Aviation Accident Summaries

Aviation Accident Summary CHI03FA296

Grand Marais, MN, USA

Aircraft #1

N285V

Beech 58P

Analysis

The airplane was destroyed when it impacted trees and terrain about 1.5 nautical miles from the destination airport during a personal flight. The pilot made a planned en route stop prior to departing for the destination airport which had been reporting instrument meteorological condition with variable sky conditions resulting in ceilings below instrument approach minimums along with convective activity. These conditions persisted since the pilot's last reported weather briefing, about four hours prior to the approach. Prior to receiving an approach clearance, the pilot was issued a convective SIGMET encompassing the destination airport and its destination sky conditions, which were above approach minimums. There was no record of the pilot reporting a missed approach. The twin-engine airplane was destroyed by impact forces and fire. Both propellers exhibited impact signatures consistent with engine power. The flight control cables were traced to areas of separation within the wreckage as their related components had been destroyed. According to airplane records, the airplane was equipped with a four-color weather radar system.

Factual Information

HISTORY OF FLIGHT On August 28, 2003, at 1115 central daylight time, a Beech 58P, N285V, piloted by a private pilot, was reported overdue after being cleared for an approach to Grand Marais Airport (CKC), Grand Marais, Minnesota. The wreckage of the airplane was later found about 1.5 nautical miles (NM) east of the airport. Instrument meteorological conditions prevailed when the airplane was reported missing. The Title 14 Code of Federal Regulations Part 91 personal flight was operating on an instrument rules flight (IFR) plan. The pilot and one passenger received fatal injuries, and two passengers received serious injuries. The flight originated from Duluth International Airport, Duluth, Minnesota, at 0948, and was en route to CKC. At 0642:19, a person called Princeton Automated Flight Service Station (PNM AFSS) and requested and received a pilot weather briefing for N285V for an IFR flight from MIC to DLH, departing at 0730, and then departing from DLH to CKC at 0900. The caller then filed two IFR flight plans. The caller did not specify alternate airports on either flight plan. The caller said the airplane was equipped with a Global Positioning System (GPS). The caller did not specifically request weather reports pertaining to CKC at the time of the briefing. At 0650:28, the call was concluded and there were no further contacts between PNM AFSS and N285V. A transcript of the briefing is included in the docket of this report. The following transmissions were transcribed between Duluth Air Traffic Control Tower (DLH), Minneapolis ARTCC Sector 25 Radar Controller (ZMP25), and N285V. At 0957:45, N285V transmitted, "minneapolis uh baron two eight five victor is with you seven thousand on course cook county." At 0957:51, ZMP25 transmitted, "baron two eight five victor minneapolis center roger the grand marais altimeter is three or correction two niner eight four." At 0957:58, N285V transmitted, "niner eight four eight five victor." At 0959:15, ZMP25 transmitted, "attention all aircraft convective sigmet valid until one six five five for wis or michigan wisconsin minnesota and lake superior from international falls to three zero south of thunder bay to four zero west south west of rhinelander to four zero west of nodine to three zero north northeast of minneapolis to international falls developing area of thunderstorms moving from two five zero at four zero tops to flight level four one zero." At 1005:02, N285V transmitted, "minneapolis center baron two eight five victor requesting lower." At 1005:05, ZMP25 transmitted, "baron two eight five victor descend at pilots discretion maintain five thousand." At 1005:09, N285V transmitted, "(unintelligible) thousand eight five victor." At 1005:27, ZMP25 transmitted, "baron two eight five victor do you have the current grand marais weather one four five five." At 1005:32, N285V, transmitted, "say again for eight five victor." At 1005:34, ZMP25 transmitted, "do you have the current grand marais weather at one four five five u t c." At 1005:39, N285V transmitted, "negative." At 1005:40, ZMP25 transmitted, "o k we're showing uh the wind at zero five zero at three visibility four miles and heavy thunderstorms it's uh let's see there's a cloud layer at three hundred feet scattered ceiling is one thousand four hundred overcast temperature one four dew point one three altimeter two niner eight six and it says uh the remarks there is lightening in uh distant all quadrants At 1006:04, N285V transmitted, "o k we copy that that's all passed through there though." At 1006:07, ZMP25 transmitted, "yeah it appears so from here but radar coverage up in that area is kind of marginal and two eight five victor is cleared for approach to the grand marais airport maintain uh maintain five thousand til established on a published portion of the approach." At 1006:21, N285V transmitted, "can you give us radar vectors." At 1006:23, ZMP25 transmitted, "uh no sir i don't have the coverage uh radar or radio wise i'm going to lose you on both very shortly here." At 1006:28, N285V transmitted, "k cleared for the approach into grand marais and uh we'll uh keep talking to you as long as we can otherwise i'll cancel on the ground." At 1006:34, ZMP25 transmitted, "november two eight five victor roger." At 1007:34, ZMP25 transmitted, "november two eight five victor your radar contact is lost change to advisory frequency is approved." About 1030, a witness at CKC heard "routine" radio calls from N285V asking Cook County UNICOM about the ceiling. The witness was outside when he heard the transmission and began walking over to the radio located in the office. The witness asked if N285V needed a ceiling report. N284V made a transmission and said let me get my approach together and I'll get back with you. The witness saw the bottom of the airplane, "just barely" when it flew over runway 27, on runway heading, executing a missed approach. Everything sounded "normal" with regard to engine sound and the pilot's voice. It didn't sound as if he were having any problems with the approach or the airplane. There wasn't any other air traffic that landed before or after N265V's approach. The ceilings were "varying a lot" and the visibility was "fine underneath." About 1250, the Minnesota Wing of the Civil Air Patrol was notified of the missing airplane. About 1630, the airplane was located in a wooded area about 1.5 NM east of CKC at an elevation of about 1,840 feet mean sea level (MSL). PERSONNEL INFORMATION The pilot, age 55, held a private pilot certificate with airplane single-engine land, airplane multiengine land, and instrument airplane ratings. He was issued a third class airman medical certificate on January 11, 2002, with the following limitations: "HOLDER SHALL WEAR CORRECTIVE LENSES." On June 27, 1981, the pilot was issued a private pilot certificate with an airplane single-engine land rating. He reported a total flight time of 49 hours. On April 4, 1983, he failed the flight examination portion for an instrument rating. Upon his reapplication for the rating, he was to be reexamined on the following: "III. C. ADF APPROACH." On April 7, 1983, he was reexamined and issued an instrument airplane rating. He reported a total flight time of 294 hours. On January 18, 1990, he failed the practical portion of his examination for a multiengine land rating using a Beech 76 airplane in which he reported a total time of 7.6 hours; the PIC time block in this section of the application has no entry. He reported a total flight time of 817 hours. Upon his reapplication for the rating, he was to be reexamined on the following: "Area of operation: IX. FLIGHT AT CRITICALLY XII. EMERGENCY OPERATIONS: C, D, ENGINE INOPERATIVE DEMO. WAS CONFUSED ON GETTING BACK TO THE AIRPORT.." On February 22, 1990, he failed his second attempt during the practical examination. Upon his reapplication, "AREA OF OPERATION: TASK V.A. (cross wind takeoff) NO OTHER OPERATIONS TESTED." On March 25, 1990, he was reexamined and issued a multi-engine land rating using a Beech 55 airplane in which he reported a total flight time of 6.5 hours and a PIC time of 0 hours. He reported a total flight time of 845 hours. On April 29, 2002, the pilot received a biennial flight review using a Piper PA-28R-200 during a local flight from MIC with a total flight duration of 1.1 hours. On June 6, 2002, the pilot was involved in an accident at MIC, which was investigated by the National Transportation Safety Board under accident number CHI02LA154. The Safety Board determined the probable cause(s) as follows: The pilot's failure to maintaining control of the aircraft during an aborted landing. On August 7, 2002, the pilot received a reexamination of his airplane single-engine land rating using a Beech 36 airplane. The reexamination was conducted by a Federal Aviation Administration (FAA) inspector. On October 31, 2002, the pilot began Beech 58P initial pilot training at a commercial simulator training facility that made use of a fixed Beech 58P simulator. The pilot received 10 hours of flight training in the left seat. and 10 hours in the right seat with another pilot who accompanied the accident pilot to receive training. A pilot logbook recovered from the accident site indicated the last entry was dated August 21, 2003, with a total time of 1,332 hours, of which 1,134.1 hours were pilot-in-command (PIC), 1,025.9 hours were single-engine land airplane, 266.6 hours were multiengine airplane, 208.1 hours were actual instrument, and 85.7 hours were simulated instrument. AIRCRAFT INFORMATION The 1977 Beech 58P, serial number TJ-118, was a six-seat multiengine airplane powered by two Continental TSIO-520-WB engines. On January 15, 1991, FAA Form 337, Major Repair and Alteration, was dated stating the installation of a Bendix RDS-82 four-color weather radar system. On May 8, 2000, FAA Form 337 was dated stating that a Garmin GNS-430 GPS/VOR/ILC/COM transceiver interfaced with a King KI-525 horizontal situation indicator. The GNS-430 was coupled to a Bendix/King KFC-200 system autopilot. On October 1, 2000, a logbook entry was dated stating that the airplane's registration number had changed from N812RJ to N285V. On February 5, 2003, the airplane was a registered to Quintessence Air Service LLC, of which the pilot was listed as president on the aircraft registration application. On July 1, 2003, the airplane received an annual/100-hour inspection, at a total aircraft time of 5,705.2 hours and a Hobbs time of 61.7 hours. On August 27, (year not indicated), a "N285V BARON HOBBS SHEET" was dated with an entry indicating the "End Hobbs" to be 96.8. METEOROLOGICAL INFORMATION The CKC Automated Weather Observation System (AWOS-3) located at the airport recorded the following weather observations: At 0635: wind 130 degrees at 8 knots, gust 15 knots; surface visibility 10 statute miles (SM); sky condition broken 500 feet above ground level (AGL); temperature 12 degrees C; dew point 11 degrees C; altimeter setting 29.90 inches mercury (Hg); remarks - lightning distant north and west. At 0655; wind 120 degrees at 9 knots, gust 14 knots, 099 degrees variable 159 degrees; visibility 10 SM; sky condition overcast 300 feet AGL; temperature 12 degrees C; dew point 11 degrees C; altimeter setting 29.89 inches Hg; remarks - lightning distant northwest. At 0755; wind 130 degrees at 10 knots, gust 20 knots; surface visibility 3/4 SM; thunderstorm, mist; sky condition overcast 100 feet AGL; temperature 13 degrees C; dew point 12 degrees C; altimeter 29.85 inches (Hg); remarks - lightning distant west thru northeast. At 1001; sky condition broken 300 feet AGL; visibility 5 SM; light rain; remarks - lightning at airport and distant all quadrants. At 1009; sky condition scattered 300 feet AGL, overcast 1,000 feet AGL; visibility 7 SM; remarks - lightning at airport and distant north thru south At 1015; wind 040 degrees at 4 knots; surface visibility 7 SM; sky condition broken 300 feet AGL, overcast 1,000 feet AGL; temperature 14 degrees C; dew point 13 degrees C; altimeter setting 29.85 inches Hg; remarks - lightning distant north thru east. At 1027; sky condition broken 300 feet AGL, overcast 1,000 feet AGL; visibility 7 SM; remarks - lightning distant northeast. At 1030; sky condition scattered 300 feet AGL, overcast 1,000 feet AGL; visibility 7 SM; remarks - lightning vicinity and distant northeast. At 1035; wind 090 degrees at 6 knots; surface visibility 7 SM; thunderstorms in the vicinity (Not at aerodrome. Between 5 and 10 SM of the point(s) of observation); sky condition scattered 300 feet AGL, broken 1,000 feet AGL, overcast 1,700 feet AGL; temperature 14 degrees C; dew point 13 degrees C; altimeter setting 29.83 inches; remarks - lightning distant northeast. At 1045; sky condition broken 300 feet AGL, overcast 1,000 feet AGL; visibility 7 SM; remarks - lightning distant northeast. AIRPORT INFORMATION CKC was an uncontrolled airport served by runway 09-27 (4,200 feet by 75 feet, asphalt) with an airport elevation of 1,798 feet MSL. The touchdown elevation for runway 09-27 is listed as 1,796 feet. Runway 09-27 was equipped with runway edge identifier lights, medium intensity runway lights, and a precision approach path indicator. The CKC AWOS-3 had a radio frequency of 119.925 Mhz. Radio aids to navigation listed for the airport were the Ironwood, Michigan, Vortac 351 degrees and 79.1 nautical miles to CKC and the CKC nondirectional beacon (NDB), which was located at the field. NDB Runway 27 and global positioning system (GPS) Runway 27 are the only instrument approaches published for the airport. The NDB approach had a minimum safe altitude (MSA) of 3,200 feet MSL extending 25 NM from the CKC NDB. The GPS approach had a MSA of 3,200 feet MSL extending 25 NM from runway 27. The NDB initial approach fix was the CKC NDB from which the initial approach segment had an outbound procedure track of 105 degrees and a minimum altitude of 3,500 feet MSL. The intermediate/final segment of the approach had an inbound procedure track of 285 degrees. The category A and B straight-in approach minimums were 2,340 feet MSL (544 feet AGL) and 1 SM visibility; category C approach minimums ware 2,340 feet MSL (544 feet AGL) and 1-1/2 SM visibility; category D minimums were not authorized. The missed approach procedure was: climb to 3,000 feet MSL, then climbing left turn to 3,500 feet MSL direct CKC NDB and hold. The GPS intermediate/initial approach fix was WHIFY and the final approach fix was TUMDE located, 10 NM and 5 NM from runway 27, respectively. The intermediate segment minimum altitude between WHIFY and TUMDE was 3,400 feet MSL. The category A and B straight-in approach minimums were 2,340 feet MSL (444 feet AGL) and 1 SM visibility; category C approach minimums were 2,240 feet MSL (444 feet AGL) and 1-1/4 SM visibility; category D minimums were not authorized. The missed approach procedures were: Climb to 3,000 feet MSL, then climbing left turn to 4,000 feet MSL direct BYPOR waypoint and hold. The BYPOR waypoint was located about 3.1 NM southeast of CKC. WRECKAGE AND IMPACT INFORMATION The wreckage was located in a wooded area consisting of 6-8 inch diameter trees which were about 55 feet in height. The wreckage path was oriented on a heading of 160/240 degrees and was about 100 feet in length. The northern area of the wreckage path contained fallen trees and a ground scar with red lens material. South of this area was the forward cabin area of fuselage which was oriented on heading of 090 degrees, and the tail section of the fuselage, which was oriented on a heading of 180. The right wing and right engine were located against a tree east of the fuselage and towards the center of the wreckage path. The southern area of the wreckage path consisted of left wing and left engine. The fuselage from the nose section to an area aft of the rear bulkhead was consumed by fire. The instrument panel exhibited fire and impact damage. The two aft cabin seats, in which the seriously injured passengers were seated, were found lying about 10 feet south from the main cabin. Examination of the attitude indicator revealed that the gyro was able to move on its gimbals without binding. The gyro was spun by hand and no binding was noted. No circumferential scoring of the gyro was noted. The left engine driven vacuum pump was attached to the accessory section of the engine and its hosing was broken off. The right engine vacuum pump was broken off and was found lying next to the right engine. The elevator and rudder control cables were attached to their respective controls surfaces. These cables were separated from their supporting components and extended into the cabin/cockpit area where they were separated from the cockpit controls, which were fractured in several places. The elevator trim actuator was extended 1.5 inches which equates to 25 degrees tab down. The rudder trim actuator was extended 4 inches which equates to 2-3 inches tab left. The aileron cables from both wings were attac

Probable Cause and Findings

The continued descent below minimum descent altitude and the altitude/clearance not maintained by the pilot during approach to the airport. The low ceiling was a contributing factor.

 

Source: NTSB Aviation Accident Database

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