Rocksprings, TX, USA
N43KM
BEECH C90
The pilot was cleared to 17,000 feet approximately 7 minutes after takeoff. After arriving at 17,000 feet, radar showed the airplane in a meandering flight path increasingly off course that continued through the end of the flight, even after several prompts from the controller. The pilot was cleared to flight level 240 (24,000 feet) after about 6 minutes at 17,000 feet, and about 2 minutes later, while passing through about 18,000 feet, he made his last radio transmission, acknowledging a corrected heading. About 6 minutes later, the airplane arrived at 24,000 feet and the pilot did not make any intelligible responses to controller inquiries for the remainder of the flight. At 1456, radar showed the airplane in a descent to 21,000 feet before beginning a rapid descent and continuing to impact. The airplane was substantially damaged by the impact forces and the pilot, who was the only occupant, was fatally injured. During the review of the air traffic control recordings, it was determined that none of the voice transmissions from N43KM sounded as if the pilot was speaking through an oxygen mask microphone. At the accident scene both bleed air switches were observed to be in the closed position and the airplane pressurization switch on the console was observed to be in the dump position. No other preimpact anomalies were observed that would have prevented the normal operation of the airplane.
HISTORY OF FLIGHT On December 14, 2008, approximately 1500 hours central standard time, a Beech C90A King Air, N43KM, registered to and operated by Western Wings Corp., Roseburg, Oregon as a 14 CFR Part 91 flight, impacted terrain following a descent from cruise flight. Visual meteorological conditions prevailed and an instrument flight rules (IFR) flight plan had been filed. The airplane was substantially damaged by the impact forces. The commercial pilot, who was the only occupant, was fatally injured. The airplane had departed the Hondo Municipal Airport (HDO) Hondo, Texas at approximately 1425, en route to the Phoenix Goodyear Airport (GYR) Goodyear, Arizona. The pilot was cleared to 17,000 feet approximately 7 minutes after takeoff. After arriving at 17,000 feet, the pilot began a meandering flight path increasingly off course that continued through the end of the flight, even after several prompts from the controller. He was cleared to flight level 240 (24,000 feet) after about 6 minutes at 17,000 feet, and about 2 minutes later, while passing through about 18,000 feet, he made his last radio transmission, acknowledging a corrected heading. About 6 minutes later, he arrived at 24,000 feet, and did not make any intelligible responses to controller inquiries at that time or for the remainder of the flight. At 1456 he descended to 21,000 feet before beginning a rapid descent. Several witnesses reported seeing the airplane just before it impacted terrain. The first call to 9-1-1 emergency was logged at 1500. The accident flight was the first flight following an aircraft repaint at a Federal Aviation Administration (FAA) certificated repair station (CRS) at the HDO airport. Two mechanics at that CRS said the owner of N43KM and several other persons arrived in the owner’s Falcon 10 “at 2:00 pm sharp”. During the time before N43KM departed, the aircraft owner first took several photos of the newly painted airplane. They then observed that the owner spent several minutes in the cockpit with the pilot of N43KM. After a restroom stop the pilot then climbed back into N43KM, started the right engine first, left engine second, and then taxied out toward the north. While N43KM was stationary and facing north the owner got a cell phone call from the pilot in N43KM. The owner told the pilot "you have to switch the toggle switches for fuel transfer or you won't get any fuel". Several minutes after that cell phone call they heard the engines rev up and witnessed N43KM takeoff to the south on runway 17L. The aircraft made a normal takeoff and all three landing gears retracted. Another witness was the owner of N43KM. His party, which included the accident pilot, arrived on a Falcon Jet flight from Oregon and landed at the HDO airport at 1345. After arrival the owner said he observed that the pilot of N43KM took 45 minutes to prepare and preflight the aircraft including about 10 minutes spent on an exterior preflight. The owner said he went into the cockpit with the pilot to verify his understanding of the Shadin fuel computer and he verified that the tanks were full of fuel and the pilot had plenty of fuel to make it to GDY. The pilot told the owner that he would most likely stop in EI Paso to refuel just for safety's sake. The owner then watched the pilot start the engines and taxi north to the end of runway 17. He heard the pilot perform the over-speed governor check, the auto-feather check, and the full propeller feather check. Before taking the active runway, the pilot made a cell phone call to the owner to verify the position of the fuel switch positions on the fuel panel. The pilot confirmed that he had it correct and that he understood that nomenclature, but was just checking to make sure. The owner said he then observed the takeoff which appeared picture perfect. A witness at the accident scene was a ranch employee who said he heard a loud bang and looked up and saw the airplane falling out of the sky in a slow spin with a lot of white smoke. The witness lost sight of the airplane prior to impact. The witness then went to the crash site where he saw another witness. Another witness was an unnamed person that the owner of N43KM personally interviewed near the accident scene on the day after the accident. In a December 31, 2008 e-mail message the owner of N43KM wrote: “I then spoke to an eye witness who observed the aircraft coming down. The witness said the plane was in a spin all the way from altitude until impact. He thinks it took 2 to 3 minutes from when he first heard it until it crashed. He said it sounded like someone doing aerobatics. He believed, but was not sure the aircraft was spinning counterclockwise. This witness said he observed at least one of the engines depart the aircraft and saw smoke as the engine departed. This was shortly before he lost site of the airplane and heard the impact with the ground. He estimated the impact was 5 to 10 seconds after he saw the engine depart the aircraft. He said he continued to see pieces of aluminum raining down for quite some time after the impact”. PERSONNEL INFORMATION The pilot, age 67, held a commercial pilot certificate with airplane single-engine land, multi-engine land and instrument airplane ratings. The pilot was issued a second class medical certificate on April 29, 2008, with no restrictions. The pilot's log book was not located during the investigation. Records provided by the aircraft owner show the pilot had an estimated 3,500 hours of pilot experience, of which 1,300 hours were in multi-engine airplanes with an estimated 250 hours of experience in the accident airplane. The pilot completed the "BE-90/100/200, 61.157 Initial Course" at the Flight Safety training center at Long Beach, California on August 31, 2007. That training included 2.0 hours of ground training in King Air F-90 differences and included 10.0 hours of training in a King Air 200 Level C flight simulator. The pilot completed a biennial flight review (BFR) concurrent with the training course. The pilot completed the "King Air 200 Recurrent Training course with 90 differences" at Jet Aeronautical LLC, El Cajon, California on October 15, 2008. That training included 8 hours of ground training in aircraft systems and flight procedures relating to the King Air 200/ F90 aircraft. It also included 6 hours of training in a King Air 200 advanced aviation training device (AATD). A BFR was not completed at that time. AIRCRAFT INFORMATION N43KM (s.n. LJ-1345), a model C90A King Air, was a low-wing, 7-place, multi engine land airplane manufactured by the Beech Aircraft Corporation in 1993. At the time of manufacture the airplane was originally equipped with two Pratt & Whitney Canada (PWC) turbo propeller PT6A-21 engines each rated at 550 horsepower, driving two McCauley 4-blade, constant speed, aluminum alloy propellers. The airplane was equipped with a Bendix/King Enhanced Ground Proximity Warning System (EGPWS). A review of the airplane logbooks and FAA Records revealed the following: The airplane was being maintained in accordance with the manufacturer's inspection program. A CRS in Medford, Oregon installed two PWC PT6A-135A engines in accordance with Blackhawk Modification, STC SA10341SC and two Hartzell 4-blade propellers were installed in accordance with Raisbeck Engineering, STC SA3593NM. A new cabin door seal P/N 50-430043•1211 and seal assembly P/N 50-430061-21 were installed and a pressurization check was performed in accordance with Beechcraft Maintenance Manual Chapter 21-30-00. No discrepancies were reported. The airplane oxygen tank and oxygen regulator were removed for testing and overhaul, reinstalled, and the oxygen tank was serviced. The most recent inspection, a phase four inspection, was completed by the CRS on October 24, 2008, at 3711.5 total flight hours. At the time of the accident the airplane had accumulated a total of 3,725.1 flight hours and was powered by two PWC turbo propeller PT6A-135A engines (s.n. PCE-PZ0797 and s.n. PCE-PZ0798) each rated at 550 horsepower, driving Hartzell 4-blade, constant speed, aluminum alloy propellers On November 8, 2008, the airplane was flown to the HDO airport to be re-painted. The flight control surfaces were removed before painting the airframe, and were then balanced and re-installed on the airframe. The re-paint was completed at 3724.7 total flight hours. There were no reported open maintenance discrepancies with the airplane at the time of the accident. METEOROLOGICAL INFORMATION Surface analysis charts at 1200 and at 1500 depicted a low pressure system located over the Texas panhandle with cold fronts extending to the east over northeastern Oklahoma and to the west over southeastern Arizona. The accident site was located well to the southeast of the center of the advancing low pressure system. Observations surrounding the accident site indicated visual flight rules (VFR) conditions with mostly clear skies and visibilities of 9 to 10 miles prevailing at the time of the accident. At 1451, the automated surface observing system (ASOS) at Kimble County Airport (JCT), Junction, Texas, located approximately 47 miles northeast of the accident site, reported the wind from 240 degrees at 8 knots, visibility 10 statute miles, clear of clouds, temperature 28 degrees Celsius, dew point 2 degrees Celsius, and an altimeter setting of 29.71 inches of Mercury. COMMUNICATIONS At 1429:56, N43KM contacted the FAA Houston Air Route Traffic Control Center (ARTCC) Stonewall Radar (STV-R) controller and said “houston center king air (unintelligible) three kilo mike (unintelligible) pick up our i f r up to goodyear arizona”. At 1430:18, the controller instructed N43KM to squawk a transponder code of 4016 and N43KM responded. At 1431:56, the controller said “november four three kilo mike radar contact ah six miles northwest of hondo and i show you passing six thousand”. At 1432:03, N43KM responded by stating “six thousand five hundred yes sir”. At 1432:06, the controller said “november three kilo mike roger you’re cleared to ah golf yankee romeo airport as filed climb and maintain one seven thousand---the ah uvalde altimeter two niner seven four”. At 1432:15, N43KM responded by stating “two niner seven four cleared to one seven thousand to ah goodyear”. At 1438:17, the STV-R controller said “november three kilo mike contact ah houston center one three two correction ah one two five point seven five”. At 1438:26, N43KM responded by stating “one two five seven five for ah three kilo mike”. At 1438:53, N43KM contacted the Houston ARTCC, Rocksprings Radar (RSG-R) controller and reported at 17,000 feet. At 1440:30 the RSG-R controller cleared N43KM to climb to and maintain FL 240. N43KM acknowledged the clearance. At 1442:08, the controller instructed N43KM to amend their altitude and maintain 17,000. At 1442:13, N43KM acknowledged the clearance by stating, "one seven thousand four kilo mike". At 1442:24, the controller said “november four three kilo mike i show you turned north to a turned to the north a little bit are you back direct el paso”. At 1442:30, N43KM responded by stating “back direct el paso”. At 1442:36, the controller said “november four three kilo mike ah just want to make that ah you’re not experiencing any problems or emergencies (unintelligible)”. At 1442:41, N43KM responded by stating “yeah (unintelligible) okay”. At 1442:51, the controller said “november four three kilo mike did you deviate around some weather or something---you were ah through one seven thousand and you descended and turned north”. At 1442:58, N43KM responded by stating “yes sir we’re testing an autopilot and had a malfunction but it’s corrected”. At 1443:02, the controller said “okay thank you sir”. At 1444:51, the controller said “november four three kilo mike climb and maintain flight level two four zero”. At 1444:55, N43KM responded by stating “two four zero for four kilo mike”. At 1446:25, the controller said “november four three kilo mike are you proceeding direct el paso yeah you’re still ah right of course”. At 1446:31, N43KM responded by stating “show direct el paso i’ll correct”. At 1446:36, the controller said “what do you show the heading”. At 1446:39, N43KM responded by stating “ah two nine zero”. At 1446:42, the controller said “(unintelligible) four three kilo mike i’m showing a no wind heading of two eight five take into account the winds you probably need about a two eight zero heading---possibly even two seven five for now november four three kilo mike fly heading two eight zero when able direct el paso”. At, 1446:53, N43KM responded by stating “heading two eight zero direct el paso when able”. At 1455:36, the controller said “november four three kilo mike houston”. At 1455:58, the controller said “november four three kilo mike houston” At 1456:07, the controller said “november four three kilo mike houston”. At 1456:16, the controller said “november four three kilo mike no reply received if you hear center ident”. At 1456:52, the controller said “king air four three kilo mike houston center”. At 1457:35, the controller said “november four three kilo mike houston center”. At 1457:39, an unintelligible sound was heard that lasted approximately two seconds. At 1457:43, the controller said “and ah if that was november four three kilo mike i didn’t get a voice i just ah got carrier only ident please if you hear center november four three kilo mike”. The controller called N43KM six more times over the next 4 1/2 minutes but received no response. During the Safety Board’s review of the air traffic control (ATC) recordings the sound of an aural warning was not heard on any of the transmissions from N43KM. Further, none of the voice transmissions from N43KM sounded as if the pilot was speaking through an oxygen mask microphone. RADAR INFORMATION A direct course from the HDO airport to El Paso, Texas was measured at approximately 293 degrees at a distance of 398 nautical miles. A review of the radar data from the first radar contact at 1430 until 1440 shows the airplane's flight path was tracking a course of approximately 294 degrees. At 1440, after the airplane had leveled at 17,000 feet it began a meandering course of approximately 340 degrees until 1442. For the next three minutes it began to turn back to the left with a course of approximately 300 degrees. At 1445 the airplane then began to drift back to the right to a course of approximately 318 degrees. At 1446, the airplane turned to the left for an average course of 290 degrees until 1453. During the next five minutes the airplane meandered from 270 degrees to 340 degrees with an average course of approximately 322 degrees. Radar data shows the airplane began to climb from 17,000 feet at 1445 and reached flight level 240 at 1453. The airplane began to descend from flight level 240 at 1456. The last radar contact at 1457:59 was 4,800 feet to the southwest from the main wreckage location. WRECKAGE AND IMPACT INFORMATION Investigators from the Safety Board, the FAA, and Hawker Beechcraft Corporation examined the wreckage at the accident scene on December 15 and 16, 2008. The accident site was on relatively flat rocky and grassy terrain with adjacent areas that were sparsely covered with scrub trees. The main wreckage was located at 30 degrees, 10 minutes, 23 seconds north latitude, and 100 degrees, 35 minutes, 30 seconds west longitude, at an estimated elevation of 2,200 feet mean sea level (MSL). All recovered portions of the wreckage of the airplane were found in an area approximately 1,000 feet by 1,600 feet. The wreckage examination revealed the following: The fuselage was observed upright on a measured heading of 120 degrees. The rear fuselage was separated forward of the FS 364 bulkhead. The left cabin upper sidewall was separated from the left cabin lower sidewall forward of the air stair door, and the cabin was rolled over
The pilot's failure to properly configure the pressurization controls, resulting in his impairment and subsequent incapacitation due to hypoxia.
Source: NTSB Aviation Accident Database
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