ANNUAL REVIEW OF AIRCRAFT ACCIDENT DATASummary of Losses 1 20 38 Accident Rates 2 21 39 List of...

PB2002-106890NTSB/ARC-02/01

NATIONALTRANSPORTATIONSAFETY BOARDWASHINGTON, D.C. 20594

ANNUAL REVIEW OFAIRCRAFT ACCIDENT DATA

U.S. AIR CARRIER OPERATIONSCALENDARYEAR 1997

DISTRIBUTION STATEMENTAApproved for Public Release

Distribution Unlimited

7425

20020806 100

Annual Review ofAircraft Accident Data

U.S. Carrier OperationsCalendar Year 1997

NTSB/ARC-02/01PB2002-106890 National Transportation Safety BoardNotation 7425 490 L'Enfant Plaza, S.W.Adopted January 24, 2002 Washington, D.C. 20594

National Transportation Safety Board. 2002. U.S. Air Carrier Operations, Calendar Year 1997. AnnualReview of Aircraft Accident Data NTSB/ARC-02/01. Washington, DC.

Abstract: This publication presents the record of aviation accidents involving revenue operations of U.S.air carriers including commuter air carriers and on-demand air taxis for calendar year 1997.

The report is divided into three major sections according to the Federal regulations under which the flightwas conducted: 14 CFR Part 121, Scheduled 14 CFR Part 135, or Nonscheduled 14 CFR Part 135. In eachsection of the report, tables are presented to describe the losses and characteristics of 1997 accidents toenable comparison with prior years.

The National Transportation Safety Board is an independent Federal agency dedicated to promoting aviation,railroad, highway, marine, pipeline, and hazardous materials safety. Established in 1967, the agency is mandated byCongress through the Independent Safety Board Act of 1974 to investigate transportation accidents, determine theprobable causes of the accidents, issue safety recommendations, study transportation safety issues, and evaluate thesafety effectiveness of government agencies involved in transportation. The Safety Board makes public its actionsand decisions through accident reports, safety studies, special investigation reports, safety recommendations, andstatistical reviews.

Recent publications are available in their entirety on the Web at <http://www.ntsb.gov>. Other information aboutavailable publications also may be obtained from the Web site or by contacting:

National Transportation Safety BoardPublic Inquiries Section, RE-51490 ['Enfant Plaza, S.W.Washington, D.C. 20594(800) 877-6799 or (202) 314-6551

Safety Board publications may be purchased, by individual copy or by subscription, from the National TechnicalInformation Service. To purchase this publication, order report number PB2002-106890 from:

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CONTENTS

Introduction ........................ .......................... 1

14 CFR 121 Operations ................... ...................... 3

Scheduled 14 CFR 135 Operations ........... ................ 22

Nonscheduled 14 CFR 135 Operations ........ ............... 35

Appendix A -- Midair Collision Accidents ...... ............ 55

Appendix B -- Explanatory Notes ........... ................ 57

Appendix C -- Cause/Factor Table - 14 CFR 121 .... .......... .. 60

Appendix D -- Cause/Factor Table - Scheduled 14 CFR 135 . . .. 63

Appendix E -- Cause/Factor Table - Nonscheduled 14 CFR 135 . . 65

Appendix F -- NTSB Form 6120.4 .......... ................. 69

- iii -

LIST OF TABLES WITH TABLE NUMBERS

Sched NonschPart Part Part121 1 1 9 1-4

Summary of Losses 1 20 38

Accident Rates 2 21 39

List of Accidents 3 22 40

Accidents and Rates by Type of Operation 4 .. ..

Persons by Role and Degree of Injury 5 23 41

Aircraft by Damage and Degree of Injury 6 24 42

Aircraft by First Occurrence and Degree of Injury and by Damage 7 25 43

Aircraft by First Occurrence and Broad Phase of Operation 8 26 44

Aircraft by Phase of Operation and Degree of Injury and by Damage 9 27 45

Aircraft by Condition of Light and Type of Weather 10 28 46

Aircraft by Type of Operation and Degree of Injury 11 29 47

Aircraft by Proximity to Airport and Flight Plan -- 30 48

Aircraft by Occurrence of Fire and Degree of Injury and by Damage 12 31 49

Type of Aircraft by Degree of Injury and by Damage -- 32 50

Broad Cause/Factor Assignments 13 33 51

Accidents, Fatal Accidents, Fatalities, and Rates 14 .. ..

Accidents, Fatal Accidents, Fatalities, and Rates(Sched. Ops.) 15 34 --

Accidents, Fatal Accidents, Fatalities, and Rates(Nschd. Ops.) 16 -- 52

First Occurrences in All and in Fatal Accidents 17 35 53

First Phases of Operation in All and in Fatal Accidents 18 36 54

Broad Cause/Factor Assignments in All and in Fatal Accidents 19 37 55

Mid-air Collision Accidents (U.S. Air Carrier Ops. 1987 - 1997) app A .. ..

Explanatory Notes appB .. ..

Detailed Cause/Factor Assignments app C app D app E

NTSB Form 6120.4 appF .. ..

- iv -

INTRODUCTION

This report presents a statistical compilation and review of air carrier accidents that occurred in 1997

and that involved U.S.-registered aircraft conducting operations under Title 14 Code of Federal Regulations

(CFR) Parts 121 and 135. Briefly stated, Part 121 applies to air carriers, such as major airlines and cargo haulers,

that fly large transport aircraft. Part 135 applies to commercial air carriers commonly referred to as commuter

airlines and on-demand air taxi operators. Please note that in March 1997 the Federal Aviation Administration

(FAA) issued a reclassification for major airlines (as defined in 14 CFR Part 121). For this reason scheduled Part

135 carrier planes with 10 or more seats are now classified as a Part 121 operation. This change in the

regulations during 1997 affected both the National Transportation Safety Board's (NTSB) classification of

accidents based on category of operation and the Federal Aviation Administration's (FAA) estimate of flight

activity by category. This reclassification of Part 121 and Part 135 operations, in turn, affects comparisons

between 1997 and past years.

The report is divided into three major sections: 14 CFR Part 121 Operations; Scheduled 14 CFR Part

135 Operations; and Nonscheduled 14 CFR Part 135 Operations. Each section begins with an overview of

accidents and their consequences (injuries and aircraft damage) for 1997 and for the 10 preceding years. Several

tables then present accident parameters for 1997 only. Each section concludes with tabulations that present

comparative statistics for 1997 and for the 10-year period 1987-1996.

Exposure data (flight hours, miles, and departures) used to compute accident rates for operations under

Part 121 and for scheduled operations under Part 135 were obtained from the FAA, which compiled data

reported by carriers to the Research and Special Programs Administration (RSPA) of the U.S. Department of

Transportation (DOT). Flight hours for nonscheduled operations under Part 135 were obtained by the FAA in

its surveys of general aviation activity. National Transportation Safety Board Report Form 6120.4 (appendix F)

shows the data elements upon which this report is based.

In many of the tables presented in this report (such as table 4), the number of accidents in a given

category is small. In these tables, even a small change in the number of accidents would result in a substantial

change in the accident rate. Therefore, the reader should exercise caution in the use of these rates and in

comparing numbers and percentages of accidents between two time periods when the number of accidents is

small.

Beginning with the 1998 Annual Reviews, the Safety Board will present annual statistics for commercial

and general aviation in a revised format. The new statistical reviews will present more information in the form

of graphs rather than tables and will include expanded text explanations of the graphs. For those interested in the

underlying data used to develop the annual reviews, associated tabular data will be available through the NTSB

Web site: www.ntsb.gov.

2

14 CFR Part 121 Operations

There were 49 accidents in Part 121 operations in 1997. The overall accident rate for 1997 was

0.309 accidents per 100,000 hours flown, a 15 percent increase from the 1996 rate of 0.269. The 1997 rate

was 37 percent higher than the overall rate of 0.225 for the period from 1987 through 1996. However, due

to a regulatory change in the definition of Part 121 that encompassed many smaller aircraft, there were

several accidents occurring after March that may have qualified as Part 135 operators had the rule change not

been effected. (The exact number of accidents is difficult to identify because aircraft size is not the sole

determinate for certificate of operation.) If consideration for this rule change were factored into rate

comparisons with past years, as many as six accidents may not have been Part 121 operations. With

consideration for that adjustment, the 1997 rate would have shown very little change from the previous 10-

year average.

There were four fatal accidents involving Part 121 operators in 1997 with a fatal accident rate of

0.025 per 100,000 hours flown, a 31 percent decrease from the 1996 rate of 0.036. This change in rate is not

particularly meaningful given the small number of fatal accidents that occur in a given year (the previous 10-

year average of fatal accidents per year was 4.6). But it is important to note that those four fatal accidents in

1997 involved only 8 fatalities out of 5,574 involved persons and it favorably compares to a previous 10-

year average of 172 fatalities per year. Three of the four fatal accidents in 1997 resulted in only one fatality

each, the fourth accident involved a McDonnell Douglas DC-8 in Miami, Florida, with five fatalities.

3

Table 1 - SUMMARY OF LOSSES

14 CFR 121 OPERATIONS1987 - 1997

1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997

Accidents

Fatal 5 3 11 6 4 4 1 4 3 5 4Serious Injury 12 16 5 11 11 12 13 12 16 18 25Minor Injury 3 4 5 1 2 0 3 3 1 6 7No Injury 14 7 7 6 9 2 6 4 16 8 13

Total 34 30 28 24 26 18 23 23 36 37 49

Fatalities

Passenger 213 255 259 8 40 26 0 228 152 321 2Crew 17 19 17 4 9 5 0 9 10 29 4Other Persons 2 11 2 27 13 2 1 2 6 30 2

Total 232 285 278 39 62 33 1 239 168 380 8

Aircraft Damage

Destroyed 5 3 7 3 5 3 1 3 3 5 2Substantial 16 13 11 8 10 3 8 8 18 14 20Minor 4 0 0 4 3 1 3 3 2 7 6None 12 14 10 10 9 11 11 9 14 13 21

Total 37V 30 28 25a 27a 18 23 23 37a 39' 49

The number of aircraft damaged is higher than the number of accidents because the accidentsincluded collisions between two aircraft.

Table 2 - ACCIDENT RATES14 CFR 121 OPERATIONS

1987 - 1997

1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997

Accidents Rates d

Miles Flown b .0076 .0064 .0061 .0049 .0054 .0036 .0044 .0040 .0064 .0063 .0073Hours Flown c .310 .260 .248 .198 .221 .146 .181 .168 .267 .269 .309Departures Flown c .434 .376 .366 .297 .333 .228 .285 .267 .426 .450 .475

Fatal Accident Rates d

Miles Flown b .0009 .0004 .0024 .0012 .0008 .0008 .0002 .0007 .0005 .0009 .0006Hours Flown c .038 .018 .098 .049 .034 .032 .008 .030 .022 .036 .025Departures Flown .053 .026 .144 .074 .051 .051 .012 .049 .035 .061 .039

b Per Million Miles FlownC Per Hundred Thousand Hours and Departures Flownd A nonfatal accident, occurring 4/7/94, that involved criminal activity is excluded from

accident rates. The 12/21/88 sabotage involving a Pan Am B747-100 and the 12/7/87 suicide/sabotageinvolving a PSA BAe-146e are also excluded from accident rate computations.

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Table 4 - ACCIDENTS AND RATES BY TYPE OF OPERATION14 CFR 121 OPERATIONS

1997

Type of Operation

Scheduled

Passenger/ All All Non-Cargo Cargo All Scheduled All

Accidents 43 1 44 5 49Fatal Accidents 3 0 3 1 4

Aircraft Miles Flown 6,011,191 323,369 6,334,559 357,134 6,691,693(Thousands)

Aircraft Hours Flown 14,239,830 821,832 15,061,662 776,447 15,838,109Departures Flown 9,395,336 525,233 9,920,569 393,257 10,313,826

Accident Rates

Per Million Miles Flown 0.0060 0.0034 0.0059 0.0142 0.0065Per Hundred Thousand 0.254 0.130 0.247 0.775 0.276

Hours FlownPer Hundred Thousand 0.422 0.201 0.408 1.589 0.462

Departures Flown

Fatal Accident Rates

Per Million Miles Flown 0.0006 0. 0.0006 0.0047 0.0009Per Hundred Thousand 0.025 0. 0.023 0.258 0.036

Hours FlownPer Hundred Thousand 0.041 0. 0.038 0.530 0.061

Departures Flown

Table 5 - PERSONS BY ROLE AND DEGREE OF INJURY14 CFR 121 OPERATIONS

1997

Degree of Injury

Role of Person Fatal Serious Minor None Total

Pilot 1 1 1 46 49Copilot 1 0 2 46 49Flight engineer 1 0 0 9 10Cabin attendants 0 21 25 160 206Other crew 1 0 3 15 19Passenger 2 21 259 4655 4937

Total aboard 6 43 290 4931 5270

Other aircraft* 0 0 0 297 297Other ground 2 0 2 3 7

Grand total 8 43 292 5231 5574Percent 0.1 0.8 5.2 93.8

9

Table 6 - AIRCRAFT BY DAMAGE AND DEGREE OF INJURY14 CFR 121 OPERATIONS

1997

Degree of injury Aircraft

Aircraft damage None Minor Serious Fatal No. Percent

None 0 0 19 2 21 42.9Minor 0 0 5 1 6 12.2Substantial 13 6 1 0 20 40.8Destroyed 0 1 0 1 2 4.1

AircraftNumber - 13 7 25 4 49Percent - 26.5 14.3 51.0 8.2

Table 7 - AIRCRAFT BY FIRST OCCURRENCE AND DEGREE OF INJURY AND BY DAMAGE14 CFR 121 OPERATIONS

1997

Degree of injury Aircraft damage Aircraft

None Minor Seri- Fatal None Minor Substan- De-Type of first occurrence ous tial stroy No. Percent

Altitude deviation, uncontrolled 0 0 1 0 1 0 0 0 1 2.0Airframe/component/system 1 0 2 0 1 1 1 0 3 6.1

failure/malfunctionMain gear collapsed 0 1 0 0 0 0 1 0 1 2.0Nose gear collapsed 0 1 0 0 0 0 1 0 1 2.0Hard landing 2 1 0 0 0 0 2 1 3 6.1In flight collision with object 1 0 0 0 0 0 1 0 1 2.0In flight encounter with weather 0 0 12 1 11 2 0 0 13 26.5Loss of control - in flight 0 0 1 1 0 1 0 1 2 4.1Loss of control - on ground 0 1 0 0 0 0 1 0 1 2.0Collision between aircraft 1 0 0 0 0 0 1 0 1 2.0

(other than midair)Near collision between aircraft 0 0 2 0 2 0 0 0 2 4.1On ground collision with object 2 2 1 0 0 0 5 0 5 10.2On ground encounter with terrain 1 1 0 0 0 0 2 0 2 4.1Loss of engine power 1 0 0 0 0 0 1 0 1 2.0Loss of power (partial) -1 0 0 0 0 0 1 0 1 2.0

nonmechanicalUndetermined 0 0 0 1 1 0 0 0 1 2.0Miscellaneous/other 3 0 5 1 4 2 3 0 9 18.4Not reported 0 0 1 0 1 0 0 0 1 2.0

AircraftNumber - 13 7 25 4 21 6 20 2 49Percent - 26.5 14.3 51.0 8.2 42.9 12.2 40.8 4.1

•First occurrence is the first (or in some cases the only) occurrence in the accident sequence ofevents. "Occurrences" are relatively major events that may be further described by "findings."See Appendix B for further explanation and an example.

i0

Table 8 - AIRCRAFT BY FIRST OCCURRENCE AND BROAD PHASE OF OPERATION14 CFR 121 OPERATIONS

1997

Phase of operation Aircraft

Type of first occurrence Stndg Taxi Tkoff Climb Cruis Dscnt Landg Manvr Nrept No. Percent

Altitude deviation, 0 0 0 0 1 0 0 0 0 1 2.0uncontrolled

Airframe/component/system 0 1 1 0 0 0 1 0 0 3 6.1failure/malfunction

Main gear collapsed 0 0 0 0 0 0 1 0 0 1 2.0Nose gear collapsed 0 0 0 0 0 0 1 0 0 1 2.0Hard landing 0 0 0 0 0 0 3 0 0 3 6.1In flight collision w/obj. 0 0 0 0 0 0 0 1 0 1 2.0In flight encounter w/wx. 0 0 0 3 6 4 0 0 0 13 26.5Loss of control - in flight 0 0 1 0 0 1 0 0 0 2 4.1Loss of control - on ground 0 0 0 0 0 0 1 0 0 1 2.0Collision between aircraft 0 1 0 0 0 0 0 0 0 1 2.0

(other than midair)Near collision between 0 0 0 0 0 2 0 0 0 2 4.1aircraft

On ground collision w/obj. 1 4 0 0 0 0 0 0 0 5 10.2On ground encounter w/ter. 0 2 0 0 0 0 0 0 0 2 4.1Loss of engine power 0 0 0 1 0 0 0 0 0 1 2.0Loss of power (partial) - 0 0 1 0 0 0 0 0 0 1 2.0

nonmechanicalUndetermined 1 0 0 0 0 0 0 0 0 1 4.1Miscellaneous/other 4 2 1 0 1 0 0 0 1 9 18.4Not reported 0 0 0 0 0 0 0 0 1 1 2.0

AircraftNumber - 6 10 4 4 8 7 7 1 2 49Percent - 12.2 20.4 8.2 8.2 16.3 14.3 14.3 4.1 2.0

Table 9 - AIRCRAFT BY PHASE OF OPERATION AND DEGREE OF INJURY AND BY DAMAGE14 CFR 121 OPERATIONS

1997


Phase of operation * None Minor Ser Fatal None Minor Subs Dest No. Percent

Standing 0 1 0 0 0 0 1 0 1 2.0Standing - starting engines 1 0 0 0 0 0 1 0 1 2.0Standing - engines not 0 0 3 1 2 2 0 0 4 8.2operating

Taxi 1 0 0 0 0 0 1 0 1 2.0Taxi - pushback/tow 0 0 2 1 3 0 0 0 3 6.1Taxi - to takeoff 2 0 1 0 0 0 3 0 3 6.1Taxi - from landing 1 2 0 0 0 0 3 0 3 6.1Takeoff 1 0 0 1 0 0 1 1 2 4.1Takeoff - roll/run 0 0 1 0 0 1 0 0 1 2.0Takeoff - initial climb 1 0 0 0 0 0 1 0 1 2.0Climb 0 0 2 0 2 0 0 0 2 4.1Climb -to cruise 1' 0 1 0 1 0 1 0 2 4.1Cruise 0 0 3 1 3 1 0 0 4 8.2Cruise -normal 0 0 4 0 3 1 0 0 4 8.2Descent 0 0 1 0 1 0 0 0 1 2.0Descent - normal 0 0 6 0 5 1 0 0 6 12.2Landing - flare/touchdown 2 1 0 0 0 0 2 1 3 6.1Landing roll 1 3 0 0 0 0 4 0 4 8.2Maneuvering 1 0 0 0 0 0 1 0 1 2.0Not reported 1 0 1 0 1 0 1 0 2 4.1


* Phase of Operation is the phase of flight in which the first occurrence happened.

11

Table 10 - AIRCRAFT BY CONDITION OF LIGHT AND TYPE OF WEATHER14 CFR 121 OPERATIONS

1997

Type of weatherAircraft

Condition of

light VMC IMC Unknown No. Percent

Dawn 0 1 0 1 2.0Daylight 19 6 0 25 51.0Night (dark) 9 1 0 10 20.4Night (bright) 4 1 0 5 10.2Dusk 2 0 0 2 4.1Not reported 2 1 3 6 12.2

AircraftNumber - 36 10 3 49

Percent - 73.5 20.4 6.1

Table 11 - AIRCRAFT BY TYPE OF OPERATION AND DEGREE OF INJURY14 CFR 121 OPERATIONS

1997

Degree of Injury Aircraft

Type of Operation None Minor Serious Fatal No. Percent

Scheduled Domestic Passenger 7 6 15 0 28 57.1Scheduled Domestic Cargo 0 0 1 0 1 2.0Scheduled Domestic Pax/Cargo 1 0 2 0 3 6.1Scheduled International Pax 3 0 4 3 10 20.4Scheduled Int'l Pax/Cargo 0 0 2 0 2 4.1Nonscheduled Domestic Cargo 2 1 0 0 3 6.1Nonscheduled Int'l Passenger 0 0 1 0 1 2.0Nonscheduled International Cargo 0 0 0 1 1 2.0


Table 12 - AIRCRAFT BY OCCURRENCE OF FIRE AND DEGREE OF INJURY AND BY DAMAGE14 CFR 121 OPERATIONS

1997


Aircraft fire None Minor Ser Fatal None Minor Subs Dest No. Percent

None 11 6 24 3 21 5 18 0 44 89.8In-flight 1 0 0 0 0 0 1 0 1 2.0On ground 1 1 1 1 0 1 1 2 4 8.2


12

Table 13 - BROAD CAUSE/FACTOR ASSIGNMENTS*14 CFR 121 OPERATIONS

1997

Cited as Eithera Cause or a

Cited as a Cause Cited as a Factor Factor(or Both)

Fatal All Fatal All Fatal All

Cause/Factor Accidents Accidents Accidents Accidents Accidents Accidents

Aircraft # 0 5 0 5 0 8Propulsion System and Controls 0 0 0 0 0 0Flight Control System 0 0 0 0 0 0Airframe 0 0 0 2 0 2Landing Gear 0 3 0 2 0 4Systems/Equipment/Instruments 0 2 0 1 0 3

Environment # 0 10 1 11 1 20Weather 0 9 1 9 1 18Light Conditions 0 0 0 3 0 3Object (trees, wires, etc.) 0 0 0 1 0 1Airport/Airways Facilities, Aids 0 1 0 2 0 3Terrain/Runway Condition 0 0 0 1 0 1

Personnel # 3 36 2 9 3 37Pilot 2 14 0 6 2 16Others (Aboard) 0 9 1 1 1 10Others (Not Aboard) 1 14 1 4 1 15

Number of Aircraft 4 49

NTSB Determined Probable Cause 3 43

* Multiple causes and factors may be assigned in an accident.

# This category is composed of the sub-categories indented below it. The number ofaircraft cited in a category may be less than or equal to the sum of the sub-category citations.

13

Table 14 - ACCIDENTS, FATAL ACCIDENTS, FATALITIES, AND RATESALL 14 CFR 121 OPERATIONS

1987 - 1997

Fatalities Accident Rate per 100,000*Aircraft Hours Flown

Aboard AircraftYear Accidents Fatal Accidents Total In This Category Hours Flown Total Fatal

1987 34 5 232 230 10,645,192 0.310 0.0381988 30 3 285 274 11,140,548 0.260 0.0181989 28 11 278 276 11,274,543 0.248 0.0981990 24 6 39 12 12,150,116 0.198 0.0491991 26 4 62 49 11,780,610 0.221 0.0341992 18 4 33 31 12,359,715 0.146 0.0321993 23 1 1 0 12,706,206 0.181 0.0081994 23 4 239 237 13,124,315 0.168 0.0301995 36 3 168 162 13,505,257 0.267 0.0221996 38 5 380 350 13,746,112 0.276 0.0361997 49 4 8 6 15,838,109 0.309 0.025

* Suicide and sabotage accidents excluded from rates as follows:

Total - 1987 (1), 1988 (1), 1994 (1)Fatal - 1987 (1), 1988 (1)

Figure 1-ACCIDENTS AND FATAL ACCIDENTSALL 14 CFR 121 OPERATIONS

51-

42-

N 33-

24-

15-1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997

Year

1987 1988 1989 1990 1991 1992 1993 1994 1 95 1996 199712-

.~8-

• 4-

01

14

Figure 2 - NUMBER OF FATALITIESALL 14 CFR 121 OPERATIONS

400-

. 300-

2 00--

0-

1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997Year

Figure 3 - ACCIDENTS PER 100,000 HOURS FLOWNALL 14 CFR 121 OPERATIONS

0.40-

•- 0.30- "-

oo0.20- / '

0.10-

1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997

Year

1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 19970.12-

" 0.08-

- 0.04-

0.00-

15

Table 15 - ACCIDENTS, FATAL ACCIDENTS, FATALITIES, AND RATESSCHEDULED 14 CFR 121 OPERATIONS

1987 - 1997



1987 32 4 231 229 10,115,407 0.306 0.0301988 29 3 285 274 10,521,052 0.266 0.0191989 24 8 131 130 10,597,922 0.226 0.0751990 22 6 39 12 11,524,726 0.191 0.0521991 25 4 62 49 11,139,166 0.224 0.0361992 16 4 33 31 11,732,026 0.136 0.0341993 22 1 1 0 11,981,347 0.184 0.0081994 19 4 239 237 12,292,356 0.146 0.0331995 34 2 166 160 12,776,679 0.266 0.0161996 32 3 342 342 12,971,676 0.247 0.0231997 44 3 3 3 15,061,662 0.292 0.020

* Suicide and sabotage accidents excluded from rates as follows:Total - 1987 (1), 1988 (1), 1994 (1)Fatal - 1987 (1), 1988 (1)

Figure 4 - ACCIDENTS AND FATAL ACCIDENTSSCHEDULED 14 CFR 121 OPERATIONS

45-

40-

., 35-

2 30-

S25-

20-

151987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997

Year

1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 19978-

6-

4-

S 2- __

0-

16

Figure 5 - NUMBER OF FATALITIES

SCHEDULED 14 CFR 121 OPERATIONS

400-

3 300-

S200--

S100-

0-

1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997

Year

Figure 6 - ACCIDENTS PER 100,000 HOURS FLOWNSCHEDULED CFR 121 OPERATIONS

0.40-

0.30-

, 0.20-

0.10-1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997

Year

1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 19970.09-

S0.06-

~ 0.03-

0-

17

Table 16 - ACCIDENTS, FATAL ACCIDENTS, FATALITIES, AND RATESNONSCHEDULED 14 CFR 121 OPERATIONS

1987 - 1997



1987 2 1 1 1 529,785 0.378 0.1891988 1 0 0 0 619,496 0.161 0.0001989 4 3 147 146 676,621 0.591 0.4431990 2 0 0 0 625,390 0.320 0.0001991 1 0 0 0 641,444 0.156 0.0001992 2 0 0 0 627,689 0.319 0.0001993 1 0 0 0 724,859 0.138 0.0001994 4 0 0 0 831,959 0.481 0.0001995 2 1 2 2 728,578 0.275 0.1371996 5 2 38 8 774,436 0.646 0.2581997 5 1 5 4 776,447 0.644 0.129

Figure 7- ACCIDENTS AND FATAL ACCIDENTS

NONSCHEDULED 14 CFR 121 OPERATIONS

5-

4-

N 3-

2-

1-

1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997

Year

1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 19973-

. ~2-

0-

18

Figure 8 - NUMBER OF FATALITIESNONSCHEDULED 14 CFR 121 OPERATIONS

150-

3100-

S50-

0-1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997

Year

Figure 9 - ACCIDENTS PER 100,000 HOURS FLOWNNONSCHEDULED 14 CFR 121 OPERATIONS

0.90-

0.60-

S0.30-

0.00-1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997

Year

1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 19970.45-

'~0.30-

' 0.15-\

"0.00-

19

Table 17 - FIRST OCCURRENCES IN ALL ACCIDENTS AND IN FATAL ACCIDENTS

14 CFR 121 OPERATIONS

1997 AND 1987 - 1996

All Accidents Fatal Accidents

1997 1987 - 1996 1997 1987 - 1996

Type of Occurrence No. Percent Mean Percent No. Percent Mean Percent

In flight encounter with weather 13 26.5 6.3 22.9 1 25.0 .1 2.1

On ground collision with object 5 10.2 4.1 14.3 0 .0 .9 19.1

Airframe/component/system failure/ 3 6.1 4.0 13.9 0 .0 .7 14.9

malfunction

Miscellaneous/other 9 18.4 3.0 10.5 1 25.0 .2 4.3

Loss of control - in flight 2 4.1 1.1 3.8 1 25.0 .9 19.1

Loss of engine power(total) - 0 .0 .9 3.1 0 .0 .2 4.3

mechanical failure/malfunction

Collision between aircraft 1 2.0 .9 3.1 0 .0 .1 2.1

(other than midair)

Not reported 1 2.0 .8 2.8 0 .0 .3 6.4

Hard landing 3 6.1 .8 2.8 0 .0 .0 .0

In flight collision with terrain 0 .0 .8 2.8 0 .0 .5 10.6In flight collision with object 1 2.0 .6 2.1 0 .0 .1 2.1Altitude deviation,uncontrolled 1 2.0 .5 1.7 0 .0 .0 .0

Fire 0 .0 .5 1.7 0 .0 .1 2.1On ground collision with terrain 2 4.1 .5 1.7 0 .0 .0 .0Loss of control - on ground 1 2.0 .4 1.4 0 .0 .1 2.1Abrupt maneuver 0 .0 .3 1.0 0 .0 .0 .0Dragged wing, rotor, pod, or float 0 .0 .3 1.0 0 .0 .0 .0

Fire/explosion 0 .0 .3 1.0 0 .0 .0 .0Loss of engine power(total) - 0 .0 .3 1.0 0 .0 .0 .0

non-mechanical

Wheels up landing 0 .0 .3 1.0 0 .0 .0 .0Propeller blast or jet exhaust 0 .0 .3 1.0 0 .0 .0 .0

Explosion 0 .0 .2 .7 0 .0 .2 4.3

Main gear collapsed 1 2.0 .2 .7 0 .0 .0 .0On ground encounter with weather 0 .0 .2 .7 0 .0 .1 2.1

Overrun 0 .0 .2 .7 0 .0 .0 .0

Nose gear collapsed 1 2.0 .1 .3 0 .0 .0 .0

Tail gear collapsed 0 .0 .1 .3 0 .0 .0 .0Midair collision 0 .0 .1 .3 0 .0 .0 .0

Loss of engine power 1 2.0 .1 .3 0 .0 .1 2.1Loss of engine power(partial) - 0 .0 .1 .3 0 .0 .0 .0


Engine tearaway 0 .0 .1 .3 0 .0 .0 .0Propeller/rotor contact to person 0 .0 .1 .3 0 .0 .1 2.1

Undershoot 0 .0 .1 .3 0 .0 .0 .0Vortex turbulence encountered 1 2.5 .0 .0 0 .0 .0 .0Near collision between aircraft 2 4.1 .0 .0 0 .0 .0 .0

Loss of engine power(partial) - 1 2.0 .0 .0 0 .0 .0 .0

non-mechanical

Undetermined 1 2.0 .0 .0 1 25.0 .0 .0

Total 49 100.0 28.7 100.0 4 100.0 4.7 100.0

20

Table 18 - FIRST PHASES OF OPERATION IN ALL ACCIDENTS AND IN FATAL ACCIDENTS14 CFR 121 OPERATIONS1997 AND 1987 - 1996


1997 1987 - 1996 1997 1987 - 1996

Phase of Operation No. Percent Mean Percent No. Percent Mean Percent

Cruise 8 16.3 5.3 18.5 1 25.0 .7 14.9Taxi 10 20.4 4.8 16.7 1 25.0 .4 8.5Takeoff 4 8.2 3.7 12.9 1 25.0 1.1 23.4Landing 7 14.3 3.5 12.2 0 .0 .3 6.4Standing 6 12.2 3.0 10.5 1 25.0 .5 10.6Descent 7 14.3 3.0 10.5 0 .0 .0 .0Climb 4 8.2 1.9 6.6 0 .0 .4 8.5Approach 0 .0 2.2 7.7 0 .0 .8 17.0Not reported 2 4.1 .9 3.1 0 .0 .4 8.5Maneuvering 1 2.0 .3 1.0 0 .0 .1 2.1Other 0 .0 .1 .3 0 .0 .0 .0

Total Aircraft 49 100.0 28.7 100.0 4 100.0 4.7 100.0

Table 19 - BROAD CAUSE/FACTOR ASSIGNMENTS IN ALL ACCIDENTS AND IN FATAL ACCIDENTS14 CFR 121 OPERATIONS1997 AND 1987 - 1996


1997 1987 - 1996 1997 1987 - 1996

Broad Cause/Factor No. Percent Mean Percent No. Percent Mean Percent

Other Person 15 30.6 10.9 38.0 1 25.0 2.5 53.2(Not Aboard)

Pilot 16 32.7 9.2 32.1 2 50.0 1.3 27.7Weather 18 36.7 7.7 26.8 1 25.0 .8 17.0Other Person (Aboard) 10 20.4 4.9 17.1 1 25.0 .2 4.3Systems/Equipment/ 3 6.1 4.2 14.6 0 .0 .9 19.1

InstrumentsPropulsion System and 0 .0 2.5 8.7 0 .0 .3 6.4

ControlsObject (tree,wires,etc) 1 2.0 1.1 3.8 0 .0 .1 2.1Airframe 2 4.1 1.1 3.8 0 .0 .7 14.9Landing Gear 4 8.2 1.3 4.5 0 .0 .1 2.1Light Conditions 3 6.1 1.2 4.2 0 .0 .1 2.1Terrain/Runway Condition 1 2.0 .7 2.4 0 .0 .1 2.1Flight Control System 0 .0 .6 2.1 0 .0 .2 4.3Airport/Airways 3 6.1 .5 1.7 0 .0 .3 6.4Facilities, Aids

Total Aircraft 49 100.0 28.7 100.0 4 100.0 4.7 100.0

NTSB Determined 43 26.3 3 3.9Probable Cause

21

Scheduled 14 CFR Part 135 Operations

There were 16 accidents involving scheduled 14 CFR Part 135 operations (commuter air carriers) in

1997. The average number of accidents per year in this category for the years 1987 through 1996 was 18.

The accident rate per 100,000 hours flown for 1997 was 1.628, compared with 0.744 for the period 1987

through 1996. The number of hours flown in 1997 by scheduled Part 135 operators was the lowest in a

decade and less than half the activity recorded for the previous year (1996). This decrease in activity is

associated with the regulatory reclassification of Part 135/Part 121 operations and has a direct effect on the

accident rate.

For the purpose of comparison, one can estimate the accident rate in 1997 if there had been no

reclassification of Part 121/135 operations. Six accidents occurred after March that, based on aircraft size,

would probably have been classified as Part 135 operations instead of Part 121 operations if there had been

no regulatory reclassification. If those six are added to the 16 Part 135 accidents (raising the total to 22) and

divided by the average hours flown by Part 135 operators (average hours flown from 1987 to 1996 was

2,405,500) the accident rate for 1997 drops to 0.915 per 100,000 flight hours flown.

Five fatal accidents in 1997 resulted in 46 fatalities in Part 135 operations (one of these accidents

which occurred in January 1997 had 29 fatalities; had that accident occurred later in the year it would have

been classified as a Part 121 operation). The annual average for the period 1987 through 1996 was 4.5 fatal

accidents and 31 fatalities per year in scheduled Part 135 operations. The fatal accident rate for 1997 was

0.509 per 100,000 hours flown. This rate, the highest since 1987, is directly affected by the substantially

lower activity measure of aircraft hours flown for 1997.

22

Table 20 - SUMMARY OF LOSSESSCHEDULED 14 CFR 135 OPERATIONS

1987 - 1997

1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997

Accidents

Fatal 10 2 5 3 8 7 4 3 2 1 5Serious Injury 5 2 2 2 3 1 2 1 2 1 1Minor Injury 6 2 3 1 3 3 2 1 0 5 3No Injury 12 12 9 9 9 12 8 5 8 4 7

Total 33 18 19 15 23 23 16 10 12 11 16

Fatalities

Passenger 42 17 25 3 64 13 19 19 7 10 40Crew 15 4 6 1 13 8 4 6 2 2 6Other Persons 2 0 0 2 22 0 1 0 0 2 0

Total 59 21 31 6 99 21 24 25 9 14 46

Aircraft Damage

Destroyed 11 3 5 2 9 7 4 3 3 1 5Substantial 19 14 14 12 13 16 10 6 9 10 11Minor 2 1 0 1 0 0 0 1 0 0 0None 1 0 1 0 1 0 2 0 0 0 0

Total 33 18 20a 15 23 23 16 10 12 11 16

a The number of aircraft damaged is higher than the number of accidents because these

accidents included collisions between two aircraft.

Table 21 - ACCIDENT RATESSCHEDULED 14 CFR 135 OPERATIONS

1987 - 1997

1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997

Accidents Rates d

Miles Flown b .094 .047 .048 .033 .053 .043 .029 .017 .022 .019 .064Hours Flown ' 1.695 .860 .848 .641 1.004 .942 .606 .359 .457 .399 1.628Departures Flown ' 1.174 .619 .674 .475 .815 .706 .444 .279 .373 .313 1.148

Fatal Accident Rates d

Miles Flown b .029 .005 .013 .009 .018 .014 .007 .005 .004 .002 .020Hours Flown C .514 .096 .223 .171 .349 .300 .152 .108 .076 .036 .509Departures Flown 0 .356 .069 .177 .127 .284 .225 .111 .084 .062 .028 .359

b Per Million Miles FlownC Per Hundred Thousand Hours and Departures Flown

d The 4/17/92 suicide involving a Mesaba Airline Fairchild SA-227AC is excluded from

accident rate computation.

23

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co E H I a4 u

0 14 0 0

00 001 0 In n

00,IH In I

1 4IH 0 0)4-4 -oHl104 04

0404

0 to 0 0

0H 1 0 H H3HJ 1 04 - 04

UH I > ý

4J1I ) P-

H I o m o t<Io ) 25

Table 23 - PERSONS BY ROLE AND DEGREE OF INJURYSCHEDULED 14 CFR 135 OPERATIONS

1997

Degree of Injury


Pilot 4 0 1 11 16Copilot 1 0 0 1 2Cabin attendants 1 0 0 0 1Passenger 40 1 10 27 78

Total aboard 46 1 11 39 97

Other aircraft* 0 0 1 3 4

Grand total 46 1 12 42 101Percent 45.5 1.0 11.9 41.6

* Injuries carried opposite "Other aircraft" are injuries occurring in

aircraft that are not part of this tabulation, but which were involvedin collisions with aircraft which are a part of this tabulation.

Table 24 - AIRCRAFT BY DAMAGE AND DEGREE OF INJURYSCHEDULED 14 CFR 135 OPERATIONS

1997


None Minor Seri- FatalAircraft damage ous No. Percent

Substantial 7 3 1 0 11 68.8Destroyed 0 0 0 5 5 31.3


Table 25 - AIRCRAFT BY FIRST OCCURRENCE AND DEGREE OF INJURY AND BY DAMAGESCHEDULED 14 CFR 135 OPERATIONS

1997


Type of first occurrence None Minor Seri- Fatal None Minor Substan- De- No. Percentous tial stroy

Airframe/component/system 0 1 0 0 0 0 1 0 1 6.3failure/malfunction

In flight collision with object 0 0 0 1 0 0 0 1 1 6.3In flight collision with terrain 1 0 0 2 0 0 1 2 3 18.8Wheels up landing 1 0 0 0 0 0 1 0 1 6.3In flight encounter with weather 1 1 0 0 0 0 2 0 2 12.5Loss of control - in flight 0 0 0 2 0 0 0 2 2 12.5Loss of power (partial) - 0 1 0 0 0 0 1 0 1 6.3mechanical failure/malfunction

Nose gear collapsed 1 0 0 0 0 0 1 0 1 6.3Midair collision 0 0 1 0 0 0 1 0 1 6.3Miscellaneous/other 2 0 0 0 0 0 2 0 2 12.5Not reported 1 0 0 0 0 0 1 0 1 6.3

AircraftNumber - 7 3 1 5 0 0 11 5 16Percent - 43.8 18.8 6.3 31.3 .0 .0 68.8 31.3

26

Table 26 - AIRCRAFT BY FIRST OCCURRENCE AND BROAD PHASE OF OPERATION

SCHEDULED 14 CFR 124 OPERATIONS1997


Type of first occurrence Tkoff Cruis Dscnt Aprch Landg Manvr Nrept No. Percent

Airframe/component/system 1 0 0 0 0 0 0 1 6.3

failure/malfunctionNose gear collapsed 0 0 0 0 1 0 0 1 6.3In flight collision w/obj.0 0 0 0 0 1 0 1 6.3

In flight collision w/ter.0 0 1 0 1 1 0 3 18.8Wheels up landing 0 0 0 0 1 0 0 1 6.3In flight encounter w/wx. 0 0 0 2 0 0 0 2 12.5Loss of control - in flight 1 0 0 1 0 0 0 2 12.5Loss of engine power - 1 0 0 0 0 0 0 1 6.3

(partial) - mechanicalMidair collision 0 0 0 1 0 0 0 1 6.3

Miscellaneous/other 0 1 1 0 0 0 0 2 12.5Not reported 0 0 0 0 0 0 1 1 6.3

AircraftNumber - 3 1 2 4 3 2 1 16Percent - 18.8 6.3 12.5 25.0 18.8 12.5 6.3

Table 27 - AIRCRAFT BY PHASE OF OPERATION AND DEGREE OF INJURY AND BY DAMAGE



None Minor Seri- Fatal None Minor Substan- De-Phase of operation * ous tial stroy No. Percent

Takeoff - initial climb 0 2 0 1 0 0 2 1 3 18.8

Cruise 1 0 0 0 0 0 1 0 1 6.3Descent 0 0 0 1 0 0 0 1 1 6.3Descent - normal 1 0 0 0 0 0 1 0 1 6.3

Approach 0 0 0 1 0 0 0 1 1 6.3Approach - VFR pattern - 1 1 1 0 0 0 3 0 3 18.8final approach

Landing 1 0 0 0 0 0 1 0 1 6.3Landing - flare/touchdown 1 0 0 0 0 0 1 0 1 6.3Landing - roll 1 0 0 0 0 0 1 0 1 6.3Maneuvering 0 0 0 2 0 0 0 2 2 12.5Not reported 1 0 0 0 0 0 1 0 1 6.3

AircraftNumber - 7 3 1 5 0 0 11 5 16Percent - 43.8 18.8 6.3 31.3 .0 .0 68.8 31.3

• Phase of Operation is the phase of flight in which the first occurrence happened.

27

Table 28 - AIRCRAFT BY CONDITION OF LIGHT AND TYPE OF WEATHER



Condition of Not

light VMC IMC reported No. Percent

Daylight 8 4 1 13 81.3Night (dark) 2 0 0 2 12.5Not reported 1 0 0 1 6.3

AircraftNumber - 11 4 1 16

Percent - 68.8 25.0 6.3

Table 29 - AIRCRAFT BY TYPE OF OPERATION AND DEGREE OF INJURY




Scheduled Domestic Passenger 0 2 1 3 6 37.5Scheduled Domestic Pax/Cargo 6 1 0 2 9 56.3Scheduled International Passenger 1 0 0 0 1 6.3

AircraftNumber - 7 3 1 5 16

Percent - 43.8 18.8 6.3 31.3

Table 30 - AIRCRAFT BY PROXIMITY TO AIRPORT AND FLIGHT PLANSCHEDULED 14 CFR 135 OPERATIONS

1997

Flight planAircraft

CmpnyAccident location None VFR IFR VFR No. Percent

Off airport/airstrip 1 4 1 2 8 50.0On airport 1 2 1 3 7 43.8On airstrip 0 0 0 1 1 6.3

AircraftNumber - 2 6 2 5 16

Percent - 12.5 37.5 12.5 31.3

28

Table 31 - AIRCRAFT BY OCCURRENCE OF FIRE AND DEGREE OF INJURY AND BY DAMAGE


1997


None Minor Seri- Fatal None Minor Substan- Dest

Aircraft fire ous tial No. Percent

None 7 3 1 4 0 0 11 4 15 93.8

On ground 0 0 0 1 0 0 0 1 1 6.3

Aircraft

Number - 7 3 1 5 0 0 11 5 16

Percent - 43.8 18.8 6.3 31.3 .0 .0 68.8 31.3

Table 32 - AIRCRAFT BY TYPE OF AIRCRAFT AND DEGREE OF INJURY AND BY DAMAGE


1997


None Minor Seri- Fatal None Minor Substan- Dest No. Percent

Type of aircraft ous tial

Fixed Wing - Single 2 2 0 1 0 0 4 1 5 31.3

Reciprocating Engine

Fixed Wing - Multiengine 3 0 1 1 0 0 4 1 5 31.3

Fixed Wing - Turboprop 2 1 0 3 0 0 3 3 6 37.5

Aircraft

Number - 7 3 1 5 0 0 11 5 16

Percent - 43.8 18.8 6.3 31.3 .0 .0 68.8 31.3

29

Table 33 - BROAD CAUSE/FACTOR ASSIGNMENTS*


1997

Cited as Either

a Cause or a

Cited as a Cause Cited as a Factor Factor (or Both)



Aircraft # 0 4 1 1 1 5Propulsion System and Controls 0 1 1 1 1 2

Airframe 0 2 0 0 0 2

Landing Gear 0 1 0 0 0 1

Environment # 0 0 2 8 2 8

Weather 0 0 2 6 2 6

Terrain/Runway Condition 0 0 0 3 0 3

Personnel # 4 11 2 6 4 11Pilot 4 11 2 5 4 11

Others (Not Aboard) 0 1 0 1 0 1




# This category is composed of the sub-categories indented below it. The number ofaircraft cited in a category may be less than or equal to the sum of the sub-

category citations.

30

Table 34 - ACCIDENTS, FATAL ACCIDENTS, FATALITIES, AND RATESSCHEDULED 14 CFR 135 OPERATIONS

1987 - 1997



1987 33 10 59 57 1,946,349 1.695 0.5141988 18 2 21 21 2,092,689 0.860 0.0961989 19 5 31 31 2,240,555 0.848 0.2231990 15 4 7 5 2,341,760 0.641 0.1711991 23 8 99 77 2,291,581 1.004 0.3491992 23 7 21 21 2,335,349 0.942 0.3001993 16 4 24 23 2,638,347 0.606 0.1521994 10 3 25 25 2,784,129 0.359 0.1081995 12 2 9 9 2,627,866 0.457 0.0761996 11 1 14 12 2,756,755 0.399 0.0361997 16 5 46 46 982,764 1.628 0.509

* Suicide and sabotage accidents excluded from rates as followsTotal - 1992 (1)

Figure 10- ACCIDENTS AND FATAL ACCIDENTSSCHEDULED 14 CFR 135 OPERATIONS

40-

S 30-

S20-

10-1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997

Year

1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 199712-

0-

31

Figure 11 - NUMBER OF FATALITIESSCHEDULED 14 CFR 135 OPERATIONS

100-

. 80-

S60-

* 40-

S20-

0-1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997

Year

Figure 12 - ACCIDENT RATE PER 100,000 HOURS FLOWNSCHEDULED 14 CER 135 OPERATIONS

1.80-

t 1.40-

S1.00-

-o 0.60-

0.20-1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997

Year

1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 19970.60-

S0.40-

S0.20-

0.00-

32

Table 35 - FIRST OCCURRENCES IN ALL ACCIDENTS AND IN FATAL ACCIDENTS


1997 AND 1987 - 1996


1997 1987 - 1996 1997 1987 - 1996


On ground collision with object 0 .0 2.8 15.5 0 .0 .1 2.2

Loss of control - in flight 2 12.5 2.2 12.2 2 40.0 1.1 24.4

In flight collision with terrain 3 18.8 2.1 11.6 2 40.0 1.1 24.4

In flight encounter with weather 2 12.5 1.6 8.8 0 .0 .8 17.8

Airframe/component/system failure/ 1 6.3 1.4 7.7 0 .0 .2 4.4

malfunction

Hard landing 0 .0 .6 3.3 0 .0 .0 .0

In flight collision with object 1 6.3 .6 3.3 1 20.0 .1 2.2

Loss of control - on ground 0 .0 .6 3.3 0 .0 .0 .0

Overrun 0 .0 .6 3.3 0 .0 .0 .0

Loss of engine power(total) - 0 .0 .5 2.8 0 .0 .1 2.2

non-mechanical

Gear not extended 0 .0 .4 2.2 0 .0 .0 .0

Midair collision 1 6.3 .4 2.2 0 .0 .2 4.4

Loss of engine power(total) - 0 .0 .4 2.2 0 .0 .0 .0


Loss of engine power(partial)- 1 6.3 .4 2.2 0 .0 .1 2.2


Propeller/rotor contact to person 0 .0 .4 2.2 0 .0 .1 2.2

Undershoot 0 .0 .4 2.2 0 .0 .0 .0

Nose gear collapsed 1 6.3 .3 1.7 0 .0 .0 .0

On ground encounter with terrain 0 .0 .3 1.7 0 .0 .0 .0

Vortex turbulence encountered 0 .0 .3 1.7 0 .0 .1 2.2

Miscellaneous/other 2 12.5 .3 1.7 0 .0 .0 .0

Main gear collapsed 0 .0 .2 1.1 0 .0 .0 .0

Loss of engine power 0 .0 .2 1.1 0 .0 .2 4.4

Loss of engine power(partial) - 0 .0 .2 1.1 0 .0 .0 .0

non-mechanical

Not reported... 1 6.3 .1 .6 0 .0 .1 2.2

Dragged wing, rotor, pod or float 0 .0 .1 .6 0 .0 .0 .0

Fire 0 .0 .1 .6 0 .0 .0 .0

Explosion 0 .0 .1 .6 0 .0 .0 .0

Complete gear collapsed 0 .0 .1 .6 0 .0 .0 .0

Undetermined 0 .0 .1 .6 0 .0 .0 .0

Gear retraction on ground 0 .0 .1 .6 0 .0 .0 .0

Propeller/failure malfunction 0 .0 .1 .6 0 .0 .1 2.2

Collision between aircraft 0 .0 .1 .6 0 .0 .1 2.2

(other than midair)

Wheels up landing 1 6.3 .0 .0 0 .0 .0 .0

Total 16 100.0 18.1 100.0 5 100.0 4.5 100.0

33

Table 36 - FIRST PHASES OF OPERATION IN ALL ACCIDENTS AND IN FATAL ACCIDENTSSCHEDULED 14 CFR 135 OPERATIONS

1997 AND 1987 - 1996


1997 1987 - 1996 1997 1987 - 1996

Phase of operation No. Percent Mean Percent No. Percent Mean Percent

Landing 3 18.8 3.5 19.3 0 .0 .1 2.2Takeoff 3 18.8 2.8 15.5 1 20.0 .4 8.9Approach 4 25.0 2.8 15.5 1 20.0 1.6 35.6Taxi 0 .0 2.5 13.8 0 .0 .0 .0Cruise 1 6.3 1.9 10.5 0 .0 1.1 24.4Standing 0 .0 1.4 7.7 0 .0 .2 4.4Descent 2 12.5 1.2 6.6 1 20.0 .2 4.4Maneuvering 2 12.5 1.1 6.1 2 40.0 .6 13.3Climb 0 .0 .5 2.8 0 .0 .1 2.2Not reported 1 6.3 .4 2.2 0 .0 .2 4.4

Total Aircraft 16 100.0 18.1 100.0 5 100.0 4.5 100.0

Table 37 - BROAD CAUSE/FACTOR ASSIGNMENTS IN ALL ACCIDENTS AND IN FATAL ACCIDENTSSCHEDULED 14 CFR 135 OPERATIONS

1997 AND 1987 - 1996


1997 1987 - 1996 1997 1987 - 1996


Pilot 11 68.8 12.6 69.6 4 80.0 3.5 77.8Other Person 1 6.3 6.5 35.9 0 .0 1.9 42.2

(Not Aboard)Weather 6 37.5 5.3 29.3 2 40.0 1.8 40.0Terrain/Runway Condition 3 18.8 4.0 22.1 0 .0 1.2 26.7Light Conditions 0 .0 2.6 14.4 0 .0 .7 15.6Propulsion System and 2 12.5 2.0 11.0 1 20.0 .6 13.3

ControlsObject (tree,wires,etc) 0 .0 1.4 7.7 0 .0 .1 2.2Airframe 2 12.5 1.2 6.6 0 .0 .2 4.4Landing Gear 1 6.3 1.2 6.6 0 .0 .0 .0Systems/Equipment/ 0 .0 1.0 5.5 0 .0 .3 6.7

InstrumentsAirport/Airways 0 .0 .8 4.4 0 .0 .2 4.4

Facilities, AidsFlight Control System 0 .0 .4 2.2 0 .0 .2 4.4Other Person (Aboard) 0 .0 .2 1.1 0 .0 .0 .0

Total Aircraft 16 100.0 18.1 100.0 5 100.0 4.5 100.0


34

Nonscheduled 14 CFR Part 135 Operations

There were 82 accidents involving nonscheduled 14 CFR Part 135 aircraft (air taxis) in 1997. For

the period 1987 through 1996, the average number of accidents per year in this category is 89.8 with an

overall accident rate of 4.08 per 100,000 hours flown. The accident rate in 1997 was 3.64 accidents per

100,000 hours flown, an 18 percent decrease from the 1996 rate of 4.44.

There were 15 fatal accidents involving 39 fatalities in 1997. During the period 1987 through 1996,

the yearly average was 26.2 fatal accidents and 62.4 fatalities. The fatal accident rate for 1997 was 0.67 per

100,000 hours flown, the lowest in 10 years.

35

Table 38 - SUMMARY OF LOSSES


1987 - 1997

1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997

Accidents

Fatal 30 28 25 29 28 24 19 26 24 29 15

Serious Injury 9 15 12 14 10 5 8 9 5 11 14

Minor Injury 7 11 14 12 8 9 13 13 7 10 14

No Injury 50 48 59 52 42 38 29 37 39 40 39

Total 96 102 110 107 88 76 69 85 75 90 82

Fatalities

Passenger 31 22 46 20 42 43 20 40 29 31 22

Crew 32 33 35 29 32 22 22 22 23 32 17

Other Persons 2 4 2 2 4 3 0 1 0 0 0

Total 65 59 83 51 78 68 42 63 52 63 39

Aircraft Damage

Destroyed 34 37 32 39 32 26 26 24 21 37 23

Substantial 61 63 79 68 53 49 44 60 54 51 58

Minor 4 1 0 1 2 1 0 0 1 0 2

None 0 1 0 1 2 0 0 2 0 3 1

Total 99a 102 1i1l 109, 89a 76 70' 864 761 91a 84a

The number of aircraft damaged is higher than the number of accidents because these accidents

included collisions between two aircraft.

Table 39 - ACCIDENT RATES


1987 - 1997

1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997

Accident Rates

Hours Flown b 3.61 3.88 3.64 4.76 3.93 3.86 4.16 4.58 4.39 4.44 3.64

Fatal Accident Rates

Hours Flown b 1.13 1.06 0.83 1.29 1.25 1.22 1.15 1.40 1.41 1.43 0.67

SPer Hundred Thousand Hours Flown

36

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0 0J 0 44 0ý 0r40 44 0 4.0 440dIa) 0 a 0 0a 0 0 0) 0 0) 0 0) 0 0 0

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F) 04 c l ý ) ý J ) ý 4 ý

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P 1a u 0 04 CD 04 -N CO uu

- ' 0 04~C 0 4

04 0 H 04 - 0n 0 - 0 0 004~~~~ý 0 '0 00 - 0 0 0) H 0

04 - ) 0 0 4 A 0- 44 ý44-- 41 0) E- M -Hý 0040 0 0 4 -4 0 0 "0 0D 0 ) H u 0 CO4 -14

044 4 0y 0l 0 04 4- 0 44 0044 1 4 0 0 011 HH H) 44 03 04r 4-04-)10 0T F4 rH H1 .0 0 0) -H -H Ha 0f 0

M)1 04 CO4- 4 0 4 CO 04 4- ) 4 0 0 4

04- H - N 03) H O ) 3' 00) 0'T '0 H ) 0D4PI(Y CO CO 0A 0 H H N 0D 0 H H N N CO)

04 03 C H H H Hý H N N N N N N (NH H H H H H H IH H

41

Table 41 - PERSONS BY ROLE AND DEGREE OF INJURY


1997

Degree of Injury


Pilot 13 11 11 49 84

Copilot 2 0 1 7 10

Other crew 2 0 1 2 5

Passenger 22 11 18 123 174

Total aboard 39 22 31 181 273

Other ground 0 1 0 1 2

Grand total 39 23 31 182 275

Percent 14.2 8.4 11.3 66.2

Table 42 - AIRCRAFT BY DAMAGE AND DEGREE OF INJURY


1997


None Minor Seri- Fatal

Aircraft damage ous No. Percent

None 0 0 2 0 2 2.4

Minor 1 0 0 0 1 1.2

Substantial 39 9 9 1 58 69.0

Destroyed 1 5 3 14 23 27.4

Aircraft

Number - 41 14 14 15 84

Percent - 48.8 16.7 16.7 17.9

42

Table 43 - AIRCRAFT BY FIRST OCCURRENCE AND DEGREE OF INJURY AND BY DAMAGE

NONSCHEDULED14 CFR 135 OPERATIONS

1997


None Minor Seri- Fatal None Minor Substan- De-

Type of first occurrence ous tial stroy No. Percent

Airframe/component/system 2 2 1 1 0 0 5 1 6 7.1

failure/malfunction

Propeller failure/malfunction 1 0 0 1 0 0 1 1 2 2.4

Fire 1 0 0 0 0 0 1 0 1 1.2

Gear collapsed 1 0 0 0 0 0 1 0 1 1.2

Main gear collapsed 2 1 0 0 0 0 3 0 3 3.6

Hard landing 1 0 2 0 0 0 2 1 3 3.6

In flight collision with object 2 0 0 1 0 0 2 1 3 3.6

In flight collision with terrain 2 1 2 2 0 0 4 3 7 8.3Wheels up landing 1 0 0 0 0 0 1 0 1 1.2

In flight encounter with weather 3 3 2 3 0 0 5 6 11 13.1

Loss of control - in flight 0 1 0 2 0 0 0 3 3 3.6Loss of control - on ground 2 0 0 0 0 0 2 0 2 2.4

Collision between aircraft 4 0 0 0 0 1 3 0 4 4.8

(other than midair)

On ground collision with object 3 0 0 0 0 0 3 0 3 3.6

On ground collision with terrain 3 3 0 0 0 0 5 1 6 7.1

Overrun 2 1 0 0 0 0 3 0 3 3.6

Loss of engine power 3 1 1 1 0 0 5 1 6 7.1

Loss of engine power(total) - 2 0 0 1 0 0 2 1 3 3.6


Loss of engine power(partial) - 0 0 1 1 0 0 2 0 2 2.4mechanical failure/malfunction

Loss of engine power(total) - 3 1 2 1 0 0 5 2 7 8.3

non-mechanical

Loss of engine power(partial) - 1 0 1 0 0 0 1 1 2 2.4

non-mechanical

Propeller/rotor contact to person 0 0 1 0 1 0 0 0 1 1.2

Undershoot 1 0 0 0 0 0 1 0 1 1.2

Missing aircraft 0 0 0 1 0 0 0 1 1 1.2

Miscellaneous/other 0 0 1 0 1 0 0 0 1 1.2Not reported 1 0 0 0 0 0 1 0 1 1.2

Aircraft

Number - 41 14 14 15 2 1 58 23 84Percent - 48.8 16.7 16.7 17.9 2.4 1.2 69.0 27.4

43

Table 44 - AIRCRAFT BY FIRST OCCURRENCE AND BROAD PHASE OF OPERATION


1997


Type of first occurrence Stndg Taxi Tkoff Climb Cruis Aprch Dscnt Landg Manvr Nrept No. Percent

Airframe/component/system 0 0 0 1 4 1 0 0 0 0 6 7.1

failure/malfunction

Propeller failure/ 0 0 0 0 2 0 0 0 0 0 2 2.4

malfunction

Fire 0 0 0 1 0 0 0 0 0 0 1 1.2

Gear collapsed 0 0 0 0 0 0 0 1 0 0 1 1.2

Main gear collapsed 0 0 0 0 0 0 0 3 0 0 3 3.6

Hard landing 0 0 0 0 0 0 0 3 0 0 3 3.6

In flight collision w/obj. 0 0 1 0 1 1 0 0 0 0 3 3.6

In flight collision w/ter. 0 0 2 0 0 2 0 0 3 0 7 8.3

Wheels up landing 0 0 0 0 0 0 0 1 0 0 1 1.2

In flight encounter w/wx. 0 0 1 2 4 2 0 0 2 0 11 13.1

Loss of control - in flight 0 0 2 0 1 0 0 0 0 0 3 3.6

Loss of control - on ground 0 0 2 0 0 0 0 0 0 0 2 2.4

Collision between aircraft 2 2 0 0 0 0 0 0 0 0 4 4.8

(other than midair)

On ground collision w/obj. 0 1 2 0 0 0 0 0 0 0 3 3.6

On ground collision w/ter. 0 0 3 0 0 0 0 3 0 0 6 7.1

Overrun 0 0 1 0 0 0 0 2 0 0 3 3.6

Loss of power 0 0 0 0 4 1 0 0 1 0 6 7.1

Loss of power (total) - mech. 0 0 1 0 1 1 0 0 0 0 3 3.6

failure/malfunction

Loss of power (partial) - 0 0 0 1 1 0 0 0 0 0 2 2.4

mech. failure/malfunction

Loss of power (total) - 0 0 0 1 1 3 2 0 0 0 7 8.3

non-mechanical

Loss of power (partial) - 0 0 0 1 0 1 0 0 0 0 2 2.4

non

Propeller/rotor contact 1 0 0 0 0 0 0 0 0 0 1 1.2

to person

Undershoot 0 0 0 0 0 1 0 0 0 0 1 1.2

Missing aircraft 0 0 0 0 0 0 1 0 0 0 1 1.2

Miscellaneous/other 1 0 0 0 0 0 0 0 0 0 1 1.2

Not reported 0 0 0 0 0 0 0 0 0 1 1 1.2

Aircraft

Number - 4 3 15 7 19 13 3 13 6 1 84

Percent - 4.8 3.6 17.9 8.3 22.6 15.5 3.6 15.5 7.1 1.2

44

Table 45 - AIRCRAFT BY PHASE OF OPERATION AND DEGREE OF INJURY AND BY DAMAGENONSCHEDULED 14 CFR 135 OPERATIONS

1997


None Minor Seri- Fatal None Minor Substan- De-

Phase of operation ous tial stroy No. Percent

Standing - engines 1 0 0 0 0 0 1 0 1 1.2

operating

Standing - engines 1 0 1 0 1 0 1 0 2 2.4

not operating

Standing - idling rotors 0 0 1 0 1 0 0 0 1 1.2

Taxi 1 0 0 0 0 0 1 0 1 1.2

Taxi - to takeoff 1 0 0 0 0 0 1 0 1 1.2

Taxi - from landing 1 0 0 0 0 1 0 0 1 1.2

Takeoff 1 0 0 0 0 0 1 0 1 1.2

Takeoff - roll/run 5 1 0 0 0 0 5 1 6 7.1

Takeoff - initial climb 3 1 1 2 0 0 4 3 7 8.3

Takeoff - aborted 1 0 0 0 0 0 1 0 1 1.2

Climb 2 0 1 1 0 0 3 1 4 4.8

Climb - to cruise 0 1 2 0 0 0 2 1 3 3.6

Descent 0 1 0 1 0 0 1 1 2 2.4

Descent - normal 1 0 0 0 0 0 1 0 1 1.2

Cruise 4 4 3 3 0 0 9 5 14 16.7

Cruise - normal 2 0 0 3 0 0 3 2 5 6.0

Approach 4 1 1 1 0 0 5 2 7 8.3

Approach - VFR pattern - 1 0 1 0 0 0 1 1 2 2.4

final approach

Approach - FAF/outer marker 3 0 0 0 0 0 3 0 3 3.6

to threshold (IFR)Missed approach 0 0 0 1 0 0 0 1 1 1.2

Landing 1 0 0 0 0 0 1 0 1 1.2

Landing - flare/touchdown 1 1 2 0 0 0 3 1 4 4.8

Landing - roll 4 3 0 0 0 0 7 0 7 8.3

Emergency landing after 1 0 0 0 0 0 1 0 1 1.2

takeoff

Maneuvering 1 1 1 2 0 0 2 3 5 6.0

Maneuvering - turn to reverse 0 0 0 1 0 0 0 1 1 1.2

directionNot reported 1 0 0 0 0 0 1 0 1 1.2

Aircraft

Number - 41 14 14 15 2 1 58 23 84

Percent - 48.8 16.7 16.7 17.9 2.4 1.2 69.0 27.4

45

Table 46 - AIRCRAFT BY CONDITION OF LIGHT AND TYPE OF WEATHERNONSCHEDULED 14 CFR 135 OPERATIONS

1997


Condition of

light VMC IMC No. Percent

Daylight 45 9 54 64.3Night (dark) 13 8 21 25.0Night (bright) 2 0 2 2.4Dusk 2 1 3 3.6Not reported 3 1 4 4.8

AircraftNumber - 65 19 84

Percent - 77.4 22.6

Table 47 - AIRCRAFT BY TYPE OF OPERATION AND DEGREE OF INJURYNONSCHEDULED 14 CFR 135 OPERATIONS

1997



Domestic Passenger 17 10 7 4 38 45.2Domestic Cargo 20 2 6 7 35 41.7Domestic Pax/Cargo 1 0 1 4 6 7.1International Passenger 3 2 0 0 5 6.0


Table 48 - AIRCRAFT BY PROXIMITY TO AIRPORT AND FLIGHT PLANNONSCHEDULED 14 CFR 135 OPERATIONS

1997

Flight planAircraft

VFR/ CmpnyAccident location None VFR IFR IFR VFR No. Percent

Off airport/airstrip 5 8 8 1 23 45 53.6On airport 2 3 15 0 7 27 32.1On airstrip 1 0 0 0 5 6 7.1Not reported 1 1 2 0 2 6 7.1

AircraftNumber - 9 12 25 1 37 84Percent - 10.7 14.3 29.8 1.2 44.0

46

Table 49 - AIRCRAFT BY OCCURRENCE OF FIRE AND DEGREE OF INJURY AND BY DAMAGE

NONSCHEDULED 14 CFR 135 OPERATIONS1997


None Minor Seri- Fatal None Minor Sub- De-

Aircraft fire ous stantial stroy No. Percent

None 39 13 11 12 2 1 56 16 75 89.3

In-flight 1 0 0 0 0 0 1 0 1 1.2

On ground 1 1 3 3 0 0 1 7 8 9.5

Aircraft

Number - 41 14 14 15 2 1 58 23 84

Percent - 48.8 16.7 16.7 17.9 2.4 1.2 69.0 27.4

Table 50 - AIRCRAFT BY TYPE OF AIRCRAFT AND DEGREE OF INJURY AND BY DAMAGE

NONSCHEDULED 14 CFR 135 OPERATIONS1997


None Minor Seri- Fatal None Minor Sub- De-

Type of aircraft ous stantial stroy No. Percent

All Fixed Wing * 39 12 11 12 1 1 54 18 74 88.1

Single reciprocating engine 19 8 4 5 0 0 30 6 36 42.9

Mutiple reciprocating engine 11 2 5 5 0 1 14 8 23 27.4

Turboprop 6 2 2 2 1 0 7 4 12 14.3

Turbojet 3 0 0 0 0 0 3 0 3 3.6

All Rotorcraft * 2 2 3 3 1 0 4 5 10 11.9

Turbine Engine 2 2 3 3 1 0 4 5 10 11.9

Aircraft

Number - 41 14 14 15 2 1 58 23 84

Percent - 48.8 16.7 16.7 17.9 2.4 1.2 69.0 27.4

• Not included in column totals

47

Table 51 - BROAD CAUSE/FACTOR ASSIGNMENTS*


1997

Cited as Either

a Cause or a

Cited as a Cause Cited as a Factor Factor (or Both)



Aircraft # 6 25 4 10 8 32Propulsion System and 5 20 0 3 5 23

Controls

Flight Control System 1 1 0 0 1 1

Airframe 1 1 0 0 1 1

Landing Gear 0 4 0 0 0 4

Systems/Equipment/ 1 2 3 4 3 5

Instruments

Environment # 0 3 12 45 12 46Weather 0 0 7 24 7 24Light Conditions 0 0 3 11 3 11

Object(trees,wires,etc.) 0 2 0 4 0 6

Airport/Airways Facilities, 0 0 0 2 0 2

Aids

Terrain/Runway Condition 0 1 6 26 6 27

Personnel # 11 60 8 27 13 63Pilot 10 52 8 23 12 57Others (Aboard) 0 2 2 3 2 5

Others (Not Aboard) 1 7 3 8 4 14




# This category is composed of the sub-categories indented below it. The number of

aircraft cited in a category may be less than or equal to the sum of the sub-category citations.

48

Table 52 - ACCIDENTS, FATAL ACCIDENTS, FATALITIES, AND RATESNONSCHEDULED 14 CFR 135 OPERATIONS

1987 - 1997



1987 96 30 65 63 2,657,000 3.613 1.1291988 102 28 59 55 2,632,000 3.875 1.0641989 110 25 83 81 3,020,000 3.642 0.8281990 107 29 51 49 2,249,000 4.758 1.2891991 88 28 78 74 2,241,000 3.927 1.2491992 76 24 68 65 1,967,000 3.864 1.2201993 69 19 42 42 1,659,000 4.159 1.1451994 85 26 63 62 1,854,000 4.585 1.4021995 75 24 52 52 1,707,000 4.394 1.4061996 90 29 63 63 2,029,000 4.436 1.4291997 82 15 39 39 2,250,000 3.644 0.667

Figure 13 - ACCIDENTS AND FATAL ACCIDENTSNONSCHEDULED 14 CFR 135 OPERATIONS

110-

. 95-

< 80-

65-1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997

Year

1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 19973 0-

• 20-

15-

49

Figure 14 - NUMBER OF FATALITIESNONSCHEDULED 14 CFR 135 OPERATIONS

88-

52-

40-1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997

Year

Figure 15 - ACCIDENT RATE PER 100,000 HOURS FLOWNNONSCHEDULED 14 CFR 135 OPERATIONS

5.00-

4.50-

S4.00-

3.50-1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997

Year

1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 19971.45-

1.25 -

S1.05-•

a 0.85-

0.65-

50

Table 53 - FIRST OCCURRENCES IN ALL ACCIDENTS AND IN FATAL ACCIDENTSNONSCHEDULED 14 CFR 135 OPERATIONS

1997 AND 1987 - 1996


1997 1987 - 1996 1997 1987 - 1996


In flight collision with terrain 7 8.3 9.3 10.2 2 13.3 5.8 22.1Loss of control - in flight 3 3.6 8.2 9.0 2 13.3 4.5 17.1Loss of engine power(total) - 3 3.6 7.3 8.0 1 6.7 1.6 6.1mechanical failure/malfunction

Airframe/component/system failure/ 6 7.1 6.9 7.6 1 6.7 2.5 9.5malfunction

In flight encounter with weather 11 13.1 6.8 7.5 3 20.0 3.5 13.3Loss of control - on ground 2 2.4 6.8 7.5 0 .0 .0 .0Loss of engine power(total) - 7 8.3 5.1 5.6 1 6.7 .6 2.3non-mechanical

In flight collision with object 3 3.6 5.0 5.5 1 6.7 2.0 7.6

On ground collision with object 3 3.6 4.4 4.8 0 .0 .0 .0Loss of engine power 6 7.1 4.0 4.4 1 6.7 .9 3.4On ground collision with terrain 6 7.1 2.9 3.2 0 .0 .0 .0Overrun 3 3.6 2.9 3.2 0 .0 .1 .4

Loss of engine power(partial) - 2 2.4 2.3 2.5 1 6.7 .6 2.3mechanical failure/malfunction

Hard landing 3 3.6 1.7 1.9 0 .0 .0 .0Midair collision 0 .0 1.5 1.7 0 .0 .8 3.0Loss of engine power(partial) - 2 2.4 1.5 1.7 0 .0 .5 1.9non-mechanical

Not reported 1 1.2 1.4 1.5 0 .0 .3 1.1

Main gear collapsed 3 3.6 1.4 1.5 0 .0 .0 .0Fire 1 1.2 1.1 1.2 0 .0 .7 2.7Miscellaneous/other 1 1.2 1.1 1.2 0 .0 .6 2.3Undershoot 1 1.2 1.0 1.1 0 .0 .0 .0Gear not extended 0 0.0 0.8 0.9 0 .0 .0 .0Dragged wing, rotor, pod, or float 0 0.0 0.7 0.8 0 .0 .1 .4Nose gear collapsed 0 .0 0.7 0.8 0 .0 .0 .0Roll over 0 0.0 0.7 0.8 0 .0 .0 .0Nose over 0 0.0 0.6 0.7 0 .0 .0 .0Collision between aircraft 4 4.8 0.6 0.7 0 .0 .0 .0

(other than midair)Altitude deviation,uncontrolled 0 0.0 0.5 0.6 0 .0 .1 .4Propeller/rotor contact to person 1 1.2 0.5 0.6 0 .0 .2 .8Gear collapsed 1 1.2 0.4 0.4 0 .0 .0 .0Abrupt maneuver 0 0.0 0.3 0.3 0 .0 .2 .8Missing aircraft 1 1.2 0.3 0.3 1 6.7 .3 1.1Wheels up landing 1 1.2 0.3 0.3 0 .0 .0 .0Fire/explosion 0 0.0 0.2 0.2 0 .0 .0 .0Forced landing 0 0.0 0.2 0.2 0 .0 .0 .0Gear not retracted 0 0.0 0.2 0.2 0 .0 .0 .0Propeller blast or jet exhaust/suction 0 0.0 0.2 0.2 0 .0 .0 .0Undetermined 0 0.0 0.2 0.2 0 .0 .2 .8Rotor failure/malfunction 0 0.0 0.2 0.2 0 .0 .0 .0Cargo shift 0 0.0 0.1 0.1 0 .0 .1 .4Explosion 0 0.0 0.1 0.1 0 .0 .0 .0Hazardous materials leak/spill 0 0.0 0.1 0.1 0 .0 .0 .0Nose down 0 0.0 0.1 0.1 0 .0 .0 .0On ground encounter with weather 0 0.0 0.1 0.1 0 .0 .0 .0Vortex turbulence encountered 0 0.0 0.1 0.1 0 .0 .1 .4Propeller failure/malfunction 2 2.4 0.1 0.1 1 6.7 .0 .0

Total 84 100.0 90.9 100.0 15 100.0 26.3 100.0

51

Table 54 - FIRST PHASES OF OPERATION IN ALL ACCIDENTS AND IN FATAL ACCIDENTSNONSCHEDULED 14 CFR 135 OPERATIONS

1997 AND 1987 - 1996


1997 1987 - 1996 1997 1987 - 1996

Phase of operation No. Percent Mean Percent No. Percent Mean Percent

Cruise 19 22.6 20.4 22.4 6 40.0 8.5 32.3Takeoff 15 17.9 19.3 21.2 2 13.3 4.4 16.7Landing 13 15.5 16.5 18.2 0 .0 .6 2.3Approach 13 15.5 12.6 13.9 2 13.3 5.6 21.3Maneuvering 6 7.1 7.1 7.8 3 20.0 3.2 12.2Taxi 3 3.6 4.8 5.3 0 .0 .0 .0Climb 7 8.3 3.6 4.0 1 6.7 1.4 5.3Descent 3 3.6 2.5 2.8 1 6.7 1.2 4.6Standing 4 4.8 2.2 2.4 0 .0 .6 2.3Not reported 1 1.2 1.9 2.1 0 .0 .8 3.0

Total Aircraft 84 100.0 90.7 100.0 15 100.0 26.3 100.0

Table 55 - BROAD CAUSE/FACTOR ASSIGNMENTS IN ALL ACCIDENTS AND IN FATAL ACCIDENTSNONSCHEDULED 14 CFR 135 OPERATIONS

1997 AND 1987 - 1996


1997 1987 - 1996 1997 1987 - 1996


Pilot 57 67.9 66.8 73.5 12 80.0 21.1 80.2Weather 24 28.6 28.3 31.1 7 46.7 11.1 42.2Terrain/Runway Condition 27 32.1 26.3 28.9 6 40.0 6.2 23.6Propulsion System and 23 27.4 19.0 20.9 5 33.3 4.7 17.9Controls

Other Person 14 16.7 16.4 18.0 4 26.7 5.3 20.2(Not Aboard)

Light Conditions 11 13.1 12.1 13.3 3 20.0 5.8 22.1Object (tree,wires,etc) 6 7.1 7.6 8.4 0 .0 2.0 7.6Systems/Equipment/ 5 6.0 7.5 8.3 3 20.0 1.9 7.2

InstrumentsLanding Gear 4 4.8 5.8 6.4 0 .0 .2 .8Airframe 1 1.2 2.9 3.2 1 6.7 .9 3.4Flight Control System 1 1.2 1.8 2.0 1 6.7 .8 3.0Airport/Airways 2 2.4 1.4 1.5 0 .0 .1 .4Facilities, Aids

Other Person (Aboard) 5 6.0 .5 .6 2 13.3 .3 1.1

Total Aircraft 84 100.0 90.9 100.0 15 100.0 26.3 100.0


52

BY THE NATIONAL TRANSPORTATION SAFETY BOARD

MARION C. BLAKEY JOHN A. HAMMERSCHMIDTChairman Member

CAROL J. CARMODY JOHN J. GOGLIAVice Chairman Member

GEORGE W. BLACK, JR.Member

Adopted: January 24, 2002

53

Appendix A

Midair Collision AccidentsU.S. Air Carrier Operations

1987 - 1997

55

APPENDIX A

MIDAIR COLLISION ACCIDENTS

U.S. AIR CARRIER OPERATIONS

1987 - 1997

Number of Accidents

by Segements ofAviation Involved

Accidents S135 N135 N135 S121Total and and and and

Year Total Fatal Fatalities GA N135 GA Forgn

1987 5 2 12 3 0 2 0

1988 2 1 4 0 0 2 0

1989 1 1 2 0 0 1 0

1990 3 2 5 1 1 1 0

1991 2 2 9 0 1 1 0

1992 2 1 3 0 0 2 0

1993 1 0 0 0 0 0 1

1994 0 0 0 0 0 0 0

1995 0 0 0 0 0 0 0

1996 1 0 0 0 1 0 0

1997 1 0 0 1 0 0 0

18 9 35 5 3 9 1

NOTE: S135 = Scheduled 14 CFR 135 Operation

N135 = Nonscheduled 14 CFR 135 Operation

S121 = Scheduled 14 CFR 121 Operation

Forgn = Foreign Registered Aircraft Operation

GA = General Aviation

56

Appendix B

Explanatory Notes

57

APPENDIX B -- EXPLANATORY NOTES

AIRCRAFT ACCIDENT: The accidents included herein are the occurrences incident to flight in

which, as a result of the operation of an aircraft, any person (occupant or nonoccupant)

receives fatal or serious injury or any aircraft receives substantial damage. The

definition of substantial damage is:

Substantial damage means damage or failure which adversely affects the structural

strength, performance, or flight characteristics of the aircraft, and which would

normally require major repair or replacement of the affected component. Engine

failure or damage limited to an engine if only one engine fails or is damaged, bent

fairings or cowling, dented skin, small punctured holes in the skin of fabric,

ground damage to rotor or propeller blades, and damage to landing gear, wheels,

tires, flaps, engine accessories, brakes, or wingtips are not considered"substantial damage."

AIRCRAFT-MILES: The distance flown by aircraft in terms of great circle airport-to-airport

distances measured in statute miles.

CAUSES AND RELATED FACTORS: In determining probable cause(s) of an accident, all facts,

conditions, and circumstances are considered. The objective is to ascertain those cause

and effect relationships in the accident sequence about which something can be done to

prevent recurrence of the type of accident under consideration. Accordingly, for

statistical purposes, where there are two or more causes of an accident, each is recorded

and no attempt is made to establish a primary cause. Therefore, in the cause and related

factor table, the figures shown in the columns dealing with cause will exceed the total

number of accidents. The term "factor" is used, in general, to denote those elements of an

accident that further explain or supplement the probable cause(s); this provides a means

for collecting essential items of information that could not be readily categorized

elsewhere in the system.

COLLISION BETWEEN AIRCRAFT: Collisions between aircraft are so classified only when both

aircraft are occupied. This includes collisions wherein both aircraft are airborne

(midair); one is airborne, the other on the ground; and both are on the ground. A

collision with a parked, unoccupied aircraft is classified under the broad category of

collision with objects.

FATAL INJURY: Any injury which results in death within 30 days of the accident.

INJURY INDEX: Injury index refers to the highest degree of personal injury sustained as a

result of the accident.

NONSCHEDULED SERVICE: Revenue flights that are not operated in regular scheduled service,

such as charter flights, and all nonrevenue flights incident to such flights.

PASSENGER-MILES: One passenger transported 1 mile. Passenger miles are computed by the

summation of the products of the aircraft-miles flown on each inter-airport flight

multiplied by the number of passengers carried on the flight.

58

PERSONNEL (NON-PILOT): As defined for the Broad Cause/Factor tables may include any of the

following personnel:

Rules, Regulations, Standards Personnel Flight Instructor on Ground

Maintenance, Servicing, Inspection Personnel Operational Supervisor Personnel

Weather Service Personnel Air Traffic Control Personnel

Airport Management Airways Facilities Personnel

Production-Design Personnel Pilot of Another Aircraft

Ground Signalman Ground Crewman

Passenger Spectator

Driver of Vehicle Third Pilot

Flight Engineer Navigator

Radio Operator Flight Attendant

Other Flight Personnel Dispatching Personnel

PHASE OF OPERATION: The phase of flight in which the first occurrence happened.

REVENUE PASSENGER: A person receiving air transportation from an air carrier for which

remuneration is received by the air carrier. Air carrier employees and others receiving

air transportation for which a token service charge is levied are considered nonrevenue

passengers.

REVENUE PLANE-MILES: The total plane-miles flown in revenue service.

SERIOUS INJURY: Any injury which 1) requires hospitalization for more than 48 hours,

commencing within 7 days from the date the injury was received; 2) results in a fracture of

any bone (except simple fractures of fingers, toes, or nose); 3) involves lacerations which

cause severe hemorrhages, nerve, muscle, or tendon damage; 4) involves injury to any

internal organ; or 5) involves second-or third-degree burns, or any burns affecting more

than 5 percent of body surface.

TYPE OF OCCURRENCE: The concept of sequence of events as a method of accident

classification was introduced in 1982 to describe the circumstances in an accident. A

maximum of five occurrences may be used. Typically each occurrence is further described by

one or more "findings" which, when presented chronologically, depict the accident scenario

from beginning to end. The findings are developed by Safety Board analysts from a menu of

words and phrases, and are the most detailed means of classifying an accident. The

findings are also used to describe the probable cause of and related factors in an

accident. The example below illustrates the relationship between occurrences and findings.

Occurrence #1 LOSS OF POWER (PARTIAL) - MECHANICAL FAILURE/MALFUNCTION

Phase of Operation TAKEOFF - GROUND RUN

Finding(s)

1. COMPRESSOR ASSEMBLY - FATIGUE

2. COMPRESSOR ASSEMBLY - FAILURE, TOTAL

3. MATERIAL DEFECT (INADEQUATE QUALITY CONTROL) - MANUFACTURER

TYPES OF WEATHER CONDITIONS: Weather condition is described as visual meteorological

conditions (VMC) or instrument meteorological conditions (IMC) and is expressed in terms of

visibility, distance from clouds, and ceilings in accordance with Part 91 of the Federal

Aviation Regulations.

59

Appendix C

Detailed Cause/Factor Assignments14 CFR 121 Operations

60

CAUSE/FACTOR TABLE


1997

Causeor

Factor Cause

AIRCRAFTAll engines 1 1Door, cargo/baggage 1 0Landing gear 1 0Landing gear,brake temperature system 1 0Landing gear, gear locking mechanism 1 1Landing gearmain gear 1 1Landing gear,main gear attachment 1 0Landing gear, tire 1 1Misc eqpt/furnishings,galley/personnel lift 1 1Wing 1 0

FACILITYAircraft manuals 1 0Airport facilities,ramp facilities 1 0Airport facilities,taxiway condition 2 1

ENVIRONMENTCrosswind 2 0Dark night 2 0Icing conditions 1 0Other 1 0Other 1 0Other 1 0Rain 1 0Snow 1 0Terrain condition 1 0Turbulence 3 2Turbulence in clouds 2 0Turbulence(thunderstorms) 1 1Turbulence,clear air 7 6Whiteout 1 0

FLIGHT CREWAborted takeoff 1 0Aircraft control 2 2Aircraft preflight 1 0Airspeed(Vref) 1 0Autopilot 1 1Clearance 1 1Directional control 1 1Evasive maneuver 1 1Flight into adverse weather 1 1Go-around 1 0Ice/frost removal from aircraft 1 1In-flight planning/decision 1 1Low altitude flight/maneuver 1 0Proper descent rate 2 2Recovery from bounced landing 1 1Remedial action 1 1Rotation 1 1Supervision 1 1Visual lookout 1 1Wrong taxi route 1 1

OTHER PERSONAcft/equip, inadequate aircraft component 1 1Aircraft preflight 1 1Airport snow removal 1 1Airspeed 2 2

61

CAUSE/FACTOR TABLE


1997

Causeor

Factor Cause

OTHER PERSON(continued)Approach/departure control service 1 1Autopilot 1 0Clearance 2 2Communications 1 1Crew/group briefing 1 1Crew/group coordination 1 1Design stress limits of aircraft 1 1Dispatch 1 1Diverted attention 1 0Facility inadequate, visual restriction 1 0Improper use of procedure 1 1Inadequate initial training 1 0Inadequate surveillance of operation 1 1Instructions,written/verbal 2 2Maintenance,inspection 2 2Miscellaneous 2 2Miscellaneous equipment 1 1Procedure inadequate 2 1Procedures/directives 2 1Radar separation 1 1Remedial action 1 1Safety advisory 1 0Seat belt 5 5Seat belt sign 2 2Stall 1 1Traffic advisory 1 1Transponder 1 1Unsafe/hazardous condition 3 3Visual lookout 2 1

62

Appendix D

Detailed Cause/Factor AssignmentsScheduled 14 CFR 135 Operations

63

CAUSE/FACTOR TABLE


1997

Causeor

Factor Cause

AIRCRAFTDoor, cargo/baggage 2 2Engine assembly, connecting rod bolt 1 1Fluid, fuel 1 0Landing gear, nose gear attach point 1 1

FACILITYAirport facilities,runway/landing area condition 2 0

ENVIRONMENTCrosswind 2 0Downdraft 1 0Fog 2 0Icing conditions 1 0Low ceiling 2 0Obscuration 1 0Rain 1 0Terrain condition 1 0

FLIGHT CREWAbort above Vi 1 1Aircraft preflight 2 2Aircraft weight and balance 1 1Airspeed 1 1Altimeter 1 1Altitude/clearance 1 1Clearance 1 1Compensation for wind conditions 1 1Descent 1 1Directional control 1 1Diverted attention 1 0Flight into known adverse weather 1 1Gear extension 1 1Go-around 2 0Ice/frost removal from aircraft 1 1In-flight planning/decision 1 1Lack of familiarity with geographic area 1 0Proper alignment 1 1Raising of flaps 1 0Refueling 1 0Self-induced pressure 1 0Stall/spin 1 1Touchdown 1 0VFR flight into IMC 3 3VFR procedures 1 1Visual illusion 1 1

OTHER PERSONAirport snow removal 1 1Condition(s)/step(s) in improper sequence 1 0Inadequate certification/approval 1 1Inadequate surveillance of operation 3 1Inadequate training 1 1Information unclear 1 1

64

Appendix E

Detailed Cause/Factor AssignmentsNonscheduled 14 CFR 135 Operations

65

CAUSE/FACTOR TABLENONSCHEDULED 14 CFR 135 OPERATIONS

1997

Causeor

Factor Cause

AIRCRAFT1 engine 1 0Accessory drive assy,drive gear 1 1Aircraft performance,engine out capability 1 0Airframe 2 0Anti-ice/deice system, windshield 1 0Cabin heater 1 0Cooling system, cowling 1 1Engine assembly, connecting rod 1 1Engine assembly, cylinder 2 1Engine assembly,push rod 1 1Exhaust system, manifold/pipe 1 1Fluid, fuel 7 6Fuel system 2 2Horizontal stabilizer 1 1Ignition system, ignition lead 1 0Ignition system,magneto 1 1Induction air control,alternate air/door 1 1Landing gear 1 1Landing gear,main gear 1 1Landing gear,main gear attachment 1 1Landing gearnormal retraction/extension assembly 1 1Misc eqpt/furnishings,cargo restraints 1 0Misc eqpt/furnishings,survival equipment 1 0Miscellaneous,engine 1 1Propeller system/accessories,blade 1 1Propeller system/accessories,hydraulic pitch ctl 1 1Rotor drive system,tail rotor drive shaft 1 1Rotor system, tail rotor 2 2Throttle/power lever, cable 1 0Turboshaft engine,free turbine governor 1 1Wing,spar 1 1

FACILITYAirport facilities,perimeter fence 2 0Airport facilities,runway/landing area condition 1 0

ENVIRONMENTAnimal(s) 2 2Carburetor icing conditions 1 0Clouds 3 0Crosswind 2 0Dark night 9 0Downdraft 4 0Fog 4 0Gusts 2 0High density altitude 2 0High wind 2 0Icing conditions 3 0Low ceiling 7 0Night 1 0Obscuration 1 0Other 1 0Other 2 0Pole 1 0Snow 2 0Tailwind 4 0Terrain condition 26 1Tree(s) 1 0Turbulence,terrain induced 2 0Unfavorable wind 1 0

66

CAUSE/FACTOR TABLE


1997

Cause

orFactor Cause

ENVIRONMENT(continued)Utility pole 1 0Whiteout 2 0

FLIGHT CREWAborted takeoff 2 2Aircraft control 1 1Aircraft preflight 2 2Aircraft weight and balance 1 0Airspeed 3 1All available runway 1 0Altitude 2 2Altitude/clearance 4 4Checklist 2 1Clearance 4 4Decision height 1 1Directional control 1 1Distance 1 1Distance/altitude 1 1Emergency procedure 2 2Flare 1 1Flight into adverse weather 1 1Flight into known adverse weather 2 2Fuel management 3 3Fuel supply 1 1Fuel tank selector position 2 2Gear extension 1 1Gear retraction 1 1Ground loop/swerve 1 1Hazardous weather advisory 1 1IFR procedure 2 2Ice/frost removal from aircraft 1 1Impairment (drugs) 1 0In-flight planning/decision 5 5Information 1 0Judgment 1 1Lack of recent instrument time 1 0Lack of total experience in type operation 1 0Load tie-down/security 1 0Loss of tail rotor effectiveness 1 0Lowering of flaps 2 0Maintenance,installation 1 0Maneuver 1 1Minimum descent altitude 1 1Overconfidence in personal ability 1 0Passenger briefing 1 0Planning/decision 2 2Porpoise/pilot-induced oscillation 1 1Preflight planning/preparation 3 2Procedures/directives 3 2Propeller feathering 1 1Proper alignment 1 1Proper glidepath 1 1Proper touchdown point 3 3Raising of flaps 1 1Recovery from bounced landing 1 1Refueling 1 1Remedial action 1 1Self-induced pressure 1 0Stall/spin 1 1Unsuitable terrain or takeoff/landing/taxi area 6 5

67

CAUSE/FACTOR TABLE


1997

Causeor

Factor Cause

FLIGHT CREW(continued)VFR flight into IMC 5 4Visual illusion 1 0Visual lookout 4 3Visual/aural detection 1 1Weather evaluation 4 3

OTHER PERSONAircraft weight and balance 1 1Airspeed 1 1Clearance 1 1Condition(s)/step(s) insufficiently defined 1 0Crew/group coordination 1 0Emergency equipment 1 0Inadequate surveillance of operation 1 0Information 1 0Instructions,written/verbal 2 0Insufficient standards/requirements 1 0Maintenance 1 1Maintenance,adjustment 1 0Maintenance, inspection 1 1Maintenance, installation 1 1Maintenance,modification 1 0Maintenance,overhaul 1 1Pressure induced by others 1 0Procedure inadequate 1 0Procedures/directives 1 0Proper assistance 1 0Proper touchdown point 1 1Reason for occurrence undetermined 1 1Seat belt 1 0Shoulder Harness 1 0Unsafe/hazardous condition 1 1Visual lookout 2 1

68

Appendix F

NTSB Form 6120.4

69

NTSB Accidentflncident Number

National Transportation Safety Board

FACTUAL REPORT lL..LL I WLLLLAVIATION-- 3 l-v tation

1 Accident 1 NTSB

2 Incident 2 j FAA Delegated

4 Aimraft Registration Number S Nearest City/Place 6 State 7 Zip Code (First 5 numbers only)

8 Date of Accident (Nos.forMD,1 9Dayof Week (Fint21eners) 10 Loc ime (24 hour clock) 11 Time Zone

12 Narrative Statement of Facts, Conditions and Circumstances ertinent to the Accidetlcdent

A tional Persons Participatng in this Accidentancident Inves*iation (Name, address, affiliation. Continue on page 2 if necessary)

'g<X0........ ...........o

13 Date (Nos. for MD, Y) 14 Agency 15 Namel/Sigature

NTSBForm 6120.4 (Rev 12/91) Page I

NTSB Aceddent/lnddmt NumberNational Transportation Safety Board

FACTUAL REPORTAVIATION

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ I I I I I I I I I I~iMii12 Narrative Statanemt of Facts, Conditions and Circumstances Pertinent to the Accident/Incideat (continued)

Attach additional pages as necessary (Page 2b 2c 2d etc)

NTSBForm6120.4 (Rev 12/91) Page 2

NTSB Accident/Incideuat NumsberNational Transportation Safety Board


i.l oaie t 18 rprt aN e 20 ae From Airot Center 21Drco rom AirotInformation (Nearest SM)

1 El Off airport/airstrip - a2 [jOn airport FjNot 19 _ __ AiprdniirS

3 -On airstrip Applicable 91[]UNK/NA4 - UINK/NA (go to Block 28) 1 [:] UNK/NA

22 Rmn-way Used Identifier 23Runway 4Runway Width 25 Airport Elevation

____________ Foot _____Feet _____Ft. MSL

1 Ej] UNK/NA 1F_ [] NKINA I []j UNK/NA 1 [:] UNK/NA

26 Runway(Landing Surface 27 Runway/Landing Surface Condition (Multiple entry)

1 Macadam 1 Dry 11 Water--glassy2 Asphalt 2 Wet 12 Rubber deposits3 Concrete 3 Ice covered 13 Soft4 Gravel 4 Snow--dry 14 Rough5 Dirt 5 Snow-wt 15 Slush covered8 Grass/turf 6 Snow--crusted 16R Holes7 Snow 7- Snow--compacted 17 UINK/NA8 Ice 8 Vegetation9 Water 9 Water--calrn

10 Metal/Wood 10 Water--choppy1IF1 UINK/NA

28 Type lnstnnnent Approac f~lowni (Multple entry) 29 VFR Approacl laing (Multiple entry)

1 None 12 LDA 1 None 7[] Full stop2 ADF/NDB 13 ASR 2 U Traffic pattern 8 Stop and go3 SDF 14 PAR 3 1]Straight-in 9 Simulated forced landing4 VOR/IVOR 15 Sidestep 4 [jValley/terrain following 10~ Forced landing5 VORIDME 16 Visual 5 LiGo around 11U Precautionary landing6 TACAN 17 Contact 6 [jTouch and go 12[j UNK/NA7 ILS-complete 18 Circling8 ILS-localizer 19 Practice9 ILS-backcourse 20 UNK/NA

lo- RNAV11 L MLS

... . .. .. . ..... . .... . . . . . .. . . .: i%

30Arrf i acturer 31Aircraf Model/' 32 nali No. 3Cetfcted MaximumGross Wei&h

1 F] UNK/NA 1E[] UINKJNA

34 Type of Aircraft 35 Type Airworthiness Certificate (Mfulatipe entry) 36 Home Built

1 LIAirplane 5 []Blimp/dirigible Standard Special 1 []Yes2 [j Helicopter 6 [jUltrallght 1 []Normai 5 [- Restricted 10 [] UINK/NA 2 LiNo3 [j Glider 7NL Gyroplane 2 U Utility 6 - Umited 3 UINK/NA4 [j Balloon A Specify 3 L Acrobatic 7 U Provisional

4 U]Transport 8 LiSpecial flight9, Experimental

NTSB Form 6120.4 (Rev 12 / 91) Page 3

NTSB Accident/Incident Number



3 adingtear

1 N Tnicycle--flxed 4 Tailwheel--all retractable 7 N Hull 0[ION Ski 13 []High SkidTricycle--retractable Tailwheet--retractable mains 8 Float 11 Ski/wheel 14 UNK/NATailwhesl--all fixed Amphibian 9 Emerg float 12 Skid

3 N f ts 39 Stall Warning System 40 Aircraft Not Engine Powered 41 Engine TypeInstalled

Go t blck 4 1] Reciprocating--carburetor 5 ~ Turbo fan1 D 1UNK/NA 1 [] Yes 2 Go to block 46 Reciprocating--fuel injected 6 Turbo shaft

2 _ No 3 Turbo prop 7 UNK/NA

3 UNK/NA 4 Turbo jet

42 Engine Manufacturer 43 Engine Model and Series 44 Engine Rated Power 45 Number of EnginesA _ Horsepower

B_ Lbs. Thrust IC_ UNK/NA 1 U UNK/NA

46 Type of Last Inspection 47 Da Last Inspection 48 Time Since Inspection Emergency Locator 1 2 3Performed Hours Transmitter (ELT) Yes No UNK/NA

Ifl Annual (Nos. for M. D. 10or _____ ___

2E 100 hour 1 [:] UNK/NA 50 Instled3 MIP -e49 Airframe Total Timer-

4F Continuous airworthiness 1E[] UNK/NA _____Hours 51 Operated_____1 1 j UNK/NANA1Opertasted

UNK/NA 5 52 Aided in locationS1II UNK/NA of accident site

***/~~~ ~~ ..~y ..... ... ......

*....... ..

Registered raft Owner AddressName:

55 Operator ofArat 1 Saeas registered owner 56 Address 1 L!ae as registered owner 57 OPrtor DesignatorA Name: A e____________

B d~ba___________________2 M UNKINA 2=j UNK/NA

S/ - Li. "•A~~A$ '-y.- 58 None (Go to block 62)

5a Ai arer perabong er te (Check all applicable) 6peratng te 1 Operator Certificate

1 Flag ca ie/domestic (121)4 Large helicopter (127) Other operator of 1 Rotorcraft--externai load operator (133)2 Supplemental 5 Commuter air carrer large aircraft 2 Agnculturai aircraft (137)3 All cargo (418) 6 On-demand air taxi

.... .......... .. . '.

62 Regulation Hlight Conducted Under1 14 CFR 91 (only) 4 14 CFR 105 7'[ 14 CFR 127 10[] 14 CFR 1372 14 CFR 91D 5 14 CFR 121 8 14 CFR 133 11 14 CFR 129 (Foreignflag)3 14 CFR 103 6 14 CFR 125 9 14 CFR 135 A Specify

(Complete 63 a, b, c ONLY ifflight was a revenue operation conducted under 121, 125, 127, 129, 135)

63a 63b 63c

I R Scheduled 1 [B Domestc I 1 Passenger 3 []Passenger/cargoNon-scheduled 2 International 2 Li Cargo 4 [j Mail contract ONLY

NTSBForm6120.4 (Rev 12/91) Page 4

NTS Accident/Lincident NumberNational Transportation Safety Board


(Complet 64 ONLY if 63 a, b, c are not applicable)64

1 Personal 4 []Executivelcorporate 7 []Other work use 10[] Positioning2 Business 5 U Aerial application 8 LiPublic use3 Instructional rincluding air carrier training) 6 [jAerial observation 9 [jFerry A Specify____

65Nae (Last, First. Initial) 66PltCriie N. 67 y

I F-j UNK/NA i[]- UNK/NA I[r] UNK/NA

68Sae6 ateeo it (Nos. forM, D,Y)1 70 AV 71 Se

1 [II UNI(/NA 1E]L UNK/NA 1 []j UNK/NA 2HFemnale

72 ~ Set pid 73nncipal Proesin 74Ci sO (Mautpie entry)

I] Left 1I[ Pilot--civilian 7 []Doctor/dentist 13~ Feiner/rancher 1W Student 6~ Flight Engineer2W Right 2 Pilot--mnilitary a jj Police 1 4 Nj Retired 2 Private 7 H Military3L Center 3 [jOther--military 9 []Student 15 LiUNK/NA 3 ~JComrmercial 8 U None4U Front 4 [jAircraft mechanic 10 L]Clergy 4 []Airline Transport 9 U Foreign5U Rear 5 [JBusiness 11 Teacher 5 [jFlight Instructor 10 LiUNK/NA6LJ] UNK/NA 6 Uj Lawyer 12F-1 Engineer

7S Rting-Airlane76 Rotercraft/Glider LTA 77 Instrument Rating 79 strcter Rating(s)-(muliple entry) (multiple enty) (muliple entry) (mulltiple entry)

1 [ Norie 1 [Nonei1 [I None I] None 6 [N Glider2 U Single engine land 2[ Helicopter 2 []Airplane 2 LiAirplane SE 7 LiInstrument airplane

3 L Muhfiengine land 3LiGyroplane 3 [jHelicopter 3 LiAirplane ME 8 L Instrument helicopter4~L Single engine sea 4LiAirship 4 LiHelicopter5 L Muhfiengine sea 5L Free balloon 5 LiGyroplane

6 [Li Glider79 Type-Rating Endorsement This 0Nes Flgt Review 81 onhssicLa oBFR 82 BFR (or equivalen)

Aircraft (reuvw)Aircraft Make/Model

1 Yes1] Yes Months A Make_ ___

21 No 1 [oI] UNK/NA3 L UNK/NA 3 UKN oe

C []UNKN83 edalericate 8 t aiiy8 aeo A eia

1 None 1IL Valid medical--no waivers/limnitations; (Nos. for M, Dl, Y)

2 Class 1 2 LiValid medical--with waiversilimitations3 Class 2 3 LiNon valid medical for this flight 1 ýUKN

4 j Class 3 4 LiExpired IF NKN

5Li UNK/NA 5 No mriedical certicate6FLi UNK/NA

NTSB Form 6120.4 (Rev12/9 1 PageS

NTSD AccidentfIncident Number



86 Source of Pilot Flight Tume (Mulaple entry)

1 Pilot log 3 [] FAA 5[] Investigators Estimate 7 []Other Person2 R Company 4 M Pilot/Operator Report 6 U Relative 8 [JUNK/NA

A a C D K F G14u H I LWIFlight Time All A/C ni MW.a Aking-Egu AMuhhnla Night_ ______m ______ CMW L1

87 Total Time__ _ _ __ _ _____ __ _ ___ __ _ _ _ _

88 Pilot in Command (PIC) __ _ _ __ _ __ _ _ __ ___ _ _ _ _ _____

89 Instructor__________ ____ ______

90 Last 90 Days-_ _ _ _ _ __ _ _ _ _ __ _ _ _ _

91 Last 30 Days_____ _________ _____ ______ ___ ____

92 Last 24 Hours

93 Seatbelt Used 94 holdr Harness Used 95Atpy efre (This pilot)

1 RYes 3DFýUNKJNA 1 []Yes 3D[]UNKINA 1 []Yes 3D[]UNKINA

% oxicolegy Performed (77us pilot) 97 Person at Controls 9 end Pilot

1 Ys1 Pilot in command 4 on-pilot I [::] Yes

[ No2 Second pilot 5 Noon

(Complete second pilot supplement)

1 6~4 - ----

Last Departure Point 1 etntion 101 Flight Plan Flied1 E Same as accidentlincident location orA Airport identifier 1______ B Same as accidentlincident location or 1 NoneB City/Place ___________2 U Local flight 2 -Visual Flight Rules (VFR)C State 2 [:: UNKINA A Airport Identifier ________ 3 Instrument Flight Rules (IFR)

102 Time of Departure B City/Place _________4 VFRIIFR

A Time 1 [:] UNK/NA C state __________5 Company (VFR)

B TmeZon 3F_ýUNMA6 Military (VFR)B Tie Zne _________3[I UN/NA7 UNK/NA

103 Type of Clearance (Multiple entry) 104 Airspace (Multiple enviy)

1I1 None 6 [IVFR on top 1 Uncontrolled 8 Stage 11 TRSA 15 L]Warning area2 U VFR 7 [j]Cruise 2 Controlled 9 Stage Ill TRSA 16 FAR 933 Special VFR 8 UTraffic Advisory 3 Airport traffic area 10 Prohibited area 17 U (Special air traffic areas)4 IFR 9 U VFR Flight 4 Control zone 11 Restricted area 18 U UNK/NA5 Special IFR Following 5 Airport advisory area 12H Military Operation Area (MOA)

10 [1]j UNK/NA 6 Positive control area 13 Student Jet Training Area7 Terminal control area 14 Domeo Area

10 Lead DescriptionI~ None 3 []Cargo 5D Towing banner 7 []Parachutists 9 1]Chemical 11E Illegal cargo

2R Passengers 4 Towing glider 6 U Other external 8 U Water 10 U] Livestock 12 [J UNK/NA

NTSB Fonn 6120.4 (Rev 12/ 91) Page 6

NTSB Accident/Incident NumberNational Transportation Safety Board


e o e s ( M u l ~ p l e e m i y ) e d i d n ey1I[ No record of briefing (Go to block 109) 6 []Company ~ety2 U National Weather Service (NWS) 7 Commercial weather service 1I[ In person3 L Flight Service Station 8 ~JTV/radio weather 2 LiTeletype4'L PATWAS (Pilot Automated T(l. WX Answering Svc) 9 ~JMilitary 3 L TelephoneS Li VRS (Voice Response System) 10 Li UINK/NA 4 U Aircraft radio

5 K]TV/radioe K UNKJNA

108 Completeness of Weather Briefing 109 Investigator's Source of Weather 110 Weather Observation Facility

1I[ Weather not pertinent IfrainA Identfie ____

2 U Full 1 []Pilot (Go to block)11)) B Time of obseration _ __zone____

3 L Partiai--limlited by pilot 2 U Witness (Go to block)))1) C Elevation _____feet MSL4 Partla--limited by briefer/forecaster 3 LiWeather obervation failt D Distance from accident site ____NM

5L I IKNII E Direction from accident site 0 magneti111 Basic We&te Conditions at Accident Site 112 Conditions of Light 11 lTiy/Lowest/Cloud Conditions 114 Lowest Ceiling

I Visual Meteorological Conditions (VMC) I Dawn I Clear 1 ]None2 Instrument Meteorological Conditions (IMC) 2 Daylight 2 Scattered 2 K]Broken3 K]UNK/NA 3 Night (Dark) 3K Thin broken 3 Overcast

4 Night (Bright) 4 Thin overcast 4 Obscured

6 IK/NA 6[_ NK/NA A _ __Feet AGL____________ ____A Feet AGL _______

115 Visibility (Decimals) 116 Temperature 118 Wind Fom 1 Wind~ Spe 2 ;s 121 AltimeterSetn

A ____ SM _ __F 2 [] Variable 1 [] Calm 1 None .'Hg

8RVR _____Feet []_jUNK/NA 1 LI NK/NA 2 Li ght and 2 UINK/NA 1 [j] UINK/NAC V M117 Dew Point A ____ Magnetic VaibeA 1t 22 D-enit-y Atitude

IF1 [] NK/NA F 3F-[] UNK/NA feet

1 E UNK/NA A __ _Kts. 1 [j UNK/NA123 Restrictions to Visibility- 124ype of Precipitation 12S Itensity of Preciptio

1 None 1 None (Go to block 126) 10o[- Snow pellets (SP) 1 Light2 -Haze (H) 2 Raln (R) ii K Snow Gralns (SG) 2 LiModerate3 -Dust (D) 3 Snow (S) 12 LiFreezing drizzle (ZL) 3 LiHeavy4 -Smoke (K) 4 Hall (A) 13 K]Ice crystals (IC) 4 LiUNK/NA5 -Fog (F) 5- Raln showers (RW) 14-L Ice pellet shower (IPW)6 -Ice fog (IF) 6 Freezing rain (ZR) 15 Li] UNK/NA7 -Ground fog (GF) 7 Snow shower (SW)8 Blowing spray (BY) 8 Drizzle (L)9 Blowing dust (BD) 9 Ice pellets (IP)

10 Blowing snow (BS)11 Blowing sand (BN)12H UNK/NA

126 Aircraft Damsge 127 Aircraft F'ire 128 Explosion

1 [N None 4 [1] Destroyed 1 []None 3[R]On ground 1 [] None 3[]On ground2 LiMinor 5 K] NK/NA 2 Li In-flight 4LiUN K/NA 2 LiIn-flight 4 L IUNK/NA3 L Substantial

NTSB Formn6120.4 ( Rev 12/ 91) Page 7

National Transportation Safety Board NS cievnietNme


............... . .. . . . . . . . .... . ....

12 Ijury Index (Most critical injury)

1 FE1None 2I-j minor 3L-J Serious 4 FI1Fatal

A B C D Ehnunry 'Summary Fatal Serious Minor None Totall 12Casfcto

131 CorstPilot 1 U1 U.S. Registered Aircraft on U.S. Soil,131 CopilotTerritories and Possessions, or

132 Dual Student _________International Waters

133 Check Pilot _________2[-j] U.S. Registered Aircraft on foreign

134 Flight Engineer Soil

135 abi Atendntsa [ U.S. Registered Aircraft operated by a135 Cbin ttenantsForeign Operator

136___________ Ote Crew Foreign Registered Aircraft on U.S.137 Passengers ____Soil, Territories or Possessions

138 TOTAL ABOARD 5__ __ Military Aircraft

139 Other Aircraft ________ ____6 Aircraft not Registered

140 Other Ground_______

141 GRAND TOTAL

1 Pat Fil n (ulule144y Incorrect Part (Multiple enhy)

I~ None 4 ] Part/component #3 1 N None 4E[] Part/component #32 Part/component #1 5[ UNK/NA 2 Part/component #1 5 LiUNK/NA3 Port/component #2 3 Part/component #2

A Part/Component #1 B Part/Component #2 C Part/Component 13

145 Part Name

146 Bogus Part 1iD1Yes 2DNo ilZYes 2DNo 1-j Yes 2 No

NTSBForrn612O.4 (Revl2/91) Page 8

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