Aviation Accident Summaries

Aviation Accident Summary FTW03FA059

Eagleton, AR, USA

Aircraft #1

N127YV

Beech 1900C

Analysis

The aircraft collided with mountainous terrain in a level descent during a visual approach to the destination airport. According to recorded radar data, 10 minutes after descending from 15,000 feet, the flight impacted about 200 feet below the top of the partially obscured ridgeline (elevation of 2550 feet), and 8 miles from the destination. The data indicates the flight path was similar to the global positioning satellite (GPS) approach to the airport. Six minutes before the accident, and the pilot's last transmission to air traffic control, he was informed and acknowledged that radar service was terminated. The flight was 12.4 miles from the accident site when radar contact was lost. Reduced visibility due to fog hampered search & rescue efforts, and the aircraft wreckage was located the next day. The aircraft was equipped with a GPS navigation system; however the installation was incomplete, restricting its use to visual flight rules (VFR) only. The investigation did not determine if the GPS was being used at the time. A non-enhanced Ground Proximity Warning System was also installed. The maximum elevation figure listed on the sectional aeronautical chart covering the area of the accident site and destination airport was 3000 feet mean sea level. The chart also shows an advisory for the area to use caution due to rapidly rising.

Factual Information

HISTORY OF FLIGHT On December 9, 2002, approximately 1140 central daylight time (CDT), a Beech 1900C twin turboprop airplane, N127YV, registered to Raytheon Aircraft Credit Corporation of Wichita, Kansas, and operated by Raytheon Aircraft Services Inc., of Wichita, Kansas, was destroyed when it collided with terrain approximately 8 miles north of the Mena Intermountain Municipal Airport (M39), Mena, Arkansas. The airline transport pilot and 2 airline transport pilot rated passengers sustained fatal injuries. The flight originated from Mid-Continent Airport (ICT), Wichita, Kansas, at 1043, and its intended destination was Mena, Arkansas. Visual meteorological conditions prevailed en route from Wichita toward Mena, and a flight plan was not filed for the Title 14 Code of Federal Regulations Part 91 business flight. VFR flight following was requested by the pilot after takeoff from Wichita. The airplane had been in Mena, Arkansas, at Rose Aviation Inc., undergoing refurbishment and final preparations for a acceptance/delivery flight to its new owner. Rangeflyers Inc., of Wichita, Kansas, was contracted by Raytheon Credit Corporation to provide pilot services to Rose Aviation to facilitate delivery of the airplane to Hageland Airlines, of Anchorage, Alaska. On the morning of the accident the airplane departed Mena at 0620 with two Rangeflyers pilots; one acting as the pilot-in-command (PIC), and the other pilot who, according to Rangeflyers, was listed as a pilot rated passenger. The intent of the flight was to pick up the CEO/President of Hageland Airlines, who was the airline's representative to accept delivery and finalize the purchase of the airplane. The airplane landed at Wichita approximately 0745 after an uneventful flight from Mena. The airplane parked approximately 2.5 hours at the Raytheon Aircraft Services ramp at Wichita waiting to make a return flight to Mena. The intent of the flight from Wichita to Mena was to transport the CEO of Hageland Airlines to Mena (Rose Aviation) so he could authorize a pre-purchase agreement for another 1900C, after which, he was going to fly from Mena to Wichita with a Rangeflyers PIC to accept delivery of N127YV. Just prior to takeoff from Wichita, a Raytheon employee witnessed the non-PIC Rangeflyers pilot close the main cabin door. According to air traffic control (ATC) records provided by the FAA, at 1031, the PIC of N127YV contacted Wichita Clearance Delivery and requested "VFR to Mena, Arkansas," at 17,500 feet. Wichita Clearance Delivery acknowledged the request and assigned transponder code "0451." At 1043, the airplane departed Wichita en route to Mena. At 1049, Wichita Departure Control contacted N127YV and advised them that radar services were terminated, and to squawk "VFR." N127YV then requested radar flight following en route to Mena. Wichita Departure Control then assigned N127YV to Kansas City Center for radar flight following. At 1128, N127YV switched frequencies from Kansas City Center to Memphis Center, and advised Memphis Center that they were at an altitude of 15,500 feet and "VFR." Memphis Center acknowledged, "report Mena airport in sight, Fort Smith altimeter [setting] three zero three six." From recorded radar data provided by the FAA, the airplane began what appeared to be a steady descent out of 15,500 feet at 1130:22. At 1132:35, radar showed the airplane descending through 11,900 feet. At 1133:09, radar showed the airplane descending thru 9,800 feet, at 241 knots ground speed, on a bearing of 122 degrees. The last recorded radar data point, at 1135:58, showed the airplane at 5,100 feet, at 190 knots ground speed, on a bearing of 126 degrees. At 1136:43, Memphis Center advised N127YV that radar contact was lost and radar services were terminated (which was normal for the mountainous area in which the airplane was flying). At 1136:49, the pilot of N127YV acknowledged, "thanks, have a good one." No further radio transmissions were received from N127YV. The airplane did not arrive in Mena. A missing airplane search was initiated by the Civil Air Patrol (CAP) and local law enforcement. The wreckage was spotted in rugged mountainous terrain near the top of a 2,550-foot ridge line by a CAP airplane on the afternoon of December 10, 2002. Foot access to the accident site was hindered by rain, fog and steep, rocky terrain. When plotted on a topographical chart, the distance between the last radar contact of the airplane and the accident site was approximately 12.4 nautical miles. The distance between the accident site and the airplane's intended destination (Mena) was approximately 8 nautical miles. PERSONNEL INFORMATION The pilot's personal flight logbook was not reviewed. FAA records showed that the pilot held a valid airline transport pilot certificate, issued on August 1, 2002. He was type-rated in the BE-1900, ME-300, and BE-400 and had completed the Flight Safety International 1900D airliner pilot recurrent course on February 28, 2001. He also held an instrument rating and instructor ratings for single engine land, multi-engine land, and instrument airplane. The pilot held a valid FAA first class medical certificate dated, July 8, 2002, with no limitations. As of the date of his last medical certificate application, the pilot reported 10,108 total flight hours with 150 flight hours in the previous 6 months. The pilot had been contracted by Rangeflyers, Inc. to provide pilot services in support of the pending sale of the accident airplane. As of the date of the accident, the pilot had completed seven check flights in the accident airplane, totaling 4.3 hours. AIRCRAFT INFORMATION The 1990 model Beechcraft 1900C Airliner, serial number UC-127, was configured as a passenger transport, and was powered by 2 Pratt & Whitney, Canada, Inc., PT6A-65B turbo propeller engines. Each engine was equipped with a Hartzell Propeller, Inc., HC-B4MP-3A four-bladed (composite blades), hydraulically operated, constant-speed propeller with feathering and reversing capabilities. The airplane had seating for 19 passengers, two aircrew stations, and dual flight controls. A cockpit voice recorder system was installed. A flight data recorder system was not installed. The airplane had a separate pitot static system for the pilot's flight instruments and for the co-pilot's flight instruments, and was equipped with dual communication and navigation radios. Time Summary Airframe S/N UC-127: Approximately 12,473.7 hours since manufactured. Left Engine S/N GG32390: Approximately 12,128.9 hours since new, 462.1 hours since overhaul. Left Propeller S/N FWA3367: Approximately 11,064 hours since new. Right Engine: S/N GG32543: Approximately 12,537.9 hours since new, 462.1 hours since overhaul. Right Propeller S/N FWA3368: Approximately 10,625 hours since new. A GPS navigation system was installed, and the airplane was equipped with a non-enhanced GPWS (ground proximity warning system). A review of the Honeywell GPWS Pilot Guide revealed the following listed system constraint: A non-enhanced GPWS may give little or no advanced warning time for flight into precipitous terrain where there are few or no preceding obstructions. This particularly applies if the aircraft is in a stabilized descent at a normal approach descent rate, and there is no ILS glide slope signal being received or not available. A review of FAA registration records revealed that the airplane was purchased by Beech Acceptance Corporation, Inc. on November 30, 1990, and was leased to Mesa Airlines during the period, December 4, 1990, to January 5, 1996. Beech Acceptance Corporation, Inc. became Raytheon Credit Corporation, Inc. The airplane was leased to Raytheon Aircraft Services during the period, April 1, 1997, until November 28, 1999. A review of the airplane's logbooks revealed that Raytheon Aircraft Services (RAS) located in Rockford, Illinois, inspected the airplane on February 21, 2000, at 12,460.0 hours total airframe time and 0.0 hour meter time. On March 7, 2000, and March 17, 2000, RAS conducted routine maintenance. Cutter Aviation, Inc., located in Albuquerque, New Mexico, made logbook entries to reflect the airplane was being maintained in preservation during the period September 11, 2000, until October 17, 2001. Airplane flight log records showed that the airplane was delivered to Rose Aircraft Services, Inc., located at Mena Intermountain Municipal Airport on September 24, 2002, at a airplane total time of 12,467.5 hours, and hour meter 10.6 hours. According to the flight logs, seven maintenance flights were flown by the accident pilot between November 21, 2002, and December 6, 2002, totaling 4.3 hours. It was noted in the logs that during the first maintenance flight, the hour meter was not operating. The hour meter read 13.8 hours on December 6, 2002, at the completion of the last maintenance flight. The flight logs and aircraft records did not show any outstanding discrepancies. Hageland Airlines had contracted with Raytheon Aircraft Airline Sales (RAAS) to purchase UC-127 after their specified alterations had been completed. RAAS contracted Rose Aviation, which is located at Mena Intermountain Municipal Airport, to perform the work. That work included paint and interior modifications and the installation of a Bendix/King KLN 90B GPS navigation system. The airframe and engines were inspected, and the propellers were overhauled. Rangeflyers, Inc. was contracted by RAAS to provide pilot support to Rose Aviation for function maintenance flights and for the delivery of the airplane. A review of the airplane FAA Form 337 revealed A KLN 90B GPS installation was completed on November 11, 2002. The Form 337 installation description reported that the KLN90B system was coupled to the installed Collins HPU 74 EHSI (pilot's horizontal situation indicator) through a switching unit controlled by a switch labeled NAV/GPS. The Form 337 reported that a placard stating "GPS Approved For VFR Use Only" had been installed on the pilot instrument panel, and the requirements of FAR 91.407 (b) had not been complied with. The AlliedSignal Aerospace KLN 90B Pilot's Guide, P/N 006-08773-000, Chapter 1 - KLN 90B System Components states the following: "A basic KLN 90B system consists of a panel mounted KLN 90B GPS sensor/navigation computer, a data base cartridge, and an antenna. An altitude input is required to obtain full navigation and operational capabilities. Additional system components may be added or interfaced to the KLN 90B which increases its features and capabilities. Some of these optional components include an external course deviation indicator (CDI) or HSI, RMI, fuel management system, air data system, ARTEX ELS 10 emergency locator transmitter (ELT), autopilot, and external annunciators." "The KLN 90B panel mounted unit contains the GPS sensor, the navigation computer, a CRT display, and all controls required to operate the unit. It also houses the data base cartridge which plugs directly into the back of the unit." (The data base can be updated by either replacing the data cartridge or by interfacing a laptop computer to the panel mounted unit. The data base is updated every 28 days.) The Pilot's Guide, Chapter 6, states the following caution: "CAUTION: The KLN 90B obtains approach information from the database. Therefore, it is extremely important that the database is current. The KLN 90B is approved for IFR non-precision approaches only when the database is current. If you attempt to select an approach when the database is out of date, you will be given the status-message: "OUTDATED DB" in the bottom center portion of the screen as a reminder." "In some installations the aircraft will have a NAV/GPS switch to select which navigation source is displayed on the primary HIS or CDI." A review of the KLN 90B installation FAA Form 337 revealed that the IFR QAI installation procedures had not yet been completed, consequently there was a placard stating "GPS Approved For VFR Use Only" installed on the pilot instrument panel. There was no record that the database had been updated. The instrument panel was examined at the accident site and again at ASOD, but the NAV/GPS switch could not be identified. The KLN 90B panel mounted unit and the pilot's EHSI unit were consumed by the post impact fire. It is unknown whether or not the KLN 90B was being utilized for navigation at the time of the accident. METEOROLOGICAL INFORMATION Verbal reports from local law enforcement, rescue personnel, and the Civil Air Patrol were given to the NTSB IIC. Low clouds and reduced visibility had initially restricted air search efforts and ground crews from reaching the accident site. Interviews of residents in the valley below the ridgeline, revealed that they recalled the ridgeline to be partially obscured about the time of the accident. The local sheriff reported that he recalled that cloud layers were obscuring the ridgeline about the time of the accident, and that it was "typical" for the ridgeline to be obscured at that time of the year in the late morning hours. The following are METAR reports from available weather reporting facilities within 50 miles of the accident site: Mount Ida, Arkansas (MWT), located about 33 miles southeast of the accident site, at 1153 reported calm wind, visibility 10 miles, overcast 5,500, temperature 6 degrees Celsius, dew point 1 degree Celsius. Poteau, Oklahoma (RKR), located about 35 miles to the northeast of the accident site, at 1131 reported wind from 040 at 3 knots, overcast 5,000, temperature 6 degrees Celsius, dew point 2 degrees Celsius. AIDS TO NAVIGATION Recorded radar information was obtained from the FAA, and was plotted on a topographic map along with the position of M39 Runway 17/ 35, the accident site position, and the M39 GPS RWY 17 approach. A review of the FAA radar information and the plot revealed the airplane started a descent from 15,500 feet MSL at 1130 CST, while tracking 125 degrees over the ground. The last recorded radar contact was recorded at 1135:58 CST, at which time the airplane was at 5,100 feet MSL, and had been on a ground track of about 125 degrees and at a ground speed of about 190 knots. When the radar ground track was extended it intersect the GPS RWY 17 approach for M39 at the BATEZ initial approach fix (IAF). The accident site location was 0.6 nm right of the GPS RWY 17 inbound course and before (north) of the approaches MIDHY final approach fix (FAF). The approach's published minimum altitude between the IAF and FAF positions was "no lower than" 3,600 feet MSL altitude. The highest point in the immediate area of the accident site is identified on the current Memphis Sectional Aeronautical Chart as being 2,570 msl. The current Sectional Aeronautical Chart had the following caution associated with the mountainous area north of Mena: "Rapidly Rising Terrain Use Caution During Periods Of Low Ceiling And Visibility." The Maximum Elevation Figure (MEF) denoted on the Memphis Sectional in the quadrant that encompasses both the accident site and Mena Intermountain Airport was 3,000 feet msl. The MEF, which is annotated on sectional charts in large, bold, blue numerals, is based on information available concerning the highest known feature in each quadrangle, including terrain and obstructions. FLIGHT RECORDERS The cockpit voice recorder (CVR) was recovered and transported to the NTSB Vehicle Recorder Laboratory in Washington, DC. CVR's housing was intact but showed evidence of thermal distress on the outside. When opened in the laboratory, the internal components displayed severe thermal damage and the recorder's tape could not be downloaded. No information was derived from the CVR. See NTSB CVR Group Chairman's Report for further details. The airplane was not equipped, nor was it required to be equipped, with a flight data recorder. WRECKAGE AND IMPACT INFORMATION Initial examination of the wreckage at the accident site commenced on December 12, 2002. The wreckage was located on rising, heavily wooded, mountainous terrain, Global Positioning System (GPS) coordinates; North 34 degrees 41 minutes 15 s

Probable Cause and Findings

In-flight collision with terrain due to the pilot's failure to maintain clearance and altitude above rapidly rising terrain while on a VFR approach. Contributing factors were the obscuration of the terrain due to clouds.

 

Source: NTSB Aviation Accident Database

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