Kodiak, AK, USA
N401CK
BEECH C-45H
The solo airline transport pilot departed on a commercial cargo flight in a twin-engine, turboprop airplane. As the flight approached the destination airport, visibility decreased below the 2 mile minimum required for the initiation of the approach. The pilot entered a holding pattern, and waited for the weather to improve. After holding for about 45 minutes, the ceiling and visibility had improved, and the flight was cleared for the ILS 25 instrument approach. After the pilot's initial contact with ATCT personnel, no further radio communications were received. When the flight did not reach the destination airport, it was reported overdue. A search in the area of an ELT signal located the accident airplane on a hilly, tree-covered island. A witness located to the north of the airport reported seeing a twin-engine turboprop airplane flying very low over the water, headed in an easterly direction, away from the airport. The witness added that the weather at the time consisted of very low clouds, fog, and rain, with zero-zero visibility. A local resident also stated that the weather conditions were often much lower over the water adjacent to the approach end of the airport than at the airport itself. The missed approach procedure for the ILS 25 approach is a climbing left turn to the south. About one minute after the accident, a special weather observation was reporting, in part: Wind, 060 degrees (true) at 11 knots; visibility, 2 statute miles in light rain and mist; clouds and sky condition, 500 feet broken, 900 feet broken, 1,500 feet overcast; temperature, 46 degrees F; dew point, 44 degrees F. According to FAA records, the company was not authorized to conduct single pilot IFR operations in the accident airplane, and that the accident pilot was the operator's chief pilot. Toxicology tests revealed cocaethylene and chlorpheniramine in the pilot's blood and urine.
HISTORY OF FLIGHT On June 14, 2004, about 1137 Alaska daylight time, a Beech C-45H Volpar, twin-engine turboprop airplane, N401CK, was destroyed during an in-flight collision with tree-covered terrain, about 10 miles east of Kodiak, Alaska. The airplane was being operated as an instrument flight rules (IFR) non-scheduled domestic cargo flight under Title 14, CFR Part 135, when the accident occurred. The airplane was owned by Kamichia M. Darby, and operated by Bellair, Inc., of Anchorage, Alaska. The solo airline transport pilot received fatal injuries. Instrument meteorological conditions prevailed at the flight's destination airport, and an IFR flight plan was filed. The flight originated at the Ted Stevens Anchorage International Airport, Anchorage, about 0955, and was en route to Kodiak. According to Federal Aviation Administration (FAA) personnel assigned to the Anchorage air route traffic control center (ARTCC), at 0955 the accident airplane departed from Anchorage southwest toward Kodiak. As the flight approached Kodiak, ceilings and visibility around the airport continued to deteriorate below the 2 mile visibility limit required before the approach could be initiated. The pilot elected to hold east of the airport, and wait for more favorable weather conditions before being cleared for an ILS approach to the airport. After holding for about 45 minutes, and after the ceilings and visibility had improved to 500 feet broken and 2 miles visibility respectively, the flight was cleared for the ILS 25 instrument approach. At 1132, the pilot was instructed to contact the Kodiak air traffic control tower (ATCT). After the pilot made initial contact with Kodiak ATCT personnel, no further radio communications were received from the accident airplane. When the flight did not reach the Kodiak Airport, it was reported overdue at 1137. In addition, Kodiak ATCT personnel reported a faint emergency locator transmitter (ELT) signal was being received. Search personnel from the Coast Guard and Alaska State Troopers initiated an extensive search in the area of the ELT signal. Shortly after initiation of the search, a Coast Guard helicopter crew located the accident airplane on the southern end of Long Island, within an area of hilly, tree-covered terrain. A Coast Guard rescue swimmer was lowered to the accident site, and discovered that the pilot had been fatally injured. During a telephone conversation with the National Transportation Safety Board (NTSB) investigator-in-charge (IIC), on June 17, a witness who resides in Kodiak, reported that about the time of the accident, she saw a light-colored, twin-engine turboprop airplane flying very low over the water, headed in an easterly direction, away from the Kodiak Airport. The witness added that weather conditions at the time consisted of low clouds, fog, and rain. In her written statement to the NTSB, she wrote, in part: "The fog visibility was 0.0. [zero-zero] at most times that morning." DAMAGE TO AIRCRAFT The airplane was destroyed by impact forces. CREW INFORMATION The accident pilot was the chief pilot for the company. He held an airline transport pilot certificate with airplane single-engine land, and multiengine land ratings. He also held a flight engineer rating for reciprocating engine airplanes. The most recent first-class medical certificate was issued to the pilot on May 27, 2004, and contained the limitation that he wear corrective lenses. No personal flight records were located for the pilot, and the aeronautical experience listed on page 3 of this report was obtained from a review of FAA airmen records on file in the Airman and Medical Records Center. On the pilot's application for medical certificate, dated May 27, 2004, the pilot indicated that his total aeronautical experience consisted of 18,600 hours, of which 300 were accrued in the previous 6 months. A review of the pilot's medical records on file with the FAA's airman branch revealed that on May 15, 1990, the pilot pled no contest to State of Alaska charges of attempted misconduct involving a controlled substance, cocaine. The pilot received a suspended imposition of sentence for one year. The conditions of the suspension were that the he have no criminal violations for a year, and serve 72 hours in jail. According to the pilot's FAA medical records, the FAA was not aware of this conviction until November 1992. The pilot's FAA medical records also revealed that the pilot tested "positive" for cocaine use in July 1990, during a "reasonable suspicion" drug test that was initiated by the pilot's employer. A memo entered into the accident pilot's medical records by the pilot's employer's medical review officer (MRO), a third party drug and alcohol program administrator, stated in part: "[The pilot] admitted to having used cocaine." The pilot told the MRO, in part: "I have already talked to my employer about this. It was really stupid thing to do. It was one time, and I'll never do it again." The MRO noted "He was briefly questioned as to the cause of the reasonable suspicion test. He indicated that he had been stopped by the Anchorage police some months ago for being in a car with some friends who were found to be in possession of cocaine. His employer had become aware of this by Flight Standards, who are considering a certificate action, and requested the test on that basis." On August 13, 1990, FAA medical records note "Assistant Chief Counsel, AAL-7, ordered an emergency order of revocation of this airman's pilot certificate for a recent conviction involving drugs. Airman voluntarily surrendered the attached medical certificate and signed the accompanying release." During a conversation with the NTSB IIC on June 21, 2005, the FAA's Regional Counsel, Alaska Region, reported that to the best of his recollection, after a review by FAA headquarters staff, the certificate revocation was reduced to a one year suspension, and that during an informal hearing with the pilot regarding the suspension, the pilot surrendered his medical certificate. The pilot subsequently began outpatient treatment for alcohol/cocaine abuse. A discharge summary dated March 13, 1991, from an outpatient treatment center notes "...The client is assessed as alcohol/cocaine abusive. His secondary issues include ...denial - minimization of alcohol abuse... though the client admits to being alcohol/cocaine abusive, it is still uncertain if he has accepted and internalized this. ... The client's prognosis is fair if he complies with his Aftercare recommendations..." An April 10, 1991 neuropsychology evaluation noted, in part: "History was obtained exclusively through a clinical interview with the patient. ... has had 36 random urinalyses during the past five months and was found to be consistently clean ... When asked about his cocaine history, the patient stated that he had used it a few times during the year prior to being found "dirty" in May, 1990. ... he has never had a problem with alcohol abuse. ... states that he only used the cocaine a few times. ... Obviously, he went through a very difficult time following the death of his wife, and used cocaine to self-medicate some of his emotional pain. He is no longer at risk for using recreational drugs in this respect. He has resolved much of his grief reaction, and is not in need of any further psychiatric care at present. Prognosis is quite good for continued prosocial adjustment during coming years. ..." On June 14, 1991, the FAA Aeromedical Certification Division sent the pilot a letter that affirmed the pilot's eligibility for a first class medical certificate. The FAA's letter mandated that continuing eligibility for certification was contingent on random drug screening with a 24-hour notice and remaining substance-free. Failure to submit to the random drug screening, or a positive test, would be grounds for immediate invalidation/revocation. This requirement was restated in an April 29, 1992 letter of medical certification from the FAA requiring the pilot to "... remain substance free from all mood altering chemicals ..." A July 8, 1992 letter to the pilot noted that he had completed required drug screening and that "...continuing eligibility for certification is contingent upon your sustained total abstinence from the use of any illegal drugs. ..." There are no records of any drug tests in the pilot's FAA medical file except for the initial positive test in July 1990. On August 30, 1995, an FAA aviation drug abatement program inspector entered a memo into the accident pilot's medical records file stating, in part: "...an informant who wishes to remain anonymous advised me that [the pilot] attempted to obtain drugs from a friend of his. The informant stated that a female friend (who is also a pilot) and a female companion were approached by a man claiming to be [the pilot] while they were at... an Anchorage bar... the man asked if they could get him some crack or cocaine. The female pilot asked the man how he could get away with using drugs since he was a pilot and the man stated that he [unreadable] get around the drug tests. The informant claims that the female pilot left, but claims that someone subsequently sold the man some drugs." There was no record of any FAA follow up concerning this allegation. On March 20, 1996, a memo faxed to the regional flight surgeon, Alaska Region, from the medical review officer for the pilot's employer at the time, states, in part: "[The Pilot] called me earlier this week to seek advice as to how to approach the fact that he recently had a DUI arrest." According to the fax, the medical review officer contacted the pilot's employer, and noted that there was no observations to suggest impairment or alcohol use in any proximity to the workplace or that the pilot was using alcohol excessively while not at work. The closing remark in the fax, stated: "I now understand that [the pilot] is going to see you later this week..." There was no record in the pilot's FAA medical records noting that the pilot contacted the regional flight surgeon as indicated. The pilot's May 1, 1996 application for first class medical certificate indicated that he had been convicted on charges of driving while intoxicated. A review of the Alaska State Court System records revealed that on October 29, 1995, the accident pilot was arrested for driving while intoxicated. He subsequently pled guilty on January 8, 1996. On May 20, 1996, the pilot completed a psychiatric evaluation. The examining physician noted in his written report, in part: "... on October 29 of last year [the pilot] was prosecuted for a driving while intoxicated offense, although at the time of the current evaluation the ultimate conclusion of that proceeding is not clear. ... alcohol consumption has approximated four to six beers per week over the 12 months leading up to his DWI arrest last fall. ... in an incident of poor judgment, he apparently blew a breathalyzer greater than 0.1 and is now in the midst of some scrutiny from the FAA and Anchorage Police Department. ... I do not believe he is need of formal psychotherapeutic interventions as he is not 'mentally ill.' On the other hand, he would benefit from complete abstinence from all alcohol, and continuation of random urinalysis and/or breathalyzer testing ..." There is no indication in the medical file that the FAA ever received or reviewed the report of arrest or conviction, or that any additional random testing was ever performed. On December 16, 1996, the regional flight surgeon, Alaska Region, wrote a letter to the pilot stating: "Your application for first class medical certificate dated May 1, 1996, has been forwarded to this office by the Aeromedical Certification Division in Oklahoma City for our review.... The first class medical certificate issued to you by [the doctor] is valid as issued. ...Additionally, your continued airman medical certification will remain contingent on your total abstinence from use of alcohol." On August 26, 1997, the Alaska regional flight surgeon sent a letter to the pilot stating, in part: "...medical information reveals a history of alcohol abuse. You are ineligible for medical certification... We have determined, however, that you may be granted authorization for special issuance of the enclosed first-class airman medical certificate... This authorization expires October 31, 1997. Prior to consideration for a new authorization, you must provide letters from your employer, counselor, and AA sponsor attesting to your total abstinence and sobriety for the use of alcohol or other mood altering substances. ...Your continued airman medical certification is contingent on your complete abstinence and sobriety from the use of alcohol or other mood-altering substances." According to a representative from the regional flight surgeon's office, Alaska Region, the pilot had several meetings with the regional flight surgeon in the flight surgeon's office. The representative noted that there was no record of the pilot submitting the required documentation outlined in the August 26, 1997, letter to the pilot. On October 15, 1997, a memo about the pilot from the regional flight surgeon's office, Alaska region, to the aeromedical certification division, reported that the pilot had since moved from his previous residence, and left no forwarding address. The memo states, in part: "Our security folks went out knocking on doors trying to find him. They did, and we have a new address for him. Not sure how long this one will last. ... He's not happy about his time limited certificate; however, he does have one now plus a requirement for a follow up." A January 5, 1998, "Notice of Client Assessment and Recommendations" from a treatment center, indicates "The client was not found appropriate for Intermediate Care or Outpatient Treatment due to findings of no criteria needing treatment. He does not need our services at the present time ..." Except for this notice, there are no additional reports in the medical file of any evaluations of any sort for substance abuse after May 20, 1996. A May 5, 1998 memo regarding the pilot from the FAA Alaska Regional Flight Surgeon's office to the FAA Aeromedical Certification division notes "... This airman recently went to AME and got a new medical. I spoke with you last week regarding airman issuance by AME, which you stated was okay. ..." The pilot's most recent application for 1st class airman medical certificate dated September 1, 2003, indicates "yes" for "substance dependence or failed a drug test ever," for "history of ... any conviction(s) involving driving while intoxicated ..."...and for "history of nontraffic conviction(s) ..." Under "explanations" is noted "previously reported." The NTSB's medical officer provided an extraction of the accident pilot's FAA medical records. A copy of the extracted records is included in the public docket for this accident. Prior to being hired by Bellair, Inc., the pilot received a preemployment drug test as part of the Department of Transportation's Drug Abatement Program on March 9, 2001. The results were negative. During a telephone conversation with the NTSB IIC on December 10, 2004, a representative from Alaska Aviation Toxicology, Inc. (AAT), the company that provided third party administration of Bellair's drug abatement program, reported that after the accident pilot received his preemployment drug test on March 9, 2001, no additional drug tests were conducted. The representative added that when a computer generated random drug was requested, a notice would be sent to Bellair's president/owner, who would then contact the pilot who was required to submit to the random drug test. According to the AAT representative, the accident pilot had not been randomly selected for an additional drug test while employed by Bellair, Inc. A review of pilot's airman certification records, on file with the FAA's airman branch, revealed that on January 7, 2004, the pilot landed a Beech C-45H Volpar, twin-engine turboprop airplane, on Taxiway Yankee at the Ted Stevens Anchorage International Airport, Anchorage. According
The pilot's failure to follow proper IFR procedures by not adhering to the published missed approach procedures, which resulted in an in-flight collision with tree-covered terrain. Factors contributing to the accident were a low ceiling, fog, rain, and the insufficient operating standards of company management by allowing unauthorized single pilot instrument flight operations. Additional factors were the pilot's impairment from cocaine, alcohol, and over the counter cold medication, and the FAA's inadequate medical certification of the pilot and follow-up of his known substance abuse problems.
Source: NTSB Aviation Accident Database
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