PAK WEST AIRLINES INC

Operated by Pak West Airlines Inc. (per NTSB report)

The flight crew’s continuation of an unstable dark night visual approach and the captain’s instruction to use air brakes during the approach contrary to airplane operating limitations, which resulted in a descent below the glide path, and a collision with terrain. Contributing to the accident was the captain’s poor crew resource management and failure to take over pilot flying responsibilities after the first officer repeatedly demonstrated deficiencies in flying the airplane, and the operator’s lack of safety management system and flight data monitoring program to proactively identify procedural non-compliance and unstable approaches.

Operated by Pak West Airlines (per NTSB report)

Failure of the left main landing gear to fully extend due to a lack of hydraulic fluid and during emergency extension procedures, which resulted in the collapse of the landing gear during landing and the subsequent runway excursion and collision with a sign.

Sanction: $6,000 · case closed 2017-03-17

Sanction: $3,000 · case closed 2006-08-23

Part: NONE — NONE · airframe 24,961 hrs · 14,784 cycles

LEFT ENGINE FIRE WARNING LIGHT CAME ON IN CRUISE FLIGHT. ALL ENGINE PARAMETERS WERE NORMAL. THE CREW DECLARED AN EMERGENCY AND DIVERTED. THE LEFT ENGINE WAS SHUT DOWN PER EMERGENCY CHECKLIST AND THE AIRCRAFT SUCCESSFULLY LANDED SINGLE ENGINE IN KSHV. NO VISIBLE TRACE OF FIRE / HEAT WERE OBSERVED AFTER LANDING. SUSPECTED FALSE FIRE WARNING.

Part: TORQUE LINK — FAILED (NLG)

DURING TAXIING OFF THE RUNWAY, THE RT MLG UPPER TORQUE LINK SNAPPED AT THE JOINT WHERE THE UPPER AND LOWER LINKS CONNECT. THERE WERE NO VISUAL INDICATION OF EXISTING CRACKS AT THE RADII. THE DATA PLATE FOR THE UPPER TORQUE LINK WAS MISSING. PROBABLE CAUSE WAS A SHARP TURN AND STRESS ON THE GEAR CAUSING IT TO SNAP AT THE RADII. THE PART HAS BEEN REPLACED WITH THE RECOMMENDED PN 2751544005.

Part: FIRE DETECTOR — FALSE INDICATION (LT NACELLE)

LEFT ENGINE FIRE LIGHT CAME ON AFTER TAKEOFF. CREW PERFORMED A FULL SHUTDOWN, RETURNED TO THE FIELD AND LANDED WITHOUT ANY FURTHER INCIDENT. NO APPARENT FIRE. POST FLIGHT INSPECTION BY THE CREW DID NOT SHOW ANY TRACE OF FIRE. MAINTENANCE STILL INVESTIGATING.

Part: LINE — CHAFED (ENGINE OIL)

DURING FLIGHT FROM ISN TO MOT, PILOT NOTICED FLUCTUATING OIL PRESSURE, THEN OIL PRESSURE DROPPED BELOW THE YELLOW ARC. PILOT SHUT DOWN THE ENGINE, LANDING WITHOUT INCIDENT. FOUND OIL LINE FROM NTS TEE TO GEARBOX HAD CHAFED THROUGH ON ANOTHER OIL LINE. SHOULD HAVE BEEN DISCOVERED DURING PHASE INSPECTION.

Part: SERVO VALVE — FAILED (NLG STEERING)

UPON DEPARTURE, UNCOMMANDED STEERING TAKEOFF FROM ESC CONTINUED. REPLACED NOSE GEAR STEERING ACTUATOR MANIFOLD AND NOSE GEAR STEERING SERVO VALVE. OPS CHECKS GOOD. REFERENCE MALA975452.

Part: MANIFOLD — FAILED (NLG STEERING)

UPON DEPARTURE, UNCOMMANDED STEERING TAKEOFF FROM ESC CONTINUED. REPLACED NOSE GEAR STEERING ACTUATOR MANIFOLD AND NOSE GEAR STEERING SERVO VALVE. OPS CHECKS GOOD. (M)

Part: STEERING — MALFUNCTIONED (NLG)

FLT 3148 - DURING TAKEOFF ROLL A LEFT UNCOMMANDED TURN FROM NOSE WHEEL STEERING TOOK PLACE. TAKEOFF WAS ABORTED. MAINTENANCE PERFORMED FUNCTION PER MEL 32.1, PERFORMED TAXI TEST AND NO LEAK NOTED ON HYDRAULIC SYSTEM. ALL CHECKS GOOD. (M)

Part: CONNECTORS — CONTAMINATED (TE FLAPS)

FLT 2910 - ON APPROACH TO STC, THE FLAPS WOULD ONLY EXTEND TO HALF. CYCLED THE FLAPS WITH NO CHANGE. AIR TURN BACK TO MSP. LANDED WITH NO FLAPS. MAINTENANCE FOUND MOISTURE ON FLAP POT TERMINALS. RESEALED TERMINALS. OPS AND RIG CHECKS GOOD. (M)

Part: CENTERING POT — FAILED (NLG)

FLT 3208 - DURING TAXI OUT OF MSP, CREW RECEIVED UNCOMMANDED NOSE WHEEL STEERING HARD TURN TO LEFT, THEN NOSE WHEEL STEERING BECAME INOP, NOSE WHEEL STEERING FAIL LIGHT DID NOT ILLUMINATE AND GREEN LIGHT STAYED ON WITH NO NOSE WHEEL STEERING. AIRCRAFT RETURNED TO BLOCK. MAINTENANCE FOUND NOSE WHEEL CENTERING POT TO BE AT FAULT. MAINTENANCE INSTALLED SERVICEABLE NOSE WHEEL CENTERING POT. TAXI CHECKS AND OPS CHECKS GOOD. (M)

Part: DOWNLOCK SWITCH — FAILED (NLG)

FLT 3211 - DURING LANDING IN PIR, NO GREEN DOWN AND LOCKED LIGHT ON GEAR EXTENSION. POST FLIGHT INSPECTION SHOWED GEAR TO BE DOWN AND LOCKED. AIRCRAFT FERRIED TO MSP. MAINTENANCE REMOVED AND REPLACED LEFT NOSE GEAR DOWNLOCK SWITCH. MAINTENANCE PERFORMED GEAR SWINGS. ALL CHECKS GOOD. (M)

Part: ANGLE — WORN (RT WING/NAC)

DURING A BLOCK INSPECTION IN MSP, MAINTENANCE FOUND THE RT INBOARD UPPER WING SKIN TO NACELLE ATTACH ANGLE REPAIR DOUBLER WORN. REMOVED EXISTING REPAIR AND FOUND ANGLE P/N 27-35112 WORN ALSO. REMOVED AND REPLACED ANGLE WITH NEWLY FABRICATED FROM SAME MATERIAL AND INSTALLED A 6 INCH REPAIR DOUBLER OVER AREA OF NACELLE SKIN, IAW FAIRCHILD SRM 51-00-00 PAGE 4 PART FOR PART REPLACEMENT AND FAC SRM 51-90-02, 51-40-02 REV JUNE 93. (M)

Part: SWITCH — DIRTY (NLG)

FLT 2931 - ON APPROACH TO GPZ, THE NOSE GEAR GREEN LGIHT FAILED TO ILLUMINATE AFTER GEAR EXTENSION. THE CREW CYCLED THE GEAR UNTIL THE LIGHT ILLUMINATED. MAINTENANCE CLEANED, DRIED AND LUBED THE DOWN POSITION SWITCHES. ALL CHECKS SATISFACTORY. (M)

Part: UPLOCK SWITCH — FAILED (NLG)

FLIGHT NR 3087 - ON CLIMB-OUT FROM YQT, NO NOSE GEAR INTRANSIT LIGHT WAS NOTED DURING GEAR RETRACTION. THE AIRCRAFT CONTINUED TO MSP WITH THE GEAR DOWN. MAINTENANCE REPLACED THE NOSE GEAR UPLOCK POSITION SWITCH. SYSTEM OPERATED SATISFACTORILY. (M)

Part: ATTACH ANGLE — CRACKED (RT NACELLE)

MSP - DURING A SCHEDULED INSPECTION, MAINTENANCE PERSONNEL NOTED A CRACK IN THE RIGHT INBOARD LOWER WING TO NACELLE ATTACH ANGLE. THEY STOP DRILLED A CRACK AND INSTALLED A REPAIR DOUBLER IAW FAC ARP 54-20-9101. (X)

Part: DOUBLER — WORN (LT TE FLAP)

MSP - DURING A SCHEDULED INSPECTION, MAINTENANCE PERSONNEL NOTED EXCESSIVE WEAR ON THE LEFT FLAP WALKING BEAM ROLLER DOUBLER. THEY REPLACED THE DOUBLER AND INSTALLED A REINFORCEMENT IAW FAC SRM 57-90-10. (X)

Part: DOUBLER — WORN (RT TE FLAP)

MSP - DURING A SCHEDULED INSPECTION, MAINTENANCE PERSONNEL NOTED EXCESSIVE WEAR ON THE RIGHT FLAP WALKING BEAM ROLLER DOUBLER. THEY REPLACED THE DOUBLER AND INSTALLED A REINFORCEMENT IAW FAC SRM 57-90-10. (X)

Part: TORQUE TUBE — CORRODED (RT HORIZ STAB)

MSP - DURING A SCHEDULED INSPECTION, MAINTENANCE PERSONNEL NOTED CORROSION IN THE RIGHT ELEVATOR TORQUE TUBE. THEY REPLACED THE TORQUE TUBE IAW WITH FAC SRM 51-00-00. (X)

Part: TORQUE TUBE — CORRODED (LT HORIZ STAB)

MSP - DURING A SCHEUDLED INSPECTION, MAINTENANCE PERSONNEL NOTED CORROSION IN THE LT ELEVATOR TORQUE TUBE. THEY REPLACED THE TORQUE TUBE IAW FAC SRM 51-00-00. (X)

Part: ANGLE — CRACKED (LT NACELLE)

MSP - DURING A SCHEDULED INSPECTION, MAINTENANCE PERSONNEL NOTED A CRACK IN THE LT LOWER INBOARD WING TO NACELLE ATTACH ANGLE. THEY STOP DRILLED THE CRACK AND INSTALLED A REPAIR DOUBLER IAW FAC ARP 54-20-9101. (X)

Part: RIB — CRACKED (LT TE FLAP)

MSP - DURING A SCHEDULED INSPECTION, MAINTENANCE PERSONNEL NOTED A CRACK IN THE LT FLAP END RIB. THEY REPLACED THE END RIB IAW FAC SRM 51-00-00. (X)

Part: DOOR FRAME — CRACKED (CARGO COMPT)

MSP - DURING A SCHEDULED INSPECTION, MAINTENANCE PERSONNEL NOTED A CRACK IN THE FUSELAGE FORWARD CARGO DOOR FRAME. THEY REPAIRED THE CRACK BY REMOVING THE CRACKED AREA AND INSTALLING DOUBLERS IAW FAC ARP 53-20-9503. (X)

Part: SKIN — CRACKED (WS 66.584)

DURING A SCHEDULED INSPECTION IN MSP, INSPECTORS NOTED A CRACK IN THE RIGHT WING SKIN AT WS 66.584. MAINTENANCE PERSONNEL FABRICATED AND INSTALLED AN EXTERNAL DOUBLER OVER THE CRACK. (M)

Part: RADAR TR UNIT — FAILED (COCKPIT)

FLT NR 3208 - ON CLIMB-OUT FROM MSP, THE WEATHER RADAR BECAME INOPERATIVE. THE AIRCRAFT RETURNED TO MSP. MAINTENANCE REPLACED THE WEATHER RADAR TRANSCEIVER. SYSTEM OPERATED SATISFACTORILY. (M)

Part: WHEEL — OUT OF BALANCE (NLG)

YQT - FLT 3087 - ON CLIMB-OUT, THE AIRCRAFT EXPERIENCED A VIBRATION UNTIL SHORTLY AFTER THE GEAR WAS UP AND LOCKED. THE AIRCRAFT RETURNED TO YQT. MAINTENANCE REPLACED THE NOSE WHEEL/TIRE ASSEMBLY. ALL SYSTEMS OPERATED SATISFACTORILY. (X)

Part: BEARING — FAILED (RT INBD WHEEL)

DURING TAKEOFF, THE OUTBOARD BEARING ON THE RT INBOARD TIRE FAILED. AFTER THE BEARING BROKE DOWN, IT LET THE WHEEL ASSEMBLY LEAVE THE AXLE WITH THE NUT AND COTTER PINS STILL INSTALLED. NO DAMAGE TO THE AXLE OR BRAKE ASSY. CAUSE OF FAILURE IS UNKNOWN. BEARINGS HAD GREASE.

Part: PIN — BENT (CARGO DOOR)

MSP - FLT 3295 - IN CRUISE FLIGHT, THE CARGO DOOR ANNUNCIATOR LIGHT ILLUMINATED IN FLIGHT AT A 4.0 DIFFERENTIAL. THE AIRCRAFT CONTINUED TO MSP. MAINTENANCE REPLACED A BENT BAYONET PIN. SYSTEM OPERATED SATISFACTORILY. (X)

Part: STRUT — LOW PRESSURE (NLG)

MSP - FLT 3084 - ON CLIMB-OUT, NOSE GEAR INTRANSIT LIGHT REMAINED ILLUMINATED AFTER RETRACTING GEAR. THE AIRCRAFT RETURNED TO MSP. MAINTENANCE SERVICED THE NOSE GEAR STRUT. SYSTEM OPERATED SATISFACTORILY DURING A TEST FLIGHT. (X)

Part: SWITCH — OUT OF ADJUST (NLG)

MSP - FLT 3213 - DURING CLIMB-OUT, NOSE GEAR INTRANSIT LIGHT DID NOT GO OUT AFTER TAKEOFF. THE CREW CYCLED THE GEAR AND THE PROBLEM CONTINUED. THE AIRCRAFT RETURNED TO MSP. MAINTENANCE RERIGGED THE UP LIMIT SWITCH. SYSTEM OPERATED SATISFACTORILY. (X)

Part: FRAME — CRACKED (FS 133.87)

MSP - DURING A MAINTENANCE INSPECTION, FOUND RT LOWER BELT FRAME PN 27-22125-021 AT FS 133.87 CRACKED AT THE UPPER CORNER CUT OUT RADIUS. COMPLETED REPAIR TO THE LOWER BELT FRAME IAW FAIRCHILD SRM 53-90-20, REPAIR NR 19.

Part: FRAME — CRACKED (FS 242)

MSP - DURING MAINTENANCE INSPECTION, FOUND LT LOWER BELT FRAME PN 27-22100-035 AT FS 242 CRACKED AT LOWER CORNER CUT OUT RADIUS. COMPLETE REPAIR TO THE LOWER BELT FRAME IAW FAIRCHILD SRM.

Part: FRAME — CRACKED (FS 174.24)

MSP - DURING A MAINTENANCE INSPECTION, FOUND INNER RT FLANGE OF CONSTANT FRAME PN 27-22093-146 AT FS 174.24 CRACKED AT FLANGE BEND RADIUS. COMPLETED REPAIR TO THE FRAME FLANGE IAW FAIRCHILD SRM REPAIR SCHEME NR 20.

Part: FRAME — CRACKED (FS 174.24)

MSP - DURING AMAINTENANCE INSPECTION, FOUND UPPER LT FLANGE OF CONSTANT FRAME PN 27-22093-146 AT FS 174.24 CRACKED AT THE FLANGE BEND RADIUS. COMPLETED REPAIRS TO THE FRAME FLANGE IAW FAIRCHILD SRM 53-90-20 REPAIR NR 19.

Part: FRAME — CRACKED (FS 145.95)

MSP - DURING A MAINTENANCE INSPECTION, FOUND RT LOWER BELT FRAME PN 27-22093-145 AT FS 145.95 CRACKED AT THE UPPER CORNER CUT OUT RADIUS. COMPLETED REPAIR TO THE LOWER BELT FRAME IAW FAIRCHILD SRM 53-90-20, REPAIR NR 19.

Part: FRAME — CRACKED (FS 212.27)

MSP - DURING A MAINTENANCE INSPECTION, FOUND RT LOWER BELT FRAME PN 27-22104-047 AT FS 212.27 CRACKED AT THE UPPER CORNER CUT OUT RADIUS. COMPLETED REPAIR TO THE LOWER BELT FRAME IAW THE FAIRCHILD SRM 53-90-20, REPAIR NR 19.

Part: SKIN — DAMAGED (FS 461-487)

MSP - DURING A MAINTENANCE INSPECTION, FOUND RT AFT EXTERNAL SKIN BETWEEN FS 461 AND FS 487 CREASED. COMPLETED REPAIR TO FUSELAGE EXTERIOR SKIN PANEL IAW FAIRCHILD SRM.

Part: DOUBLER — WORN (LT TE FLAP)

MSP - DURING A MAINTENANCE INSPECTION, FOUND LT FLAP WALKING BEAM ROLLER BEARING SUPPORT DOUBLER PN 27-31141-001 WORN. COMPLETED REPAIR BY THE PART-FOR-PART REPLACEMENT OF THE ROLLER BEARING SUPPORT DOUBLER IAW FAIRCHILD SRM.

Part: FRAME — DENTED (CARGO DOOR)

MSP - DURING A MAINTENANCE INSPECTION, FOUND LOWER FRAME MEMBER OF THE AFT CARGO DOOR PN 27-24050-083 DENTED. COMPLETED REPAIR TO THE AFT CARGO DOOR BY THE PART-FOR-PART REPLACEMENT IAW THE FAIRCHILD SRM.

Part: FRAME — CRACKED (FS 159.24)

MSP - DURING A MAINTENANCE INSPECTION, FOUND RT LOWER BELT FRAME PN 27-22093-145 AT FS 159.24 CRACKED AT THE UPPER CORNER CUT OUT RADIUS. COMPLETED REPAIR TO THE LOWER BELT FRAME IAW FAIRCHILD SRM.

Part: TORQUE TUBE — CHAFED (RUDDER)

DURING A MAINTENANCE INSPECTION IN MSP, MAINTENANCE FOUND THE RUDDER TORQUE TUBE P/N 27-42051-037 TO BE CHAFED AT PHENOLIC PRESSURE SEAL CONTACT AREA. COMPLETED REPAIR TO THE RUDDER BY THE REPLACEMENT OF THE TORQUE TUBE IAW THE FAIRCHILD SRM. (Z)

Part: RIB — ELONGATED (LT WING)

DURING MAINTENANCE INSPECTION IN MSP, FOUND THE LEFT WING RIB P/N 27-84010-005 TO HAVE ELONGATED HOLE AT HYDRAULIC LINE PASS THROUGH, FORWARD OF MAIN SPAR. COMPLETED REPAIR TO LEFT WING RIB IAW FAIRCHILD ARP 57-20-9313 AND SRM. (Z)

Part: SUPPORT — CRACKED (LWR FUSELAGE)

DURING A MAINTENANCE INSPECTION IN MSP, MAINTENANCE FOUND THE FORWARD BELLY SUPPORT CHANNEL P/N 27-31110-033 AT BL 0.00 TO BE CRACKED AT THE PLUMBING PASS THROUGHS. COMPLETED REPAIR TO THE FORWARD BELLY SUPPORT CHANNEL BY REPLACEMENT OF THE CHANNEL AND INSTALLATION OF CHANNEL SUPPORT STIFFENERS IAW THE FAIRCHILD SRM 57-90-30 REPAIRS NR 1 AND NR 2. (Z)

Part: FRAME — CRACKED (FS 174.24)

DURING MAINTENANCE INSPECTION IN MSP, FOUND THE LEFT LOWER FLANGE OF CONSTANT FRAME P/N 27-22093-146 AT FS 174.24 TO BE CRACKED AT THE FLANGE BEND RADIUS. COMPLETED REPAIRS TO THE FRAME FLANGE IAW FAIRCHEILD ARP 53-20-9148 REV A. (Z)

Part: SKIN — DAMAGED (RT TE FLAP)

DURING A MAINTENANCE INSPECTION IN MSP, COMPLETED REWORK OR PREVIOUSLY ACCOMPLISHED REPAIRS TO THE RT FLAP UPPER SKIN (P/N 27-36069-004) AT FLAP TRAILING EDGE AND WS 90.3. REPAIR WAS COMPLETED BY REMOVAL OF EXISTING REPAIR AND THE FABRICATION AND INSTALLATION OF A REPAIR PATCH AND INTERNAL DOUBLER IAW FAIRCHILD SRM 51-90-04 PGS 17 AND 18. (Z)

Part: SKIN — DAMAGED (RT TE FLAP)

DURING A MAINTENANCE INSPECTION IN MSP, COMPLETED REWORK OF PREVIOUSLY ACCOMPLISHED REPAIR TO THE RT FLAP UPPER SKIN (P/N 27-36069-004) JUST INBOARD OF WS 90.3 4.5 INCHES FORWARD OF TRAILING EDGE. REPAIR WAS ACCOMPLISHED BY REMOVAL OF EXISTING REPAIR AND THE FABRICATION AND INSTALLATION OF A REPAIR PATCH AND INTERNAL DOUBLER IAW FAIRCHILD SR. (Z)

Part: FRAME — CRACKED (FS 159.24)

DURING A MAINTENANCE INSPECTION IN MSP, FOUND THE LEFT LOWER BELT FRAME P/N 27-22093-145 AT FS 159.24 TO BE CRACKED AT THE LOWER CORNER CUTOUT RADIUS. COMPLETED REPAIR TO THE LOWER BELT FRAME IAW THE FAIRCHILD SRM AND FAIRCHILD ARP 53-20-9148 REV A. (Z)

Part: FRAME — CRACKED (FS 242)

DURING A MAINTENANCE INSPECTION IN MSP, FOUND THE RT LOWER BELT FRAME P/N 27-22100-035 AT FS 242 TO BE CRACKED AT THE LOWER CORNER CUTOUT RADIUS. COMPLETED REPAIR TO THE LOWER BELT FRAME IAW THE FAIRCHILD SRM 53-90-20, REPAIR NR 19. (Z)