ATL89MA072

NTSB accident investigation · Hawker Siddeley HS.748 Series 2A · Tipp City, OH · January 12, 1989

Accident · FatalMajor investigationFinal report
Date
January 12, 1989, 04:45 local (09:45 UTC)
Place
Tipp City, OH
Injuries
2 fatal
Damage
Destroyed
Phase of flight
Takeoff
Aircraft
CGDOVHawker Siddeley HS.748 Series 2A
Weather
Instrument (IMC) · Night/dark
Status
Completed · report December 10, 1990
Report
Approved by Office Director
Case key
8076

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 NTSB’s determination of the probable cause, and any contributing factors.

Improper IFR procedure by the first officer (copilot) during takeoff, his lack of instrument scan (improper use of flight/navigation instruments), his failure to maintain a positive rate of climb or to identify the resultant descent, and the captain's inadequate supervision of the flight. Contributing factors were: dark night, low ceiling, drizzle, the first officer's lack of total experience in the type of operation, and possible spatial disorientation of the first officer.

Analysis

Drg ngt cargo opn, check capt (rgt seat) was evaluating the 1st officer (f/o, left seat) for psbl upgrade to capt. bfr depg, flt was clrd for rgt turn after tkof to 020 deg. Tkof bgn at 0441:11. Wtr/methanol injection was used (to 1st pwr rdcn). At 0441:49, lndg gear was retracted; 8 sec ltr 1st pwr rdcn was made, then a freq chg was approved. Capt noted they shld clb to 1500' MSL (aprx 500' AGL) bfr turning. At abt 300' AGL, acft entered ovc & bgn a steep rgt turn. CVR indcd capt was performing cockpit duties at this time & giving info to f/o abt the dep. FDR showed acft rchd max alt of 423' AGL & bgn dscndg. At 0442:22, capt remarked to f/o, 'don't go down . . . Get up . . . Up up up . . . Up, OH!' At abt that time, acft hit in an open fld, but contd flying for aprx 3/4 mi. It then hit a tree & crashed in a wooded area. Inv revealed that drg svrl trng flts & 2 check flts, the f/o demonstrated difficulty in performing instrument flt due todisorientation, narrow focus of attention, or lack of instrument scan (inst fixation), especially drg hi task work load.

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/waterTakeoff
Light condition - dark nightFactor
Weather condition - low ceilingFactor
Weather condition - drizzle/mistFactor
Ifr procedure - improperCopilot/second pilotCause
Flight/navigation instrument(s) - improper use ofCopilot/second pilotCause
Climb - not maintainedCopilot/second pilotCause
Descent - not identifiedCopilot/second pilotCause
Spatial disorientationCopilot/second pilotFactor
Lack of total experience in type operationCopilot/second pilotFactor
Supervision - inadequatePilot in commandCause
In flight collision with objectOther
Object - tree(s)

Aircraft

Registration
CGDOV
Reported as
Hawker Siddeley HS.748 Series 2A (HS.748 SER)
Category
Airplane
Serial number
1582
Airframe hours
35,817
Engine
Rolls-Royce DART-7/MK.534, 2,040 horsepower, turbo prop
Damage
Destroyed
Fire
In-Flight
Flight
Part 129
Operator
Bradley Air Service, Ltd
Registered owner
Bradley Air Services Ltd
Airworthiness certificate
Standard, Transport
Last inspection
Continuous airworthiness · January 8, 1989 · 25 hours before
Departed
DAY · Dayton, OH
Destination
YUL · Montreal
Flight plan
IFR
Airport
DAY · James M Cox/Dayton Intl, runway 24R, 9,500 × 150 ft, asphalt

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
37
Certificates
Foreign, Airline transport
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--no waivers/lim.
Seat
Right
Toxicology
Performed
Flight hours
5,847 total · 3,200 in this make and model · 139 in the last 90 days · 33 in the last 30 days · 3 in the last 24 hours

Weather

Conditions
Instrument (IMC) · Night/dark
Wind
210° at 8 knots
Visibility
1 statute miles
Lowest ceiling
300 ft overcast
Temperature
50 °F, dew point 48 °F
Altimeter
30.00 inHg
Observed at
DAY, 1 nm away