ANC98FA091

NTSB accident investigation · Swearingen SA-26AT · St. George, AK · July 7, 1998

Accident · FatalField investigationFinal report
Date
July 7, 1998, 15:47 local (23:47 UTC)
Place
St. George, AK
Injuries
2 fatal
Damage
Destroyed
Phase of flight
Approach
Aircraft
N501FSSwearingen SA-26AT
Weather
Instrument (IMC) · Day
Status
Completed · report March 30, 2000
Report
Approved by Office Director
NTSB office
Alaska Regional Office
FAA report
19980707015999A
Case key
43058

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

The pilot-in-command's failure to adequately monitor the instrument approach and the co-pilot's failure to intercept and maintain the proper NDB bearing on the approach. Contributing factors were the pilot-in-command's obstructed view of the NDB indicator and his overconfidence in his personal ability, the terrain (cliffs), low ceiling, and the flight crew's disregard of the minimum descent altitude.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

In flight collision with terrain/waterApproach - iaf to faf/outer marker (ifr)
Flight/nav instruments,radio magnetic indicator - obstructedFactor
Monitoring - inadequatePilot in commandCause
Overconfidence in personal abilityPilot in commandFactor
Terrain condition - cliffFactor
Proper alignment - not obtained/maintainedCopilot/second pilotCause
Weather condition - low ceilingFactor
Minimum descent altitude - disregardedFlightcrewFactor

Analysis

The flight departed Anchorage, Alaska, and was en route to Saint George, Alaska, to pick up passengers for a return flight to Anchorage. The pilot-in-command (PIC) was seated in the right seat, and the copilot was seated in the left seat. This was the copilot's third flight in this make and model airplane, and he was not qualified as a crewman in it under 14 CFR Part 135. There was no record of when the copilot last performed a nondirectional beacon (NDB) approach. The NDB indicator in the cockpit was on the left side of the left control column, partially blocked from the view of the PIC. The minimum altitude for the segment of the approach prior to the final approach fix (FAF) was 1,700 feet. The Minimum Descent Altitude (MDA) for the final segment of the approach was 880 feet. The reported ceiling was 100 feet overcast. The Air Route Traffic Control Center radar altitude readout for the airplane revealed that the airplane descended below 600 feet prior to reaching the FAF. The radar ground track revealed the airplane on course prior to the course reversal procedure turn on the published approach. The radar ground track showed that after the course reversal, the airplane continued through the published final approach course, and turned to parallel the inbound track three miles north of course. The radar plot terminates about the location of the 550 feet high cliffs where the airplane was located. Weather at the time of the accident was reported as 100 foot overcast. This location was 5.5 miles (DME) from the airport. A review of radar tapes from the day prior to the accident, show the same airplane and PIC tracking the published course outbound and inbound, and descending below the published approach minima to below 500 feet. This flight successfully landed at the airport. An interview with the copilot from the successful flight revealed that the PIC intentionally descended to 300 feet on the approach until he acquired visual contact with the ocean, then flew to the airport to land. An aircraft flying on the published inbound final approach course at 5.5 DME is over water, approximately three miles from the nearest terrain.

Factual narrative

History of flight

On July 7, 1998, about 1547 Alaska daylight time, a Swearingen SA-26AT Merlin-IIB airplane, N501FS, operated by F. S. Air Service, Inc., of Anchorage, Alaska, was destroyed when it impacted terrain about 5.5 miles west-northwest of the New Saint George Airport, Saint George, Alaska. The two occupants, both flight crewmembers, sustained fatal injuries. The pilot-in-command (PIC) was the president and owner of F. S. Air Service, Inc., and occupied the right pilot seat. The copilot was not qualified as a pilot-in-command of the SA-26AT, and occupied the left pilot seat. The flight was conducted under 14 CFR Part 91 as a positioning flight to pick up three passengers for an on-demand charter flight from Saint George. The flight departed Anchorage International Airport at 1240 under a VFR flight plan, and an IFR clearance was received approximately 100 nautical miles northeast of Saint George. Instrument meteorological conditions prevailed at Saint George at the time of the accident.

The last recorded radio communication from the airplane was at 1527, when the flight was cleared by the Anchorage Air Route Traffic Control Center (ARTCC) to perform the NDB/DME-A instrument approach.

A witness who was awaiting pickup by the accident airplane told the NTSB investigator-in-charge (IIC) that he was waiting at the airport and heard an airplane fly over the airport on a southwesterly course about 1545. He said that the airplane transmitted that it was F. S. Air beginning the approach. No other transmission was overheard. The witness stated that the ceiling was about 300 feet.

About 1600, the flight was reported overdue, and a search was initiated. The wreckage was located about 1630 by fishing boats near the northwest end of the island.

The main wreckage came to rest on a beach, at the bottom of an approximately 550 feet high cliff. The location was 5.5 nautical miles on a magnetic bearing of 285 degrees from the airport. Portions of the wreckage was consumed by a postcrash fire. Lightweight debris from the airplane was located on the top of the cliff.

Damage to aircraft

The airplane was destroyed by a combination of impact forces and postcrash fire.

Personnel information

Pilot-In-Command

The PIC was seated in the right seat. He held an airline transport pilot certificate with ratings for multiengine airplanes, and a commercial pilot certificate with ratings for single-engine land and sea airplanes, and multiengine seaplanes. He held type ratings in the CASA-212 and Lear Jet. He was authorized to fly as pilot-in-command under 14 CFR Part 135 in SA-26AT, SA-227, LR-35, CASA-212, SC-7, BE-18T, and PA-31 airplanes.

His most recent 14 CFR 135.293, 135.297, and 135.299 checks were completed on June 12, 1998, in a PA-31 airplane. This check was administered by a company check airman, and included an NDB approach.

Records of flight time were not up to date on the PIC. The most recent records available indicated that he had accumulated over 13,000 hours of flight experience, with over 5,000 hours in multiengine airplanes, more than 1,000 hours in instrument conditions, and over 250 in the SA-26AT. Company records indicated that in the previous 30 days, the pilot had flown 56 hours, 46 in the SA-26AT.

On the day prior to the accident (July 6), he had flown the same airplane to Saint George, and flown the NDB A approach in instrument conditions. During the flight on July 6, he was seated in the left seat of the SA-26AT.

Copilot

The copilot held an airline transport pilot certificate, with ratings for multiengine and single-engine land airplanes, and a commercial pilot certificate with ratings for single engine seaplanes. He had accumulated 3,989 total hours of flight experience at the time of the accident, of which about 900 were in multiengine airplanes, and 500 were in actual or simulated instrument conditions. In the previous 30 and 90 days, he had flown 41 and 66 hours for the company, respectively.

He held a first class medical certificate, with the restriction that "Holder shall wear corrective lenses." He possessed a Statement Of Demonstrated Ability (SODA) for defective distant vision of 20/200, which was correctable to 20/20 with lenses.

The copilot had accumulated 3 hours, 2 flights, 1 instrument approach, and 5 landings in the SA-26AT prior to the accident. In the previous 90 days he had performed 10 instrument approaches in company aircraft. No record was available to determine if any of these were non-precision or NDB type approaches. There was no record of the copilot having flown to Saint George previously.

The copilot was a part-time employee of the company. He had received salaried pay and completed monthly flight and duty time records as a pilot for F. S. Air Service, Inc., since April of 1998. On his FAA medical certificate application, FAA Form 8600-8, dated April 16, 1998, he lists his occupation as "Part Time Pilot" and his employer as "F.S. Air."

He completed initial company training as a pilot on April 17, 1998, and successfully completed 135.293 checkrides as a second-in-command on the Lear-35 and SA-227. He had not completed a check as second-in-command for the SA-26AT.

The 135.293 check flight report for the SA-227 on June 5, 1998, indicated that the copilot performed an ILS precision approach. There were no records that he performed an NDB or ADF nonprecision approach on either check flight.

Aircraft information

The airplane had accumulated 7,804 hours in service. It was maintained under an Approved Aircraft Inspection Program (AAIP), and 10 hours had been flown since the previous inspection.

The navigation equipment included VOR/DME receivers, an NDB/ADF receiver, a radio altimeter, and a Global Positioning System (GPS). The GPS was not integrated to provide flight guidance information to the pilot's heading indicator, flight director, or autopilot.

Each pilot position had standard flight instruments, Radio Magnetic Indicators (RMIs), and Distance Measuring Equipment (DME) displays. The GPS and radio altimeter display was visible from either pilot position. The fixed card NDB/ADF display was located on the lower left side of the left control column, visible to the left seat pilot, but partially obstructed from the view of the right seat pilot.

Meteorological information

The weather reporting for the New Saint George Airport was provided by an Automated Surface Observing System (ASOS). There is no official weather observer on the island. The ASOS information is available from the FAA Flight Service Stations, via aircraft radio, or telephone.

Between 1053 and the time of the accident, 10 observations were recorded. The ceilings for all ten of these observations varied between 100 feet and 300 feet, with visibility ranging from 1/4 mile to 10 miles.

The weather reported at 1453 ADT was a measured ceiling of 100 feet overcast, with 2 1/2 miles visibility in fog, temperature and dew point both at 46 degrees Fahrenheit, and winds from 210 degrees at 11 knots.

The weather reported at 1553 was a ceiling of 1,000 feet broken, 1,400 feet overcast, visibility of 10 miles. The temperature was 47 degrees Fahrenheit, dew point was 46 degrees Fahrenheit, and winds of 200 degrees at 7 knots.

A U. S. Fish and Wildlife biologist who arrived at the top of the cliff about 2000, told the NTSB IIC that the prevailing winds were southwest at 10 miles per hour, which created an updraft along the cliffs.

Aids to navigation

Navigation to the airport is provided by a nondirectional beacon (NDB) and a DME transmitter, located at the south end of the runway. The outbound course to be followed on the NDB/DME-A approach is 245 degrees magnetic after crossing the NDB. After performing a course reversal turn south of the outbound course, the inbound course to be flown is 065 degrees magnetic.

The minimum altitudes specified for the appro

Aircraft

Registration
N501FS
Reported as
Swearingen SA-26AT
Category
Airplane
Serial number
T26-146
Airframe hours
7,799
Engine
Garrett TP-331-1-151G, 665 horsepower, turbo prop
Damage
Destroyed
Fire
On-Ground
Flight
Positioning · Part 91
Operator
F. S. Air Service, Inc., doing business as F.S. Air
Registered owner
F. S. Air Service, Inc.
Airworthiness certificate
Standard, Normal
Last inspection
AAIP · July 5, 1998 · 10 hours before
Departed
ANC · Anchorage, AK
Destination
PBV
Flight plan
VFR/IFR
Airport
PBV · New St. George

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
58
Certificates
Commercial, Airline transport
Airplane ratings
Single-engine sea, Multi-engine sea, Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--w/ waivers/lim
Seat
Right
Toxicology
Performed
Flight hours
13,000 total · 250 in this make and model · 12,500 as pilot in command · 150 in the last 90 days · 56 in the last 30 days · 6 in the last 24 hours

Weather

Conditions
Instrument (IMC) · Day
Wind
210° at 11 knots
Visibility
2.5 statute miles
Lowest ceiling
100 ft overcast
Temperature
46 °F, dew point 46 °F
Altimeter
29.00 inHg
Observed at
PBV, 5 nm away

Docket · 27

The files NTSB released with the investigation on March 26, 1999, on NTSB’s docket system: statements, records, photos and specialists’ reports. 6.6 MB in all.

Supplement C - Wreckage DocumentationItem 1 · .PDF · 459 KBSupplement D - Cockpit DocumentationItem 2 · .PDF · 505 KBSupplement E - Second Pilot InfornationItem 3 · .PDF · 146 KBSupplement K (Seat 1) - Occupant, Survival and Injury InformationItem 4 · .PDF · 419 KBSupplement K (Seat 2) - Occupant, Survival and Injury InformationItem 5 · .PDF · 432 KBSupplement S - Aircraft Occupant and Injured Ground PersonnelItem 6 · .PDF · 70 KBPilot/Operator Aircraft Accident Report, NTSB Form 6120.1Item 7 · .PDF · 375 KBPassenger StatementsItem 8 · .PDF · 143 KBMaps or Charts of Accident Area, Wreckage DiagramsItem 9 · .PDF · 213 KBWeather Reports and RecordsItem 10 · .PDF · 170 KBTranscript of Radio CommunicationsItem 11 · .PDF · 289 KBDamage SketchesItem 12 · .PDF · 194 KBApproach ChartItem 13 · .PDF · 213 KBOverlay of Radar TrackItem 14 · .PDF · 536 KBEARTS Plots July 7, 1998 (4 pages)Item 15 · .PDF · 545 KBEARTS from July 6, 1998Item 16 · .PDF · 395 KBAfter Accident Flight Inspection ReportItem 17 · .PDF · 234 KBNavigation Indicator LayoutItem 18 · .PDF · 44 KBTraining ManualItem 19 · .PDF · 56 KBCo-pilot Check Flights No NDB ApproachesItem 20 · .PDF · 202 KBStatement of Party Representatives to NTSB InvestigationItem 21 · .PDF · 65 KBRelease of Aircraft Wreckage, NTSB Form 6120.15Item 22 · .PDF · 108 KBToxicological ReportItem 23 · .PDF · 85 KBPhoto 1. Overhead View of Accident Site. Note debris on top of cliff, scarrring on cliff face, and main wreckage at bottom of cliff.Item 24 · .PDF · 174 KBPhoto 2. Empennage Exhibiting Postcrach Fire Damage. (No Negative)Item 25 · .PDF · 163 KBPhoto 3. Empennage With Scratches Oriented From Right To Left, Fore To Aft.Item 26 · .PDF · 231 KBPhoto 4. Photo of Cockpit of N501FS Before Accident. Note location of RMI with ADF/NDB Indicator is below and left of the left side control column. View of this indicator is blocked from right seat by control column. (NoItem 27 · .PDF · 124 KB

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.

Other investigations on N501FS · 1

Matched to the same aircraft by N-number and date.