Aviation Accident Summaries

Aviation Accident Summary CHI01FA083

Beaver Island, MI, USA

Aircraft #1

N318DH

Swearingen SA227-AT

Analysis

The airplane was on an on-demand air-taxi flight operating under 14 CFR Part 135 and was destroyed when it impacted trees and terrain while circling to land during a non-precision instrument approach at night. The airplane came to rest 1.74 nautical miles and 226 degrees magnetic from the intended airport. A weather briefing was obtained and instrument meteorological conditions were present along the route of flight at the time of the briefing. Weather conditions for the two reporting stations closest to the destionation were obtained by the airplane prior to executing the approach. The weather reports listed ceilings and visibilities as 400 to 500 feet overcast and 5 to 7 statute miles. The airport elevation is 669 feet and the minimum descent altitude for the approach was listed as 1,240 feet. There was no weather reporting station at the destination airport at the time of the accident. According to the operators General Operations Manual, the pilot was responsible for the dispatch of the airplane including flight planning, and confirming departure, en-route, arrival and terminal operations compliance. The manual also states, "For airports without weather reporting, the area forecast and reports from airports in the vicinity must indicate that the weather conditions will be VFR [visual flight rules] at the ETA so as to allow the aircraft to terminate the IFR operations and land under VFR. (Note: a visual approach is not approved without weather reporting)." For 14 CFR Part 135 instrument flight operations conducted at an airport, federal regulations require weather observations at that airport. Furthermore, the regulations state that, for 14 CFR Part 135 operations, an instrument approach cannot be initiated unless approved weather information is available at the airport where the instrument approach is located, and the weather information indicates that the weather conditions are at or above the authorized minimums for the approach procedure. The commercial pilot held a type rating for the accident airplane. The right seat occupant was a commercial pilot employed by the operator and did not hold an appropriate type rating for the accident airplane. The pitch trim selector switch was found set to the co-pilot side. The regulations state that 14 CFR Part 135 operators cannot use the services of any person as an airman unless that person is appropriately qualified for the operation for which the person is to be used. The circling approach was made over primarily unlit land and water. An FAA publication states that during night operations, "Distance may be deceptive at night due to limited lighting conditions. A lack of intervening references on the ground and the inability of the pilot to compare the size and location of different ground objects cause this. This also applies to the estimation of altitude and speed. Consequently, more dependence must be placed on flight instruments, particularly the altimeter and the airspeed indicator." No anomalies were found with respect to the airframe, engines, or systems that could be associated with a pre-impact condition.

Factual Information

HISTORY OF FLIGHT On February 8, 2001, about 1920 eastern standard time (all times herein are est), a Swearingen SA227-AT, N318DH, operated by Northern Illinois Flight Center (NIFC) and piloted by a commercial pilot, was destroyed when it impacted trees and terrain 1.74 nautical miles and 226 degrees magnetic from the Beaver Island Airport (SJX), Beaver Island, Michigan. The 14 CFR Part 135 on-demand air-taxi flight was operating in instrument meteorological conditions and was on an instrument flight rules (IFR) flight plan. The pilot and pilot rated front seat occupant were fatally injured. Two passengers received minor injuries and two passengers received serious injuries. There were a total of six persons on board the aircraft. The flight departed the Chicago Midway Airport (MDW), Chicago, Illinois, at 1810, with SJX as the intended destination. According to a certified re-recording from the Kankakee, Illinois, Automated Flight Service Station, a call was received about 1738 to file an IFR flight plan for the accident airplane. During the call, the flight service station specialist issued the current weather conditions for the two reporting stations closest to the destination were given. The weather at Charlevoix, Michigan was given as: Wind 110 at 9 knots; Visibility 10 statute miles; Ceiling 1,100 feet overcast; Temperature 1 degree Celsius; Dew point -1 degree Celsius. The weather at Pellston, Michigan was given as: Wind 110 at 10 knots; Visibility 8 statute miles; Ceiling 900 feet overcast; Temperature 0 degrees Celsius; Dew point -1 degree Celsius. The airplane was cleared for takeoff from MDW at 1810. The airplane proceeded to fly to SJX. At 1841, the pilot established communications with the Minneapolis Air Route Traffic Control Center (ARTCC). At 1908, the controller cleared the airplane for the instrument approach to SJX. Aircraft radar track data was obtained from 1833:58 to 1919:53. The last recorded radar return was at 1919:53. The radar data was plotted on the instrument approach procedure chart and on a sectional aeronautical chart using commercial software. These plots are appended to this report. The last recorded radar position was at 45 degrees, 41 minutes, 03 seconds north latitude and 85 degrees, 32 minutes, 12 seconds west longitude. The last radar position is about 1.3 nautical miles and 110 degrees magnetic from SJX. The chief pilot for the airplane operator stated in a telephone conversation that the pilot of the accident airplane was informed that the flight was only to be executed if visual meteorological weather conditions existed at the destination airport. PERSONNEL INFORMATION The pilot held commercial pilot and flight instructor certificates with airplane multiengine land, airplane single engine land, and instrument airplane ratings. The pilot was type-rated in BE-1900 and SA227 aircraft. The pilot held a second-class aviation medical certificate issued on August 17, 2000. The medical certificate listed the restriction, "Must wear corrective lenses." A written report submitted by the airplane operator states that the pilot had accumulated 6,500 hours total flight time, of which 3,500 hours were in multi-engine airplanes and 250 hours in the same make and model as the accident airplane. The pilot-rated front seat occupant held a commercial pilot certificate with airplane multiengine land, airplane single engine land, and instrument airplane ratings. He also held a flight instructor certificate with an airplane single engine rating. He was not type-rated in the SA227. He held a first-class aviation medical certificate issued on November 14, 2000. The medical certificate listed the restriction, "Must wear corrective lenses." A written report submitted by the airplane operator states that the pilot-rated front seat occupant had accumulated 800 hours total flight time, of which 10 hours were in multi-engine airplanes. In a telephone conversation, the chief pilot for the operator stated that the front seat occupant was not a required crew-member and was on the airplane for observation purposes only. AIRCRAFT INFORMATION The airplane was a Swearingen model SA227-AT, serial number AT469, manufactured in 1981. The SA227-AT is a twin-engine turboprop aircraft. The fuselage is a semi-monocoque structure. The interior of the airplane was configured to accommodate 12 passengers in addition to the two crew stations. Two Honeywell model TPE331-11U-611G engines, each producing 1,000 shaft-horsepower, powered the airplane. Maintenance records supplied by the operator state that the airplane had accumulated 7,280.5 hours of flight time. The maintenance records further state that the right and left engines had accumulated 4,222.2 and 4,359.5 hours, respectively, since overhaul. The NIFC Operations Specifications state that the operator was authorized to use the airplane and its autopilot system in lieu of a second-in-command pilot, provided that the pilot has satisfactorily completed the proficiency check requirements, and the autopilot system is operational. Documents regarding the seating configuration of the airplane were provided to the NTSB. In a letter to NIFC, a representative of Fairchild Aerospace, the airplane type certificate holder, stated, "We, Fairchild Aerospace, have no technical objections with your plan for an Alternate Configuration B: 9 passenger with couch placarded, not to be occupied for take off and landing." In a letter to the FAA, NIFC stated, "The aircraft will be configured for 9 passengers in accordance with the letter from Fairchild." A letter from the FAA to NIFC stated, "This aircraft must be operated in a factory authorized configuration of 9 passenger seats or less." METEOROLOGICAL INFORMATION At the time of the accident, SJX did not have a weather reporting station. According to the instrument approach procedure chart for the NDB or GPS runway 27 approach at SJX, the Pellston altimeter setting is to be used for the approach. The Pellston, Michigan, surface weather observation station, KPLN, located about 100 degrees true and 35 nautical miles from the accident site recorded the following observations: Time-1854; type-METAR; wind-130 degrees at 12 knots; visibility-5 miles; present weather-mist; sky condition-overcast 500 feet; temperature-00 degree Celsius; dew point-00 degree Celsius; altimeter setting-30.09 inches hg. Time-1954; type-METAR; wind-110 degrees at 11 knots; visibility-5 miles; present weather-mist; sky condition-overcast 500 feet; temperature-00 degree Celsius; dew point-00 degree Celsius; altimeter setting-30.01 inches hg. The Mackinac Island, Michigan, surface weather observation station, KMCD, located about 075 degrees true and 42 nautical miles from the accident site recorded the following observations: Time-1855; type-METAR; wind-120 degrees at 4 knots gusting 14 knots; visibility-4 miles; present weather-mist; sky condition-overcast 300 feet; temperature-00 degree Celsius; dew point-00 degree Celsius; altimeter setting-30.08 inches hg. Time-1955; type-METAR; wind-130 degrees at 10 knots gusting 21 knots wind 110 degrees variable 190 degrees; visibility-10 miles; present weather-none; sky condition-overcast 500 feet; temperature-00 degree Celsius; dew point-minus 01 degree Celsius; altimeter setting-30.00 inches hg. The Newberry, Michigan, surface weather observation station, KERY, located about 039 degrees true and 39 nautical miles from the accident site recorded the following observations: Time-1855; type-METAR; wind-110 degrees at 10 knots gusting 16 knots; visibility-2 1/2 miles; present weather-mist; sky condition-overcast 400 feet; temperature-minus 03 degree Celsius; dew point-minus 05 degree Celsius; altimeter setting-30.07 inches hg. Time-1955; type-METAR; wind-110 degrees at 10 knots; visibility-2 miles; present weather-mist; sky condition-overcast 400 feet; temperature-minus 03 degree Celsius; dew point-minus 04 degree Celsius; altimeter setting- 30.00 inches hg. Additional meteorological information is appended to this report. COMMUNICATIONS The airplane was in radio communication with the Minneapolis ARTCC prior to the accident. The following are excerpts from the transcript of those communications. 1841:58 N318DH minneapolis center merlin three one eight delta hotel with you flight level one nine zero direct to beaver island 1842:04 ZMP02 november three one eight delta hotel minneapolis center roger 1846:30 ZMP02 november three one eight delta hotel change to my frequency one three two point niner 1846:34 N318DH one three two point niner your frequency 1846:40 N318DH and center merlin three one eight delta hotel with you 1846:47 ZMP02 november eight delta hotel roger 1851:18 N318DH minneapolis center merlin three one eight delta hotel we would like ah lower altitude if we get it 1851:23 ZMP02 november eight delta hotel pilots discretion maintain seven thousand pellston altimeter three zero zero niner 1851:29 N318DH pilots discretion to seven thousand three one eight delta hotel 1853:36 ZMP02 ah metro eight delta hotel at beaver island there i got ah one notam for um a lets see here it's for thin loose snow on runway that's it 1853:46 N318DH okay thank you very much eight delta hotel 1859:00 ZMP02 november three one eight delta hotel descend at pilots discretion maintain three thousand 1859:05 N318DH pilots discretion to three thousand eight delta hotel 1900:49 N318DH and eight delta hotel do you have any weather here at beaver island 1900:55 ZMP02 calling center go ahead 1900:59 N318DH and center this is three one eight delta hotel do you have any ah nearest weather for beaver island 1901:04 ZMP02 i'll get right back with you here sir it will be just a minute 1902:37 ZMP02 and three one eight delta hotel i got schoolcraft weather if you would like it 1902:40 N318DH (unintelligible) 1902:42 ZMP02 yup twenty three thirty five observation at schoolcraft off the automated winds are one one zero at one two gusts to one seven visibility seven miles at a ceiling four hundred overcast temperature minus one dew point minus one altimeter three zero zero four 1902:58 N318DH all right thank you eight delta hotel 1904:31 N318DH and center this is merlin three one eight delta hotel can i get the pellston weather please 1904:37 ZMP02 three one eight delta hotel pellston ah two three five four observation off the automated winds three ah one three zero at one two visibility five miles and mist ceilings are five hundred overcast temperature zero dew point zero altimeter three zero zero niner 1904:53 N318DH ah roger three one eight delta hotel thanks 1908:09 ZMP02 three one eight delta hotel cleared for approach beaver island maintain at or above ah two thousand ah five hundred until established on a segment of the approach 1908:18 N318DH okay maintain two thousand five hundred established cleared for approach eight delta hotel 1908:22 ZMP02 eight delta hotel affirmative change to advisory approved your arrival or cancellation you can attempt on one thirty four six with cancel otherwise it will be ah arrival with flight service 1908:32 N318DH all right we will try one thirty four six then we will switch to advisory The Minneapolis ARTCC received no further communications from the accident airplane. AIRPORT INFORMATION The SJX airport has a 4,000 foot by 50 foot paved asphalt runway (runway 09/27), and two intersecting turf runways. The turf runways are listed in the Airport/Facility Directory as being closed between November and April and when the runways are snow covered. The airport is located on the western edge of Beaver Island, Michigan. The western shore of the island is about 1 mile from the departure end of runway 27. Heavily wooded areas are located to the south and west of the airport. The terrain south and west of the airport is primarily unlit. The only instrument approach listed for the SJX airport is the NDB or GPS RWY 27 approach. The instrument approach procedure lists a minimum descent altitude of 1,240 feet MSL for both the straight-in runway 27 and circling approaches. The missed approach procedure is listed as "Climb to 2400, then right turn direct SJX NDB and hold." The airport elevation at SJX is 669 feet MSL. WRECKAGE AND IMPACT INFORMATION The main wreckage was located in a densely wooded area at a GPS location of 45 degrees 40.277 minutes north latitude and 85 degrees 35.785 minutes west longitude. The first impact point was about 365 feet and 335 degrees magnetic from the main wreckage. All components of the aircraft were located between the first impact point and the main wreckage. The main wreckage site consisted of the entire fuselage and the wings from a point just outboard of the right engine nacelle across the centerline to a point about 9 feet from the left wingtip. The wing structure had separated from the fuselage. The fuselage was oriented on an approximately 155 degree heading and was resting inverted. The forward fuselage was separated from the remainder of the fuselage at a point approximately even with the wing leading edge. The fuselage forward of this point was crushed. The wing center section was lying atop the fuselage and was upright facing approximately opposite of the fuselage orientation. The landing gear was found in the down and locked position. An odor consistent with aviation jet fuel was noted around the accident site. A fluid consistent with jet fuel was leaking from the remains of the left wing fuel tank. Both engines and propellers were found in the immediate area of the main wreckage. The control system was examined at the accident site. The right rudder cable was found to have a break in the area near the wing leading edge. The left rudder cable had a break in the wing carry-thru area. Both breaks exhibited signatures consistent with overload failure. The elevator cables were found intact except for a single break in the down elevator cable. The break exhibited signatures consistent with overload failure. The aileron cables were broken in the wing carry-thru area and exhibited signatures consistent with overload failure. The pushrods from the rudder/aileron interconnect assembly were found broken about 6 inches from the bellcrank. The breaks in both pushrods exhibited signatures consistent with overload and bending. The examination of the cockpit revealed that the altitude alert was set for 1,100 feet msl, and the pitch trim selector switch was found set to the co-pilot side. The airframe manufacturer's report of the airframe examination is appended to this report. No anomalies were found with respect to the airframe tha

Probable Cause and Findings

The flightcrew not maintaining altitude/clearance during the circling instrument approach. Factors were the pilot in command initiating the flight without proper weather reporting facilities at the destination, the flightcrew not flying to an alternate destination, the flightcrew not following company and FAA procedures/directives, the lack of certification of the second pilot, the operator not following company and FAA procedures/directives, and the dark night and the low ceiling.

 

Source: NTSB Aviation Accident Database

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