Aviation Accident Summaries

Aviation Accident Summary MIA02FA037

Bessemer, AL, USA

Aircraft #1

N499BA

Cessna 208B

Analysis

The flight departed from Little Rock, Arkansas, about 2356 cst, and approximately 49 minutes after takeoff, the FAA approved un-augmented Automated Weather Observing System (AWOS-3) installed at the destination airport began reporting the visibility as 1/4 statute mile; the visibility continued to be reported as that value for several hours after the accident. Title 14 CFR Part 135.225 indicates no pilot may begin an instrument approach procedure to an airport with an approved weather reporting facility unless the latest weather report issued by that weather reporting facility indicates that weather conditions are at or above the authorized IFR landing minimums for that airport. The listed minimums for the ILS approach to runway 05 was in part 3/4 mile visibility. A METAR taken at the destination airport approximately 2 minutes after the accident indicated overcast clouds existed at 100 feet, the temperature and dew point were 4 and 2 degrees Celsius, respectively, and the altimeter setting was 30.16 inHg. No precipitation was present across Arkansas, Mississippi, or Alabama, and no radar echoes were noted along the accident airplane's route of flight. The freezing level near the departure and destination airports at the nominal time of 0600 (4 hours 17 minutes after the accident) was 12000 and 14,500 feet mean sea level, respectively. A witness at the airport reported the fog was the thickest he had seen since working at the airport for the previous year. The flight was cleared for an ILS approach to runway 05, and the pilot was advised frequency change was approved. The witness waiting at the airport reported hearing a sound he associated with a shotgun report. Radar data indicated that between 0138:47, and 0142:11, the airplane was flying on a northeasterly heading and descended from 2,400 feet msl, to 900 feet msl. At 0142:11, the airplane was located .43 nautical mile from the approach end of runway 05. The next recorded radar target 24 seconds later indicated 1,000 feet msl, and was .20 nautical mile from the approach end of runway 05. The touchdown zone elevation for runway 05 is 700 feet msl. The airplane crashed in a wooded area located approximately 342 degrees and .37 nautical mile from the approach end of runway 05; the wreckage was located approximately 4 hours after the accident. Examination of trees revealed evidence the airplane was banked to the left approximately 24 degrees, and the descent angle from the trees to the ground was calculated to be approximately 22 degrees. All components necessary to sustain flight were either attached to the airplane or in close proximity to the main wreckage. There was no evidence of post crash fire and a strong odor of fuel was noted at the scene upon NTSB arrival. A 8-inch diameter pine tree located near the initial ground impact sight exhibited black paint transfer and a smooth cut surface that measured approximately 46 inches in length. The bottom portion of the cut was located 4 feet above ground level. The flap actuator was found nearly retracted; examination of the components of the flap system revealed no evidence of preimpact failure or malfunction. Examination of the flight control system for roll, pitch, and yaw revealed no evidence of preimpact failure or malfunction. Examination of the engine and engine components with TSB of Canada oversight revealed no evidence of preimpact failure of the engine or engine components. Examination of the propeller with FAA oversight revealed no evidence of preimpact failure or malfunction. Examination of the components of the autopilot system, selected avionics and flight instruments from the airplane with FAA oversight revealed no evidence of preimpact failure or malfunction. The pilot's attitude indicator had been replaced on October 14, 2001, and according to FAA personnel, the mechanic and facility that performed the installation did not have the necessary equipment to perform the operational checks required to return the airplane to service. The FAA flight checked the ILS approach to runway 05 two times after the accident and reported no discrepancies.

Factual Information

HISTORY OF FLIGHT On December 1, 2001, about 0143 central standard time, a Cessna 208B, N499BA, registered to and operated by Air Carriers, Inc., using call sign "Fast Check 600", collided with trees then terrain during an instrument landing system (ILS) approach to runway 05, at Bessemer Airport, Bessemer, Alabama. Instrument meteorological conditions (IMC) prevailed at the time and an instrument flight rules (IFR) flight plan was filed for the 14 CFR Part 135, on-demand, non-scheduled, domestic, cargo flight from Little Rock, Arkansas, to the Bessemer Airport, Bessemer, Alabama. The airplane was destroyed and the commercial-rated pilot and a pilot-rated passenger (another company pilot) were fatally injured. The flight originated approximately 2356 from the Adams Field Airport, Little Rock, Arkansas. Shortly after takeoff, the flight was radar identified and cleared to fly direct to the Bessemer Airport. At 0009, air traffic control (ATC) communications were transferred from the Little Rock Air Traffic Control Tower to the Memphis Air Route Traffic Control Center (Memphis ARTCC). The flight remained in contact with that facility from 0009 to 0122; radar data indicates that between 0011 and 0122, the flight was conducted at 9,000 feet mean sea level (msl). At 0055, the R13 sector controller provided the pilot the Birmingham altimeter setting of 30.17 inHg. At 0122, ATC communications were transferred to Birmingham Air Traffic Control Tower (KBHM ATCT). According to a transcription of communications between the pilot of Fast Check 600 and the Birmingham ATCT, at 0122:51, the pilot contacted the facility and advised the controller that the flight was at 9,000 feet msl. The controller acknowledged the contact and advised the pilot "expect lower in one zero miles and visual approach Bessemer airport." The pilot responded with, "600." At 0126:41, the controller cleared the flight to descend and maintain 4,000 feet msl, which was acknowledged. At 0126:57, the pilot requested radar vectors for the instrument landing system approach, to which the controller responded initially roger, followed by, "maintain three thousand till brookwood cleared ILS runway five approach to Bessemer." The pilot acknowledged the descent clearance and at 0137:44, he advised the controller that the flight was "about to intercept", to which the controller replied, "fast check six hundred roger change to advisory frequency is approved report your cancellation in the air this frequency or on the ground clearance delivery frequency." The pilot acknowledged the transmission from the controller with, "fast check six hundred." There were no further recorded radio transmissions from the accident pilot, and there was no record that the Birmingham ATCT controller provided the pilot with an altimeter setting. A witness who was on the airport waiting for the flight to arrive reported hearing the engine sound at a distance, and then heard a sharp sound he associated with a shotgun report north of runway 5. The witness reported heavy fog existed at the airport at the time of the accident. Review of radar data from Atlanta Air Route Traffic Control Center (ARTCC) associated with the accident airplane revealed that between 0138:47, and 0142:11, the airplane was flying on a northeasterly heading and descended from 2,400 feet msl, to 900 feet msl. At 0142:11, the airplane was located at 33 degrees 18 minutes 12 seconds North latitude, and 086 degrees 56 minutes 22 seconds West longitude, or approximately 225 degrees and .43 nautical mile from the approach end of runway 05. The next recorded radar target 24 seconds later at 0142:35, was indicating 1,000 feet msl, and was located at 33 degrees 18 minutes 41 seconds North latitude, and 086 degrees 55 minutes 56 seconds West longitude, or 005 degrees and .20 nautical mile from the approach end of runway 05. The touchdown zone elevation for runway 05 is 700 feet msl. A search for the airplane was conducted; the wreckage was located approximately 4 hours after the accident. PERSONNEL INFORMATION The pilot-in-command seated in the left front seat was the holder of a commercial pilot certificate, with airplane single and multi-engine land, and instrument airplane ratings. He was issued a second-class medical certificate on August 30, 2001, with the limitation, "Holder shall wear lenses that correct for distant vision and possess glasses that correct for near vision while exercising the privileges of his airman certificate." Air Carriers, Inc., and BancServ Air, Inc., are owned by the same individual. Air Carriers, Inc., and BancServ Air, Inc., were assigned Air Carrier certificate number DKBA109S and VKSA957T, respectively. Air Carriers, Inc., and BancServ Air, Inc., were authorized by the Federal Aviation Administration (FAA) to conduct on-demand cargo only operations, and on-demand operations, respectively, in accordance with the certificates issued under Title 14 CFR Part 119. Review of the pilot-in-command's Air Carriers, Inc., training file revealed he completed his initial new hire basic indoctrination training, and general emergency training in Cessna 206 and 210 airplanes on October 11, 2000. He completed initial hazardous materials training on October 12, 2000, and completed the initial new-hire equipment ground training for Cessna 210 airplanes on October 13, 2000. Initial new-hire equipment flight training that consisted of 3.1 hours in an undesignated type airplane was completed on October 14, 2000. He was assigned as pilot-in-command in Cessna 206 and 210 airplanes on October 16, 2000; he was not assigned as pilot-in-command on Cessna 208 airplanes. His last airman competency/proficiency check flight in accordance with 14 CFR Part 135.293, and 297 occurred on November 17, 2001, which consisted of a .8 hour flight in a Cessna 210 airplane. The result of the flight check was listed as "approved." The pilot-in-command's training file with BancServ Air, Inc., indicates he received initial flight and ground training in Cessna 208 airplanes on February 27, 2001. An airman competency/proficiency check flight form dated February 28, 2001, indicates he passed the flight check that was flown in the accident airplane. He was assigned that same day as pilot-in-command on Cessna 208 airplanes for BancServ Air, Inc. The pilot-rated passenger seated in the right front seat was the holder of a commercial pilot certificate, with ratings airplane single and multi-engine land, and instrument airplane. He was also the holder of a flight instructor certificate with ratings airplane single engine, multi-engine, instrument airplane, that was issued on January 16, 2001. He was issued a first class medical certificate with no limitations on June 21, 2001. He completed his ground and flight training with Air Carriers, Inc., on July 23, 2001, and was assigned to a fly as pilot-in-command Cessna 206 and 210 airplanes. He had not been trained in the Cessna 208 airplane. His last airman competency/proficiency check flight in accordance with 14 CFR Part 135.293, 297, and 299 occurred on July 21, 2001, which consisted of a 1.4 hours flight in a Cessna 210 airplane. The result of the flight check was listed as "approved." AIRCRAFT INFORMATION The airplane was a Cessna 208B, serial number 208B0689, manufactured in 1998. It was equipped with a 675 shaft horsepower Pratt & Whitney PT6A-114A engine, and a McCauley 3GFR34C703/106GA-0 propeller. The airplane was also equipped with a Shadin Key Data Recorder, a Bendix/King KFC-150 autopilot/flight director system, and an altitude preselector. BancServ Air, Inc., maintained the airplane in accordance with a Federal Aviation Administration (FAA) Approved Aircraft Inspection Program (AAIP). The last recorded altimeter, transponder, and static system checks were performed on May 10, 2000, by Southern Avionics. The engine was last overhauled on April 3, 2001, and installed in the airplane on May 12, 2001, at an airframe total time of 3,891.8 hours and 3,214 total landings. The airplane had accumulated approximately 976 hours at the time of the accident since the overhauled engine was installed. The last recorded inspection (AAIP #12) occurred on November 19, 2001, at an airplane total time of 4,783.2 hours, and 4,004 total aircraft landings. The airplane had accumulated approximately 84 hours since the inspection at the time of the accident. Review of the "Mechanical Irregularity Log" sheets recovered from the wreckage that begin with an entry dated April 13, 1999, and end with an entry dated July 16, 2001, revealed no logged discrepancies pertaining to the flight instruments. A BancServ Air, Inc., "Service Order" document dated October 14, 2001, has a discrepancy that states, "Pilots attitude indicator tumbles." On October 14, 2001, the pilot's Flight command indicator was replaced with an overhauled unit. The comments section in the maintenance record indicates, "ops ck good", and was signed off by an airframe and powerplant mechanic. According to FAA personnel, the mechanic and facility that performed the installation did not have the necessary equipment to perform the operational checks required to return the airplane to service. METEOROLOGICAL INFORMATION The pilot phoned the Anniston, Alabama, Automated Flight Service Station at 1558 hours on November 30, 2001, and filed three flight plans that included the accident flight. While in contact with that facility, the briefing specialist (specialist) asked the pilot if he needed a weather briefing to which he responded, "think I got it all." The pilot was advised the only airmet for the routes of flight was for moderate turbulence below 20,000 feet. The specialist reported looking at radar and advised the pilot, "I don't see any precipitation that should affect you, nothing…." He advised the specialist that he had NOTAM information. A FAA approved un-augmented Automated Weather Observing System (AWOS-3) is installed at the accident airport. Review of the weather reports for the accident airport taken in 5-minute intervals revealed that at 2350 (approximately 6 minutes before takeoff), the vertical visibility was 500 feet overcast, and the visibility was ½ mile. At 2355, (approximately 1 minute before takeoff), the visibility was 1 mile with clear skies reported. The visibility increased to a maximum of 7 statute miles, which occurred at 0005 (approximately 9 minutes after takeoff), then began decreasing to 1/4 statute mile, which occurred at 0045 (approximately 49 minutes after takeoff). The recorded visibility remained at 1/4 statute mile or less from 0045 until several hours after the accident. A METAR observation taken at 0145 (approximately 2 minutes after the accident), indicates the wind was from 280 degrees at 0 knots, the visibility was 1/4 mile (no sensor was installed to determine weather phenomena); overcast clouds existed at 100 feet. The temperature and dew point were 4 and 2 degrees Celsius, respectively, and the altimeter setting was 30.16 inHg. Review of 14 CFR Part 135.225, titled "Takeoff, approach and landing minimums" revealed no pilot may begin an instrument approach procedure to an airport unless it has a weather reporting facility operated by the U.S. National Weather Service, a source approved by the U.S. National Weather Service, or a source approved by the Administrator, and, "The latest weather report issued by that weather reporting facility indicates that weather conditions are at or above the authorized IFR landing minimums for that airport." NTSB personnel located in Washington, D.C., prepared a meteorological factual report that indicates at 0115, no precipitation was present across Arkansas, Mississippi, or Alabama, and no radar echoes were noted along the accident airplane's route of flight. Upper air stations near the departure and destination airports indicate that at the nominal time of 0600 (4 hours 17 minutes after the accident), the freezing level was at 12000 and 14,500 feet mean sea level, respectively. A witness who was located on the airport awaiting the arrival of the accident airplane reported that about the time of the accident, the fog was the thickest he had seen since working at the airport for the previous year. Another company pilot on a flight from St. Petersburg, Florida, to Birmingham, Alabama, who landed at Birmingham approximately 2 minutes before the accident, reported hearing the accident flight being vectored on the approach. Due to the fact that he was scheduled to fly into the accident airport after his flight landed at Birmingham, he checked the AWOS at the accident airport two times. The first time when his flight was approximately 65 miles from his destination, and again when his flight was 30 miles from it. The visibility was reported to be less than 1/4 mile with 100-foot indefinite ceiling when he checked it the first time, and 1/4 mile visibility with again 100-foot indefinite ceiling when he checked it the second time. He executed a visual approach to runway 36 at Birmingham, and while in-bound there, he observed "widespread dense fog", and couldn't see the rotating beacon at the accident airport. COMMUNICATIONS The witness who was at the accident airport awaiting the arrival of the accident airplane reported in writing hearing a sound he associated with "…tapping on radio system outside: It was like when someone is attempting to do a microphone check. Shortly after I heard, '"Flt 600 ??? [Bessemer]."' He reported during an interview hearing the pilot report "INS." AIRPORT INFORMATION The airport is equipped with one asphalt runway designated 05/23, which is 5,700 feet long and 100 feet wide, and is served by an instrument landing system (ILS) approach to runway 05. The FAA approved un-augmented Automated Weather Observing System (AWOS-3) broadcasts on 118.825 MHz. Review of the ILS Runway 05 instrument approach procedure depicted in the Southeast U.S. Terminal Procedures publication in effect on the date of the accident revealed the decision height and visibility for a straight in ILS approach to runway 05 for all categories of aircraft is 900 feet mean sea level and 3/4 mile visibility. The published missed approach procedure is to climb to 1,400 feet msl, then climbing right turn to 3,000 feet and proceed direct to the Brookwood VORTAC (OKW) and hold. WRECKAGE AND IMPACT INFORMATION The airplane crashed in a wooded area, impact damage to several trees was noted. The main wreckage was located at 33 degrees 18.794 minutes North latitude and 086 degrees 56.145 minutes West longitude, or 342 degrees and .37 nautical mile from the approach end of runway 05. All components necessary to sustain flight were attached or in close proximity to the wreckage which was upright on a magnetic heading of 280 degrees. The main wreckage was located approximately 107 feet and 209 degrees from the first tree contact location. There was no in-flight or postcrash fire; a strong odor of fuel was noted at the accident site on NTSB arrival. Examination of the accident site revealed the first observed contact to a tree was located at 33 degrees 18.817 minutes North latitude and 086 degrees 56.131 minutes West longitude. Damage to trees located 37 feet past the first tree impact site were located left and right of a line from the first tree contact to the main wreckage (centerline). The trees were located 3 feet left and 33 feet to the right of centerline and were contacted 14 feet and 30 feet above ground level (agl), respectively. The angle of bank was later calculated to be approximately 24 degrees. Continuing along the centerline towards the main wreckage, a stand of trees located to the left and right of the centerline were damaged approximately 5 feet agl; the trees were located approximately 62 feet from the first tree contact location. Components from the airplane were noted along the wreckage path. The first observed ground contact location was noted 81 feet from the first tree contact location; the angle from the first tree contact point to the ground contact point was determine to be approximately 22 degrees. A 8-inch diameter pine tree located near the initial ground impact

Probable Cause and Findings

The poor in-flight planning by the pilot-in-command for his initiation of the ILS approach to runway 05 with weather conditions below minimums for the approach contrary to the federal aviation regulations, and the failure of the pilot to maintain control of the airplane during a missed approach resulting in the in-flight collision with trees then terrain.

 

Source: NTSB Aviation Accident Database

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