Flight Safety Foundation Accident Prevention 2003

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December 2003

Propeller Failure Precipitated Wright Flyer Control Loss 8 pages. [PDF 406K]

The first fatal accident involving a powered, heavier-than-air aircraft occurred during a demonstration flight in September 1908 for the U.S. Army Signal Corps. The pilot, Orville Wright, was seriously injured; his passenger, Lt. Thomas Selfridge, was killed.

November 2003

Noncompliance With Instrument Approach Procedures Cited in King Air CFIT Accident in Australia 20 pages. [PDF 329K]

The report said that dark night conditions during the emergency medical services positioning flight also were a significant factor in the fatal controlled-flight-into-terrain accident.

October 2003

Improper Installation of Elevator Bolt Causes DC-8 Freighter to Pitch Up Uncontrollably 12 pages. [PDF 158K]

Absence of the bolt caused the right elevator control tab to become disconnected. The control tab then jammed as the flight crew began a night takeoff. During the crew’s attempt to return to the airport, the aircraft struck the ground and was destroyed. All the crewmembers were killed.

September 2003

Engine-intake Icing Sets Stage for Ditching of Shorts 360 During Cargo Flight 8 pages. [PDF 159K]

Snow likely entered unprotected engine air intakes when the twin-turboprop airplane was parked overnight facing into strong surface winds. Intake-airflow disruption resulting from the crew’s selection of the intake anti-icing vanes during departure caused nearly simultaneous flameouts of both engines.

August 2003

Fuel-quantity Miscalculation Cited in Ditching of Boeing Stratoliner 6 pages. [PDF 146K]

The crew planned a test flight of the recently restored vintage airliner based on fuel-gauge readings and the airplane’s average fuel consumption. An engine problem prompted the crew to abort the test flight, and the landing was delayed by a landing-gear problem. All four engines failed because of fuel exhaustion during an approach over water.

July 2003

B-737 Crew’s Unstabilized Approach Results in Overrun of a Wet Runway 8 pages. [PDF 136K]

Air traffic control instructions caused the Boeing 737 to be high, fast and close to the runway when the crew conducted a turn to establish the airplane on final approach to Burbank, California, U.S. Investigators concluded that the flight crew’s only safe option at the time was a go-around.

June 2003

Failure to Maintain Situational Awareness Cited in Learjet Approach Accident 8 pages. [PDF 195K]

During the approach, the crew was unaware of 40-knot winds that led to the controlled-flight-into-terrain accident during instrument meteorological conditions. At the time of the accident, no emergency locator transmitter was required on the turbojet; the accident site was not located until nearly three years after the aircraft was reported missing.

May 2003

Loss of Control Occurs During Pilot’s Attempt to Return to Departure Airport 8 pages. [PDF 179K]

Contamination by snow, an over-gross-weight condition and the pilot’s failure to adhere to the recommended wind shear recovery procedure affected the air-taxi aircraft’s performance during departure from an airport in Canada. The aircraft stalled and descended into a river, where three survivors later drowned.

April 2003

Sabreliner Strikes Mountain Ridge During Night Visual Approach 8 pages. [PDF 326K]

The flight crew did not brief a nonprecision approach procedure with several step-down segments and did not adhere to the published procedures while conducting the approach. The crew terminated the instrument approach and conducted a night visual approach over mountainous terrain in visual meteorological conditions.

March 2003

Pilot Becomes Spatially Disoriented, Aircraft Breaks Apart During Descent 6 pages. [PDF 258K]

A Raytheon Super King Air 200 was transporting members of a collegiate basketball team in instrument meteorological conditions when the alternating-current electrical system malfunctioned. The report said that the pilot became spatially disoriented. The pilot’s control inputs placed a large aerodynamic load on the aircraft and caused it to break apart at low altitude.

February 2003

Failure of Stabilizer-trim System Blamed for Crew’s Loss of Control of MD-83 16 pages. [PDF 185K]

Insufficient lubrication led to excessive wear and to failure of the jackscrew assembly in the McDonnell Douglas MD-83’s horizontal-stabilizer-trim system. The failure caused the horizontal stabilizer to jam in a position beyond normal limits and the aircraft to enter a nose-down pitch attitude from which recovery was not possible.

January 2003

Inadequate Fuel Supply Leads To Jetstream Engine Flameouts 6 pages. [PDF 51K]

The crew of the chartered Jetstream 31 conducted a missed approach because of weather conditions and was attempting another approach when a loss of power occurred in both turboprop engines. The report said that fuel exhaustion and fuel starvation were among the causes of the approach-and-landing accident.