BRANSON, MO, USA
N525KL
Cessna 525
Prior to takeoff from Lambert Field/St. Louis International Airport, St. Louis, Missouri, the pilot contacted the operations manager at M. Graham Clark Airport, Point Lookout, Missouri, and asked about the current weather conditions there. The operations manager told the pilot that the weather was "pretty poor." The airplane took off from St. Louis, at 1411 cst. At 1447:12 cst, the pilot checked in with Springfield Approach Control. The pilot was told to expect the ILS approach to runway 2 at the Springfield-Branson Regional Airport. At 1501:01 cst, the pilot requested to go to Point Lookout and shoot the GPS to runway 11. Springfield Approach instructed the pilot to descend to 3,000 feet msl and cleared him for the approach. At 1507:08 cst, Springfield radar showed the airplane crossing the initial waypoint at 3,000 feet msl, and turn to 116 degrees approach heading. At 1507:17 cst, the airplane descended to 2,500 feet msl. At 1508:51 cst, Springfield Approach cleared the pilot to change to advisory frequency. "Call me back with your cancellation or your miss." The pilot responded, "Okay we're, we're RAWBE inbound and we will call you on the miss or cancellation." The operations manager at M. Graham Clark Airport said that he heard the pilot on the airport's common frequency radio say, "Citation 525KL is RAWBE inbound on the GPS 11 approach." At 1509:01 cst, Springfield radar showed the airplane begin a descent out of 2,500 feet msl. The last radar contact was at 1509:48 cst. The airplane was five nautical miles from the airport on a 296 degree radial, at 2,100 feet msl. At 1530 cst, the operations manager heard Springfield approach trying to contact the airplane. The operations manager initiated a search for the airplane. At 1430 cst, the weather observation at the M. Graham Clark Airport was 300 feet overcast, rain and mist, 3/4 miles visibility, temperature 53 degrees F, winds variable at 3 knots, altimeter 29.92 inches HG. Approach minimum weather for the GPS RWY11 straight in approach to Point Lookout are a minimum ceiling of 600 feet and visibility of 1 mile for a category B aircraft. An examination of the airplane wreckage revealed no anomalies. The results of FAA toxicology testing of specimens from the pilot revealed concentrations of Doxepin in kidney and liver. The Physicians' Desk Reference states that "... drowsiness may occur with the use of this drug, patients should be warned of the possibility and cautioned against driving a car or operating dangerous machinery while taking the drug." The physician who prescribed the Doxepin to the pilot said that he was using it to treat the pilot's "irritable bowel" condition. According to his wife, the pilot had not slept well for several nights, up to the day of the accident, due to problems he was having with the FAA. A friend, who spoke with the pilot just before the accident flight, confirmed the pilot saying "I haven't slept for three days." The friend stated further that the pilot "wasn't himself that day."
HISTORY OF FLIGHT On December 9, 1999, at 1512 central standard time (cst), a Cessna 525, N525KL, operated by an airline transport pilot, was destroyed when it impacted a hillside on the northwest edge of the city of Branson, Missouri, 4.3 statute miles from its destination, the M. Graham Clark Airport, Point Lookout, Missouri. A post-crash fire ensued. The pilot, pilot-rated passenger, and four passengers in the cabin section of the airplane, were fatally injured. Instrument meteorological conditions prevailed at the time of the accident. The business flight was being conducted under 14 CFR Part 91. An instrument flight plan was on file. The cross-country flight originated at St. Louis, Missouri, at 1411 cst. At 1339 cst, the pilot contacted the Federal Aviation Administration Flight Service Station at St. Louis, Missouri, by telephone, and obtained a preflight weather briefing for an instrument flight rules (IFR) flight from St. Louis to Point Lookout. Following the briefing, he filed an IFR flight plan. The operations manager at M. Graham Clark Airport said that the pilot, while on the ground at St. Louis, contacted him by telephone, at 1348 cst, inquiring what the weather was at the airport. The operations manager told the pilot that the weather was pretty poor and gave him the most-recent observation, which he took a few hours earlier. "He (the pilot) asked me if I could listen for him to call on the CTAF (common traffic advisory frequency) and take a weather observation at that time for him. About 2:40 [p.m. cst] he called me on CTAF and said he was about 10 or 15 minutes out. He asked me if I could call him back with a current weather in about 10 minutes." At this time, another pilot departing the airport in a Cessna 421, N1527G, gave the pilot a pilot report (PIREP) for the field. The Cessna 421 pilot told the pilot of N525KL that the clouds were approximately 1,200 feet mean sea level (msl). The pilot of N525KL radioed the airport manager and told him to disregard the observation; he was going to Springfield, Missouri. At 1411 cst, the Air Traffic Control Tower at Lambert Field/St. Louis International Airport, cleared N525KL for takeoff. One minute later, the pilot was instructed to contact departure control. At 1447:12 cst, N525KL checked in with Springfield Air Traffic Control Tower (ATCT) Approach Control (henceforth, referenced as Springfield Approach Control), and stated that he was descending at pilot's discretion to 10,000 feet msl. Springfield Approach Control told the pilot to maintain 10,000 feet msl and expect the ILS approach to runway 2 at the Springfield-Branson Regional Airport. At 1449:29 cst, Springfield Approach Control cleared N525KL to 6,000 feet msl. N525KL responded, "okay we're down to six thousand..." At 1455:48 cst, Springfield Approach Control instructed N525KL to turn left to a heading of 200 degrees. N525KL acknowledged the instruction. At 1456:30 cst, Springfield Approach Control issued to N525KL, "pilot's discretion descend and maintain four thousand." N525KL responded, "discretion to four thousand for Kilo Lima." At 1501:01 cst, Springfield Approach Control instructed N525KL to descend and maintain 3,000 feet msl, and turn right to a heading of 280 degrees. N525KL responded, "Okay we have a request. Can you give us, we would like to try Point Lookout, the weather doesn't look that bad here now, and then, if we miss, we'll come back up with you." The Springfield Approach controller asked N525KL's pilot what kind of approach did he want. The pilot responded, "We'll take the GPS to [runway] one-one." At 1501:32 cst, Springfield Approach Control instructed N525KL to "descend and maintain three thousand until RAWBE, cleared [for the] GPS [runway] one-one approach." N525KL responded, "Okay, we're down to three [thousand], and we're direct RAWBE, and we're programming that now." At 1507:08 cst, the display of ASR-8 radar at Springfield Approach Control showed N525KL cross the RAWBE waypoint at 3,000 feet msl, and turn to a heading of 116 degrees magnetic. At 1507:17 cst, Springfield Approach Control radar showed N525KL descending out of 3,000 feet msl. At 1508:04 cst, Springfield Approach Control radar showed N525KL level off at 2,500 feet msl. At 1508:51 cst, Springfield Approach Control said, "Citation five Kilo Lima, change to advisory frequency approved. Call me back with your cancellation or your miss." N525KL responded, "Okay we're, we're RAWBE inbound and we will call you on the miss or cancellation." The operations manager at M. Graham Clark Airport said that he was at his desk in the airport operations office when he heard the pilot on the airport's common frequency radio say, "Citation 525KL is RAWBE inbound on the GPS 11 approach." The operations manager said he went to the door of the building to see if he could hear the airplane go missed approach. The weather was no better than it had been earlier. He listened for about 15 to 20 minutes, then went back in. He said that he thought he must have missed hearing the airplane and that the airplane probably went back to Springfield. At 1509:01 cst, Springfield Approach Control radar showed N525KL begin a descent out of 2,500 feet msl. At 1509:46 cst, N1101U, contacted Springfield Approach Control and inquired if N525KL had cancelled yet, or if he was still on the approach? Springfield Approach Control answered, "Still on the approach, I show him just at the final approach fix now." At 1509:48 cst, Springfield Approach Control's last radar contact position for N525KL, showed the airplane 5 nautical miles (nm) from the M. Graham Clark Airport on a 296 degree radial from the airport, at 2,100 feet msl. PERSONNEL INFORMATION The pilot held an airline transport pilot certificate with airplane single and multi-engine land, and instrument ratings. The pilot also held a certified flight instructor certificate (CFI) with privileges to instruct in single and multi-engine land, instrument airplanes. The pilot was also designated by the FAA as a pilot-examiner for the private pilot, commercial pilot, airline transport pilot, and flight instructor certificates in single and multi-engine, instrument airplanes. According to insurance records provided by the College of the Ozarks, and dated May 6, 1999, the pilot reported having approximately 10,150 hours total flying hours. Trip reports, also provided by the college, showed the pilot had logged 328 hours in the Cessna 525. According to FAA airman records, a type rating in the Cessna 525 was added to the pilot's airline transport pilot certificate on August 13, 1998. The FAA reported that the pilot had successfully completed a biennial flight review, in conjunction with the renewal of his pilot examiner authority, in a Beech BE-58, on November 10, 1999. The pilot held a current second class medical certificate, with limitations. According to the Airman Medical Examiner's report, dated August 9, 1999, the pilot's medical certificate contained the statement, "Shall wear corrective lenses." The pilot-rated passenger held a commercial pilot certificate with airplane single and multi-engine land, and instrument ratings. Federal Aviation Administration airman records showed the addition of the multi-engine rating on October 10, 1997. The pilot-rated passenger also held a certified flight instructor certificate (CFI) with privileges to instruct in single and multi-engine land, instrument airplanes. The last reported renewal of this certificate was on November 8, 1997. According to insurance records provided by the College of the Ozarks, and dated October 7, 1999, the pilot-rated passenger reported having approximately 965 hours total flying hours. The records also showed the pilot-rated passenger as having 75 hours in the Cessna 525. The pilot-rated passenger held a current first class medical certificate, with no limitations, dated November 29, 1999. AIRCRAFT INFORMATION The airplane was owned and operated by the College of the Ozarks and was used for the school's business purposes. The airplane was on a continuous maintenance program. A "Phase B" inspection conducted on October 30, 1999, showed the airplane having 753.0 total hours. Trip records provided by the College of the Ozarks showed that on December 6, 1999, the airplane had 781.5 total hours. METEOROLOGICAL INFORMATION The weather surface observation for Harrison, Arkansas, 22 miles south of Point Lookout, for 1451 cst, was 200 feet broken, 900 feet overcast skies, 2 miles visibility, rain and mist, temperature and dew point 53 degrees Fahrenheit (F), winds 100 degrees at 6 knots, and altimeter 29.91 inches of Mercury (HG). The weather surface observation for Springfield Missouri, 38 miles north of Point Lookout, for 1512 cst, was 2,200 feet broken, 6,000 feet overcast skies, 2 and 1/2 miles visibility, light rain and mist, temperature 53 degrees F, dew point 52 degrees F, winds 030 degrees at 5 knots, and altimeter 29.91 inches HG. The weather observation for the M. Graham Clark Airport, taken at 1450 cst, was 300 feet overcast, rain and mist, 3/4 miles visibility, temperature 53 degrees F. winds variable at 3 knots, and altimeter 29.92 inches HG. AIDS TO NAVIGATION The Point Lookout/M. Graham Clark Airport has a Global Positioning System (GPS) approach to runway 11. The initial waypoint, identified as RAWBE, is located 10 nautical miles west from the end of the runway. The published altitude at RAWBE is 3,200 feet msl. After crossing RAWBE, an aircraft proceeds along a 116 degree course, and is cleared to descend to 2,500 feet msl. The aircraft must remain at or above 2,500 feet msl until crossing GARYY, the final approach fix, located 5 nautical miles from the end of the runway. After crossing GARYY, the aircraft can descend to a step-down altitude of 2,000 feet msl until reaching 3.2 nautical miles from the end of the runway. When the airplane reaches 3.2 nautical miles from the end of the runway, a pilot may descend to the minimum descent altitude (MDA) of 1,460 feet msl. The airplane must remain at or above the MDA until reaching BRENL, the missed approach point, located near the runway threshold. On December 10, 1999, at 1325 cst, the FAA conducted a flight inspection of the GPS approach to runway 11 at the Point Lookout/M. Graham Clark Airport. All published waypoints and routing were flown. Flight inspection results were reported as satisfactory. A follow-on flight inspection of the Airport Surveillance Radar (ASR-8), and Mode-S equipment at Point Lookout was conducted by the FAA on December 17, 1999, at 0945 cst. The inspection examined the intermediate approach segment between RAWBE and GARYY waypoints, and checked for general terrain alerts. A general terrain alert occurred 2.5 nautical miles prior to GARYY waypoint, between 2,100 and 2,000 feet msl. Flight inspection results were reported as satisfactory. WRECKAGE AND IMPACT INFORMATION The NTSB on scene investigation began on December 10, 1999, at 1230 cst. The accident site was in Henning State Park, 1/2 mile north- northeast of Missouri Highway 76, and 1 mile west of Branson, Missouri. The accident site was situated on the west-northwest side of a wooded hill, beginning approximately 38 feet northwest of a 100 foot high observation tower which sat at the hill's peak elevation of 1,340 feet mean sea level (msl). The accident site extended west-northwest down the slope of the hill for approximately 250 feet. The accident site was also located 4.3 statute miles west-northwest of the M. Graham Clark Airport on a 290 degree magnetic course. The accident site began with a 75 foot tall oak tree located approximately 283 feet west-northwest of the observation tower on a 296 degree magnetic heading. Several of the top branches ranging from 1 to 4 inches in diameter were sheared off and had fallen east of the tree. The height at which the branches were sheared off equalled an elevation which was approximately 100 feet lower than the top of the hill. Over the next 128 feet, several smaller oak and fir trees were sheared off at locations progressively lower as the accident site progressed along a 116 degree magnetic heading. Tree trunks and branches were scattered along the damage path. Numerous small white paint chips and small metal pieces from the wing's leading edges were scattered among the trunks and branches. The airplane's right wing tip was located 109 feet from the first damaged oak tree on a 120 degree magnetic heading. The wing tip was broken longitudinally along the rivet line. The left main landing gear inboard door was located 110 feet from the first oak tree on a 117 degree magnetic heading. It was broken out at the hinges. A 30 inch section of the airplane's right horizontal stabilizer and elevator was located 110 feet from the first oak tree at a 113 degree magnetic heading. The piece was broken out and bent 75 degrees at mid-span. A piece of the right aileron and a 48 inch section of the right wing upper skin and aft spar was located 129 feet from the first oak tree on a 115 degree magnetic heading. The section was broken out and bent. The airplane's right main landing gear was located 136 feet from the first oak tree on a 115 degree magnetic heading. It was broken aft above the fork, and showed heat and smoke damage. A ground scar, 17 feet long and 10 feet wide, began 138 feet from the first damaged oak tree, and continued into the hillside until reaching an asphalt walking path, next to a 48 inch diameter, and approximately 60 foot tall fir tree. The fir tree was located 155 feet from the first damaged oak tree on a 116 degree magnetic heading. The fir tree was charred at the lower trunk and branches. The upper branches were scorched. A portion of the airplane's right wing was bent around the south side of the tree's trunk at the base. The wing piece was charred and melted. Just south of the fir tree, rested the airplane's tail cone. It was broken off just aft of the engine mounts and was crushed inward. Resting south of the tailcone was the airplane's right engine, a portion of the lower aft fuselage containing the right engine mount and hydraulic reservoir, the top of the airplane's T-tail made up of the horizontal stabilizers and elevators, the rudder, and a 38 inch long, 30 inch wide section of skin from the aft fuselage. The T-tail top was broken off at the top of the vertical stabilizer. The outboard 18 inches of the right horizontal stabilizer and elevator were bent upward and broken off. The airplane's rudder remained attached to the T-tail at an upper hinge co-located with the top 8 inches of the vertical stabilizer's rear spar. The rudder was bent and twisted. The lower aft fuselage containing the engine mount was crushed inward and charred. The piece of fuselage skin was torn out laterally and longitudinally along rivet lines and bent inward. The remainder of the airplane to include the majority of both wings, the left engine, cabin, cockpit, and nose section, was fragmented and scattered along a 116 degree magnetic heading for 75 feet. The airplane pieces rested within a burned wooded area, 82 feet long and 48 feet wide. Numerous oak and fir trees were knocked over, falling uphill along the 116 degree heading. A large piece of the inboard part of the airplane's left wing was located 191 feet from the first damaged oak tree on a 116 degree magnetic heading. The wing was broken off at the wing root, fragmented, charred and melted. The airplane's left main landing gear rested with the wing. The gear strut and cylinder was charred and melted. The tire was consumed by fire. The upper portion of the aft fuselage with the left engine, left engine pylon and base of the vertical stabilizer, was located 214 feet from the first damaged oak tree on a 114 degree magnetic heading. The section was broken open, charred and melted. The engine's cowlings were crushed upward and aft, and showed charring. A 4 foot section of the right wing was located 229 feet from the first damaged oak tree on a 112 degree magnetic heading. The wing section sh
the pilot descended below the minimum altitude for the segment of the GPS approach. Factors relating to the accident were low ceilings, rain, and pilot fatigue.
Source: NTSB Aviation Accident Database
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