Billings, MT, USA
N195GA
BEECH 1900C
About one minute after takeoff on a night Instrument Flight Rules (IFR) contract cargo flight, the tower controller advised the pilot that he was squawking the wrong transponder code. Although the pilot reset the transponder to the correct code, he was advised that he was still squawking the wrong code. He then realized that he had selected the wrong transponder, and then switched to the correct one. During the time the pilot was dealing with this issue, the airplane drifted about 30 degrees right of the assigned heading, but the pilot returned to the correct heading as he was contacting the departure controller. The departure controller cleared him to continue his climb and instructed him to turn left about 120 degrees, which he did. About 40 seconds after initiating his left turn of about 120 degrees, while climbing straight ahead through an altitude about 4,700 feet above ground level (AGL), the pilot was instructed to turn 20 degrees further left. Almost immediately thereafter, the airplane began turning to the right, and then suddenly entered a rapidly descending right turn. The airplane ultimately impacted the terrain in a nearly wings-level nose-down attitude of greater than 45 degrees. At the moment of impact the airplane was on a heading about 220 degrees to the right of the its last stabilized course. The investigation did not find any indication of an airframe, control system, or engine mechanical failure or malfunction that would have precluded normal flight, and no autopsy or toxicological information could be acquired due to the high amount of energy that was released when the airplane impacted the terrain. The determination of the initiating event that led to the uncontrolled descent into the terrain was not able to be determined.
HISTORY OF FLIGHT On May 23, 2008, about 0124 mountain daylight time, a Beechcraft 1900C, N195GA, impacted the terrain about three miles northeast of Billings-Logan International Airport, Billings, Montana. The airline transport pilot, who was the sole occupant, was killed, and the airplane, which was owned and operated by Alpine Air Express, was destroyed by the impact and a post-crash fire. The 14 CFR Part 135 contract mail flight departed Billings-Logan Airport about three minutes prior to the impact. The pilot was on an Instrument Flight Rules (IFR) flight plan. There was no report of an Emergency Locator Transmitter (ELT) activation. At 01:17 on the morning of the accident, the pilot of Alpine Flight 5008 made his initial contact with Billings Ground Control. He advised the controller that he was at the postal ramp requesting taxi for takeoff. He said that he would like to pick up his IFR clearance to Great Falls, and advised the controller that he had Information Sierra (a recording of the surface weather observation transmitted on the Automatic Terminal Information Service). The controller cleared him to taxi to runway 10 Left via taxiway Alpha. The controller then cleared the pilot to Great Falls via the Billings Two Departure and then "as filed." The controller cleared him to climb to and maintain 7,000 feet mean sea level (MSL), and told him to expect 16,000 feet as an initial cruising altitude. The pilot was then advised to squawk transponder code 4361. The pilot read back the entire clearance, and the controller then explained to the pilot that he could not assign the flight an initial cruising altitude of 18,000 feet MSL (the initially filled altitude) because of a "low altimeter." The pilot responded that he did not have any problem with being assigned the lower altitude. At 0120:27, the pilot advised the tower that he was ready for departure on runway 10 Left. The controller cleared the pilot for departure, and advised him to turn to a heading of 070 degrees after takeoff. The pilot then initiated the takeoff, and according to recorded radar data, upon reaching a point about one-half way down the runway, he established a ground track of about 070 degrees. About 0122:14, which was about one minute and thirty-five seconds after the pilot read back his takeoff clearance and pulled onto the runway to initiate the takeoff roll, the tower controller asked him to check his transponder code. The controller also reminded the pilot that his assigned code was 4361. Six seconds later, the pilot responded, "There's 4361. I rotated it one notch too far." About 20 seconds later, while the aircraft was passing through about 5,500 feet MSL, the controller transmitted, "Alpine five thousand eight, I show you on a VFR (Visual Flight Rules) code. It must be the other transponder you have on" (Note: The aircraft had two transponders, either of which could be selected by a switch located on the center console just to the right of the pilot's right knee.) Eight seconds later, the pilot responded with, "All right. Stand by." And then about six seconds after that response, the pilot asked, "How's that?" The controller advised the pilot that he was now receiving the correct code, and then directed the pilot to contact Departure Control. According to the recorded radar data, just after the pilot started dealing with the issue of the transponder code, the airplane's course started drifting to the right. At 0123:02, when the first full 4361 beacon code data was received, the airplane's course had turned about 30 degrees to the right. Immediately after the first 4361 beacon code data was received, the airplane started to turn back to the left. By about 0123:20 the airplane had returned to its original course. Upon contacting the departure controller, the pilot advised the controller that he was passing through 6,500 feet for 7,000 feet on a heading of 070. The controller advised the pilot that he had radar contact, directed him to turn left to a heading of 310 degrees, and then cleared him to climb to and maintain 16,000 feet. The pilot responded with, "Three ten. Up to one six thousand. Alpine five thousand eight," and then according to recorded radar data, turned to the assigned heading and continued his climb. About 40 seconds after the pilot had been told to turn to 310 degrees, the controller instructed him to turn further left to a heading of 290 degrees, to join Victor 187 (a low-altitude airway), and then to resume his own navigation. The pilot responded with, "Two ninety to join. Own nav. Alpine, uh, five thousand." Then, according to the recorded radar data, instead of the airplane turning further to the left, it started turning right at about the same rate of turn as it had when the pilot first initiated his turn from 070 degrees to 310 degrees. According to the Continuous Data Recording (CDR) Editor Listing Data, the last radar return containing valid mode C altitude data occurred at 0124:10. The CDR data associated with that return indicated a smoothed altitude of 7,832 feet, a magnetic heading of 329 degrees, and an airspeed of 190 knots. The next CDR data information, recorded at 0124:15, contained no reported altitude, but indicated a magnetic heading of 350 degrees, and an airspeed of 180 knots. By the time the next CDR data was recorded at 0724:21, the radar had gone into coast mode (a mode where the radar system makes predictions based upon the previous trend). Soon thereafter, a parking lot security camera at a business near the crash site recorded a portion of the fireball that accompanied the impact. The time superimposed on the video at the moment of impact indicated 0824:18. (Note: The hour indication on the camera was one hour off due to daylight savings time, and the accuracy of the minutes and seconds indication could not be verified). PERSONAL INFORMATION The 40 year old pilot held an airline transport rating (ATP) for Airplane Multi Engine Land, with commercial privileges for Airplane Single Engine Land. He had been type rated in the Beech 1900, on January 20, 2007. He had accumulated about 4,770 hours of flight time, of which about 362 hours were in the Beech 1900. According to Alpine Air, he logged 162 hours of night time, and 36 hours of actual instrument time in the 90 days prior to the accident. A review of his flight/duty activity for the three days prior to the accident revealed that on May 19 he reported for duty at 2000, and went off duty at 0430 on the morning of May 20. While on duty he flew 2.6 hours. On the evening of May 20 he reported for duty at 1945, and went off duty on the morning of May 21 at 0300. While on duty he flew 1.2 hours. He reported for duty at 1945 on the evening of May 21, and went off duty the morning of May 22 at 0730. While on duty he flew 3.5 hours. He came on duty at 2200 on the evening of May 22, and the accident occurred about three hours and 20 minutes later, on the morning of May 23. During the investigation, the Investigator-In-Charge (IIC) talked with a number of friends and associates of the pilot. According to those discussions, the pilot had been acting normally during the 72 hours leading up to the accident. He was reported as being good-natured, not dealing with any known emotional or psychological issues, and not appearing to be tired or sick. He had participated in some family activities on the evening of May 22, prior to reporting for duty at Alpine Air. When the pilot arrived at the Alpine Air hangar about 2200, he was advised that the airplane he was assigned for that night's flight to Great Falls (N125GA) was already in position at the ATO (the post office facility on the south side of the airport). He was then asked if he would taxi N195GA over to the ATO ramp. That airplane (N195GA) had just undergone maintenances, and was scheduled to be flown on the Butte/Helena, Montana, run by another pilot. He (the accident pilot) then taxied N195GA to the ATO ramp. Reportedly, after the mail had been loaded into his assigned airplane (N125GA), the pilot started his pre-flight inspection of the airplane around 2400. According to Alpine Air, during that inspection, the pilot discovered a mail cart-induced skin puncture that grounded that airplane (N125GA). Alpine Air then made the decision to have the pilot take N195GA to Great Falls, and to have another airplane, that would become available later, assigned to the Butte/Helena flight. The pilot therefore had the cargo (mail) moved from N125GA to N195GA, and then he performed a preflight inspection on N195GA. According to one of the other pilots, who briefly interacted with the accident pilot that night, he (the accident pilot) seemed a "little more serious" than usual. It was the opinion of the other pilot that the only reason for the "seriousness" was the fact that the sequence of events associated with the change of airplanes caused the accident pilot to have more activities/responsibilities on his mind during the preparation/pre-departure time. AIRCRAFT INFORMATION The airplane was manufactured in 1986, and as of May 21, 2008, the airframe had accumulated 34,650.8 hours and 48,452 cycles. It was being maintained under Alpine Air's Approved Aircraft Inspection Program (AAIP). The last D2 inspection was performed on January 8, 2008, and the last D3 inspection was performed May 1, 2008. The last C inspection was performed on May 21, 2008. Both engines underwent hot section inspections on April 14, 2008. The right propeller was last overhauled on March 30, 2004, and the left propeller was last overhauled on September 28, 2006. A review of the Aircraft Flight and Maintenance Log (AFML) revealed that after the airplane landed on the morning of May 20, 2008, an entry was made indicating that both engines were low on power (torque) at altitude, but that they made acceptable power on the ground for takeoff. According to one of the pilots who had recently flown the airplane, and who had made a write-up entry addressing this anomaly, neither of the airplane's engines developed as much torque at altitude, within ITT (Inter-Turbine Temperature) limits, as the other Beech 1900's in the fleet. He also stated that the left engine had experienced a torque loss of between 300 to 500 pounds when it was climbing through an altitude of between 7,000 to 10,000 feet MSL. It was this pilot's opinion that the torque loss did not affect the airplane's controllability, but that it could possibly be an irritant or distraction to a pilot. The corrective action listed in the AFML for both engines was, "Calibrated the ITT and torque indication. Performed an engine power check per B1900 Maintenance Manual Chapter 76. Found in an airworthy condition." The airplane did not fly on May 21, but there were three engine related entries made in the AFML. The first was, "Left ITT gauge unadjustable." The corrective action was, "Removed and replaced left ITT gauge with a serviceable unit. Calibrated ITT gauge. Ops check good." The second discrepancy entry stated, "Both engines due Torque and ITT need calibration due to not being able to determine that previous calibration was done." The corrective action listed was, "Calibrated both engines Torque and ITT systems. Both systems needed some adjustments, but were in limits when complete." The third discrepancy stated, "Both engines are low torque after Torque and ITT calibration." The corrective action listed was, "Performed engine ground runs power check per B1900 Maintenance Manual, Chapter 176, after bleed valve maintenance. Found in airworthy condition, reference LP (log page) 73492, Item 6 and 7." The airplane did not fly on May 22, but an engine bleed valve closing test was performed on both engines in accordance with chapter 73 of the Pratt & Whitney Maintenance Manual. The bleed valve on the right engine checked "Good," but the bleed valve on the left engine did not meet specifications. The left engine bleed valve seat was replaced, and the bleed valve closing check was repeated. The resulting entry on log page 73492, Items 6 and 7 was "Checks Good." AIRPLANE WEIGHT AND BALANCE During the investigation the IIC reviewed both the United States Postal Service Daily Weight Scanning Report and the Alpine Aviation Beechcraft 1900 Load Manifest for the accident flight. According to the manifest the airplane was loaded with 2,800 pounds of fuel, and a total cargo weight of 3,795 pounds. According to the manifest, the airplane's estimated takeoff weight was 15,606 pounds, which is 994 pounds below its maximum takeoff weight of 16,600 pounds. The manifest indicated that the nose cargo area was empty; bay one held 108 pounds of cargo; bay two held 854 pounds; bay three remained empty; bay four held 1,128 pounds; bay five held 997 pounds; bay six held 420 pounds; and bay seven held 288 pounds. According to the manifest, the takeoff weight index was –0.2, and the center of gravity (CG) was determined to be within limits by use of a CG calculator. METEROLOGICAL INFORMATION The hourly Billings-Logan Airport aviating surface weather observation (METAR) taken at 0053, about 30 minutes prior to the accident, indicated winds from 080 degrees at 18 knots, gusting to 24 knots. The visibility was 10 statute miles, with light rain. There were scattered clouds at 600 feet above ground level (AGL), and overcast clouds at 1,000 feet AGL. The temperature was 08 degrees Celsius, with a dew point of 06 degrees Celsius. The altimeter setting was 29.60 inches of mercury. The Special METAR taken at the same location at 0142, about 18 minutes after the accident, indicated winds from 080 degrees at 13 knots, a visibility of 10 statute miles, and light rain. There were scattered clouds at 800 feet AGL, and overcast clouds at 1,200 feet AGL. The temperature was 08 degrees Celsius, with a dew point of 07 degrees Celsius. The altimeter setting was 29.60 inches of mercury. According to the pilot of the Alpine Air flight that departed via the Billings Two Departure about five minutes prior to the accident flight (Alpine 5014), his airplane entered the clouds about 300 to 400 feet above the ground. He said that the clouds were solid up to about 7,500 to 8,000 feet mean sea level (MSL), where he broke out before entering another layer about 9,000 feet MSL. He reported encountering hard rain during the departure, but no ice or turbulence. He stated that the visibility below the clouds was good. Another Alpine Air flight took off from the same runway about two minutes after the accident flight (Alpine 5006), but with an assigned initial departure heading of 120 degrees. According to the pilot of that flight, the visibility below the clouds was good, and he encountered very little rain. He could not recall at what altitude he entered the clouds. Witnesses who were in the general area of the crash at the time of impact reported the precipitation as either a light steady rain or a drizzle. One individual said that about 10 minutes after the accident it started to rain hard. All the witnesses reported low or very low clouds in the area, with some reporting areas of fog underneath the clouds. Although some witnesses said there were some light breezes in the area, none reported strong or gusty winds at the time of impact. WRECKAGE AND IMPACT INFORMATION The center of the primary impact crater was about 15 feet north of a cinderblock building on the north side of Jerrie Lane, about 100 yards west of Main Street (State Highway 87/312). From that point wreckage and cargo were spread along a path on a magnetic heading of about 196 degrees. Some pieces of small dense cargo traveled along the impact/wreckage track to a distance of over 630 feet from the initial impact point. The primary crater measured about 20 feet from north to south, and about 15 feet from east to west. The center of the crater was about four feet deep, and mounds of displaced dirt up to one foot high had been thrown up beyond the southwest side of crater's edge. There was a separate crater adjacent to the north end of the primary crater. This crater was about two feet deep at its center, and measured about four feet north to south, and about six feet east to west. The airplane's right engine was lying
The pilot's failure to maintain aircraft control during the initial climb for undetermined reasons.
Source: NTSB Aviation Accident Database
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