# NTSB ANC04FA063: Beech C-45H, N401CK, Kodiak, AK, June 14, 2004 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: June 14, 2004, 11:37 local (19:37 UTC) - Place: Kodiak, AK - Coordinates: 57.761665, -152.303054 - Nearby events: https://openairdocs.org/map.md?lat=57.7617&lon=-152.3031&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed, report September 13, 2005 - Report: Approved by Office Director - NTSB office: Alaska Regional Office - Parties: Federal Aviation Administration (Airworthiness), Honeywell, Federal Aviation Administration (Operations) - NTSB case key (mKey): 59439 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ANC04FA063 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/59439/pdf - Page: https://openairdocs.org/ntsb/ANC04FA063 ## Probable cause 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. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - In flight collision with object, missed approach (ifr) - weather condition - low ceiling (contributing factor) - weather condition - fog (contributing factor) - insuff standards/requirements,operation/operator, company/operator mgmt (contributing factor) - weather condition - rain (contributing factor) - impairment(drugs), pilot in command (contributing factor) - ifr procedure - not followed, pilot in command (cause) - inadequate certification/approval,airman, faa(organization) (contributing factor) ## Analysis 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. ## Factual narrative 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 grou ## Aircraft - Registration: [N401CK](https://openairdocs.org/deregistered/N401CK-2017-05-31), registration cancelled 2017-05-31, S/N 51-11503, built 1952 (OpenAirDocs) - Reported make and model: BEECH C-45H - Registry model: [Beech C-45H](https://openairdocs.org/model/beech-c-45h) (registry code 1151018) (OpenAirDocs) - Registry engine: [AiResearch TPE331 series](https://openairdocs.org/engine/airesearch-tpe331-series) (registry code 01514, turbo-prop) (OpenAirDocs) - Category: Airplane - Serial number: 51-11503 - Engines: Honeywell TPE331 665 horsepower turbo prop; Honeywell TPE331 665 horsepower turbo prop - Damage: Destroyed - Flight: Part 135 - Operator: Bellair Inc - Registered owner: Kamichia M. Darby - Airworthiness certificate: Standard, Normal - Departed: ANC, Anchorage, AK - Destination: ADQ, Kodiak, AK - Flight plan: IFR - Airport: ADQ, Kodiak, runway 25, 7,548 × 150 ft ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 56; injuries: fatal; airline transport; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 1, with waivers/limitations; last flight review March 1, 2004; seat: left; toxicology performed; flight hours: 18,600 total, 2 in the last 24 hours ## Weather - Conditions: Instrument (IMC), Day - Wind: 60° at 11 knots - Visibility: 2 statute miles - Lowest ceiling: 500 ft broken - Temperature: 46 °F, dew point 43 °F - Altimeter: 30.00 inHg - Observed at: ADQ, 10 nm away ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 20040614013169A](https://openairdocs.org/incident/20040614013169A), Jun 14, 2004: Beech C45H, Kodiak, AK, Destroyed, 1 fatal. (-23) At approximately 1131 adt, the pilot in command of N401CK, who had been holding for an estimated 45 minutes east of the Kodiak, AK airport (adq) due to… From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.