incident as follows.the company maintenance personnel's improper installation of the aileron cable.



Brief of Incident

Adopted 7/31/1995

SEA95IA021File No. 5043 11/17/1994 MISSOULA, MT Aircraft Reg No. N380PH Time (Local): 06:35 MST

Make/Model: FAIRCHILD / SA227Engine Make/Model: GARRETT / TPE331-114





Last Depart. Point: HELENA, MTDestination: SPOKANE, WA


Condition of Light: DawnWeather Info Src: Pilot

Basic Weather: UnknownLowest Ceiling: Unk/Nr







Flight Time (Hours)



WHILE IN CRUISE FLIGHT, THE FIRST STAGE COMPRESSOR IMPELLER OF THE NUMBER TWO ENGINE EXPERIENCED A TOTAL FAILURE. THE CREW THEN ELECTED TO MAKE APRECAUTIONARY LANDING AT AN ALTERNATE AIRPORT. A METALLURGICAL ANALYSIS REVEALED THAT THE IMPELLER HAD EXPERIENCED A LOW CYCLE FATIGUE FRACTURE.


SEA95IA021File No. 5043 11/17/1994 MISSOULA, MT Aircraft Reg No. N380PH Time (Local): 06:35 MST

Occurrence #1: LOSS OF ENGINE POWER(TOTAL) - MECH FAILURE/MALFPhase of Operation: CRUISE

Findings 1. (C) COMPRESSOR ASSEMBLY,IMPELLER - FATIGUE 2. COMPRESSOR ASSEMBLY,IMPELLER - FAILURE


The National Transportation Safety Board determines the probable cause(s) of this incident as follows.THE FATIGUE FAILURE OF THE FIRST STAGE COMPRESSOR IMPELLER.



Brief of Incident

Adopted 10/19/1995

FTW95IA124File No. 5013 2/27/1995 AUSTIN, TX Aircraft Reg No. N369AE Time (Local): 08:05 CST

Make/Model: FAIRCHILD / SA227-ACEngine Make/Model: GARRETT / TPE 331-11U


Operating Certificate(s): Commuter Air CarrierName of Carrier: CONQUEST AIRLINES



Last Depart. Point: TYLER, TXDestination: Same as Incident

Airport Proximity: On AirportAirport Name: ROBERT MUELLER MUNICIPAL







Precipitation: None




Flight Time (Hours)



WHILE FLARING TO LAND, THE RUDDER CABLE FOR THE LEFT RUDDER SEVERED DUE TO IMPROPER ROUTING DURING THE SCHEDULED REPLACEMENT OF THE CONTROLCABLES IN COMPLIANCE WITH AN AIRWORTHINESS DIRECTIVE. THE FLIGHT CREW REPORTED HEARING A POPPING SOUND FOLLOWED BY THE RUDDER PEDAL DEFLECTING TOTHE STOP. CONTROL WAS MAINTAINED AND A NORMAL LANDING COMPLETED.


FTW95IA124File No. 5013 2/27/1995 AUSTIN, TX Aircraft Reg No. N369AE Time (Local): 08:05 CST

Occurrence #1: AIRFRAME/COMPONENT/SYSTEM FAILURE/MALFUNCTIONPhase of Operation: LANDING - FLARE/TOUCHDOWN

Findings 1. (C) FLT CONTROL SYST,RUDDER CONTROL CABLE/ROD - MISROUTED 2. (C) MAINTENANCE,COMPLIANCE WITH AD - IMPROPER - COMPANY MAINTENANCE PERSONNEL 3. (C) FLT CONTROL SYST,RUDDER CONTROL CABLE/ROD - FAILURE,TOTAL


The National Transportation Safety Board determines the probable cause(s) of this incident as follows.THE FAILURE OF THE MISROUTED RUDDER CONTROL CABLE DUE TO IMPROPER INSTALLATION DURING SCHEDULED REPLACEMENT TO COMPLY WITH AN AIRWORTHINESSDIRECTIVE.



Brief of Incident

Adopted 12/12/1995

FTW95IA126BFile No. 5016 2/27/1995 DALLAS-FT WORTH, TX Aircraft Reg No. N355AE Time (Local): 20:54 CST

Make/Model: FAIRCHILD / SA227-ACEngine Make/Model: ALLIED SIGNAL / TPE331-11U


Operating Certificate(s): Commuter Air CarrierName of Carrier: EXEC EXPRESS II



Last Depart. Point: Same as IncidentDestination: MOUNTAIN HOME, AR

Airport Proximity: On AirportAirport Name: DALLAS-FORT WORTH INTL







Precipitation: None




Flight Time (Hours)



ON THE NIGHT OF THE INCIDENT, THE LOCAL CONTROLLER CLEARED AMERICAN FLT 2351, N1763, TO LAND ON RWY 35R. SEVEN SECONDS LATER THE SAME CONTROLLERINSTRUCTED LONE STAR FLT 1219, N355AE, TO TAXI INTO POSITION AND HOLD ON RWY 35R. NEITHER CREW HEARD THE OTHER'S CLEARANCE, NOR WAS EITHER ADVISED OFTHE OTHER'S POSITION AS REQUIRED. THE TOWER CAB SUPERVISOR NOTICED THE CONFLICT & ALERTED THE CONTROLLER. THE CONTROLLER COULD NOT RECALL THE CALLSIGN FOR AA2351, AND ISSUED GO-AROUND INSTRUCTIONS USING INCORRECT CALL SIGNS AA1251 & AA1261. AA2351 OVERFLEW LS1219 BY ABOUT 35 FT BEFORE TOUCHINGDOWN. THE LOCAL FREQUENCY WAS VERY BUSY, AND THE CONTROLLER'S WORKLOAD WAS CATEGORIZED AS 'HEAVY' BY ALL FLIGHTCREWS INTERVIEWED. REVIEW OF ATCTAPES CONFIRMED THOSE OBSERVATIONS. THE CONTROLLER WAS HANDLING TRAFFIC ON RWYS 35L, 35R, AND 31R, IN ADDITION TO RECEIVING INPUTS FROM THEDEPARTURE CONTROLLER. FIFTEEN MINUTES BEFORE THE INCURSION, THE CONTROLLER WAS GETTING UNCOMFORTABLE, AND INFORMED HIS SUPERVISOR THAT HENEEDED A BREAK. THE SUPERVISOR LATER SAID THAT HE DID NOT NOTICE THAT THE CONTROLLER WAS GETTING OVERLOADED.


FTW95IA126BFile No. 5016 2/27/1995 DALLAS-FT WORTH, TX Aircraft Reg No. N355AE Time (Local): 20:54 CST

Occurrence #1: NEAR COLLISION BETWEEN AIRCRAFTPhase of Operation: STANDING - ENGINE(S) OPERATING

Findings 1. (C) CONTROL TOWER SERVICE - IMPROPER - ATC PERSONNEL(LCL/GND/CLNC) 2. (C) EXCESSIVE WORKLOAD (TASK OVERLOAD) - ATC PERSONNEL(LCL/GND/CLNC) 3. (C) SUPERVISION - INADEQUATE - ATC PERSONNEL(SUPERVISOR) 4. (F) LIGHT CONDITION - DARK NIGHT


The National Transportation Safety Board determines the probable cause(s) of this incident as follows.THE LOCAL CONTROLLER'S TASK OVERLOAD, WHICH LED HIM TO FORGET TO ISSUE APPROPRIATE TRAFFIC ADVISORIES AND TO LOSE HIS AWARENESS OF THE TRAFFICSITUATION, AND THE FAILURE OF THE CONTROLLER'S SUPERVISOR TO RECOGNIZE THAT THE CONTROLLER HAD REACHED OR EXCEEDED HIS MAXIMUM THRESHOLD OFWORKLOAD CAPABILITY AND TO TAKE APPROPRIATE ACTION.



Brief of Incident

Adopted 1/29/1996

SEA95IA082File No. 5022 4/16/1995 PASCO, WA Aircraft Reg No. N385PH Time (Local): 08:05 PDT

Make/Model: FAIRCHILD / SA-227Engine Make/Model: GARRETT / TPE331-11U-61


Operating Certificate(s): Commuter Air Carrier; Flag Carrier/DomesticName of Carrier: HORIZON AIRLINES



Last Depart. Point: Same as IncidentDestination: PORTLAND, OR






Precipitation: None




Flight Time (Hours)



DURING CLIMB OUT, THE CREW NOTICED AN UNUSUAL AIRFRAME VIBRATION, AND RETURNED TO THE DEPARTURE AIRPORT. FAA INSPECTORS DETERMINED THAT THERUDDER TRIM ACTUATOR ROD HAD BEEN IMPROPERLY INSTALLED, ALLOWING IT TO BIND AND EVENTUALLY FRACTURE.


SEA95IA082File No. 5022 4/16/1995 PASCO, WA Aircraft Reg No. N385PH Time (Local): 08:05 PDT

Occurrence #1: AIRFRAME/COMPONENT/SYSTEM FAILURE/MALFUNCTIONPhase of Operation: CLIMB - TO CRUISE

Findings 1. (C) FLT CONTROL SYST,RUDDER TRIM/TAB CONTROL - BINDING(MECHANICAL) 2. (C) MAINTENANCE,INSTALLATION - IMPROPER - COMPANY MAINTENANCE PERSONNEL 3. (C) FLT CONTROL SYST,RUDDER TRIM/TAB CONTROL - FRACTURED


The National Transportation Safety Board determines the probable cause(s) of this incident as follows.IMPROPER INSTALLATION OF THE RUDDER TRIM ACTUATOR ROD BY COMPANY MAINTENANCE PERSONNEL WHICH RESULTED IN BINDING AND FRACTURE OF THE ROD.



Brief of Incident

Adopted 9/24/1995

SEA95IA102File No. 5008 5/17/1995 SPOKANE, WA Aircraft Reg No. N2727B Time (Local): 06:30 PDT



Operating Certificate(s): Commuter Air CarrierName of Carrier: HORIZON AIR



Last Depart. Point: PORTLAND, ORDestination: Same as Incident






Precipitation: None




Flight Time (Hours)



WHILE IN CRUISE FLIGHT, THE FLIGHT CREW REPORTED THAT THERE WAS AN INTERMITTENT SONALERT FOR THE TRIM IN MOTION, HOWEVER, NEITHER THE TRIM INDICATORNOR THE AIRCRAFT TRIM WERE AFFECTED AT THIS TIME. SOME MINUTES LATER, THE ELEVATOR TRIM BEGAN TO MOVE WITHOUT CREW INPUT. BOTH THE CAPTAIN AND THECO-PILOT TRIED TO DEACTIVATE THE TRIM FROM THEIR CONTROL YOKE SWITCHES; HOWEVER, THE TRIM WOULD NOT DEACTIVATE UNTIL THE LEFT SIDE ESSENTIAL BUS WASSELECTED OFF. THE AIRPLANE THEN LANDED WITHOUT FURTHER INCIDENT. INSPECTION OF THE SYSTEM REVEALED THAT THE CAPTAIN'S SIDE TRIM POWER WIRE WASSHORTED DIRECTLY TO THE LEFT SIDE ESSENTIAL BUS, AND THE JUMPER WIRE AT THE CAPTAIN'S YOKE TRIM (GROUND SIDE) SWITCH WAS SHORTED TO THE YOKE. AFTERTHE WIRES WERE REPLACED, THE SYSTEMS OPERATION CHECKED OK.


SEA95IA102File No. 5008 5/17/1995 SPOKANE, WA Aircraft Reg No. N2727B Time (Local): 06:30 PDT


Findings 1. (C) ELECTRICAL SYSTEM,ELECTRIC WIRING - SHORTED 2. FLT CONTROL SYST,ELEVATOR TRIM/TAB CONTROL - UNCOMMANDED


The National Transportation Safety Board determines the probable cause(s) of this incident as follows.A SHORTED ELECTRICAL WIRING ON THE ELEVATOR TRIM SYSTEM.



Brief of Accident

Adopted 4/18/1996

CHI95LA341File No. 1573 9/16/1995 SOUTH BEND, IN Aircraft Reg No. N169GA Time (Local): 20:20 CDT

Make/Model: Swearingen / SA-226TCEngine Make/Model: Garrett / TPE-331-10-UA


Operating Certificate(s): CargoType of Flight Operation: Positioning



Last Depart. Point: Same as AccidentDestination: PANAMA CITY, FL

Airport Proximity: On AirportAirport Name: SOUTH BEND REGIONAL







Precipitation: None




Flight Time (Hours)



DURING A REPOSITIONING FLIGHT, THE PILOT-IN-COMMAND (PIC) WAS CONDUCTING ENGINE OUT TRAINING WITH THE COPILOT. THE PIC SIMULATED A RIGHT ENGINE FAILUREDURING INITIAL CLIMBOUT AFTER TAKEOFF APPROXIMATELY 300 FEET ABOVE GROUND LEVEL. THE AIRSPEED AND ALTITUDE STARTED TO DECAY. THE PIC SAID HE FIXATEDON AIRSPEED AND TERMINATED TRAINING AS AIRSPEED NEARED SINGLE ENGINE BEST ANGLE OF CLIMB AIRSPEED (VXSE). THE AIRPLANE STRUCK TREES NEAR THEDEPARTURE END OF THE RUNWAY AS POWER WAS APPLIED ON BOTH ENGINES, BUT THE AIRPLANE CONTINUED TO FLY AND WAS LANDED BACK AT THE AIRPORT. THE PILOTOPERATING HANDBOOK STATED UNDER A CAUTION THAT MINIMUM ALTITUDE FOR OBSTACLE CLEARANCE SHOULD BE MAINTAINED UNTIL SINGLE ENGINE BEST RATE OF CLIMBAIRSPEED (VYSE) IS ATTAINED. AT 11,500 POUNDS GROSS WEIGHT, THE SINGLE ENGINE CLIMB RATE SHOULD BEEN A POSITIVE 700 FEET PER MINUTE.


CHI95LA341File No. 1573 9/16/1995 SOUTH BEND, IN Aircraft Reg No. N169GA Time (Local): 20:20 CDT

Occurrence #1: IN FLIGHT COLLISION WITH OBJECTPhase of Operation: TAKEOFF

Findings 1. EMERGENCY PROCEDURE - SIMULATED - PILOT IN COMMAND 2. (C) SUPERVISION - INADEQUATE - PILOT IN COMMAND 3. (C) AIRSPEED - NOT OBTAINED/MAINTAINED - PILOT IN COMMAND 4. (C) PROPER CLIMB RATE - NOT OBTAINED/MAINTAINED - PILOT IN COMMAND 5. OBJECT - TREE(S) 6. (C) ALTITUDE/CLEARANCE - NOT MAINTAINED - PILOT IN COMMAND


The National Transportation Safety Board determines the probable cause(s) of this accident as follows.the Pilot-in-Command's inadequate supervision of the flight and failure to assure that proper airspeed, rate of climb, and clearance from trees were obtained/maintained.



Brief of Accident

Adopted 3/25/1997

LAX95FA338File No. 1892 9/18/1995 CHINO, CA Aircraft Reg No. N693PG Time (Local): 06:24 PDT

Make/Model: Swearingen / SA-226TEngine Make/Model: Garrett / TPE 331





Last Depart. Point: APPLE VALLEY, CADestination: Same as Accident




Visibility: .06 SMWind Dir/Speed: Calm


Precipitation: None


Certificate(s)/Rating(s)Commercial; Multi-engine Land; Single-engine Land; Single-engine Sea


Flight Time (Hours)



During arrival at dawn, the pilot contacted Approach Control about 22 miles from the airport at 8,500 feet and requested an ILS runway 26 approach. The ATIS was reporting 1/8 mile visibility withfog; the minimum published visibility for the ILS landing was 3/4 mile. The controller vectored the aircraft so that it intercepted the ILS localizer at the outer marker at an intercept angle that was 5degrees greater than the maximum allowable intercept of 30 degrees. The intercept point should have been at least 3 miles further away from the airport. The aircraft was 650 feet above the ILSglideslope at the outer marker (which was outside the ILS glideslope parameter). Instead of making a missed approach, the pilot elected to continue the ILS. As he attempted to intercept theglideslope from above, the airplane entered a high rate of descent and passed through the glideslope. The pilot was arresting the descent, when the airplane collided with level terrain about 1,000feet short of the runway. After the accident, at 0646 edt, the visibility was 1/16 mile with fog.


LAX95FA338File No. 1892 9/18/1995 CHINO, CA Aircraft Reg No. N693PG Time (Local): 06:24 PDT

Occurrence #1: IN FLIGHT COLLISION WITH TERRAIN/WATERPhase of Operation: APPROACH - FAF/OUTER MARKER TO THRESHOLD (IFR)

Findings 1. LIGHT CONDITION - DAWN 2. (F) WEATHER CONDITION - FOG 3. WEATHER CONDITION - BELOW APPROACH/LANDING MINIMUMS 4. (F) APPROACH/DEPARTURE CONTROL SERVICE - IMPROPER - ATC PERSONNEL(DEP/APCH) 5. (C) IFR PROCEDURE - IMPROPER - PILOT IN COMMAND 6. (C) PROPER GLIDEPATH - NOT FOLLOWED - PILOT IN COMMAND 7. (C) DECISION HEIGHT - BELOW - PILOT IN COMMAND 8. (C) MISSED APPROACH - NOT PERFORMED - PILOT IN COMMAND


The National Transportation Safety Board determines the probable cause(s) of this accident as follows.The pilot's improper IFR procedure by not initiating a missed approach at the outer marker, by attempting to intercept the glideslope from above after passing the outer marker, and by allowing theairplane to continue descending after reaching the decision height. Factors relating to the accident were: the adverse weather condition, and the approach controller's improper technique in vectoringthe airplane onto the ILS localizer.



Brief of Accident

Adopted 5/9/1996

CHI96LA053File No. 1809 12/15/1995 DETROIT, MI Aircraft Reg No. N31AT Time (Local): 04:23 EST

Make/Model: Swearingen / SA-226ATEngine Make/Model: Garrett / 331-3U-330G


Operating Certificate(s): On-demand Air TaxiType of Flight Operation: Positioning



Last Depart. Point: FLINT, MIDestination: Same as Accident

Airport Proximity: On AirportAirport Name: DETROIT METRO


Runway Surface: ConcreteRunway Surface Condition: Wet



Visibility: 7.00 SMWind Dir/Speed: Unk/Nr / 009 Kts


Precipitation: None




Flight Time (Hours)



The pilot reported that shortly after takeoff, the airplane's left engine started to surge. The airplane also began experiencing intermittent electrical surges which caused the instrument panel lights,cabin lights, and radios to go off and on. The pilot diverted to an alternate airport to land. He did not secure the left engine before landing because it was still developing some usable power. Heplaced the gear select handle in the down position and observed three green gear-down-and-locked lights. Prior to touchdown, both power levers were positioned to flight idle and no gear warninghorn sounded. The airplane landed gear up. Postaccident examination revealed no abnormalities with the landing gear or electrical system. The landing gear emergency extension functionedproperly. The landing gear indicating system showed a safe gear indication when the gear was extended during examination. Substantial damage to the gear doors was observed, but no damage tothe landing gear was observed.


CHI96LA053File No. 1809 12/15/1995 DETROIT, MI Aircraft Reg No. N31AT Time (Local): 04:23 EST

Occurrence #1: WHEELS UP LANDINGPhase of Operation: LANDING - FLARE/TOUCHDOWN

Findings 1. ELECTRICAL SYSTEM - UNDETERMINED 2. (C) GEAR EXTENSION - NOT PERFORMED - PILOT IN COMMAND 3. (F) DIVERTED ATTENTION - PILOT IN COMMAND


The National Transportation Safety Board determines the probable cause(s) of this accident as follows.the pilot's failure to extend the landing gear. A factor in the accident was the pilot's diverted attention.



Brief of Incident

Adopted 5/9/1996

CHI96IA066File No. 5039 12/28/1995 BEMIDJI, MN Aircraft Reg No. N159MC Time (Local): 17:48 CST

Make/Model: Fairchild / SA227-ACEngine Make/Model: Garrett / 331


Operating Certificate(s): Commuter Air Carrier; Flag Carrier/DomesticName of Carrier: MESABA AIRLINES, INC.



Last Depart. Point: MINNEAPOLIS, MNDestination: Same as Incident

Airport Proximity: On AirstripAirport Name: BEMIDJI COUNTY


Runway Surface: Unk/NrRunway Surface Condition: Dry; Snow--dry





Precipitation: None




Flight Time (Hours)



On short final, the crew noticed that the airplane had restricted up-elevator movement. They initiated a go-around and used power to control pitch for landing. Excessive descent rate and airspeedresulted in a hard landing. Postincident examination revealed a loose upper elevator stop bolt that had contacted a stringer, preventing further movement of the control column. Sixteen flights earlier,maintenance records show extensive work done to the elevator quadrant. During this work, hardware was 'loosely installed' on the quadrant so as to not be lost. The position of a nut run down onthe bolt is close to the appearance of a nut properly torqued.


CHI96IA066File No. 5039 12/28/1995 BEMIDJI, MN Aircraft Reg No. N159MC Time (Local): 17:48 CST


Findings 1. (C) FLT CONTROL SYST,ELEVATOR CONTROL - LOOSE PART/BOLT/NUT/CLAMP/ETC 2. (C) MAINTENANCE,INSTALLATION - IMPROPER - COMPANY MAINTENANCE PERSONNEL 3. (C) MAINTENANCE,INSPECTION - INADEQUATE - COMPANY MAINTENANCE PERSONNEL 4. FLIGHT CONTROL,ELEVATOR - MOVEMENT RESTRICTED

----------



The National Transportation Safety Board determines the probable cause(s) of this incident as follows.inadequate maintenance installation and inspection of the elevator flight control system which led to restricted flight control elevator movement due to a loose bolt.



Brief of Accident

Adopted 10/14/1997

CHI96LA162File No. 1408 5/17/1996 FARGO, ND Aircraft Reg No. N229AM Time (Local): 08:15 CDT

Make/Model: Swearingen / SA226TCEngine Make/Model: Garrett / TPE-331-10UA


Operating Certificate(s): Commuter Air CarrierName of Carrier: AIRVANTAGE, INC.



Last Depart. Point: MINNEAPOLIS, MNDestination: Same as Accident

Airport Proximity: On AirstripAirport Name: HECTOR INTERNATIONAL







Precipitation: None




Flight Time (Hours)



While on short final to land, the pilot-in-command landed with the nose landing gear still in the uplocked position. The maintenance logbook indicates several undetermined nose gear uplockconditions that the flight crews had to lower the nose gear by free falling it. All flights were uneventful up until this flight. A transcript of the cockpit voice recorder (CVR), indicated that the beforelanding checklist was not completed correctly. The landing gear challenge and reply checklist was recorded as saying landing gear coming down, with a horn beeping in the background. The Pilot'sOperating Handbook (POH) says, landing gear--down, with no report of three green down and locked lights.


CHI96LA162File No. 1408 5/17/1996 FARGO, ND Aircraft Reg No. N229AM Time (Local): 08:15 CDT


Findings 1. (F) LANDING GEAR,NOSE GEAR - JAMMED 2. (C) GEAR DOWN AND LOCKED - NOT COMPLIED WITH - FLIGHTCREW 3. (F) PREFLIGHT PLANNING/PREPARATION - INATTENTIVE - PILOT IN COMMAND

----------



The National Transportation Safety Board determines the probable cause(s) of this accident as follows.the flight crew did not comply with the gear down and lock checklist. The factors were a jammed nose gear and inattentive preflight planning/preparations by the pilot-in-command.



Brief of Incident

Adopted 4/29/1997

FTW96IA248File No. 5030 6/11/1996 ENID, OK Aircraft Reg No. N850LS Time (Local): 18:35 CDT

Make/Model: Fairchild / SA227-DCEngine Make/Model: Garrett / TPE-331-12UHR


Operating Certificate(s): Commuter Air CarrierName of Carrier: LONE STAR AIRLINES



Last Depart. Point: Same as IncidentDestination: DALLAS, TX






Precipitation: None




Flight Time (Hours)



The airplane experienced an uncommanded shut down of the right engine during initial climb to altitude. An emergency was declared, and an uneventful single engine landing was made at thedeparture airport. Subsequent to the incident, metallic chips were found on the chip detector. The bearings of the accessory gear housing assembly (P/N 3103601-6) was missing all of the balls.Fragments of these ball bearings were found in the bottom of the engine case. Examination of the bearing races revealed pitting and scoring. According to the operator's diagnostics, thedisintegration of the bearings allowed the gear shaft to drop down and contact the gears of the accessory drive idler gear assembly. Subsequently, the fuel pump drive gear was not driven, causingthe engine to be starved of fuel. Inspection of the idler gear assembly revealed sheared gear teeth. Examination of the gearbox oiling system, revealed no evidence of failure or thermal distress priorto the initial bearing failure. The engine manufacturer had recently issued Service Bulletins addressing the installation of heavier duty gear assemblies in applicable engine installations.


FTW96IA248File No. 5030 6/11/1996 ENID, OK Aircraft Reg No. N850LS Time (Local): 18:35 CDT

Occurrence #1: LOSS OF ENGINE POWER(TOTAL) - MECH FAILURE/MALFPhase of Operation: CLIMB - TO CRUISE

Findings 1. 1 ENGINE 2. (C) REDUCTION GEAR ASSY,ACCESSORY DRIVE BEARING - FAILURE 3. (C) REDUCTION GEAR ASSY,ACCESSORY DRIVE GEAR - SHEARED 4. (C) REDUCTION GEAR ASSY,ACCESSORY DRIVE SHAFT - DISENGAGED 5. (C) FUEL SYSTEM,PUMP - DISABLED 6. (C) FLUID,FUEL - STARVATION


The National Transportation Safety Board determines the probable cause(s) of this incident as follows.failure of the accessory drive bearing, causing the accessory drive gear teeth to shear and disengage the fuel pump accessory drive shaft, resulting in a disabled fuel pump and subsequent fuelstarvation.



Brief of Accident

Adopted 3/31/1998

CHI96FA216File No. 1663 6/25/1996 GRAND FORKS, ND Aircraft Reg No. N2692P Time (Local): 14:30 CDT

Make/Model: Fairchild / SA227ACEngine Make/Model: Garrett / TPE331


Operating Certificate(s): Commuter Air CarrierName of Carrier: MESABA AIRLINES



Last Depart. Point: Same as AccidentDestination: MINNEAPOLIS, MN






Precipitation: None




Flight Time (Hours)



The captain reported that the airplane was at 5,000 feet mean sea level, the propeller rpm was 100 percent, and other engine indications were normal. A loss of power on the number two engine was'sudden and immediate.' The flightcrew declared an emergency and recovered visually to Grand Forks without further incident. Examination of the airplane revealed eleven impact marks to the rightside of the fuselage. Two of the impacts penetrated the fuselage side. Examination of the engine revealed evidence of overload failure and penetration of the gear box. Fatigue fractures in thesecond stage compressor impeller rim emanated from a heat affected, rubbed area on the impeller blades. A corresponding rubbed area was evident on the impeller shroud, and aluminum materialwas fused to the titanium impeller. No evidence of material defects were noted.


CHI96FA216File No. 1663 6/25/1996 GRAND FORKS, ND Aircraft Reg No. N2692P Time (Local): 14:30 CDT

Occurrence #1: LOSS OF ENGINE POWER(PARTIAL) - MECH FAILURE/MALFPhase of Operation: CLIMB

Findings 1. 1 ENGINE 2. (F) COMPRESSOR ASSEMBLY,IMPELLER - FATIGUE 3. (C) COMPRESSOR ASSEMBLY - OTHER


The National Transportation Safety Board determines the probable cause(s) of this accident as follows.insufficient clearance between the second stage compressor impeller and the shroud. A factor was the subsequent fatigue failure of the impeller.



Brief of Accident

Adopted 3/25/1998

LAX97FA082File No. 577 1/5/1997 BULLHEAD CITY, AZ Aircraft Reg No. N165SW Time (Local): 12:43 MST

Make/Model: Fairchild / SA227-ACEngine Make/Model: Garrett / TPE331-11U612


Operating Certificate(s): On-demand Air TaxiName of Carrier: FNG AVIATION INC

Type of Flight Operation: Non-scheduled; Passenger Only; DomesticReg. Flight Conducted Under: Part 135: Air Taxi & Commuter


Last Depart. Point: LONG BEACH, CADestination: GRAND CANYON, AZ






Precipitation: None




Flight Time (Hours)



After executing a missed approach at the Grand Canyon Airport, the pilots diverted to the Bullhead City Airport. The pilots reported that minimal icing conditions were encountered with about 1/8 inchof ice accumulating on the aircraft wings. The pilots stated they cycled the deice boots to shed ice. They did not observe ice on the propeller spinners, and they did not activate the engines' 'override'ignition systems, as required by the airplane's flight manual. Use of 'override' ignition was required for flight into visible moisture at or below +5 degrees Celsius (+41 degrees Fahrenheit) to preventice ingestion/flameouts. Subsequently, both engines flamed out as the airplane was on about a 3 mile final approach for landing with the landing gear and flaps extended. The aircraft was destroyedduring an off-airport landing.


LAX97FA082File No. 577 1/5/1997 BULLHEAD CITY, AZ Aircraft Reg No. N165SW Time (Local): 12:43 MST

Occurrence #1: IN FLIGHT ENCOUNTER WITH WEATHERPhase of Operation: CRUISE

Findings 1. (F) WEATHER CONDITION - ICING CONDITIONS 2. (F) AIRFRAME - ICE

----------

Occurrence #2: LOSS OF ENGINE POWER(TOTAL) - NONMECHANICALPhase of Operation: APPROACH

Findings 3. ALL ENGINES 4. IGNITION SYSTEM,AUTO RE-LIGHT SYSTEM - NOT INSTALLED 5. AIRCRAFT/EQUIPMENT INADEQUATE 6. IGNITION SYSTEM,IGNITER - NOT ACTIVATED 7. (C) CHECKLIST - NOT FOLLOWED - PILOT IN COMMAND 8. (C) MISCELLANEOUS,ENGINE - ICE INGESTION

----------

Occurrence #3: FORCED LANDINGPhase of Operation: EMERGENCY DESCENT/LANDING----------

Occurrence #4: IN FLIGHT COLLISION WITH TERRAIN/WATERPhase of Operation: EMERGENCY LANDING

Findings 9. (F) TERRAIN CONDITION - NONE SUITABLE


The National Transportation Safety Board determines the probable cause(s) of this accident as follows.failure of the pilot(s) to use 'override' ignition as prescribed by checklist procedures during an encounter with icing conditions, which subsequently led to ice ingestion and dual engine flame-outs.Factors related to the accident were: the adverse weather (icing) conditions, the accumulation of airframe/engine ice, and lack of suitable terrain in the emergency landing area.



Brief of Incident

Adopted 4/24/1998

FTW97IA120File No. 5005 3/4/1997 ABILENE, TX Aircraft Reg No. N373PH Time (Local): 10:00 CST

Make/Model: Swearingen / SA227-ACEngine Make/Model: Garrett / TPE331-11V


Operating Certificate(s): Commuter Air CarrierName of Carrier: CONQUEST AIRLINES



Last Depart. Point: AUSTIN, TXDestination: Same as Incident

Airport Proximity: On AirportAirport Name: ABILENE REGIONAL







Precipitation: None




Flight Time (Hours)



Landing runways were 17L and 22. The crew requested runway 35R. During the landing roll, when the first officer engaged the nose wheel steering, the airplane made an unexpected left turn. Thecrew applied right rudder and right brake; however, the airplane exited the runway. Winds were from the S/SW at 12 knots gusting to 24 knots. No previous discrepancies for the nose wheel steeringwere noted. During a postincident maintenance taxi check, the 'aircraft made a left turn that increased it's rate rapidly.' Maintenance personnel removed and replaced the #4 brake assembly, repaireda shorting wire at the nose wheel steering power lever switch, and replaced the power lever switch. The company computed a 13 knot tailwind (company limit 10 kts) and stated that skid marks on therunway 'seem to indicate a high rate of speed very late in the landing roll.' When the nose wheel steering actuator was removed and tested, no discrepancies were found. The director of operationscommented that the incident 'would not have occurred had the aircraft been landed into the wind' and that 'possible inadvertent disconnection of the steering system was [a] contributing factor.'


FTW97IA120File No. 5005 3/4/1997 ABILENE, TX Aircraft Reg No. N373PH Time (Local): 10:00 CST


Findings 1. LANDING GEAR,STEERING SYSTEM - SHORTED 2. (F) LANDING GEAR,STEERING SYSTEM - FAILURE,PARTIAL 3. (F) WEATHER CONDITION - TAILWIND 4. (C) AIRCRAFT CONTROL - NOT MAINTAINED - FLIGHTCREW

----------



The National Transportation Safety Board determines the probable cause(s) of this incident as follows.The flightcrew's failure to maintain aircraft control. Factors were the tailwind and a partial nosewheel steering failure.



Brief of Accident

Adopted 6/26/1998

CHI97LA266File No. 1129 8/19/1997 DES MOINES, IA Aircraft Reg No. N224AM Time (Local): 22:21 CDT



Operating Certificate(s): On-demand Air TaxiName of Carrier: SUPERIOR AVIATION



Last Depart. Point: WICHITA, KSDestination: Same as Accident

Airport Proximity: On AirportAirport Name: DES MOINES INTERNATIONAL







Precipitation: None


Certificate(s)/Rating(s)Commercial; Multi-engine Land


Flight Time (Hours)



During a landing approach, the pilot noted that the right engine remained at a high power setting, when he moved the power levers to reduce power. He executed a missed approach and had difficultykeeping the airplane straight and level. The pilot maneuvered for a second approach to land. After landing, he could not maintain directional control of the airplane and tried to go around, but theairplane went off the end of the runway and impacted the localizer antenna. The pilot did not advise ATC of the problem nor did he declare an emergency. The Pilot's Operating Handbook stated thatfor a power plant control malfunction, the affected engine should be shut down, and a single engine landing should be made. The power control cable was found disconnected from the anchoringpoint. A safety tab was broken off the housing, allowing it to unscrew. About one month before the accident, maintenance had been performed on the right engine to correct a discrepancy about theright engine power lever being stiff. The mechanic re-rigged the right engine power cable.


CHI97LA266File No. 1129 8/19/1997 DES MOINES, IA Aircraft Reg No. N224AM Time (Local): 22:21 CDT


Findings 1. (F) THROTTLE/POWER LEVER,CABLE - DISCONNECTED 2. (F) MAINTENANCE,ADJUSTMENT - INADEQUATE - COMPANY MAINTENANCE PERSONNEL

----------

Occurrence #2: OVERRUNPhase of Operation: LANDING - ABORTED

Findings 3. (C) IN-FLIGHT PLANNING/DECISION - IMPROPER - PILOT IN COMMAND 4. (C) EMERGENCY PROCEDURE - NOT FOLLOWED - PILOT IN COMMAND 5. (F) DIRECTIONAL CONTROL - REDUCED 6. GO-AROUND - ATTEMPTED - PILOT IN COMMAND

----------

Occurrence #3: ON GROUND/WATER COLLISION WITH OBJECTPhase of Operation: LANDING - ABORTED

Findings 7. OBJECT - ANTENNA


The National Transportation Safety Board determines the probable cause(s) of this accident as follows.the pilot's improper in-flight planning/decision and failure to perform the emergency procedure for shut-down of the right engine. Factors relating to the accident were: the power lever cable becamedisconnected from the fuel control unit, due to improper maintenance; and reduced directional control of the airplane, when one engine remained at a high power setting.



Brief of Accident

Adopted 7/13/1998

ANC97LA127File No. 1232 8/22/1997 ANCHORAGE, AK Aircraft Reg No. N27188 Time (Local): 00:40 ADT

Make/Model: Fairchild / SA227-ACEngine Make/Model: Garrett / TPE-331


Operating Certificate(s): Flag Carrier/DomesticName of Carrier: MERLIN EXPRESS

Type of Flight Operation: Scheduled; Passenger Only; DomesticReg. Flight Conducted Under: Part 121: Air Carrier


Last Depart. Point: Unk/NrDestination: KENAI, AK

Airport Proximity: On AirportAirport Name: ANCHORAGE INTERNATIONAL







Precipitation: Rain


Certificate(s)/Rating(s)Airline Transport; Flight Instructor; Multi-engine Land; Single-engine Land; Single-engine Sea; Glider


Flight Time (Hours)



A scheduled domestic passenger flight, operating under Title 14 CFR Part 121, was taxiing from the terminal toward the departure runway. Adjacent to the end of the terminal building, an airportbaggage tug appeared from around the end of the concourse building. The driver of the tug attempted to stop, but was unable to avoid colliding with the outboard end of the right wing of the airplane.The cab portion of the tug struck the wing, about 4 feet inboard from the tip. The wing sustained crushing, and tearing of the leading edge. The tug's brakes were ineffective from wet surfaceconditions or due to a mechanical malfunction. Rain was falling at the time, and the airport ramps were wet.


ANC97LA127File No. 1232 8/22/1997 ANCHORAGE, AK Aircraft Reg No. N27188 Time (Local): 00:40 ADT


Findings 1. (F) LIGHT CONDITION - DARK NIGHT 2. (F) WEATHER CONDITION - RAIN 3. (F) AIRPORT FACILITIES,TAXIWAY CONDITION - WET 4. OBJECT - VEHICLE 5. (C) UNSAFE/HAZARDOUS CONDITION - DISREGARDED - DRIVER OF VEHICLE


The National Transportation Safety Board determines the probable cause(s) of this accident as follows.the baggage tug driver's disregard for wet taxiway/ramp conditions, which resulted in his inability to avoid a taxiing airplane as he came around the end of a concourse building. Darkness, rain, andthe wet ramp conditions were related factors.



Brief of Accident

Adopted 4/15/1999

FTW98FA073File No. 1749 12/19/1997 BYERS, CO Aircraft Reg No. N950TT Time (Local): 20:17 MST

Make/Model: Swearingen / SA226-TEngine Make/Model: Garrett / TPE331-3U303G





Last Depart. Point: DENVER, CODestination: ASPEN, CO






Precipitation: None


Certificate(s)/Rating(s)Airline Transport; Private; Multi-engine Land; Single-engine Land


Flight Time (Hours)



The pilot departed Front Range Airport (elevation 5512 feet) at approximately 2008, climbed to 7,000 feet msl, accelerated to 270 knots, and requested his IFR clearance. Weather at the time ofN950TT's departure was 500 feet overcast; witnesses reported the tops of the thin cloud condition were 8,500 feet msl and it was very dark on top (no stars or moon). The pilot made severalchanges in airspeed and climb rate until radar indicated that he had entered an 8,500 fpm decent. The pilot reported to ATC that he had 'stalled' the airplane. Radar indicated that he then climbed at7,500 fpm until his estimated airspeed was 10 knots, and then subsequently descended again at 8,400 fpm until he impacted the frozen ground. The pilot had flown 4 times for 7 hours in theprevious 40 days. Five airline pilots, each of who had 3,000 to 5,000 hours in Swearingens, stated individually that even though the airplane is single pilot certified, they believed that 'its a two pilotairplane--because the work load is too high.'


FTW98FA073File No. 1749 12/19/1997 BYERS, CO Aircraft Reg No. N950TT Time (Local): 20:17 MST

Occurrence #1: LOSS OF CONTROL - IN FLIGHTPhase of Operation: CLIMB - TO CRUISE

Findings 1. (F) LIGHT CONDITION - NIGHT 2. (F) EXCESSIVE WORKLOAD (TASK OVERLOAD) - PILOT IN COMMAND 3. (C) STALL - INADVERTENT - PILOT IN COMMAND 4. (C) AIRCRAFT CONTROL - NOT MAINTAINED - PILOT IN COMMAND 5. (C) SPATIAL DISORIENTATION - PILOT IN COMMAND

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Findings 6. TERRAIN CONDITION - OPEN FIELD 7. TERRAIN CONDITION - FROZEN


The National Transportation Safety Board determines the probable cause(s) of this accident as follows.The pilot inadvertently stalling the airplane and his subsequent spatial disorientation which prevented him from maintaining airplane control. Factors were excessive workload on the pilot and the darknight light conditions.



Brief of Accident

Adopted 2/15/2001

FTW98LA149File No. 529 3/11/1998 TYLER, TX Aircraft Reg No. N730C Time (Local): 19:40 CST

Make/Model: Fairchild / SA227-ACEngine Make/Model: Garrett / TPE331-11


Operating Certificate(s): Flag Carrier/DomesticName of Carrier: AUSTIN EXPRESS

Type of Flight Operation: Scheduled; Passenger Only; DomesticReg. Flight Conducted Under: Part 121: Air Carrier


Last Depart. Point: AUSTIN, TXDestination: Same as Accident

Airport Proximity: On AirportAirport Name: TYLER POUNDS FIELD







Precipitation: None




Flight Time (Hours)



At night, while taxiing to parking after landing, an unmanned runaway golf cart being used as a lead-in vehicle, collided with the airplane. Witnesses observed the golf cart's driver get out of the cartand the cart continue moving. The driver attempted to stop the cart; however, she was unsuccessful. The cart circled an aircraft 2 or 3 times then veered off and ricocheted off a fence. The pilotsreported that they were approximately 50 feet from their intended stopping point, when they observed a golf cart that appeared to be paralleling the fence. At that time they did not perceive it as ahazard. The golf cart then made an 'immediate' change of direction and headed towards their aircraft. After the cart made the change of direction, the pilots observed that the cart was unmanned.They immediately initiated emergency shutdown procedures; however, the cart collided with the left engine's propeller before it could be shutdown.


FTW98LA149File No. 529 3/11/1998 TYLER, TX Aircraft Reg No. N730C Time (Local): 19:40 CST


Findings 1. OBJECT - VEHICLE 2. EVASIVE MANEUVER - NOT POSSIBLE - PILOT IN COMMAND 3. (C) PARKING BRAKES - NOT SET - DRIVER OF VEHICLE 4. (C) MISCELLANEOUS - NOT PERFORMED - DRIVER OF VEHICLE


The National Transportation Safety Board determines the probable cause(s) of this accident as follows.The failure of the golf cart's driver to shutdown the engine and set the parking brake before exiting, which resulted in an unmanned runaway cart.



Brief of Accident

Adopted 4/25/2001

DEN99LA047AFile No. 52 3/5/1999 DENVER, CO Aircraft Reg No. N151SA Time (Local): 06:03 MST

Make/Model: Swearingen / SA226TCEngine Make/Model: Garrett / TPE331


Operating Certificate(s): On-demand Air TaxiName of Carrier: SUPERIOR AVIATION INC.



Last Depart. Point: Unk/NrDestination: CHEYENNE, WY

Airport Proximity: On AirportAirport Name: DENVER INTERNATIONAL







Precipitation: None




Flight Time (Hours)



N328BA was partially deiced at the ramp when they ran out of deicing fluid. The pilot asked the ramp crew to meet him at the deicing pad on the south end of the airport to finish deicing the aircraft.The pilot received taxi clearance and instructions to hold short on the taxiway, and to contact ground control. Prior to reaching the taxiway hold short lines, he received clearance to taxiway to therunway. He then realized he had forgotten to advise ramp control that he needed to deice the aircraft. According to the pilot of N328BA, at that time, he looked up and noticed that N151SA wasstopped in front of him. N328BA then impacted N151SA, striking the tail section of N151SA, causing substantial damage to the left side of the fuselage extending from the cargo door aft. The pilot ofN328BA stated in a telephone interview that while taxiing, he performed a brake test and observed no discrepancies. Immediately following the accident, a brake test was performed in the presenceof the IIC and two FAA inspectors. The brakes were found to be operational. Toxicological examinations were performed on both pilots and the results were negative.


DEN99LA047AFile No. 52 3/5/1999 DENVER, CO Aircraft Reg No. N151SA Time (Local): 06:03 MST

Occurrence #1: COLLISION BETWEEN AIRCRAFT (OTHER THAN MIDAIR)Phase of Operation: STANDING - ENGINE(S) OPERATING

Findings 1. (C) VISUAL LOOKOUT - NOT MAINTAINED - PILOT OF OTHER AIRCRAFT 2. LIGHT CONDITION - DAWN


The National Transportation Safety Board determines the probable cause(s) of this accident as follows.The pilot of N328BA's failure to maintain visual lookout while taxiing, causing the subsequent collision with N151SA.



Brief of Accident

Adopted 4/25/2001

DEN99LA047BFile No. 52 3/5/1999 DENVER, CO Aircraft Reg No. N328BA Time (Local): 06:03 MST

Make/Model: Swearingen / SA226TCEngine Make/Model: Garrett / TPE 331


Operating Certificate(s): On-demand Air TaxiName of Carrier: SUPERIOR AVIATION INC.



Last Depart. Point: Unk/NrDestination: RIFLE, CO








Precipitation: None




Flight Time (Hours)



SEE NARRATIVE FOR DEN99LA047A


DEN99LA047BFile No. 52 3/5/1999 DENVER, CO Aircraft Reg No. N328BA Time (Local): 06:03 MST

Occurrence #1: COLLISION BETWEEN AIRCRAFT (OTHER THAN MIDAIR)Phase of Operation: TAXI

Findings 1. (C) VISUAL LOOKOUT - NOT MAINTAINED - PILOT IN COMMAND 2. LIGHT CONDITION - DAWN


The National Transportation Safety Board determines the probable cause(s) of this accident as follows.The pilot of N328BA's failure to maintain visual lookout while taxiing, causing the subsequent collision with N151SA.



Brief of Accident

Adopted 8/18/2000

FTW99FA223File No. 1189 8/16/1999 SAN ANTONIO, TX Aircraft Reg No. N2671V Time (Local): 17:33 CDT

Make/Model: Swearingen / SA-227-ACEngine Make/Model: Garrett / TPE331-11U


Operating Certificate(s): Commuter Air Carrier; Flag Carrier/Domestic; On-demand Air Taxi

Type of Flight Operation: InstructionalReg. Flight Conducted Under: Part 91: General Aviation


Last Depart. Point: SAN ANTONIO, TXDestination: Local

Airport Proximity: On AirportAirport Name: SAN ANTONIO INTERNATIONAL







Precipitation: None




Flight Time (Hours)



The airplane landed wheels up after the instructor pilot failed to lower the landing gear. The instructor told the student to execute 'a no flap landing due to a simulated hydraulic pump failure.' Thestudent established the airplane on the approach and called for the 'Emergency Gear Extension Checklist.' The instructor delayed extending the gear in accordance with the operator's flightstandards manual, which stated that the landing gear should not be extended until the landing was assured. Later in the approach, when the gear warning horn stopped sounding, due to thestudent's movement of the power levers forward, the instructor removed his hand from the gear handle without extending the gear. The instructor stated that 'because [the student] had already calledfor the [Emergency Gear Extension] checklist once before, in a split second thought process, [he] mistakenly thought it had been completed.' Following the accident, the landing gear system wastested and found to operate normally. Review of the maintenance records revealed no uncorrected discrepancies. At the time of the accident, the instructor pilot was completing a 9-hour work day,and did not have a lunch break.


FTW99FA223File No. 1189 8/16/1999 SAN ANTONIO, TX Aircraft Reg No. N2671V Time (Local): 17:33 CDT

Occurrence #1: WHEELS UP LANDINGPhase of Operation: LANDING

Findings 1. (C) CHECKLIST - NOT PERFORMED - PILOT IN COMMAND(CFI) 2. (F) FATIGUE - PILOT IN COMMAND(CFI) 3. (C) WHEELS UP LANDING - INADVERTENT - PILOT IN COMMAND(CFI)


The National Transportation Safety Board determines the probable cause(s) of this accident as follows.The instructor pilot's failure to complete the Emergency Gear Extension Checklist, resulting in the inadvertent wheels-up landing. A factor was the instructor pilot's fatigued condition.



Brief of Accident

Adopted 12/5/2000

MIA00LA004File No. 1453 10/11/1999 OPA LOCKA, FL Aircraft Reg No. N438MA Time (Local): 20:24 EDT

Make/Model: Fairchild / SA227-ACEngine Make/Model: Garrett / TPE-331


Operating Certificate(s): Supplemental; On-demand Air TaxiType of Flight Operation: Positioning



Last Depart. Point: MIAMI, FLDestination: Same as Accident

Airport Proximity: On AirportAirport Name: OPA LOCKA







Precipitation: None




Flight Time (Hours)



It was the first officer's leg and after bringing both power levers to flight idle while on final approach at 30-50 feet, the captain later reported hearing, 'both engines go into a ground idle.' She verifiedthat both power levers were forward of the gate, then noted the sink rate increased. The airplane bounced then after touchdown, the captain brought both power levers to ground idle; the airplaneveered to the right. She attempted to maintain runway centerline with asymmetric reverse but the airplane veered off the right side of the runway. The airplane touched down 484 feet from theapproach end of the runway; distance between the first and second gouge in the runway from the right propeller indicates the ground speed was 92 knots. Examination of the airplane revealedcompression wrinkles on the lower wing skin at the wing splice location. Rigging check of both engine controls revealed no evidence of improper rigging at the flight idle position; improper rigging wasnoted at the low and high reverse positions for the right engine. Previous discrepancies were written up pertaining to asymmetric reverse. No previous reports of high rates of descent when powerlevers brought to flight idle position.


MIA00LA004File No. 1453 10/11/1999 OPA LOCKA, FL Aircraft Reg No. N438MA Time (Local): 20:24 EDT


Findings 1. PROPER DESCENT RATE - NOT ATTAINED - COPILOT/SECOND PILOT 2. (C) FLARE - IMPROPER - COPILOT/SECOND PILOT 3. (C) REMEDIAL ACTION - NOT PERFORMED - PILOT IN COMMAND

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Findings 4. MAINTENANCE,ADJUSTMENT - IMPROPER - COMPANY MAINTENANCE PERSONNEL 5. DIRECTIONAL CONTROL - DIMINISHED


The National Transportation Safety Board determines the probable cause(s) of this accident as follows.The improper flare by the co-pilot, and the failure of the captain to take remedial action by applying power to arrest the observed high rate of descent resulting in a hard landing. A finding in theaccident was the inadequate maintenance adjustment of the right engine controls which diminished directional control capability while on the runway following the hard landing.



Brief of Accident

Adopted 12/4/2000

FTW00LA078File No. 51 1/28/2000 FAYETTEVILLE, AR Aircraft Reg No. N245DH Time (Local): 21:30 CST

Make/Model: Swearingen / SA-227-ATEngine Make/Model: Garrett / TPE331


Operating Certificate(s): On-demand Air TaxiName of Carrier: AMERIFLIGHT, INC.



Last Depart. Point: TULSA, OKDestination: Same as Accident

Airport Proximity: On AirportAirport Name: FAYETTEVILLE DRAKE FIELD







Precipitation: None




Flight Time (Hours)



On departure for the night air taxi cargo flight, the flight crew experienced a problem with the crew intercom system. The crew initiated their descent at a 'later than normal distance' from the airport,and as a result, a power reduction below 25 percent torque was required, which set off the gear warning horn. The sound 'eventually became part of the background noise.' During the approach, thecaptain asked the tower to dim the runway lights. At that time, the runway and approach lights went out and the crew lost sight of the runway. While the captain was asking the tower to turn the lightsback on, the first officer called 'gear down, syncs off, speeds high, below the line check list.' The captain did not hear the first officer's callout and did not lower the landing gear. The captain statedthat he did not hear the first officer's callout 'either because of the conversation [he] was having with the tower or because of the intercom system difficulties.' As the approach continued, the firstofficer had a problem slowing the airplane to proper approach speed. The airplane touched down on the runway with the landing gear retracted, 'slid' about 2,500 feet and exited the left side of therunway.


FTW00LA078File No. 51 1/28/2000 FAYETTEVILLE, AR Aircraft Reg No. N245DH Time (Local): 21:30 CST

Occurrence #1: WHEELS UP LANDINGPhase of Operation: LANDING - FLARE/TOUCHDOWN

Findings 1. (C) GEAR EXTENSION - NOT PERFORMED - FLIGHTCREW 2. (F) AIRPORT FACILITIES,INSTRUMENT APPROACH LIGHTS - LOSS(PARTIAL) 3. (F) CHECKLIST - NOT COMPLIED WITH - FLIGHTCREW 4. (F) DIVERTED ATTENTION - PILOT IN COMMAND 5. (F) COMM/NAV EQUIPMENT,INTERCOM - FAILURE,PARTIAL


The National Transportation Safety Board determines the probable cause(s) of this accident as follows.The flight crew's failure to extend the landing gear. Contributing factors were the flight crew's non-compliance with the checklist, the pilot-in-command's diverted attention as a result of the loss ofinstrument approach/runway lighting, the partial failure of the instrument approach/runway lighting system, and the partial failure of the intercom system.



Brief of Accident

Adopted 1/2/2002

DEN00FA092File No. 11230 5/19/2000 DENVER, CO Aircraft Reg No. N235BA Time (Local): 06:39 MDT

Make/Model: Swearingen / SA226TCEngine Make/Model: Garrett / TPE331-IOUA


Operating Certificate(s): On-demand Air TaxiName of Carrier: SUPERIOR AVIATION, INC.



Last Depart. Point: Same as AccidentDestination: MONTROSE, CO








Precipitation: None


Certificate(s)/Rating(s)Airline Transport; Commercial; Multi-engine Land; Single-engine Land; Helicopter


Flight Time (Hours)



When the pilot added power for takeoff, at the origination of a cross-country cargo flight, he heard an impact sound on the right side of the airplane, and the right engine began to vibrate violently. Heshut down both engines, declared an emergency, and when the engines had spooled down he exited the airplane. Inspection revealed the right hand propeller had shed a blade, which causeddamage to the right engine mounts, right engine nacelle, and propeller shrapnel damage to the fuselage, right wing, and right flap. Examination provided evidence that the propeller blade fractureddue to a fatigue crack that emanated from a stress corrosion crack region at the mid span portion on the flat side of the blade. The coating on the surface of the blade in the area of the stresscorrosion cracking had been breached. The breach in the coating allowed corrosion media to attack the blade.


DEN00FA092File No. 11230 5/19/2000 DENVER, CO Aircraft Reg No. N235BA Time (Local): 06:39 MDT

Occurrence #1: PROPELLER FAILURE/MALFUNCTIONPhase of Operation: TAKEOFF - ROLL/RUN

Findings 1. (C) PROPELLER SYSTEM/ACCESSORIES,BLADE - CORRODED 2. (C) PROPELLER SYSTEM/ACCESSORIES,BLADE - FATIGUE 3. (C) PROPELLER SYSTEM/ACCESSORIES,BLADE - FAILURE,TOTAL


The National Transportation Safety Board determines the probable cause(s) of this accident as follows.propeller blade fatigue failure due to stress corrosion.



Brief of Accident

Adopted 4/18/2003

CHI01FA032File No. 13141 11/9/2000 FORT WAYNE, IN Aircraft Reg No. N731AC Time (Local): 01:23 EST



Operating Certificate(s): On-demand Air TaxiType of Flight Operation: Non-scheduled; Cargo; Domestic

Reg. Flight Conducted Under: Part 135: Air Taxi & Commuter


Last Depart. Point: Same as AccidentDestination: MILWAUKEE, WI


Condition of Light: NightWeather Info Src: Weather Observation Facility




Precipitation: Rain




Flight Time (Hours)



The airplane was destroyed on impact with trees and terrain after takeoff. A post-impact fire ensued. A courier stated that he put 14 cases and 5 bags into the airplane and that "everything tookplace as it normally does." A witness stated, "I heard a very low flying aircraft come directly over my house. ... It sounded very revved up like a chainsaw cutting through a tree at high speed." Theaccident airplane's radar returns, as depicted on a chart, exhibited a horseshoe shaped flight path. That chart showed that the airplane made a left climbing turn to a maximum altitude of 2,479 feet.That chart showed the airplane in a descending left turn after that maximum recorded altitude was attained. The operator reported the pilot had flown about 75 hours in the same make and modelairplane and had flown about 190 hours in the last 90 days. The weather was: Wind 090 degrees at 7 knots; visibility 1 statute mile; present weather light rain, mist; sky condition overcast 200 feet;temperature 9 degrees C; dew point 9 degrees C. No pre-impact engine anomalies were found. NTSB's Materials Laboratory Division examined the annunciator panel and recovered lightassemblies and stated, "Item '29' was a light assembly with an identification cover indicating that it was the '[Right-hand] AC BUS' light. Examination of the filaments in the two installed bulbsrevealed that one had been stretched, deformed and fractured and the other had been stretched and deformed." The airplane manufacturer stated that the airplane's left-hand and right-hand attitudegyros are powered by the 115-volt alternating current essential bus. Two inverters are installed and one inverter is used at a time as selected by the inverter select switch. The inverter select switchis located on the right hand switch panel. The airplane was not equipped with a backup attitude gyro and was not required to be equipped with one. The airplane was certified with a minimum flightcrew of one pilot. Subsequent to the accident, the operator transitioned "from the single pilot operation of our Fairchild Metroliner to the inclusion of a First Officer."


CHI01FA032File No. 13141 11/9/2000 FORT WAYNE, IN Aircraft Reg No. N731AC Time (Local): 01:23 EST

Occurrence #1: IN FLIGHT COLLISION WITH OBJECTPhase of Operation: TAKEOFF

Findings 1. OBJECT - TREE(S) 2. VISUAL LOOKOUT - NOT POSSIBLE - PILOT IN COMMAND 3. (F) EXCESSIVE WORKLOAD (TASK OVERLOAD) - PILOT IN COMMAND 4. (C) ELECTRICAL SYSTEM - FAILURE 5. (F) WEATHER CONDITION - LOW CEILING 6. (F) LIGHT CONDITION - NIGHT

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Findings 7. TERRAIN CONDITION - DIRT BANK/RISING EMBANKMENT


The National Transportation Safety Board determines the probable cause(s) of this accident as follows.The indicated failure of the right hand AC bus during takeoff with low ceiling. The factors were the low ceiling, night, and the execssive workload the pilot experienced on takeoff with an electricalfailure without a second in command.



Brief of Accident

Adopted 7/2/2002

CHI01FA083File No. 11951 2/8/2001 Beaver Island, MI Aircraft Reg No. N318DH Time (Local): 19:20 EST

Make/Model: Swearingen / SA227-ATEngine Make/Model: Allied Signal / TPE331


Operating Certificate(s): On-demand Air TaxiType of Flight Operation: Non-scheduled; Passenger Only; Domestic



Last Depart. Point: Chicago, ILDestination: Same as Accident








Certificate(s)/Rating(s)Flight Instructor; Commercial; Multi-engine Land; Single-engine Land


Flight Time (Hours)



The airplane was on an on-demand air-taxi flight operating under 14 CFR Part 135 and was destroyed when it impacted trees and terrain while circling to land during a non-precision instrumentapproach at night. The airplane came to rest 1.74 nautical miles and 226 degrees magnetic from the intended airport. A weather briefing was obtained and instrument meteorological conditionswere present along the route of flight at the time of the briefing. Weather conditions for the two reporting stations closest to the destionation were obtained by the airplane prior to executing theapproach. The weather reports listed ceilings and visibilities as 400 to 500 feet overcast and 5 to 7 statute miles. The airport elevation is 669 feet and the minimum descent altitude for the approachwas listed as 1,240 feet. There was no weather reporting station at the destination airport at the time of the accident. According to the operators General Operations Manual, the pilot wasresponsible for the dispatch of the airplane including flight planning, and confirming departure, en-route, arrival and terminal operations compliance. The manual also states, "For airports withoutweather reporting, the area forecast and reports from airports in the vicinity must indicate that the weather conditions will be VFR [visual flight rules] at the ETA so as to allow the aircraft to terminatethe IFR operations and land under VFR. (Note: a visual approach is not approved without weather reporting)." For 14 CFR Part 135 instrument flight operations conducted at an airport, federalregulations require weather observations at that airport. Furthermore, the regulations state that, for 14 CFR Part 135 operations, an instrument approach cannot be initiated unless approved weatherinformation is available at the airport where the instrument approach is located, and the weather information indicates that the weather conditions are at or above the authorized minimums for theapproach procedure. The commercial pilot held a type rating for the accident airplane. The right seat occupant was a commercial pilot employed by the operator and did not hold an appropriate typerating for the accident airplane. The pitch trim selector switch was found set to the co-pilot side. The regulations state that 14 CFR Part 135 operators cannot use the services of any person as anairman unless that person is appropriately qualified for the operation for which the person is to be used. The circling approach was made over primarily unlit land and water. An FAA publicationstates that during night operations, "Distance may be deceptive at night due to limited lighting conditions. A lack of intervening references on the ground and the inability of the pilot to compare thesize and location of different ground objects cause this. This also applies to the estimation of altitude and speed. Consequently, more dependence must be placed on flight instruments, particularlythe altimeter and the airspeed indicator." No anomalies were found with respect to the airframe, engines, or systems that could be associated with a pre-impact condition.


CHI01FA083File No. 11951 2/8/2001 Beaver Island, MI Aircraft Reg No. N318DH Time (Local): 19:20 EST

Occurrence #1: IN FLIGHT COLLISION WITH OBJECTPhase of Operation: CIRCLING (IFR)

Findings 1. (F) FLT WITH INADQT EN ROUTE/DESTN FACILITIES - INITIATED - PILOT IN COMMAND 2. (F) NOT PERFORMED - FLIGHTCREW 3. (F) LIGHT CONDITION - DARK NIGHT 4. (F) PROCEDURES/DIRECTIVES - NOT FOLLOWED - FLIGHTCREW 5. (F) WEATHER CONDITION - LOW CEILING 6. (C) ALTITUDE/CLEARANCE - NOT MAINTAINED - FLIGHTCREW 7. (F) LACK OF CERTIFICATION - COPILOT/SECOND PILOT 8. (F) PROCEDURES/DIRECTIVES - NOT FOLLOWED - COMPANY/OPERATOR MANAGEMENT


The National Transportation Safety Board determines the probable cause(s) of this accident as follows.The flightcrew not maintaining altitude/clearance during the circling instrument approach. Factors were the pilot in command initiating the flight without proper weather reporting facilities at thedestination, the flightcrew not flying to an alternate destination, the flightcrew not following company and FAA procedures/directives, the lack of certification of the second pilot, the operator notfollowing company and FAA procedures/directives, and the dark night and the low ceiling.



Brief of Accident

Adopted 1/2/2002

CHI01LA302File No. 11296 8/28/2001 West Chicago, IL Aircraft Reg No. N104BR Time (Local): 17:20 CDT

Make/Model: Swearingen / SA226-TEngine Make/Model: Garrett / 331





Last Depart. Point: DuPage, ILDestination: Springfield, MO

Airport Proximity: On AirportAirport Name: DUPAGE







Precipitation: None




Flight Time (Hours)



The airplane was substantially damaged during a takeoff roll on runway 1L (6,700 feet by 100 feet, dry grooved concrete). A wind from 050 degrees at 10 knots was recorded by the airport'sautomated surface observing system. The airplane veered towards the left when the pilot deselected nose wheel steering at approximately 60 knots. Examination of the airplane revealed that thetrailing edge flaps and their respective cockpit control were in the 1/2 flap position. Two of left propeller's start locks were engaged. The third start lock was damaged. Two of the right propeller'sstart locks were not engaged. The right propellar's remaining start lock cam had a witness mark prior to the locking point of the cam. The airplane's checklist states that the flaps are to be in theretracted position and the engine's start locks are to be disengaged prior to takeoff. Also, the airplane flight manual does not have performance data for takeoff configurations with 1/2 flaps.Examination of the airplane revealed no anomalies.


CHI01LA302File No. 11296 8/28/2001 West Chicago, IL Aircraft Reg No. N104BR Time (Local): 17:20 CDT

Occurrence #1: IN FLIGHT COLLISION WITH TERRAIN/WATERPhase of Operation: TAKEOFF - ROLL/RUN

Findings 1. (F) PROPELLER SYSTEM/ACCESSORIES - LOCKED 2. (C) CHECKLIST - NOT FOLLOWED - PILOT IN COMMAND 3. (C) DIRECTIONAL CONTROL - NOT MAINTAINED - PILOT IN COMMAND


The National Transportation Safety Board determines the probable cause(s) of this accident as follows.the checklist not followed and the directional control not maintained by the pilot. A contributing factor was the left propellers start locks being engaged.



Brief of Accident

Adopted 5/1/2003

NYC02LA047File No. 13110 1/8/2002 Covington, KY Aircraft Reg No. N556UP Time (Local): 05:26 EST

Make/Model: Swearingen / SA-227-ATEngine Make/Model: Garrett / TPE-331-11U


Operating Certificate(s): On-demand Air TaxiType of Flight Operation: Non-scheduled; Cargo; Domestic



Last Depart. Point: Same as AccidentDestination: Birmingham, AL

Airport Proximity: On AirportAirport Name: Northern Kentucky Intl

Runway Identification: Unk/NrRunway Length/Width (Ft): Unk/Nr

Runway Surface: UnknownRunway Surface Condition: Unknown





Precipitation: None


Certificate(s)/Rating(s)Airline Transport; Flight Engineer; Multi-engine Land; Single-engine Land


Flight Time (Hours)



The pilot was taxiing an airplane across an open lighted ramp area at night. He observed a tug closing from his left side and when the tug did not give way to the airplane, he initiated braking. Thetug struck the airplane on the nose, inflicting substantial damage. The tug driver reported that he did not observe the airplane in time to prevent the collision. No obstructions to visibility were presentfor the pilot or tug driver. Airport rules required vehicles to yield the right-of-way to airplanes.


NYC02LA047File No. 13110 1/8/2002 Covington, KY Aircraft Reg No. N556UP Time (Local): 05:26 EST


Findings 1. OBJECT - VEHICLE 2. (C) VISUAL LOOKOUT - INADEQUATE - DRIVER OF VEHICLE


The National Transportation Safety Board determines the probable cause(s) of this accident as follows.the tug driver's inadequate visual lookout which resulted in his failure to see the airplane in time to prevent the collision.


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