# NTSB LAX93FA177: British Aerospace BA 3101, N131CA, Merced, CA, April 20, 1993 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Field investigation · Final report - Date: April 19, 1993, 23:20 local (Apr 20, 1993, 06:20 UTC) - Place: Merced, CA - Coordinates: 37.350093, -120.420982 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=37.3501&lon=-120.4210&mi=10 - Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping) - Highest injury: Serious injuries - Injuries: 1 serious, 2 minor - Status: Completed, report August 31, 1994 - Report: Approved by Office Director - NTSB case key (mKey): 28322 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX93FA177 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/28322/pdf - Page: https://openairdocs.org/ntsb/LAX93FA177 ## Probable cause THE FIRST OFFICER'S FAILURE TO MAINTAIN AN ADEQUATE RATE OF CLIMB AFTER A SINGLE-ENGINE LOSS OF POWER WAS SIMULATED, AND THE COMPANY CHECK PILOT'S INADEQUATE SUPERVISION AND FAILURE TO NOTE THE DESCENT. DARKNESS WAS A RELATED FACTOR. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - In flight collision with terrain/water, takeoff - emergency procedure - simulated, check pilot - proper climb rate - not maintained, copilot/second pilot (cause) - descent - not corrected, copilot/second pilot (cause) - light condition - dark night (contributing factor) - supervision - inadequate, check pilot (cause) - inattentive, check pilot (cause) ## Analysis THE COMPANY CHIEF PILOT/CHECK PILOT WAS GIVING A CHECK FLIGHT TO A COMPANY FIRST OFFICER (F/O). AN FAA INSPECTOR WAS ABOARD TO OBSERVE THE CHECK PILOT'S ABILITY TO GIVE PROFICIENCY CHECK FLIGHTS. SOON AFTER LIFT-OFF ON THE 2ND TAKEOFF, THE CHECK PILOT SIMULATED AN ENGINE FAILURE. THE F/O, WHO WAS WEARING A VISION LIMITING DEVICE, ALLOWED THE AIRPLANE TO DRIFT TO THE LEFT, BUT THE FAA INSPECTOR NOTED THAT THE F/O SUCCESSFULLY REGAINED DIRECTIONAL CONTROL. THE INSPECTOR THEN LOOKED AWAY FROM THE COCKPIT, & WHEN HE LOOKED BACK, THE AIRPLANE WAS DESCENDING. MOMENTS LATER, IT COLLIDED WITH THE GROUND. THE FAA INSPECTOR REPORTED THAT THE CHECK PILOT WAS LOOKING TO THE LEFT, OUTSIDE OF THE AIRCRAFT, & DID NOT HAVE HIS HAND NEAR THE POWER QUADRANT. REVIEW OF THE CVR TAPE REVEALED THAT, FROM THE TIME THE F/O WAS GIVEN THE SIMULATED LEFT ENGINE FAILURE UNTIL IMPACT, THE CHECK PILOT DID NOT SAY ANYTHING TO THE F/O. NO MAINTENANCE DISCREPANCY OR MATERIAL DEFICIENCY WAS NOTED DURING THE INVESTIGATION. THE F/O HAD 3925 HOURS IN THIS MAKE/MODEL OF AIRCRAFT. ## Factual narrative HISTORY OF FLIGHT: On April 19, 1993, at 2320 hours Pacific daylight time, a British Aerospace BA-3101, N131CA, collided with the terrain during an uncorrected descent after takeoff about 1/4 mile north of the Merced, California, airport. The local area instructional flight was operated by Westair Commuter Airlines, Incorporated, doing business as United Express, under the provisions of 14 CFR Part 91 of the Federal Aviation Regulations. The airplane was destroyed during the impact sequence. The company check airman, an airline transport pilot, received serious injuries. The first officer, an airline transport pilot taking an annual proficiency check ride, received minor injuries. An FAA operations inspector aboard the airplane to observe the company check airman also received minor injuries. Visual meteorological conditions prevailed and a company visual flight rules flight plan was filed. Statements were provided by all crew members aboard the aircraft at the time of the accident and by another United Express, Incorporated, first officer who underwent an annual proficiency check ride with the other three crew members the night of the accident. They reported that the purpose of the flight was for the company check airman to administer an annual proficiency check for the first officers. The FAA operations inspector was aboard the airplane to observe the company check airman to determine if he could satisfactorily administer proficiency check rides and to certify him for that function. The three United Express pilots waited for the FAA operations inspector at the airport in Merced. They reported that they began their oral examination at 1630 hours and completed the oral portion of the proficiency flight check at 1930 hours. After completion of the oral examination, the group of four went to dinner. Upon returning to the Merced airport, the first proficiency check ride was administered. The FAA operations inspector said the check airman did not pass the first pilot (a first officer) and that the pilot was de-briefed in the airplane at Merced and released. The FAA operations inspector further reported that the remaining first officer and the check airman stayed in the airplane to prepare for the proficiency check ride while he (the FAA operations inspector) went inside a building at the airport for a "short" break. The crew members reported that the pre-flight briefing and preparation for takeoff were completed while the FAA operations inspector was taking a break. The accident airplane was equipped with a cockpit voice recorder (CVR). A readout of the CVR was conducted at the NTSB headquarters on June 21, 1993, under the supervision of an NTSB electronic engineer. Five parties to the investigation were in attendance at the CVR readout. Transcripts of the CVR readout and crew member witness statements indicate a safety briefing was conducted; crew member duties were discussed; and checklist items were completed prior to beginning the takeoff for the second period proficiency check ride. Review of crew member statements and the CVR transcript revealed that the first takeoff was about 2310 hours. The takeoff culminated in the check airman calling for an aborted takeoff. The FAA operations inspector reported that the aborted takeoff was satisfactorily performed by the first officer. According to the first officer and the FAA inspector, the crew prepared for a second takeoff. They said the first officer was wearing "foggles," a device worn to restrict the vision of the pilot outside the aircraft and to simulate an instrument takeoff. They said the takeoff began about 2318 hours. The FAA inspector aboard the airplane said he was sitting in the forward most right side aisle passenger seat, directly behind the first officer. They were separated by a bulkhead that extended from the floor to the ceiling of the airplane. The inspector provided a statement which detailed the takeoff and subsequent accident. He said the takeoff began behind the numbers on runway 30. About 1/4 to 1/2 of the length of the runway, the airplane became airborne. He said that the company check pilot retarded the left throttle to what he thought was about the flight idle position to simulate an engine failure just after takeoff, or just after V1. The inspector said his view outside the airplane looking through the front windshield was restricted by the bulkhead and by the pilots in their respective seats. He said he could see portions of the instrument panel by looking around the pilots and their seats. The inspector said that the first officer allowed the airplane to "drift" to the left by up to 70 degrees in heading. He said the first officer then got the airplane back on the required heading and he also noted the vertical speed indicator was indicating a climb of about 500 feet per minute. He said that at that point he thought everything was under control, so he leaned over to his right to get a notebook. He said that when he looked up again, the vertical speed indicator was indicating level flight; then indicated about a 200 feet per minute rate of descent; and then indicated a 500 feet per minute rate of descent. He further said that he noticed the airplane's airspeed increase from about 120 miles per hour to about 130 miles per hour. He said he looked through the airplane's windscreen and saw trees. He said he did not remember anyone trimming the airplane. He said he did not see the check pilot's hand on the power quadrant and that he noticed the check pilot looking toward the left. He reported that he did not remember the impact sequence from that point until the time the airplane came to a rest. He said he did not remember the check airman saying anything about the airplane's heading or altitude from the time of takeoff until the impact. In his statement, the first officer said that he thought the airplane only got about 10 to 15 degrees off heading after the simulated loss of the left engine. He said he did not notice the airplane descending and did not remember the impact sequence. The check pilot was interviewed by an FAA inspector about two weeks after the accident. The check pilot did not remember the impact sequence nor any details of the accident. The transcript of the CVR readout indicated that the airplane's engines began to "spool up" one minute and fifty one seconds prior to what the CVR readout group thought was the sound of an impact. The transcript indicated the company check pilot called "V1 rotate" one minute and 40 seconds before impact. The exact time of the check pilot giving the simulated engine failure was not included in the transcript. Thirty seconds prior to impact, the transcript noted a sound similar to that of a gear warning horn. According to a British Aerospace Technical Representative, the gear warning horn is activated when the landing gear is retracted and one or both engines are retarded to the flight idle position. The transcripts indicated nothing was said until about one second before the sound similar to t ## Aircraft - Registration: [N131CA](https://openairdocs.org/deregistered/N131CA-1993-10-06), registration cancelled 1993-10-06, S/N 787 (OpenAirDocs) - Reported make and model: BRITISH AEROSPACE BA 3101 - Registry model: [British Aerospace BAE JETSTREAM 3101](https://openairdocs.org/model/british-aerospace-bae-jetstream-3101) (registry code 1500216) (OpenAirDocs) - Category: Airplane - Serial number: 787 - Airframe hours: 8873 - Engines: ALLIED SIGNAL TPE 331-1-10 940 horsepower turbo prop - Damage: Destroyed - Flight: Instructional, Part 91 - Operator: Westair Commuter Airlines, Inc, doing business as United Express - Registered owner: First Security Bank Of Utah - Airworthiness certificate: Standard, Transport - Departed: MCE - Destination: MCE - Flight plan: Company VFR - Airport: MCE, Merced Municipal, runway 30, 5,904 × 150 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 50; airline transport, flight instructor; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 1, valid medical--w/ waivers/lim; seat: left; flight hours: 16,990 total, 600 in this make and model, 16,110 as pilot in command ## Weather - Conditions: Visual (VMC), Night/dark - Wind: calm - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 55 °F, dew point 48 °F - Altimeter: 30.00 inHg - Observed at: MER, 6 nm away ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 19930419009649A](https://openairdocs.org/incident/19930419009649A), Apr 19, 1993: Bag JETSTM3101, Merced, CA, Destroyed. (.4) The company chief pilot/check pilot was giving a check flight to a company first officer (f/o). An FAA inspector was aboard to observe the check pilot's… From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.