N131CA

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 that of the impact. The check pilot was identified by the CVR group as saying "Mike." The FAA inspector was identified by the same group as saying "look out," about seven tenths of a second prior to the identified impact sound.

On scene investigation indicated the airplane collided with the terrain at about the airport boundary, northwest of the airport. The airplane came to a rest in a plowed field, across a road from the airport boundary, about 1/4 mile from the airport.

According to the Merced County Sheriff's Report (case number 9309356), an individual who lives close to the accident site heard a "loud bang" and decided to investigate. He located the airplane in the field and told his wife to dial "911" to report the accident. The individual and the responding Sheriff's Deputy located the FAA inspector and the First Officer outside the airplane. The report stated the individual who reported the accident and the Sheriff's Deputy then removed the check pilot from his seat in the fuselage.

The accident site is located about 37 degrees and 18 minutes north latitude and 120 degrees and 31 minutes west longitude.

CREW INFORMATION:

FAA airman record files and company records were reviewed. According to those records, all three occupants hold Airline Transport Pilot certificates and type ratings in the BA-3101 aircraft. Review of all records examined revealed that the company check airman and first officer were qualified for the operation conducted in accordance with applicable Federal Aviation Regulations.

According to United Express dispatch records and statements by United Express management personnel, the check airman, who is also the company's chief pilot for the BA-3101, was off duty for the two day...