FLAGSTAFF, AZ, USA
N746FE
CESSNA 208B
A WITNESS LOCATED NEAR THE DEPARTURE END OF THE RUNWAY SAW THE AIRPLANE INITIALLY CLIMB IN A NORMAL MANNER, THEN STAY BELOW THE CLOUDS AND MAKE A SHALLOW BANK 180-DEGREE LEFT TURN AND DESCEND BELOW A TREE LINE. TOWER TAPES REVEALED THAT THE PILOT TWICE TRANSMITTED THAT HE WAS "COMING BACK" TO THE AIRPORT DURING WHICH THE BACKGROUND SOUND OF THE "FUEL SELECTOR OFF" WARNING HORN WAS HEARD. THE PILOT THEN INFORMED THE CONTROLLER "I'VE GOT TO GET BACK", AND NO WARNING HORN WAS HEARD. THE AIRPLANE COLLIDED WITH TREES AND CAME TO REST ABOUT 6,500 FEET SSE OF THE RUNWAY'S END. PRIOR TO DEPARTURE, THE AIRPLANE WAS REFUELED WITH 40 GALS OF JET A (20 GALS PER TANK), WHICH INCREASED THE TOTAL FUEL LOAD TO 148 GALS. THE FLIGHT MANUAL REQUIRED THAT THE FUEL BALANCE BETWEEN THE LEFT AND RIGHT TANKS BE KEPT WITHIN 200 POUNDS, AND SUGGESTED TURNING OFF ONE FUEL SELECTOR TO CORRECT UNBALANCE SITUATIONS. THE CONDITION OF ONE FUEL SELECTOR TURNED OFF WILL CAUSE THE "FUEL SELECTOR OFF" WARNING HORN TO SOUND. EXAM OF THE AIRCRAFT REVEALED NO EVIDENCE OF PREIMPACT FAILURES. PROP BLADE BUTT SIGNATURES INDICATED IT WAS OPERATING IN THE GOVERNING RANGE, AND ENGINE POWER WAS BEING PRODUCED AT IMPACT.
HISTORY OF FLIGHT On January 11, 1995, about 1805 hours mountain standard time (mst), a Cessna 208B, N746FE, operated by Empire Airlines, Inc. as flight number 7551, collided with terrain, about 1.5 nautical miles (nm) south of the Flagstaff Pulliam Airport, Flagstaff, Arizona. The accident occurred while the pilot was attempting to return to the airport after taking off from runway 21. The airplane was transporting cargo under contract with Federal Express during the dark nighttime air taxi flight. Instrument meteorological conditions prevailed, and an instrument flight plan was filed. The airplane was destroyed, and the airline transport pilot was fatally injured. Prior to taking off on the accident flight, the airplane was partially refueled, and it was loaded with cargo. The scheduled block out time was 1800. At 1746, the local air traffic controller cleared N746FE (using radio call sign "Empire five fifty-one") to taxi for takeoff. The pilot indicated that he desired to fly under instrument flight rules to Phoenix, Arizona. A few minutes later, the controller informed the pilot that his departure would be delayed because air traffic was busy. At 1801:56 the controller cleared N746FE for takeoff. The controller reported to the National Transportation Safety Board that he estimated the airplane became airborne about 3,000 feet down the runway. Nothing unusual was noted. Another pilot, who was waiting for takeoff in a Beech King Air near the approach end of runway 03, reported that when the accident airplane passed over the departure end of runway 21, it had climbed 200 to 300 feet above the runway's surface. Nothing unusual was noted except that the airplane "did not seem to be climbing very well." The Beech pilot further reported that the airplane commenced turning left approximately 1/4 to 1/2 mile beyond the end of the runway. The rate of turn "seemed normal and not excessive." At 1803:50 the controller instructed N746FE to contact Albuquerque Center, and three seconds later the pilot acknowledged the instruction. Then, at 1803:57 the pilot stated "Five fifty-one's coming back in," which was followed 6 seconds later with "I'm coming back to the airport." The controller asked the pilot if he had the airport in sight. The pilot replied at 1804:12 with the following brief statement: "No but I've got to get back." The controller then stated "OK Empire five fifty-one say nature of difficulty please." The pilot's reply was unintelligible. At 1804:25 the controller stated "Empire five fifty-one your not in sight cleared to land either runway." The Beech King Air pilot provided the following account of his observations regarding the accident airplane's flight path: After taking off, the airplane initially flew straight ahead, but then commenced a left 180-degree turn to an approximate heading of 030 degrees to parallel the runway. "The rate of turn seemed normal and not excessive (and the airplane) . . . did not seem to be climbing and may have even been descending." The Beech pilot further reported that the airplane "did not appear to be stalled or wobbling when last seen." The Beech pilot said that he lost sight of the airplane's lights when it descended behind trees. The crash site was located in a snow-covered hilly forest, approximately 6,500 feet south-southeast of the runway's departure end. A Federal Express ramp agent, who was located at the airport, also observed the airplane depart. The agent indicated that the airplane passed "overhead (by) approximately 100 to 120 feet" and was climbing. The airplane then entered a left bank turn, lost altitude, and disappeared over a tree line. PERSONNEL INFORMATION The pilot held an airline transport pilot certificate, with single and multiengine land ratings, a multiengine sea rating, and several type ratings. The pilot also possessed a certified flight instructor certificate for single and multiengine airplanes which was last renewed in April of 1994. Empire Airlines (the operator) hired the pilot in March of 1990. In April of 1993, the FAA approved the pilot to serve as a check airman in the Cessna 208. The pilot was authorized to give proficiency and line checks to the operator's pilots. In March, 1994, the pilot completed recurrent academic and simulator training by Flight Safety International. In October, 1994, the pilot successfully completed a 1.4-hour-long flight competency check in the Cessna 208, which included normal and emergency procedures. By the accident date, the pilot had logged about 10,000 hours of total flight time, of which about 2,000 hours were logged flying the Cessna 208 series airplanes. The pilot had logged about 2,000 hours of night flying time and about 800 hours of time flying in instrument weather conditions. During the preceding 24-hour, 30-day, and 90-day period, the pilot had flown the Cessna 208 for 2, 36, and 100 hours, respectively. Also, during the preceding 90 days the pilot had flown about 25 hours at night. The operator's flight time records indicated that during the 30-day period which preceded the crash, the pilot had flown the accident airplane between Flagstaff and Phoenix over 34 times. Family members reported that the pilot only flew airplanes for the operator, and recently he only flew Cessna 208s. The pilot resided near Flagstaff, and he was extremely familiar with the terrain which surrounded the airport. AIRCRAFT INFORMATION Refueling. The airplane was manufactured in 1990, and it was equipped with 2 wing fuel tanks, each having a usable capacity of 165 gallons. In preparation for takeoff, around 1730, the airplane was fueled with 40.0 gallons of jet A fuel (20 gallons per tank), which increased the total fuel load to approximately 148 gallons (1,006.4 pounds). Weight. The maximum certificated airplane weight for flight into known icing conditions with the cargo pod installed was 8,550 pounds. On takeoff, the airplane's estimated gross weight was 7,963 pounds which included a cargo load of about 2,211 pounds. Takeoff Distance. Based upon Cessna and Federal Express supplied data and calculations, projections were made to determine the takeoff distance (required runway length) and the approximate altitude the airplane could have attained upon passing the end of the runway (assuming no snow). The airplane, as loaded, was calculated to have been able to climb to between 100 and 200 feet above the surface upon passing the runway end. Flight Path Data. Additional calculations were performed to determine the required rate of turn (degrees per second) necessary to arrive at the accident site assuming utilization of a normal departure climb speed profile and witness described flight path. After takeoff, an airplane commencing a left turn at an approximate rate between 3 and 6 degrees per second could arrive in the vicinity of the crash site while flying in an arc consistent with the accident airplane's observed flight path. Maintenance. The airplane's routine maintenance records, including engine condition trend monitoring/performance data, and nonroutine records involving avionics discrepancies, engine exceedences, and repetitive write ups, etc., were reviewed by the Federal Aviation Administration (FAA). No irregularities pertinent to the accident flight were identified. The airplane's flight record logbook was recovered from the accident site. A review of the logbook revealed no evidence of pertinent squawks or deferred items. Fuel System Operation and Warnings. The following statement was contained in the Cessna 208B Caravan Information Manual: "Before refueling, or when the airplane is parked on a slope, turn off one of the fuel tank selectors. . . ." The Information Manual provided pilots with the following instructions regarding fuel unbalance situations: "Fuel unbalance should be monitored to assure it does not exceed 200 pounds. . . . If fuel unbalance approaching 200 pounds does occur, the fuel tank selector for the tank with less fuel should be turned OFF until the tanks become balanced. With one fuel tank selector OFF and fuel remaining in the tank being used less than approximately 25 gallons, the FUEL SELECT OFF annunciator will illuminate and a warning horn will be activated." The airplane is placarded with the following statement: "MAXIMUM FUEL UNBALANCE IN FLIGHT: 200 LBS." The Information Manual stated the following regarding the Fuel Selectors Off Warning System: "A fuel selectors off warning system is incorporated to alert the pilot if one or both of the fuel tank selectors are left in the OFF position inadvertently. The system includes redundant warning horns, (and) a red annunciator light labeled FUEL SELECT OFF. . . ." In pertinent part, the system functioned as follows: "(1) If both the left and right fuel tank shutoff valves are closed (fuel tank selectors in the OFF position), the red FUEL SELECT OFF annunciator illuminates and one of the fuel selector off warning horns is activated; (2) During an engine start operation (STARTER switch in START or MOTOR position) with either the left or right fuel tank shutoff valves closed, the red FUEL SELECT OFF annunciator illuminates and both of the fuel select off warning horns are activated; (3) With one fuel tank selector OFF and fuel remaining in the tank being used less than approximately 25 gallons, the FUEL SELECT OFF annunciator illuminates and one of the fuel selector off warning horns is activated." Regarding taking off with both of the airplane's fuel selectors in the off position, the Information Manual stated that "there is only enough fuel in the reservoir for approximately 1-1/2 minutes of engine operation at maximum continuous power after illumination of the RESERVOIR FUEL LOW annunciator." Flight Into Icing Conditions. The airplane was certificated and equipped for flight into known icing conditions. In pertinent part, the Information Manual stated the following: "The in-flight ice protection equipment was not designed to remove ice, snow, or frost accumulations on a parked airplane sufficiently enough to ensure a safe takeoff or subsequent flight. Other means (such as . . . approved de-icing solutions) must be employed to ensure that all wing, strut, landing gear, cargo pod, tail, control, propeller, and windshield surfaces and the fuel vents are free of ice, snow, and frost accumulations, and that there are no internal accumulations of ice or debris in the control surfaces, engine intakes, pitot-static system ports, and fuel vents prior to takeoff." Airplane Deice Program. Empire Airlines had an FAA Approved Part 135 deice program in place for the operation of its Caravans. In brief, the program indicated that the pilot-in-command was responsible for deciding when deicing or anti-icing was necessary, and for coordinating with local facilities for its accomplishment. In the program, deicing was defined as "a procedure by which ice, frost or snow is removed from the aircraft in order to provide clean, aerodynamically correct surfaces." Anti-icing was defined as "a procedure which provides protection against formation of frost or ice and accumulation of snow or slush on clean surfaces of the aircraft for a limited period of time. . . ." The program indicated that ". . . when snow . . . is falling, deicing should be accomplished as close to departure time as possible. Also, when moderate-to-heavy snow is falling at departure time, it may be necessary to perform a two step procedure. After the initial deicing is accomplished, a second fluid application may need to be applied in order to maximize protection. Regarding ice removal, the program indicated that when wet snow is falling, anti-icing solution should be applied to the entire airplane if the airplane will not depart within 15 minutes. Empire Airlines had a policy of not deicing its Caravans with the engine running. To additionally ensure that the airplane was free of contamination, pilots were provided with the following guidance regarding performance of a pretakeoff check: "This check of the representative surface(s) is made by the pilot from the cockpit within five minutes of takeoff any time there is a threat of contamination. If contamination is sticking to the representative surface(s) the airplane should be deiced again before takeoff. The representative surface of the Caravan is the upper surface of the wing-mounted radar pod." METEOROLOGICAL INFORMATION Weather Briefings. At 1236, the pilot received a direct user access system (DUAT) weather briefing for a proposed 1 hour 10 minute flight between Phoenix and Flagstaff. The proposed departure time was 1600. At 1255, the pilot received an abbreviated weather briefing from the Prescott Flight Service Station for a proposed round trip flight between Phoenix and Flagstaff. The proposed return trip departure time out of Flagstaff was 1800. Regarding the forecast for Flagstaff weather, the briefer made the following statement to the pilot: ". . . up until four o'clock (2100 mst) they're forecasting ceilings two hundred overcast winds two two zero at ten occasional two hundred scattered ceiling seven hundred broken visibility three miles light rain light snow and fog. . . ." At 1304, the pilot received another DUAT weather briefing for a proposed flight between Phoenix and Flagstaff. Airplane Ice/Snow. Several witnesses observed N746FE prior to its departure. Empire Airlines and Federal Express personnel reported that the pilot did not make a request to have the airplane deiced, and none reported observing any ice or snow on the airplane. One of the witnesses reported that around 1730 the airplane had just finished being refueled and was parked outside on the ramp. By 1744 the cargo loading operation had been completed, and the witness moved his truck away from the airplane. A minute later, the airplane taxied away. The witness further reported "it was snowing a heavy wet snow which was accumulating on the trucks." Another witness reported that while the airplane was waiting for takeoff "the snowfall increased (wet & heavy)." Still another witness reported that while waiting for the airplane to takeoff, "the snow was coming down heavily." This witness also reported that just before the airplane departed he returned to his vehicle and observed a lot of slush on it. The Beech King Air pilot reported that about 1800 he taxied from a warm hanger to takeoff on runway 03. The pilot made the following written report regarding his observations of the snow: "Initially it was snowing heavily with big wet snowflakes. The snow on my aircraft was accumulating only on the outboard wing panels (outboard of the prop blast and appeared to be melting and running off. It seems we waited for our clearances for a long time. I am going to estimate a 15 minute wait. Toward the end of the wait for clearance the snow fall changed to small dry snowflakes and the visibility improved." Flagstaff Weather. An automated surface observing system (A02A) was installed at the Flagstaff Airport which recorded the local weather at 5 minute intervals. According to the A02A reports, around 1715 the temperature dropped from 35 to 34 degrees Fahrenheit, and a light snow began falling. Around 1755 the temperature lowered to 33 degrees F. The snow continued until after the accident. The local air traffic controller reported to the Safety Board that at 1746 it was snowing when he cleared N746FE to taxi for takeoff. Thereafter, the controller observed the airplane taxi past the tower and recalled that it was still snowing. At 1801:21, the controller made the following statement to N746FE regarding the weather: "Empire five fifty-one flagstaff weather zero zero five six observation (1756 mst) measured ceiling two hundred broken one thousand overcast visibility three quarters of a mile with light snow and fog." The pilot acknowledged the report. AIDS TO NAVIGATION, COMMUNICATIONS, AND SERVICES According to FAA records of facility operations, all electronic aids to navigation pertinent to the airplane's route of fl
The pilot's failure to properly configure the aircraft fuel system prior to takeoff, and his failure maintain an adequate terrain clearance altitude while maneuvering to return to the airport. Factors in the accident were the dark night lighting conditions, low ceilings, restricted visibility conditions, and the pilot's diverted attention which resulted from activation of the airplane's fuel selector warning horn system.
Source: NTSB Aviation Accident Database
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