lornajarrettblanchard

— 23  NTSB. AAR. Atlantic Southeast Airlines, Inc., Flight 2311…Brunswick… 1992, p. v.

— 23  NYT. “Plane Crash in Georgia Kills 23, Including Former Senator Tower.” 4-6-1991.

 

Narrative Information

 

NTSB Executive Summary: “On April 5, 1991, Atlantic Southeast Airlines, Inc., flight 2311, an Embraer EMB-120, N270AS, crashed during a landing approach to runway 07 at the Glynco Jetport,[1] Brunswick, Georgia. The flight was a scheduled commuter flight from Atlanta to Brunswick, Georgia, and was being conducted under instrument flight rules. The airplane was operating in visual meteorological conditions at the time of the accident. The aircraft was destroyed; and the two pilots, the flight attendant, and all 20 passengers received fatal injuries.

 

“Flight 2311 was cleared for a visual approach to Glynco Jetport a few minutes before the accident. Witnesses reported that as the airplane approached the airport, it suddenly turned or rolled to the left until the wings were perpendicular to the ground. The airplane then fell in a nose-down attitude and disappeared out of sight behind the trees.

 

“Examinations of the left propeller components indicated a propeller blade angle of about 3 degrees at impact while the left propeller control unit ballscrew position was consistent with a commanded blade angle of 79.2 degrees. The discrepancy between the actual propeller blade angle and the angle commanded screw is a strong indication that there was a discrepancy inside the propeller control unit prior to impact and that the left propeller had achieved an uncommanded low blade angle.

 

“The discrepancy in the propeller control unit was found to have been extreme wear on the propeller control unit quill spline teeth which normally engaged the titanium-nitrided splines of the propeller transfer tube. It was found that the titanium-nitrided surface was much harder and rougher than the nitrided surface of the quill. Therefore, the transfer tube spines acted like a file and caused abnormal wear of the gear teeth on the quill. The investigation found that wear of the quill was not considered during the certification of the propeller system.

 

“The investigation revealed crew rest practices that may be detrimental to crew performance although they probably had no bearing in the cause of this accident.

 

“The National Transportation Safety Board determines that the probable cause of this accident was the loss of control in flight as a result of a malfunction of the left engine propeller control unit which allowed the propeller blade angles to go below the flight idle position. Contributing to the accident was the deficient design of the propeller control unit by Hamilton Standard and the approval of the design by the Federal Aviation Administration. The design did not correctly evaluate the failure mode that occurred during this flight, which resulted in an uncommanded and uncorrectable movement of the blades of the airplane’s left propeller below the flight idle position.

 

“As a result of its investigation of this accident, the Safety Board made four recommendations to the Federal Aviation Administration pertaining to the certification of propeller systems, the recertification and the need to establish periodic inspection requirements for the Hamilton Standard model 14RF propellers, and regarding the flightcrew reduced rest provisions contained in 14 CFR section 135.265. In addition, the Safety Board made a recommendation to Atlantic Southeast Airlines, Inc., and the Regional Airlines Association urging them to discontinue scheduling reduced rest for flightcrews.” (NTSB. AAR. Atlantic Southeast Airlines, Inc., Flight 2311…Brunswick… 1992, pp. v-vi.)

 

NYT: “Brunswick, Ga., April 5 — A commuter plane carrying 23 people, including former Senator John G. Tower of Texas, crashed and burned today a mile and a half short of the airport near this Georgia coast city, killing everyone on board. The twin-engine turbo-prop Atlantic Southeast Airlines plane flying from Atlanta went down in a thickly wooded area within view of motorists on Interstate 95 shortly before 3 P.M., the police said…..

 

“A spokesman for Mr. Tower said the 65-year old Republican was traveling with his 35-year-old daughter, Marian Tower, to Sea Island off the Georgia coast to promote his new book. Mr. Tower had been the subject of a bitter confirmation battle that saw the Senate reject his nomination as Defense Secretary in 1989.

 

“The accident came a day after Senator John Heinz, a Pennsylvania Republican, was killed with six others when his chartered plane collided with a helicopter over a suburb of Philadelphia….

 

“Another commuter passenger was an astronaut, Capt. Manley Lanier Carter Jr., 43, who flew aboard the space shuttle Discovery on a five-day mission in November 1989….

 

“People who saw the debris said it appeared that the aircraft, a Brazilian-made Embraer 120 popular with commuter airlines, fell straight down before crashing short of the airport near Brunswick, midway between Savannah and Jacksonville, Fla. It fell into a pine forest about 150 yards off a hardtop road and half a mile from an elementary school….

 

“…a spokesman for the airline, said the flight was one of four that Atlantic Southeast operates between Atlanta and Brunswick. The Embraer 120 can hold 30 passengers….” (NYT/Keith Schneider. “Plane Crash in Georgia Kills 23, Including Former Senator Tower.” 4-6-1991.)

 

Sources

 

National Transportation Safety Board. Aircraft Accident Report. Atlantic Southeast Airlines, Inc., Flight 2311 Uncontrolled Collision with Terrain, an Embraer EMB-120, N270AS, Brunswick, Georgia, April 5, 1991 (NTSB/AAR-92/03). Washington, DC: NTSB, adopted 4-28-1992. Accessed 4-28-2016 at: http://www.ntsb.gov/investigations/AccidentReports/Reports/AAR9203.pdf

 

New York Times (Keith Schneider). “Plane Crash in Georgia Kills 23, Including Former Senator Tower.” 4-6-1991. Accessed 4-28-2016 at: http://www.nytimes.com/1991/04/06/us/plane-crash-in-georgia-kills-23-including-former-senator-tower.html

 

[1] Now known as the Brunswick Golden Isles Airport. (Wikipedia)

— 7  NTSB, AAR.  Midair Collision…Lycoming Air…Sun Company… 412.  9-17-1991, 1

— 7  The Intelligencer, Doylestown, PA. “Sen Heinz, six others killed as aircraft….” 4-5-1991, 1.

 

Narrative Information

 

April 5: “The Associated Press. U.S. Sen. John Heinz and six others, including two children, were killed Thursday after a helicopter checking the landing gear on the senator’s plane collided with the plane over a schoolyard in Lower Merion Township.

 

“Heinz and the two pilots in his twin engine [Piper] Aerostar PA60, two pilots in the Sun Co. Bell 412 helicopter, and two children on the ground were killed, police said. Early reports said the children were first-graders. Three children and two school employees were also injured.

 

“The bodies of Heinz and the two pilots were taken to Lankenau Hospital. Officials said the bodies were burned so badly that dental records were being brought in from Washington to identify which one was Heinz.

 

“John Fowler, 48, head custodian at Merion Elementary, said only a few children were outside

at the time.  Most were in class or at lunch. “Fifteen minutes later, there would have been 400 kids where the helicopter came down,” Fowler said.

 

“The collision occurred shortly after noon. Confirmation that Heinz was aboard came nearly two hours later when the senator’s Washington office said he was dead.

 

“David C. Latshaw, township manager, said the two Sun Co. pilots overheard the pilot for Heinz’s plane report to the tower that a warning light was on and that there could be a problem with the landing gear.  They went to investigate.  “This is the day of our board of directors meeting,” said Sun spokesman Dick Jackman.  The helicopter was “shuttling back and forth from the (Philadelphia) airport all day,” taking board members to the company headquarters, he said.  Jackman identified the two Sun pilots as Charles J. Burke, 42, Coatesville, and Michael Pozzano,

43, of Elverson. The two pilots of the Heinz plane were identified as Rick Shreck and Tron Stegan, both of Lycoming County.  Both worked for Lycoming Air Service, based in Williamsport.

 

“Heinz, 52, was in his third term in the U S. Senate.  He was born in Pittsburgh and was an heir to the H. J. Heinz food empire.  He was elected to the U.S. House in a special election in 1971 and was re-elected twice.  He was elected to the Senate in 1976 and was re-elected in 1982 and 1988….”  (The Intelligencer, Doylestown, PA. “Sen Heinz, six others killed as aircraft collide over school.” 4-5-1991, 1.)

 

NTSB: “On April 4, 1991, a Lycoming Air Services Piper Aerostar, PA-60, N3645D, was operating as an on-demand air taxi flight…The airplane had departed the Williamsport-Lycoming County Airport (IPT), Williamsport, Pennsylvania, around 1022 eastern standard time on an instrument flight rules (IFR) flight plan for the Philadelphia International Airport (PHL), Philadelphia, Pennsylvania. The captain, first officer, and one passenger were on board.

 

“The takeoff and en route portions of the flight were uneventful.  As it approached PHL, the flight was cleared for an instrument landing system approach to runway 17. While on the approach, at 1201:28, the captain of N3645D reported that the nose landing gear position light had not illuminated to indicate that the nose gear was in the down and locked position and that he might need to cycle the landing gear.  Lycoming Air Service representatives, upon listening to the air traffic control (ATC) recording, identified the captain‘s voice as making the transmissions from the airplane.  Lycoming Air Service officials reported that the PA-60 is normally a single-pilot airplane.  The Safety Board believes that the captain was flying the airplane, as well as making the radio transmissions.

 

Shortly before N3645D began its approach, a Bell 412SP helicopter, N78S, operated by Sun Company Aviation Department, departed from the company‘s helicopter landing pad at PHL on a visual flight rules (VFR) flight to Sun Company corporate headquarters in Radnor, Pennsylvania. The captain and first officer were the only persons on board…. As N78S departed the PHL terminal control area (TCA), the pilots heard the communications regarding the possible unsafe nose gear indication on N3645D.

 

“The crew of N3645D was told to maintain 1,500 feet to allow N78S to pass underneath as the helicopter departed the area.  As he passed under N36450, at 1202:29, one of the pilots of N78S reported to the tower “that Aerostar that went past us, looks like the gear is down.” Sun Company personnel identified the voice making the radio transmissions from the flight to ATC as being that of the first officer.  However, several subsequent transmissions from N78S were made by the captain.  The chief pilot for Sun Company indicated that the flightcrew wore head sets equipped with boom microphones and that there were push-to-talk buttons on the flight controls.  Thus, it would not be unusual for the flying pilot to transmit. The Safety Board believes that the captain was flying the helicopter, but the pilots may have switched flying roles at times during the flight .

 

“The captain of N3645D acknowledged to ATC that he had heard N78S’s transmission and stated that “I can tell it’ s down but I don’t know if it’s locked, that’s the only problem.” A reflection of the nose landing gear can be seen from the cockpit on the propeller spinner. The tower acknowledged the transmission and advised that the helicopter was no longer a factor and that N3645D was cleared to land on runway 17.  The controller later stated that he interpreted N3645D’s situation as justifying an emergency.  The tower supervisor alerted the airport’s air craft rescue and fire fighting units (ARFF).  Additionally, runway 17 arrivals were terminated through a coordinated effort between the tower and approach control, resulting in a relatively clear communications frequency.  The local controller contacted N3645D and requested the number of occupants and amount of fuel on board.

 

“At 1203:35, the controller offered N3645D the option of making a low-altitude pass by the control tower so that the tower personnel could observe the position of the nose gear. The controller further stated that there was “almost no traffic right now – we can do whatever you like.”  N3645D acknowledged that it would do a flyby of the tower.  At 1204:12, the captain of N78S advised the tower that they “could take a real close look at that if you wanted.” The tower acknowledged the transmission.  At 1204:19, the captain replied that N78S was turning back to the airport, presumably to perform an in- flight inspection of N3645D’s nose gear.

 

As N3645D passed by the control tower, the controller advised that the nose gear appeared to be down.  The captain of N3645D responded that he could see the nose gear in the reflection of the propeller spinner and that it appeared to be down, but the indicator light was not green. The controller requested N3645D to make a left turn and enter a downwind leg for runway 17. He further advised that N78S was inbound from the north and that N78S could take a look at the nose gear.  At 1205:30, the captain of N36450 stated “Okay, I appreciate it.” The controller further advised that the ARFF equipment was on the runway.

 

“Sun Company officials reported that it was company policy to be “good neighbors” and that they had offered the services of the company’s aircraft and flightcrews to local communities in the event of emergency situations, such as medical evacuations, and searching for lost persons. Several controllers reported that the Sun helicopter had, on previous occasions, assisted the tower in locating vehicles or people on the airport property.

 

“The chief pilot for Sun Company stated that he was not aware of any previous in-flight inspections of other aircraft by the pilots of N78S or other Sun Company pilots

 

“Commencing at 1205:45, the controller provided directional information to the flightcrew of N78S to assist in visually acquiring N3645D.  This information was acknowledged by the first officer.  By 1207:54, the pilots of each aircraft acknowledged that they had each other in sight and that a speed of 125 knots would be used during the join up.  At that time, the aircraft were joining up on an extended downwind leg for runway 17 at a altitude of about 1,100 feet. The controller advised IC36450 of antenna towers 6 miles ahead and requested the pilot of N3645D to notify the tower when he wanted to turn back toward the airport or make a heading change.

 

“At 1208:21, the captain of N78S contacted N3645D directly on tower frequency and requested that the pilot of N3645D slow down.  At 1208:52, the first officer of N78S contacted N3645D and stated that “we’re going to come up behind you on your left side so just hold your heading.” The captain of N3645D responded that the antenna towers were straight ahead and that he might need to change heading by 15 [degrees] to the left.  At 1209:30, the first officer of N78S stated on tower frequency “Aerostar. We’re gonna pass around your right side now, take a look at everything as we go by.”  The captain of N3645D responded with “Okay.” At 1210:30, there was a transmission from N3645D that was unintelligible because of a transmission from another aircraft.  The controller asked N3645D to repeat the transmission, and the pilot of N3645D again stated that the indicator for the nose gear did not show down and locked.

 

“At 1210:16, the first officer of N78S stated “everything looks good from here. The captain of N3645D replied “Okay, appreciate that we’ll start to turn in.” These transmissions were the last ones received from either N78S or N3545D.  The last transmission was abruptly terminated by considerable noise.  At 1210:51, the controller requested N3645D to make a left turn back to the airport, and he cleared the airplane to land on runway 17. Shortly thereafter, the controller noticed a smoke plume to the north of the airport. Subsequent attempts by the controller to contact either N78S or N3645D by radio were unsuccessful….

 

“Conclusions

1. Both aircraft were certificated, equipped, and maintained in accordance with Federal regulations and approved procedures.

 

2. There were no preexisting defects to either aircraft that contributed to the accident. The Safety Board could not determine the functional status of the nose gear down indicating light on N3645D prior to the collision.

 

3. Both flightcrews possessed the appropriate airmen’s certificates for their respective duties.

 

4. Weather was not a factor in the accident.

 

5. The Safety Board found deficiencies in the training program of Lycoming Air Services, Inc., and the flightcrew checking procedures of the FAA principal operations inspector assigned to the operator.

 

6. The emergency procedures section of the Piper PA-60 flight manual does not contain sufficient information on the actions to take if the nose landing gear down indicating light fails to illuminate.

 

7. The captain of N3645D could see from the reflection of the nose landing gear in the propeller spinners that the nose landing gear was fully extended and that the gear doors closed over the wheel well area. Therefore, there was no additional information that could be gained by flying by the tower or from an in-flight inspection.

 

8. None of the flight crewmembers of the two aircraft had experience flying in close proximity to another aircraft.

 

9. The captain of N3645D, after accepting the offer of the in-flight inspection, did not coordinate with the flightcrew of N78S the maneuvering procedures to be used to ensure the safety of his aircraft.

 

10. N78S was maneuvered into a position where it could not be seen by the flightcrew of N3645D.

 

11. The flightcrew o f N78S should have terminated the inspection after they saw that the nose landing gear locking mechanism was concealed in the wheel well.

 

12. The final movements of both aircraft that led to the midair collision could not be determined, but the pilots of N78S had the responsibility for maintaining safe separation from N3645D.

 

13. The air traffic controllers at Philadelphia International Airport acted in accordance with approved air traffic control procedures in providing assistance to the two aircraft.

 

14. The FAA principal operations inspector assigned to Lycoming Air Services, Inc., did not have sufficient time to adequately survey the operator.

 

10. Probable Cause

 

“The National Transportation Safety Board determines that the probable causes of this accident were the poor judgment by the captain of the airplane to permit the in-flight inspection after he had determined to the best of his ability that the nose landing gear was fully extended, the poor judgment of the captain of the helicopter to conduct the inspection, and the failure of the flightcrew of the helicopter to maintain safe separation.  Contributing to the accident was the incomplete training and checking that the flightcrew of N3645D received from Lycoming Air Services, Inc., and the FAA principal operations inspector assigned to the operator.”

 

(NTSB. Aircraft Accident/Incident Summary Report: Midair Collision involving Lycoming Air Services Piper Aerostar PA-60 and Sun Company Aviation Department Bell 412 ( NTSB/AAR-91-01/SUM / PB91-910407)  Washington, DC:  NTSB, Adopted 9-17-1991, pp. 1-21.)

 

Sources

 

National Transportation Safety  Board.  Aircraft Accident/Incident Summary Report: Midair Collision involving Lycoming Air Services Piper Aerostar PA-60 and Sun Company Aviation Department Bell 412 (NTSB/AAR-91-01/SUM / PB91-910407)  Washington, DC:  NTSB, Adopted 9-17-1991. Accessed 10-19-2011 at:

http://libraryonline.erau.edu/online-full-text/ntsb/aircraft-accident-summaries/AAR91-01S.pdf

 

The Intelligencer, Doylestown, PA. “Sen Heinz, six others killed as aircraft collide over school.” 4-5-1991, 1. At: http://www.newspaperarchive.com/FullPagePdfViewer.aspx?img=26998532

 

 

 

 

—  27  Baugher.  US Navy…Marine Corps BuNos Third Series (150139 to 156169). 10-29-2011.

—  27  Gero. Military Aviation Disasters: Significant Losses Since 1908.  1999, p. 154.

 

Narrative Information

 

Baugher: “Lockheed P-3C-150-LO Orion.  158930 (c/n 185-5602, VP-50) in midair collision with 159325 off coast of San Diego, CA Mar 21, 1991.  All 27 on both planes killed.” (Baugher.  US Navy…Marine Corps BuNos Third Series (150139 to 156169). 10-29-2011.)

 

Gero: “This disastrous mid-air crash occurred during an anti-submarine warfare training exercise.  Designated as the ‘on-station’ aircraft, 159325 was being relieved by 158930, having provided sonobuoy contact as part of the operation. The two four- engine turboprop patrol aircraft collided at an approximate altitude of 3,000ft (1,000m) and some 60 miles (100km) south-west of San Diego, and both then plummeted into the Pacific Ocean [~2:15 a.m.]. All 27 crewmen from both aircraft, 14 aboard 158930 and 13 aboard 159325, lost their lives….

 

“Both aircraft had been based at the Moffett Field Naval Air Station, located near San Jose, California. The altitude separation to be used in the turn-over had been established in pre-flight briefings by their crews. Though both were operat­ing under visual flight rules procedures, horizontal separation at the scene would have been afforded through air-to-air tactical air navigation (TACAN) facilities. In addition, the aircraft were in radio contact with each other.

 

“According to radar transcripts, 158930 had, prior to the accident, descended from its en-route altitude, and was maintaining its height, while 159325 had ascended an estimated 300 to 1,000ft (100-300m). Just before impact, the former was headed generally north, the latter generally east. The crew of a Navy helicopter observed the fireball produced by the collision. It was dark at the time, and the meteorological condi­tions consisted of intermittent rain, with the cloud level down to around 2,000ft (600m) and a visibility of between 5 and 10 miles (10-151cm). There was also thunderstorm activity in the area. The weather was considered a possible contributing factor.

 

“Although the exact sequence of events could not be determined, the accident apparently occurred after one crew either misunderstood the other’s inten­tions, lost situational awareness at a critical time, or violated a previous understanding or agreement made in radio communications as to how each P-3 would shift altitudes in order to effect the turn-over. Significantly, the flight of 159325 had been marked by equipment failures, an inoperative autopilot system, and extended time in turbulent weather conditions, which reportedly caused airsickness among some of its crewmen. These factors, combined with the added distractions of reported interference on its crew intercom system and fatigue associated with the length of time on station and the night-time duty, could have contributed to the accident had this crew been at fault. As previ­ously mentioned, 159325 was the aircraft that deviated from the self-assigned swap height of 2,500ft (750m), although this could have been agreed upon between both crews by radio. Despite a recommendation for such, the investigative report noted no plans to retrofit the US Navy’s P-3 fleet with crash-survivable flight data recorders.”  (Gero 1999, 154-155)

 

Sources

 

Baugher, Joseph F. US Navy and US Marine Corps BuNos Third Series (150139 to 156169). 3-31-2016 revision. Accessed at: 4-28-2016 at http://www.joebaugher.com/navy_serials/thirdseries19.html

 

Gero, David. Military Aviation Disasters: Significant Losses Since 1908. UK and Newbury Park, CA: Patrick Stephens Limited, an imprint of Hayes Publishing, 1999.

 

 

— 10  NTSB. Aircraft Accident Brief.  Location: San Diego, California.

— 10  Notable California Aviation Disasters. “The 1990s.” Oct 23, 2008 update.

— 10  Stromblad, Cory. “Reba Remembers Plane Crash Tragedy 20 Years Later.” 3-16-2011.

 

Narrative Information

 

NTSB: “…on March 16, 1991, at 0143 Pacific standard time, a Hawker Siddeley DH125-1A/522 transport-category turbojet airplane crashed into mountainous terrain about 8 nm northeast of SDM,[1] killing 10 people…. The Hawker accident site was at the 3,300-foot level of Otay Mountain and about 172 feet below the mountain’s top.

 

“The flight crew of the Hawker filed an IFR flight plan with the San Diego FSS,[2] and the FSS briefer suggested that the pilot depart under VFR[3] and pick up his IFR[4] clearance in the air.  The pilot stated that he was not familiar with SDM’s departure procedures. The pilot later telephoned the FSS again and informed the briefer that he could not find information regarding a

standard instrument departure procedure for SDM, and the FSS briefer then read to the pilot the departure procedures for runways 8 and 26. The pilot later telephoned the FSS a third time and informed the same briefer that, if he followed the procedures, he would enter the terminal control

area (now class B airspace) without a clearance. The pilot stated that it would be better if he headed northeast and stayed below 3,000 feet, and the briefer responded, ‘yeah, sure that’ll be fine.’

 

“The flight crew of the Hawker departed runway 8L under VFR, contacted terminal radar approach control, and informed the controller that the flight was waiting for its IFR clearance. When the controller asked the flight crew about the flight’s position, no response was received.

 

“The Safety Board determined that the probable cause of the Hawker accident was the pilot’s improper planning/decision, the pilot’s failure to maintain proper altitude clearance over mountainous terrain, and the copilot’s failure to adequately monitor the progress of the flight. Contributing to the accident were the insufficient terrain information provided by the FSS specialist during the preflight briefing after the pilot inquired about a low-altitude departure, both

pilots’ lack of familiarity with the geographical area, and the dark night conditions….” (NTSB. Aircraft Accident Brief. 2006, pp. 16-17.)[5]

 

Notable California Aviation Disasters:

“Date / Time: Saturday, March 16, 1991 / 1:42 a.m.

“Operator / Flight No.: Duncan Aircraft Sales / Private Charter

“Location: OtayMountain, east of San Ysidro, Calif.

 

“Details and Probable Cause:   Popular Country singing star Reba McEntire lost seven members of her band and her road manager in an early-morning chartered jet crash near San Diego, following the entertainer’s performance at a private concert for IBM executives the night before.

 

“Earlier in the day, after the performers had disembarked at San Diego’s Lindbergh Field, the twin-jet Hawker-Siddeley DH-125-1A/522 aircraft (N831LC), chartered by Prestige Touring of Dallas, Texas, and owned by Duncan Aircraft Sales of Venice, Florida, was flown to Brown Field, a former Naval air station southeast of San Diego, since a late, post-concert departure was planned and a noise curfew would be in effect at Lindbergh Field at that hour.

 

“McEntire’s next scheduled performance was set for the following evening in Fort Wayne, Indiana, and after the San Diego show her band members boarded the aircraft at Brown Field for its flight to Fort Wayne, with a planned refueling stop in Amarillo, Texas.

 

“Approximately two minutes after taking off at 1:40 a.m., the aircraft, flying at an altitude of about 3,400 feet, crashed near the top of Otay Mountain approximately 10 miles northeast of the airfield.

 

“Killed in the crash were bandleader Kirk Cappello and members Paula Kaye Evans, Michael Thomas, Terry Jackson, Joey Cigainero, Anthony Saputo and Chris Austin.   Also killed were McEntire’s road manager, Jim Hammon; the pilot, Donald Holms; and co-pilot Chris Hollinger.

 

“Additional members of the McEntire entourage had boarded a second aircraft that departed Brown Field about three minutes after the ill-fated jet and did not witness the crash.   They learned of the tragedy when their plane made a refueling stop in Memphis, Tennessee.

 

“McEntire and her husband/manager, Narvel Blackstock, who had elected to remain overnight in San Diego before flying to the Fort Wayne concert engagement the next day, were notified of the tragedy not long after it occurred.

 

“A number of factors were behind the cause of the crash, including improper planning/decision by the pilot; failure of the flight crew to maintain proper altitude and clearance over mountainous terrain; and the failure of the co-pilot to adequately monitor the progress of the flight.

 

“Fatalities: 10.”  (Notable California Aviation Disasters.  “The 1990s.” Oct 23, 2008 update.)

 

Stromblad: “Reba McEntire has posted a video on her official Facebook page[6] to commemorate the 20-year anniversary of the tragic plane crash that claimed the lives of her eight band members.

On March 16, 1991, Chris Austin, Kirk Cappello, Joey Cigainero, Paula Kay Evans, Jim Hammon, Terry Jackson, Anthony Saputo and Michael Thomas, as well as pilot Donald Holms and co-pilot Chris Hollinger, lost their lives as their charter plane crashed on the side of Otay Mountain, just outside San Diego, Calif. The band members were returning from a private event where Reba performed for IBM executives.  In addition to the touching video, Reba has planted eight Dogwood trees at the McEntire’s Ranch House Walk in memory of the crash victims.  The singer’s 1991 ‘For My Broken Heart’ album was dedicated to her fallen musical family members.” (Stromblad.  “Reba Remembers Plane Crash Tragedy 20 Years Later.”  3-16-2011.)

 

Sources

 

National Transportation Safety Board. Aircraft Accident Brief. Accident number: LAX05FA015. Operator: Med Flight Air Ambulance, Inc…Location: San Diego, California…Adopted on: May 23, 2006. Accessed 4-28-2016 at: http://www.ntsb.gov/investigations/AccidentReports/Reports/AAB0605.pdf

 

Notable California Aviation Disasters. “The 1990s.” Oct 23, 2008 update.  Accessed 10-20-2009 at: http://www.jaydeebee1.com/crash90s.html [Note: site inoperable when checked 4-28-2016.]

 

Stromblad, Cory. “Reba Remembers Plane Crash Tragedy 20 Years Later.”  3-16-2011. Accessed 4-28-2016 at: http://www.theboot.com/2011/03/16/reba-mcentire-band-plane-crash-20-year-video/

 

 

 

 

 

 

 

[1] Brown Field Municipal Airport, near San Diego, CA.

[2] Flight Service Station.

[3] Visual Flight Rules.

[4] Instrument Flight Rules.

[5] The Brief is for an October 24, 2004 Med Flight Air Ambulance crash near the same area as the 3-16-1991 crash.

[6] http://www.facebook.com/Reba

–10  USFA. Ten Elderly Victims from Intermediate Care Facility Fire Col. Springs, CO.  1999

—  9  NFPA. NFPA Today. “Today in fire history: 9 dead…”[1]

 

Narrative Information

 

USFA: “An accidental fire determined to have originated above ceiling level occurred in the early morning hours of March 4, 199l to the Crystal Springs Estates personal care boarding home in Colorado Springs, Colorado. All indicators point to this fire as having been burning in the attic undetected for some period of time, perhaps as much as an hour or more before breaking through the ceiling sheetrock and having smoke detectors react.

 

“Heat detectors were found in the attic but had not functioned. A pull station’s use and a 911 call alerted the fire department, but upon arrival they found a fire already ventilated through roof turbines. Nine elderly occupants perished, all as a result of carbon monoxide poisoning, in this fire. A tenth victim died months later of smoke aggravated lung problems.  (USFA 1999, 2-3)

 

“A total of 25 residents were in the structure at the time of the fire along with two staff members. Nine fire fatality victims were removed during the suppression of the fire. The victims ranged in aged from 77 to 97. The El Paso County Coroner’s Office has determined that all the victims died from asphyxia due to carbon monoxide inhalation. All victims but one were found in their rooms; the one outside of her room was found in the dining area. One woman, Lois Mitchell, age 82, died in December 1991 of smoke aggravated lung problems.”  (USFA 1999, 4)

 

“This tragic fire, like many other similar fires in care facilities, illustrates common, preventable problems that continue to occur.

 

“The first and foremost question deals with the inspection force and who is ultimately responsible for the well-being of the occupants in this type of facility. Colorado labeled this facility as an “intermediate or personal care facility’ instead of calling it a “nursing home.” For this category there is supposed to be a lesser degree of care needed, i.e., less nursing staff. However, as shown in this scenario, this group of residents who averaged 85 years of age, many with limited mobility, were put at a serious disadvantage by this categorization when an emergency situation arose. Other states, like Colorado, need to review their criteria and practices in this important area.

 

“Adequacy of inspections is another problem area spotlighted by this incident. Colorado currently has two inspectors for the entire state and 281 operating personal care homes. They range in size from three beds to several hundred, but most are twenty beds or smaller. The State Health Department Director is currently trying to arrange contracts with local county inspectors to maintain inspections on these facilities, but in the interim two inspectors are charged with the major portion of inspections in the state. The Director indicates these are not trained building inspectors and have only a cursory amount of training in this area.  The State Health Department Director makes the point that the bulk of these facilities are not in line for any federal aid and if forced to go with more stringent safety features, they would be forced to close. By comparison, numerous states, such as Virginia and Alabama have made sprinklering of this type of facility mandatory, and it does not appear that financial constraints have hampered them.

 

“The Colorado Springs Fire Department is to be commended for their openness during USFA’s investigation of this fire and their willingness to learn from this loss. They indicated they will implement into their plan a program of more stringent code enforcement as a result of lessons learned from this fire.  (USFA 1999, pp. 5-6)

 

Lessons Learned:

 

• Inspection for these types of care facilities must be conducted by fully qualified building inspectors as well as by health inspectors. or joint inspections should be conducted….
• Properly working heat and smoke detection equipment is a must….
• Adequate staff must be assigned for the number of occupants….
• Care facilities should be sprinklered in patient rooms and halls….
• Evacuation planning and regular drills are particularly important in facilities for the elderly….”  (USFA 1999, 7)

 

NFPA: “On, March 4, 1991 a fire of accidental origin occurred at Crystal Springs Estate, a board and care facility, in Colorado Springs, Colorado.  Nine of the building’s 25 elderly residents died during the fire.  In addition, eight other residents and five firefighters were injured.

 

“The single-story masonry and wood structure, with two separate partial basements, was divided into three fire compartments by noncombustible walls, and the corridor openings in these walls were protected with fire doors.  A fire alarm system using heat detectors as the primary initiating device protected all rooms, closets, and attic spaces.  Manual pull stations and smoke detectors located next to the fire doors were also connected to this fire alarm system.  The activation of any device in the fire alarm system would initiate alarm chimes throughout the building and would send a signal to a central monitoring station.  A separate alarm system of interconnected corridor smoke detectors was also provided and only initiated a local alarm upon the activation of any detector on the system.

 

“An electric motor in a ventilation fan apparently malfunctioned, overheated, and ignited combustible materials in the attic above the east wing.  The fire burned for an undetermined period of time, spreading in the attic space above several rooms before causing the ceiling to collapse in a residents’ lounge.  At approximately 12:35 a.m., smoke entering the occupied space activated the corridor smoke detection system, and staff began their emergency procedures.

 

“The fire also breached a wall between the wing of origin and a dining room and spread across the combustible ceiling in the dining room.  Because there was no fire door between the dining room and the corridor in the west wing, smoke and fire extended to that corridor.

 

“The first firefighters on the scene found the dining room fully involved in fire with heavy smoke and some fire extension in corridors of both wings.  They started simultaneous rescue and suppression operations.  All survivors were rescued during the first half hour, and fire suppression operations continued for approximately 4 1/2 hours.  In addition to the nine fatalities and eight injured residents, the fire destroyed two of the building’s three wings.

 

“The following factors appear to have significantly contributed to the loss of life:

 

• Heat detector system in the attic did not provide early warning,
• Fire separations did not prevent the spread of smoke and fire,
• Combustible ceiling in the dining room,
• Lack of adequate fire safety training for staff and residents.”

 

(NFPA. Today. “3-4-2016. Today in fire history: 9 dead, eight residents and five firefighters were injured in a board and care facility.”)

 

Sources

 

National Fire Protection Association. Today. Your online NFPA community. “3-4-2016. Today in fire history: 9 dead, eight residents and five firefighters were injured in a board and care facility.” Quincy, MA: NFPA. Accessed 4-28-2016 at: http://nfpatoday.blog.nfpa.org/historic-fires/page/2/

 

United States Fire Administration. Ten Elderly Victims from Intermediate Care Facility Fire, Colorado Springs, Colorado. Emmitsburg, MD:  National Fire Data Center, USFA, FEMA, 1999, 50 pages. Accessed at: http://www.interfire.org/res_file/pdf/Tr-050.pdf

 

 

 

 

[1] As the USFA notes, one of the injured survivors died months later due to “smoke aggravated lung problems.”

— 25  NTSB. AAR. Uncontrolled Descent…Collision with Terrain, United…CO Springs CO. ix.

— 25  New York Times. “Jetliner Crash in Colorado Kills All 25 People Aboard.” 3-4-1991.

 

Narrative Information

 

NTSB Executive Summary: “On March 3, 1991, a United Airlines Boeing 737, registration number N999UA, operating as flight 585, was on a scheduled passenger flight from Denver, Colorado, to Colorado Springs, Colorado. Visual meteorological conditions prevailed at the time, and the flight was on an instrument flight rules flight plan. Numerous witnesses reported that shortly after completing its turn onto the final approach course to runway 35 at Colorado Springs Municipal Airport, about 0944 mountain standard time, the airplane rolled steadily to the right and pitched nose down until it reached a nearly vertical attitude before hitting the ground in an area known as Widefield Park. The airplane was destroyed, and the 2 flight crewmembers, 3 flight attendants, and 20 passengers aboard were fatally injured.

 

“The National Transportation Safety Board determines that the probable cause of the United Airlines flight 585 accident was a loss of control of the airplane resulting from the movement of the rudder surface to its blowdown limit. The rudder surface most likely deflected in a direction opposite to that commanded by the pilots as a result of a jam of the main rudder power control unit servo valve secondary slide to the servo valve housing offset from its neutral position and overtravel of the primary slide.” (NTSB. AAR. Uncontrolled Descent and Collision with Terrain, United Airlines Flight 585, Colorado Springs, Colorado, March 3, 1991. Dec 1992, p. xv.)

 

NYT: “Colorado Springs, March 3 — A United Airlines 737 jet bound for the airport here crashed nose first into a neighborhood park this morning, killing all 25 people aboard. The plane just missed an 250-unit apartment complex and a housing development on either side, and no one on the ground was seriously injured….

 

“Flight 585, a nine-year-old Boeing 737-200, was on its way to Colorado Springs from Denver, after originating in Peoria, Ill. It exploded in flames after smashing into the park, about four miles south of the airport, in the unincorporated community of Widefield….”

 

Sources

 

National Transportation Safety Board. Aircraft Accident Report. Uncontrolled Descent and Collision with Terrain, United Airlines Flight 585, Boeing 737-200, N999UA, 4 Miles South of Colorado Springs Municipal Airport, Colorado Springs, Colorado, March 3, 1991 (NTSB AAR-01/01; NTIS PB2001-910401). Washington, DC: NTSB, Adopted December 1992. Accessed 4-28-2016 at: http://www.ntsb.gov/investigations/AccidentReports/Reports/AAR0101.pdf

 

New York Times (Dirk Johnson). “Jetliner Crash in Colorado Kills All 25 People Aboard.” 3-4-1991. Accessed 4-28-2016 at: http://www.nytimes.com/1991/03/04/us/jetliner-crash-in-colorado-kills-all-25-people-aboard.html

 

— 10  AP. “Fatal fire pinned on extension cord.” The Sun, Lowell, MA, 2-18-1991, p. 2.

— 10  AP. “Ten dead in Conn. tenement blaze.” The Sun, Lowell, MA, 2-17-1991, p. 2.

— 10  National Fire Protection Association. Home Fires with Ten or More Fatalities (webpage).

 

Narrative Information

 

AP, Feb 17: “New Britain, Conn. (AP) – “An early morning fire swept through a three-story tenement building yesterday, killing 10 people, officials said. The victims were believed to be members of two families who lived on the second and third floors of the wood-and-brick building in a predominantly Hispanic neighborhood near the city’s downtown. Five bodies were found in a second-floor kitchen area…the other five victims [were found] on the third floor….Eight other people in the building managed to escape.

 

“Firefighters were called to the building in central New Britain at 2:45 a.m. When they arrived one minute later, they saw flames shooting from the windows and roof….they were unable to get into the building because of intense heat and flames…Firefighters worked in near-zero temperatures before bringing the fire under control by 5 a.m….” (AP. “Ten dead in Conn. tenement blaze.” The Sun, Lowell, MA, 2-17-1991, p. 2.)

 

AP, Feb 18: “New Britain, Conn. (AP) – Investigators said yesterday they had traced a ferocious fire that killed 10 people in a crowded tenement[1] to an over-heated extension cord connected to a portable heater. The extension cord ran under a living-room chair that burst into flames when the cord’s insulation melted, Fire Chief Thomas Keough said.

 

“Among the 10 people who perished in Saturday morning’s fire were six children under the age of 15, including an infant; a 17-year-old; and three adults, Keough said….” (Associated Press. “Fatal fire pinned on extension cord.” The Sun, Lowell, MA, 2-18-1991, p. 2.)

 

Sources

 

Associated Press. “Fatal fire pinned on extension cord.” The Sun, Lowell, MA, 2-18-1991, p. 2. Accessed 4-28-2016 at: http://newspaperarchive.com/us/massachusetts/lowell/lowell-sun/1991/02-18/page-3?tag

 

Associated Press. “Ten dead in Conn. tenement blaze.” The Sun, Lowell, MA, 2-17-1991, p. 2. Accessed 4-28-2016 at: http://newspaperarchive.com/us/massachusetts/lowell/lowell-sun/1991/02-17/page-382?tag

 

National Fire Protection Association. Home Fires With Ten or More Fatalities (webpage) Accessed 3-20-2016 at: http://www.nfpa.org/research/reports-and-statistics/fires-in-the-us/multiple-death-fires/homes-fires-with-ten-or-more-fatalities

 

 

[1] Described as a stone-framed triple-decker.

1991 — Feb 1, Landing plane (USAir 1493) hits SkyWest 5569 on runway, LAX, CA  —     34

 

–34  NFPA (Isner). Summary Investigation Report, Aircraft Collision and Cabin Fire… P. 1.

–34  NTSB AAR. Runway Collision of USAir Flight 1493…and Skywest Flight 5569. 1991, vi.

–34  NTSB. NTSB Identification DCA91MA018A…USAIR…Feb-01-91 at Los Angeles, CA.

–34  Notable California Aviation Disasters. “The 1990s.” Oct 23, 2008 update.

–34  Rosenker, Mark V. “Testimony of…Chairman [NTSB]…U.S. Senate, 4-19-2007.”

–34  Sturkey. Mid-Air: Accident Reports and Voice Transcripts… 2008, p. 369.

–22 of 95, USAir Flight 1493

–12 of 12, Fairchild SA-227 Metroliner

 

Narrative Information

 

NTSB AAR Executive Summary: “On February 1, 1991, at 1807 Pacific standard time, USAir flight 1493, N388US, a Boeing 737-300, collided with Skywest flight 5569, N683AV, a Fairchild Metroliner (SA-227-AC), while the USAir airplane was landing on runway 24 left at Los Angeles International Airport, Los Angeles, California. The Skywest Metroliner was positioned on the same runway, at intersection 45, awaiting clearance for takeoff. As a result of the collision, both airplanes were destroyed. All 10 passengers and 2 crewmembers aboard the Metroliner and 20 passengers and 2 crewmembers aboard the USAir airplane were fatally injured.

 

“The National Transportation Safety Board determines that the probable cause of the accident was the failure of the Los Angeles Air Traffic Facility Management to implement procedures that provided redundancy comparable to the requirements contained in the National Operational Position Standards and the failure of the FAA Air Traffic Service to provide adequate policy direction and oversight to its air traffic control facility managers. These failures created an environment in the Los Angeles Air Traffic Control tower that ultimately led to the failure of the local controller 2 (LC2) to maintain an awareness of the traffic situation, culminating in the inappropriate clearances and subsequent collision of the USAir and Skywest aircraft. Contributing to the cause of the accident was the failure of the FAA to provide effective quality assurance of the ATC system.

 

“The safety issues raised in this report include:

 

• Air traffic management and equipment at Los Angeles International Airport.
• Aircraft exterior lighting and conspicuity.
• Pilot situational awareness during takeoff and landing and operations on airport surfaces.
• Air traffic controller workload, performance, and supervision.
• Air transport accident survivability, evacuation standards and procedures, interior furnishing flammability standards, and survival devices.”

 

(NTSB. AAR. Runway Collision of USAir Flight 1493, Boeing 737 and Skywest Flight 5569 Fairchild Metroliner, Los Angeles International Airport…California, February 1, 1991. p. vi.

 

NTSB ID DCA91MA018A: “SKW5569, N683AV, had been cleared to RWY 24L, at intersection 45, to position and hold. The local controller, because of her preoccupation with another airplane, forgot she had placed SKW5569 on the runway and subsequently cleared USA1493, N388US, for landing. After the collision, the two airplanes slid off the runway into an unoccupied fire station. The tower operating procedures did not require flight progress strips to be processed through the local ground control position. Because this strip was not present, the local controller misidentified an airplane and issued a landing clearance. The technical appraisal program for air traffic controllers is not being fully utilized because of a lack of understanding by supervisors and the unavailability of appraisal histories….” (NTSB. NTSB Identification DCA91MA018A…USAIR…Feb-01-91 at Los Angeles, CA.)

 

NFPA/Isner: “….The B-737 [USAir] that was involved was configured to carry 128 people including both passengers and crew; however, only 89 people were aboard at the time of the accident…. [p. 1]

 

“The incident occurred at approximately 6:08 pm which was about ¾ hour after sunset. Skies were clear and visibility was good …and the runway lights were on….

 

“During an interview after the incident, the first officer from the B-737 stated that he first saw the Metroliner after his aircraft landed on the runway. He reported seeing the tail beacon of the smaller plane directly in front of him and his aircraft’s landing lights reflecting off of the Metroliner’s propellers. The B-737 collided with the Metroliner almost immediately thereafter. The Metroliner was caught by the B-737’s left main landing gear and was dragged along by the larger aircraft…. [p. 2]

 

“Several minutes into the incident, a fire fighter was extinguishing small fires under the B-737 when he found a propeller and aircraft engine. He brought this finding to the attention of his supervisor, and the control tower was contacted regarding the potential for a second aircraft. At approximately 6:14 pm, 6 min into the incident, the tower indicated that a Metroliner might be involved…. [p. 4.]

 

“The LAX incident showed that time was a critical element affecting the survival of people during this aircraft cabin fire [USAir]. Fire entered the B-737 passenger cabin early in the incident and ignited the interior finish materials. Several exits on the B-737 were not usable, yet 40-50 survivors were able to escape in about one minute. In addition, twenty of the twenty-two victims on the B-737 were able to move from their seats toward exits before being overwhelmed by the rapidly growing fire and the combustion products that quickly filled the cabin.

 

“….Only 6 to 10 people were able to escape from the B-737 during the fire suppression and rescue operations. The rest of the people in the aircraft either escaped before the arrival of ARFF crews or were victims.

 

“Since 1965 the NFPA Fire Investigations Division has documented eleven aircraft cabin fires, and several have resulted in the deaths of many passengers. The past incidents, as well as this most recent incident at LAX, show that interior cabin fires are an immediate threat to occupants and are difficult fires to suppress unless suppression is initiated during the incipient stage. [p.5}

 

Notable CA Air Disasters: “Date / Time: Friday, February 1, 1991 / 6:07 p.m.

“Operator / Flight No.: USAir & SkyWest Airlines / Flights 1493 & 5569

“Location: Los AngelesInternationalAirport

 

“Details and Probable Cause:   Collision between aircraft.   Originating at Syracuse, New York, USAir Flight 1493, a Boeing B737-300 jetliner (N388US), made stops at Washington, D.C., and Columbus, Ohio.

 

“Inbound to Los Angeles International Airport from Columbus and carrying 83 passengers and a crew of six, the jetliner began its final approach and was cleared for a landing on Runway 24L at LAX.

 

“At the same time, SkyWest Airlines Flight 5569, a twin-engine Fairchild-Swearingen SA.227AC Metro III (N683AV), a commuter flight bound for Palmdale with 10 passengers and two crew members on board, was cleared by LAX air traffic control (ATC) to taxi into its takeoff position and hold on the same runway.

 

“The descending USAir 737, upon touchdown on Runway 24L, smashed into the stationary SkyWest Metro III and the two mangled planes, fused together, slid down the runway, crashed into an unoccupied fire station, and burst into flames.

 

“Sixty-three passengers and four crew members aboard the USAir 737 were able to scramble from the burning jetliner and reach safety, although 30 were injured, 13 of them seriously.

 

“However, 20 fellow passengers and two crew members on the USAir 737, and all 12 persons aboard the crushed SkyWest Metro III, were killed.

 

“An error by the air traffic controller, in positioning both planes in a collision situation, as well as inadequate policies and procedures at the Los Angeles air traffic control tower, were the causes named in the disaster.

 

“Fatalities: 34 — 22 on the USAir 737; all 12 aboard the SkyWest Metro III.”

 

(Notable California Aviation Disasters.  “The 1990s.” Oct 23, 2008 update.)

 

Sources

 

National Fire Protection Association (Michael S. Isner). Summary Investigation Report, Aircraft Collision and Cabin Fire, Los Angeles International Airport, February 1, 1991.  Quincy, MA: NFPA, no date, 6 pages. Accessed 4-29-2016 at: http://www.nfpa.org/research/fire-investigations/transportation

 

National Transportation Safety Board. Aircraft Accident Report. Runway Collision of USAir Flight 1493, Boeing 737 and Skywest Flight 5569 Fairchild Metroliner, Los Angeles International Airport, Los Angeles, California, February 1, 1991 (NTSB/AAR-91/08). Washington, DC: NTSB, adopted 10-22-1991, Notation 5461A. Accessed 4-29-2016 at: https://www.fss.aero/accident-reports/dvdfiles/US/1991-02-01-US.pdf

 

National Transportation Safety Board. NTSB Identification DCA91MA018A…USAIR…Feb-01-91 at Los Angeles, CA.  At:  http://www.lafire.com/famous_fires/MajorIncident-index.htm

 

Notable California Aviation Disasters. “The 1990s.” 10-23-2008 update. Accessed 10-20-2009 at: http://www.jaydeebee1.com/crash90s.html > Checked URL on 4-29-2016; was inoperable.

 

Rosenker, Mark V. “Testimony of Mark V. Rosenker, Chairman National Transportation Safety Board Before The Committee on Appropriations, Subcommittee on Transportation, HUD, and Related Agencies, U.S. Senate, 4-19-2007.” Washington, DC: NTSB. Accessed at:  http://www.ntsb.gov/speeches/rosenker/mvr070419.htm

 

Sturkey, Marion F. Mid-Air: Accident Reports and Voice Transcripts from Military and Airline Mid-Air Collisions. Plum Branch, SC: Heritage Press International, 2008.

 

 

—  62  Hinman, et al. “Acute Measles Mortality…[US], 1987-2002.” JID, 189, 2004, S69-S77.[1]

—  38  Blanchard tally from State breakouts below.

—  36  Atkinson, William L., et al. “Measles Surveillance – US, 1991.” MMWR, 41/SS-6, p. 7.

—  35  Atkinson, William L., et al. “Measles Surveillance – US, 1991.” MMWR, 41/SS-6, p. 2

–~32  CDC NCHS[2] multiple-cause Mortality database (1987-1999), in Hinman Figure 3.[3]

—  30  CDC Nat. Immunization Pgm. Surveillance Database (1987-2002), in Hinman Figure 3.[4]

 

Arizona                      (  1)

— 1  State. Atkinson, W. L., et al. “Measles Surveillance – US, 1991.” MMWR, 41/SS-6, p. 7.

 

California                   (  8)

— 8  State. Atkinson, W. L., et al. “Measles Surveillance – US, 1991.” MMWR, 41/SS-6, p. 7.

— 2  Orange County, early March. Girl, 2, male, 32.[5]

 

Florida                        (  1)

— 1  State. Atkinson, W. L., et al. “Measles Surveillance – US, 1991.” MMWR, 41/SS-6, p. 7.

 

Illinois                         (  ?)

— 0  11 cases by Mar 26. Daily Herald, IL. “Chicago staves off measles epidemic.” 3-26-1991, 4.[6]

 

New Jersey                 (  3)

— 3  State. Atkinson, W. L., et al. “Measles Surveillance – US, 1991.” MMWR, 41/SS-6, p. 7.

 

New Mexico               (  1)

— 1  Navajo Reservation, late April. Infant, less than 6-months old.[7]

 

New York                   (15)

–15  State. Atkinson, W. L., et al. “Measles Surveillance – US, 1991.” MMWR, 41/SS-6, p. 7.

–14  New York Times, by Sep 28. “Immunizations are cost-effective” (Editorial). 9-28-1991.

–13  NYC. NYC Dept. of Health, in: Davis, et al. “Reporting Efficiency…” AJPH, July 1993, 1011.

–11  NYC, by April 4. Schanberg, Sidney. “Kinder, gentler…meaner and harder.” 4-4-1991.

—  9  NYC. CDC. “Measles Outbreak – New York City, 1990-1991.” MMWR, 40/18, 5-10-1991

 

Pennsylvania              (  9)

— 9  AP, Atlanta. “Measles make resurgence.” Daily Times, Farmington, NM, 5-29-1991, p. 2.

— 9  Offit, P. A. MD. The Philadelphia Measles Outbreak; Lessons From the Past.[8]

— 8  State. Atkinson, W. L., et al. “Measles Surveillance – US, 1991.” MMWR, 41/SS-6, p. 7.

— 5  State by Feb 13. AP. “State Rep. DeWeese calls for funding of child vaccinations.” 2-13-91.[9]

— 1  Chester Co. by Feb 13. Daily News, Huntingdon, PA. “Measles Epidemic.” 2-13-1991, 8.

— 6  Philadelphia. Offit, P. A. MD. The Philadelphia Measles Outbreak; Lessons From the Past.

–1  Feb 7. Girl, 9, member of Faith Tabernacle church, north Philadelphia.[10]

–1  Feb 10. Girl, 10, member of Faith Tabernacle church, north Philadelphia. Offit #15.[11]

–1  Feb 14. Girl, 14, member of Faith Tabernacle church, north Philadelphia. Offit #20.

–1  Feb 15. Girl, 5, north-central Philly, not a member of Faith Tabernacle church. #25.

–1  Feb 15. Girl, 13, sister of previous fatality; no doctor had seen either sister. #27.[12]

–1  March 8. Boy, 19-mo., “whose family belongs to a church that shuns medical care.”[13]

–1  March 9. Child, member of Faith Tabernacle church, north Philadelphia. Offit #62.[14]

— 5  Philadelphia. NYT. “Measles and Faith Combine in 5 Deaths in Philadelphia.” 2-16-1991.

— 1  Philadelphia, ~Jan 17. Boy, 18-months. Associated Press, Philadelphia, 1-17-1991.[15]

 

Narrative Information

 

CDC: “In March 1990, a large measles outbreak began in New York City. Through December 1990, approximately 2500 cases and eight measles-associated deaths were reported. However, since January 1991, transmission has increased; through May 7, more than 2000 cases and nine deaths were reported to the New York City Department of Health (NYCDH) in 1991.

 

“Preliminary data are available for the first 2084 cases reported in 1991. Of these patients, 1383 (66%) were less than 5 years of age, of whom 735 (53%) were less than 12 months of age. Most cases have occurred among black and Hispanic children; more than 70% of cases have been reported from the Bronx and Brooklyn. Transmission has also occurred among prisoners in the city jail system and among both patients and medical staff in some local hospitals.

 

“To control the outbreak, NYCDH officials have recommended an additional dose of measles vaccine for 6- to 11-month-old children, have made walk-in immunization services available, are vaccinating eligible children in emergency rooms, and have mounted a citywide multimedia “stop measles” education and information campaign. In addition, New York state health officials have implemented emergency regulations that require health-care workers to demonstrate proof of measles immunity, have integrated immunization services with certification for the Special Supplemental Program for Women, Infants, and Children, and are implementing requirements for hospitals and licensed health-care facilities to offer immunization to all children served. Reported by: K Ong, MD, S Friedman, MD, A Nazitto, D Hurley, New York City Dept of Health; LF Novick, MD, GS Birkhead, MD, DL Morse, MD, State Epidemiologist, New York State Dept of Health. Div of Immunization, Center for Prevention Svcs, CDC.

 

“Editorial Note: Characteristics of the current measles outbreak in New York City are similar to recent outbreaks in other large metropolitan areas of the United States, including Chicago, Houston, and Los Angeles.[16]

Sources

 

Associated Press, Philadelphia. “Child dies from measles.” Daily Times, Farmington, NM, 3-8-1991, p. 1. Accessed 5-6-2016 at: http://newspaperarchive.com/us/new-mexico/farmington/farmington-daily-times/1991/03-08?tag

 

Associated Press, Atlanta. “Measles make resurgence.” Daily Times, Farmington, NM, 5-29-1991, p. 2. Accessed 5-7-2016 at: http://newspaperarchive.com/us/new-mexico/farmington/farmington-daily-times/1991/05-29/page-2?tag

 

Associated Press, Philadelphia. “Measles on rise in state; child’s death upsets officials.” Indiana Gazette, Indiana, PA, 1-17-1991, p. 11. Accessed 5-6-2016 at: http://newspaperarchive.com/us/pennsylvania/indiana/indiana-gazette/1991/01-17/page-10?tag

 

Associated Press, Philadelphia. “Measles outbreak leaves five dead.” New Castle News, PA. 2-16-1991, p. 2. Accessed 5-6-2016 at: http://newspaperarchive.com/us/pennsylvania/new-castle/new-castle-news/1991/02-16/page-2?tag

 

Associated Press, Shiprock, NM. “Navajo infant dies from measles.” Roswell Daily Record, NM, 4-30-1991, 13. Accessed 5-7-2016 at: http://newspaperarchive.com/us/new-mexico/roswell/roswell-daily-record/1991/04-30/page-13?tag

 

Associated Press, Philadelphia. “School closed after 2 kids die of measles.” Chronicle-Telegram, Elyria, OH. 2-12-1991, p. 3. Accessed 5-6-2016 at: http://newspaperarchive.com/us/ohio/elyria/elyria-chronicle-telegram/1991/02-12/page-3?tag

 

Associated Press (Anne McGraw). “State Rep. DeWeese calls for funding of child vaccinations.” Leader-Times, Kittanning, PA, 2-13-1991, p. 3. Accessed 5-6-2016 at: http://newspaperarchive.com/us/pennsylvania/kittanning/kittanning-leader-times/1991/02-13/page-3?tag

 

Atkinson, William L., et al. “Measles Surveillance – United States, 1991.” MMWR (Morbidity and Mortality Weekly Report) CDC Surveillance Summaries, Vol. 41, No. SS-6, pp. 1-12. Atlanta, GA: Centers for Disease Control and Prevention, 11-20-1992. Accessed 5-5-2016 at: https://books.google.com/books?id=lnCt01e4gKcC&printsec=frontcover#v=onepage&q&f=false

 

Centers for Disease Control and Prevention. “Measles Outbreak – New York City, 1990-1991.” MMWR (Morbidity and Mortality Weekly Report), Vol. 40, No. 18, 5-10-1991, pp. 305-306. Accessed 5-2-2016 at: http://www.cdc.gov/mmwr/preview/mmwrhtml/00001980.htm

 

Daily News, Huntingdon, PA. “Measles Death” (con’t from p.1), 2-13-1991, p. 8. Accessed 5-6-2016 at: http://newspaperarchive.com/us/pennsylvania/huntingdon/huntingdon-daily-news/1991/02-13/page-15?tag

 

Daily News, Huntingdon, PA. “Measles Epidemic” (con’t from p.1), 2-13-1991, p. 8. Accessed 5-6-2016 at: http://newspaperarchive.com/us/pennsylvania/huntingdon/huntingdon-daily-news/1991/02-13/page-15?tag

 

Davis, Susan F., et al. “Reporting Efficiency during a Measles Outbreak in New York City, 1991.” American Journal of Public Health, July 1993, pp. 1011-1015. Accessed 5-9-2016 at: http://ajph.aphapublications.org/doi/pdf/10.2105/AJPH.83.7.1011

 

Farmington Daily Times, NM “Measles claims first life.” 4-29-1991. Accessed 5-7-2016 at: http://newspaperarchive.com/tags/measles?

 

Hinman, Alan R., et al. “Acute Measles Mortality in the United States, 1987-2002.” Journal of Infectious Diseases, Vol. 189 (Supplement 1), 2004, pp. S69-S77. Accessed 5-2-2016 at: http://jid.oxfordjournals.org/content/189/Supplement_1/S69.long

 

New York Times. “Immunizations are cost-effective” (Editorial). Reprinted in Leader-Telegram, Eau Claire, WI. 9-28-1991. 8A. Accessed 5-7-2016 at: http://newspaperarchive.com/us/wisconsin/eau-claire/eau-claire-leader-telegram/1991/09-28/page-8?tag

 

New York Times. “Measles and Faith Combine in 5 Deaths in Philadelphia.” 2-16-1991. Accessed 5-3-2016 at: http://www.nytimes.com/1991/02/16/us/measles-and-faith-combine-in-5-deaths-in-philadelphia.html?pagewanted=all

 

Orange Country Register (Susan Peterson), Santa Ana, CA. “Resurgent measles fatal for two in OC.” 3-15-1991, p. 1. Accessed 5-6-2016 at: http://newspaperarchive.com/us/california/santa-ana/santa-ana-orange-county-register/1991/03-15/

 

Schanberg, Sidney. “Kinder, gentler…meaner and harder.” Cedar Rapids Gazette, IA, 4-4-1991, 4A. Accessed 5-7-2016 at: http://newspaperarchive.com/us/iowa/cedar-rapids/cedar-rapids-gazette/1991/07-04/page-4?tag

 

Additional Reading

 

Dales, Loring G., et al. “Measles Epidemic From Failure to Immunize.” Western Journal of Medicine, Vol. 159, No. 4, October 1993, pp. 455-464. Accessed 5-9-2016 at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1022280/pdf/westjmed00074-0031.pdf

 

[1] Hinman, et al., utilize a “capture-recapture” methodology, they view as necessary in order to correct for inefficiencies in data collection employed by the NCHS and NIP which understate measles fatalities. This methodology is briefly discussed and sources referenced in their article. We do not use this number as our estimate in that it is based on a methodology, and we choose to use the number of reported deaths we have seen in sources.

[2] National Center for Health Statistics.

[3] “Acute measles deaths, by reporting source, United States, 1987-2001.” Notes: data derived from the National Center for Health Statistics underlying-cause mortality database. We write “approximately” in that the “number of deaths” is represented by a bar – in this case extending slightly above the line representing 30 deaths.

[4] “Acute measles deaths, by reporting source, United States, 1987-2001.” Notes: data derived from the National Center for Health Statistics underlying-cause mortality database.

[5] Orange Country Register (Susan Peterson), CA. “Resurgent measles fatal for two in OC.” 3-15-1991, p. 1.

[6] “During the first nine weeks of this year, 529 cases of measles were reported to the…[CDC] from 18 different regions across the country. But only 11 cases have been reported in Illinois so far, state health officials said.”

[7] Associated Press, Shiprock, NM. “Navajo infant dies from measles.” Roswell Daily Record, NM, 4-30-1991, 13. Notes: “In the past two weeks, the number of measles cases on the reservation has increased from 236 to 309, Milligan said [Carol Milligan, Indian Health Service consultant]. Of the 309 cases, 266 have been in Arizona and 43 have been in New Mexico, Milligan said.”

[8] Dr. Offit writes that as of December 3, 1992. “Among church members [Faith Tabernacle], 486 people infected and six died. Among non-church members, 938 people infected and three died. All nine deaths were in children. Attack rate in church members about 1,000-fold greater than in the surrounding community.” Slide 67.

[9] Cites State House Majority Leader H. William DeWeese to effect that “So far this year, there have been five deaths from measles, four in Philadelphia.”

[10] Offit, Paul A. (Children’s Hosp. of Philly). The Philadelphia Measles Outbreak; Lessons From the Past. Slide 15.

[11] A news article notes that after this second death “The city closed a school run by a religious group that rejects medical care after an outbreak of measles that has hilled two girls and may have infected 90 other students.” (AP, Philadelphia. “School closed after 2 kids die of measles.” Chronicle-Telegram, Elyria, OH. 2-12-1991, p. 3.) Another quotes the father, the day after his daughter’s death, to effect that immunization would have been “Interference with God’s will.” (Daily News, Huntingdon, PA. “Measles Death” (con’t from p.1), 2-13-1991, p. 8.

[12] Offit: “In the U.S., about 1 in 1,000 infected children die from measles. In some developing world countries, can reach as high as 1 in 300. In Philadelphia, 4 of 150 children with measles who attend Faith Tabernacle are dead, a rate of about 1 in 35.” (slide 28) Next slide: the CDC sent team to investigate: “The CDC’s Bill Atkinson finds that the measles deaths nave nothing to do with the circulating strain and everything to do with the parents. Children are dying because they aren’t getting intravenous fluids for severe dehydration or oxygen for pneumonia.” (slide 29)

[13] AP, Philly. “Child dies from measles.” Daily Times, Farmington, NM, 3-8-1991, p. 1. Writes child “died today after being brought to the hospital as many as 10 days after contracting measles, a hospital spokeswoman said.”

[14] We believe this refers to March 8 death.

[15] AP. “Measles on rise in state; child’s death upsets officials.” Indiana Gazette, Indiana, PA, 1-17-1991, p. 11.

[16] CDC. Update: measles outbreak-Chicago, 1989. MMWR 1990;39:317-9,325-6; CDC. Measles-United States, 1989 and first 20 weeks 1990. MMWR 1990;39:353-5,361-3; and, CDC. Measles-Los Angeles County, California, 1988. MMWR 1989;38:49-52,57.

–1,137  CDC Wonder. Compressed Mortality File 1979-1998. ICD-9 code[1] 487[2] influenza.

 

Alabama                     21        0.51     (Yellow highlight denotes higher than average death rate.)

Arkansas                     11        0.46

California                 109        0.36

Colorado                     16        0.47

Florida                        26        0.19

Georgia                       17        0.26

Idaho                           14        1.34

Illinois                        34        0.29

Indiana                                    29        0.52

Iowa                            43        1.54

Kansas                        30        1.20

Kentucky                    41        1.10

Maine                          11        0.89

Massachusetts            22        0.37

Michigan                    48        0.51

Minnesota                   56        1.26

Mississippi                 16        0.62

Missouri                     38        0.73

Nebraska                     38        2.38

New Jersey                 15        0.19

New York                   40        0.22

North Carolina            29        0.43

North Dakota              11        1.73

Ohio                            70        0.64

Oklahoma                   14        0.44

Oregon                                    15        0.51

Pennsylvania              50        0.42

Tennessee                   26        0.52

Texas                          51        0.29

Virginia                      24        0.38

Washington                28        0.56

West Virginia             14        0.78

Wisconsin                   40        0.81     US population size utilized: 253,088,068

 

States and DC not shown indicate that there were fewer than 10 deaths. Puerto Rico not included.

 

Influenza (CDC): “The flu is a contagious respiratory illness caused by influenza viruses that infect the nose, throat, and sometimes the lungs. It can cause mild to severe illness, and at times can lead to death. The best way to prevent the flu is by getting a flu vaccine each year.” (CDC. Influenza (Flu). “Key Facts About Influenza (Flu).” 10-3-2017 update.

 

Sources

 

Centers for Disease Control and Prevention, National Center for Health Statistics. Compressed Mortality File 1979-1998 on CDC Wonder Online Database, 2003. ICD-9 code 487.0, Influenza, 1991. Accessed 1-20-2019 at: https://wonder.cdc.gov

 

Centers for Disease Control and Prevention. Influenza (Flu). “Key Facts About Influenza (Flu).” 10-3-2017 update. Accessed 6-17-2018 at: https://www.cdc.gov/flu/keyfacts.htm

 

 

 

[1] ICD-9 is the 9^th revision of the International Statistical Classification of Diseases and Related Health Problems, a medical classification list by the World Health Organization.

[2] 487.0 (influenza with pneumonia), 487.1 (with other respiratory manifestations), 487.8 (with other manifestations).