Aviation Accident Summaries

Aviation Accident Summary CHI07FA009

Lawrenceville, IL, USA

Aircraft #1

N1832N

Beech 95-B55

Analysis

The airplane was operating on an instrument rules flight plan when it impacted trees and terrain during a non precision approach to the destination airport in night instrument meteorological conditions. About 1 1/2 hours before the accident, the pilot received a weather briefing that indicated expected sky conditions along the route were overcast 300-600 feet above ground level (AGL) and a present sky condition at the destination airport of an overcast ceiling at 400 feet AGL. The pilot did not file an alternate airport as required by Federal Aviation Regulations which require that the ceiling be at least 2,000 feet AGL for at least 1 hour before and for 1 hour after the estimated time of arrival. Sky conditions at the destination airport remained unchanged at the time the airplane was cleared for the approach. The approach minimum, for an aircraft with DME capability, was 410 feet above touchdown elevation. Radar track data for the airplane approach profile was consistent with a controlled approach. The wreckage path through the tree was consistent with a level flight attitude in a direction along the inbound approach course. Additionally, the airplane was configured with the landing gear extended and the flaps extended to 15 degrees, a configuration consistent with an initial approach configuration. No anomalies were noted with the airplane that would have precluded normal operation. Advisory Circular information cites the operation pitfalls in aeronautical decision making of "Get-There-Itis" and Duck-Under Syndrome." The pilot received an Authorization For Special Issuance Of A Medical Certificate, which stipulates the following conditions for its validity, "You must promptly report any adverse changes in your medical condition or medications to the FAA Medical Appeals Section, AAM-313. You are cautioned to abide by Title 14 of the Code of Federal Regulations (CFR's), Section 61.53, relating to physical deficiency, medication, or treatment. Because of your cardiac history, operation of aircraft is prohibited at any time new symptoms or adverse changes occur or if you experience side-effect, or require a change in medication." The pilot was reportedly having palpitations for 20 minutes at a time for the two months prior to the accident and noted being "tired" within a week of the accident, but there is no evidence that he sought medical treatment for the fatigue or palpitations. The investigation could not determine if the pilot's physical condition was a factor in the accident flight.

Factual Information

HISTORY OF FLIGHT On October 26, 2006, about 2212 central daylight time, a Beech 95-B55, N1832N, piloted by a private pilot, impacted trees and terrain during a non-precision approach to runway 18 (5,199 feet by 150 feet, asphalt) at Lawrenceville-Vincennes International Airport (LWV), Lawrenceville, Illinois. Night instrument meteorological conditions prevailed at the time of the accident. The 14 CFR Part 91 flight was operating on an instrument flight rules flight plan. The pilot was fatally injured. The flight departed from Indianapolis International Airport, Indianapolis, Indiana, about 2132 eastern standard time, en route to LWV. The following is a partial transcript of communications between N1832N and Terra Haute FCF/AFSS Preflight-2 position (PF-2): 2044:25, PF-2, *(terre haute) flight service 2044:27, N1832N, good evening er not so good evening uh baron one eight three two november *(up) on the ground at i n d and wanna go instruments here in about thirty minutes to lawrenceville *(i'll) check the weather and file (unintelligible) 2044:43, PF-2, okay there's an airmet for occasional moderate rime or mixed icing in clouds and in precip from the freezing level to flight level two zero zero freezing level's kinda high tonight it looks like about uh ten to eleven thousand feet for that 2044:59, N1832N, wow 2045:00, PF-2, yeah ha ha *(that's) a big change 2045:02, N1832N, *(great) 2045:03, PF-2, um and then for your descent into lawrenceville there's occasional moderate turbulence below fifteen thousand uh and then uh i f r throughout the route there is low pressure dro dominating you've got uh ha ha you're sandwiched in between low two low pressure tof trofs uh one *(in the) northern part one in the southern part of the state uh and as far as uh you being in central indiana and then as you get to lawrenceville it looks like that one the lower that (unintelligible) the trof that's in the southern part of the state is laying right over lawrenceville *(area) 2045:36, N1832N, good 2045:37, PF-2, um uh on radar scattered moderate with some ve very widely scattered heavy cells moving eastward and currently for indianapolis wind one two zero at eight visibility four miles with light drizzle and mist three hundred overcast temperature eight dew point seven and altimeter two niner niner seven and um yeah that's pretty in indicative of what you'll see along your route three hundred to six hundred overcast for the ceilings all the way across and for lawrenceville let's see their automated let's see their latest one was zero one forty one zulu five minutes ago with wind one six zero at eight two miles in mist four hundred overcast temperature eleven dew point niner and altimeter two niner niner three the uh i only have one pilot report um 2046:34, N1832N, (unintelligible) 2046:35, PF-2, over shelbyville an embraer one forty five got light rime icing from twelve thousand five hundred to fifteen thousand five hundred uh looking at the forecast let's see for lawrenceville terre haute's expecting uh seven knots out of the southeast visibilities uh variable from a mile and a half to four miles in mist and uh four hundred overcast and beginning at zero three hundred zulu in a little more than an hour they're expecting some occasional thunderstorms to start moving through that area 2047:10, N1832N, are you showing any of that 2047:13, PF-2, well there's some uh about thirty miles to the west southwest of terre haute there are some uh heavy cells let me see what those tops are it looks like tops up to flight level three five zero and that that looks to be about twenty miles south of mattoon and they also *(there's a) report of some hail in that area 2047:35, N1832N, beautiful 2047:35, PF-2, uh yeah it it's um 2047:37, N1832N, so between here and lawrenceville you're looking pretty clean 2047:41, PF-2, there's uh mostly moderate with a few widely scattered heavy cells but nothing uh that look looks it looks like just showers yeah just showers between there and terre haute once you get into illinois is when you're gonna run into that well actually *(what what) you said you're leaving in half an hour that stuff may be around the terre haute area by then 2048:00, N1832N, yeah okay 2048:03, PF-2, and it looks like it's uh it's uh easy easy enough to go around it 2048:08, N1832N, okay (unintelligible) 2048:08, PF-2, (unintelligible) around to the south of it 2048:10, N1832N, okay *(i don't) have radar but i guess you guys could help me 2048:14, PF-2, yeah yeah 2048:15, N1832N, *(yeah) 2048:15, PF-2, flight watch or flight service 2048:17, N1832N, yeah 2048:19, PF-2, uh actually 2048:19, N1832N, (unintelligible) i'd like to file 2048:20, PF-2, okay go ahead 2048:22, N1832N, there's no notams at uh lawrenceville (unintelligible) is there 2048:24, PF-2, oh let me let me look at that 2048:26, N1832N, thanks 2048:33, PF-2, no lawrenceville has no notams and actually while i'm thinking of it uh flight watch is gonna close here at the top of the hour so uh just flight service will be uh available for you to 2048:45, N1832N, is that one twenty two zero 2048:47, PF-2, no that's uh flight watch they're gonna be closed uh calling us on radio it depends on where you're at but um indianapolis area's twenty two point fifty five terre haute area's twenty two point sixty five 2049:01, N1832N, okay 2049:02, PF-2, and if all else fails one twenty two point two 2049:05, N1832N, okay let's file 2049:08, PF-2, okay 2049:09, N1832N, i f r november one eight three two november it's a b e fifty five slash i *(one) eighty knots i n d say in *(about) half an hour four thousand direct lawrenceville l w v take us about thirty five minutes four hours fuel uh [pilot's name] based at lawrenceville eight one two uh eight eight two six four four eight one aboard white red trim 2049:58, PF-2, okay your flight plan's on file uh pilot reports requested flight watch or flight service 2050:04, N1832N, okay thank you 2050:05, PF-2, sure you're welcome 2050:06, N1832N, *(all right) bye bye 2050:07, PF-2, bye bye The following is a partial transcript of communications between N1832N, Evansville Local Control (EVV LC), Eagle Flight 295 (EGF295), and an unknown agency (UNK): 2159:57, EVV LC, november one eight three to november did you check on 2200:34, N1832N, (unintelligible) one eight three two november twenty six hundred 2200:47, N1832N, evansville approach baron one eight three two november 2201:02, EVV LC, i was off line november one eight three two november did you check on 2201:07, EVV LC, eagle flight two ninety five did you hear another aircraft calling me 2201:09, EGF295, yes sir some kind of baron 2201:11 EVV LC, okay could you tell him to contact me on one two five point six it's ah three two november 2201:16, EGF295, three two november ah contact evansville on twenty five decimal six 2201:24, N1832N, evansville approach baron one eight three two november twenty six hundred 2201:28, EVV LC, baron one eight three two november evansville approach maintain two thousand six hundred till lawrenceville v o r cleared v o r runway one eight approach at lawrenceville report ah v o r outbound 2201:40, N1832N, okay can i get vectors 2201:43, EVV, i can't see you up there at twenty six hundred to give you vectors 2201:45, N1832N, okay 2202:26, EVV LC, current evansville altimeter two niner niner five 2202:31, EVV LC, three two november if you didn't get that evansville altimeter two niner niner five 2202:35, N1832N, affirmative 2203:21, EVV LC, evansville atis information foxtrot is current the wind one five zero at five visibility three and mist sky condition ceiling three hundred overcast and ah temperature one zero dew point one zero altimeter two niner niner five 2206:26, N1832N, and evansville three two november turning outbound ah on one eight 2206:31, EVV LC, baron three two november roger report procedure turn inbound 2206:35, N1832N, three two november 2213:22, N1832N, and evansville two two november established inbound to one eight 2212:25, EVV LC, november three two november roger change over to lawrenceville advisory frequency is approved report cancellation this frequency on the ground or missed approach on this frequency 2212:36, UNK, (unintelligible) There were no further transmissions from N1832N. METEOROLOGICAL INFORMATION The LWV Automated Surface Observing System, recorded the following observations: Each 5-minute observation from 1825 to 2225 recorded sky conditions as overcast 400 feet above ground level (AGL). At 1953, wind 150 degrees at 8 knots; visibility 1 1/4 statute miles (SM); mist; sky condition overcast 600 feet AGL; temperature 11 degrees Celsius (C); dew point 9 degrees C; altimeter setting 29.93 inches of mercury (Hg). At 2053, wind 170 degrees at 8 knots; visibility 2 SM; mist; sky condition overcast 400 feet AGL; temperature 11 degrees C; dew point 9 degrees C; altimeter setting 29.94 inches of Hg. At 2153, wind 170 at 8 knots, visibility 1 1/4 SM; mist; sky condition overcast 400 feet AGL; temperature 11 degrees C; dew point 9 degrees C; altimeter setting 29.93 inches of Hg. PERSONNEL INFORMATION The pilot held a private pilot certificate with airplane single-engine land, multiengine land, and instrument airplane ratings. On May 12, 2006, the pilot was issued a third class airman medical certificate with an exemption and restriction: "must have available glasses for near vision" and "not valid for any class after." The pilot indicated on his airman medical certificate application dated May 12, 2006, a total pilot flight of 2,710 hours and 0 hours in the past 6 months. According to Federal Aviation Administration (FAA) records, the pilot had no reported history of accidents, incidents, or enforcement actions. The pilot logbook(s) were not located at the accident site and no logbook(s) were received by the National Transportation Safety Board or the FAA. AIRCRAFT INFORMATION The 1981 Beech B-55, serial number TC-2413, was registered to Bomac Equipment Corp, of which the pilot was principal. The airplane was powered by two Teledyne Continental Motors IO-470-L engines (right engine serial number 297628-R and left engine serial number 297627-R). The remains of aircraft logbook(s) were not located at the accident site. A repair station provided a work order dated April 24, 2006, indicating that an annual inspection of the airplane was performed at an hour meter and aircraft total time of 2,596.4 hours. AIRPORT INFORMATION LWV was an uncontrolled airport served by runway 18/36 (5,199 feet by 150 feet, asphalt), runway 9/27 (5,198 feet by 150 feet, asphalt), and 4U/22U (1,000 feet by 200 feet, turf). Runway 18 was equipped with runway end identifier lights and a pulsating/steady burning precision approach slope indicator located on the left side of the runway. All of the runway lights were operational and able to be controlled with a handheld transceiver on a frequency of 122.8 during inspection. According to the VOR RWY 18 approach chart, the airport elevation and the runway 18 touchdown zone elevation are both 430 feet mean sea level (MSL). The minimum safe altitude is 2,600 feet MSL north and 2,100 feet south of the LWV VOR. The approach is depicted with an inbound course of 199 degrees with a procedure turn of 334 degrees and 154 degrees. The missed approach point is LWV VOR, which is 0.1 NM from runway 18. The category A and B straight-in-minimums for the VOR approach is 1,020 feet mean sea level (height above touch down 590 feet) and 1 SM visibility. The category A and B VOR approach with distance measuring equipment (DME) straight in minimums is 840 feet MSL (height above touchdown 410 feet) and 1 SM visibility. The VOR with DME final approach segment minimum decent altitudes (MDAs) depicted on the chart is 1,020 feet MSL beyond a VOR/DME distance of 1.7 miles from LWV VOR and 840 feet MSL between a VOR/DME distance of 1.1 and 1.7 miles. The category C approach minimums increased the visibility minimums to 1 1/2 miles for the VOR straight-in approach and 1 1/4 for the VOR/DME minimums. WRECKAGE AND IMPACT INFORMATION The main wreckage, which consisted of the fuselage, wings, and engines, was located in a wooded area at Global Positioning System coordinates: 38 degrees 48.1351 minutes North, 87 degrees 35.3857 West; or about 2.14 nautical miles and 016.7 degrees from runway 18. The main wreckage was approximately 2.06 NM from LWV VOR at an elevation of 530 feet MSL. The wreckage path was approximately 343 feet in length along a heading of approximately 196 degrees in a wooded area with trees approximately 50 feet in height. The wooded area was adjacent to the southern edge of a grass field. The northern edge of the wooded area contained broken branches from the tree tops with white paint chips and left wing tip lens material at the tree bases. Pieces of the aircraft windshield that were located along the wreckage path did not contain soot or damage consistent with fire. A second tree located approximately 200 feet along the wreckage path had broken branches at a height that was approximately equal to the height of broken branches associated with trees located at the northern edge of the wooded area. There was soot present on trees surrounding the main wreckage, which displayed damage consistent with post impact fire. The wings were attached to the fuselage, which was oriented on a tail to nose heading of approximately 305 degrees. The trailing edge wing flaps were extended approximately 15 degrees and the landing gear was extended. All four of the wing fuel tanks were either broken open or damaged by post impact fire. The empennage was separated from the fuselage and located approximately 20 feet north of the main wreckage. Both flaps were approximately at the 15-degree position. The aileron trim tab was approximately 2.25 degrees trailing edge down. The pitch trim tabs were about 1 degree trailing edge down and the rudder trim tab was about 9 degrees trailing edge left. The pitch flight control cables behind the instrument panel were intact and separated at the cabin floor area. The aileron cables behind the instrument panel were connected. The two aileron cables and the aileron balance cable were intact. The rudder control cables were separated at the cabin floor area. All of the flight control cable separations had features consistent with overload. The instrument panel, cockpit switches, and gauges were destroyed by fire. The Hobbs meter was separated from the instrument panel and located on the ground next to the main wreckage. The face of the Hobbs meter was separated from the unit, which indicated a time of 2,623.0 hours. The left propeller was attached to the engine and did not exhibit leading edge damage. The propeller blades were deformed aft and forward along various blade spans. The blade tips were twisted towards the lower pitch direction. The right propeller was located approximately 50 feet south-southwest of the main wreckage. The propeller was separated from the propeller flange, which exhibited features consistent with overload. Examination of both engines and accessories revealed no anomalies that would have precluded operation. MEDICAL AND PATHOLOGICAL INFORMATION The Federal Aviation Administration Final Forensic Toxicology Fatal Accident Report reported: carbon monoxide not performed, cyanide not performed, ethanol not detected in muscle and brain, metoprolol detected in liver and heart. The pilot had a heart attack with complications 18 months prior to the accident. One of the largest arteries supplying blood to his heart was found completely blocked and was reopened with a balloon device (angioplasty); a stent was placed to help maintain the artery open. Two other arteries supplying blood to the pilot's heart also had significant blockage, but were not treated. Immediately following the heart attack, the pilot had complications including abnormal heart rhythms leading to decreased blood pressure, and reduce

Probable Cause and Findings

The improper judgment by the pilot to conduct a flight to, and execute an approach to, an airport with weather conditions that were below the required minimums. Also causal was the pilot's continued descent below the approach minimum descent altitude. Contributing factors were the below approach landing weather minimums, the night light conditions, and the lack of a planned alternate airport by the pilot.

 

Source: NTSB Aviation Accident Database

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