# NTSB ATL89MA072: Hawker Siddeley HS.748 Series 2A, Tipp City, OH, January 12, 1989

- Type: NTSB accident investigation
- Classification: Accident · Fatal · Major investigation · Final report
- Date: January 12, 1989, 04:45 local (09:45 UTC)
- Place: Tipp City, OH
- Coordinates: 39.869972, -84.19049 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=39.8700&lon=-84.1905&mi=10
- Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping)
- Highest injury: Fatal
- Injuries: 2 fatal
- Status: Completed, report December 10, 1990
- Report: Approved by Office Director
- NTSB case key (mKey): 8076
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ATL89MA072
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/8076/pdf
- Page: https://openairdocs.org/ntsb/ATL89MA072

## Probable cause

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 AT 0441:49, LNDG GEAR WAS RETRACTED; 8 SEC LTR 1ST PWR RDCN WAS MADE, THEN A FREQ CHG WAS APPROVED.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

In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf).

- In flight collision with terrain/water, takeoff
  - light condition - dark night (contributing factor)
  - weather condition - low ceiling (contributing factor)
  - weather condition - drizzle/mist (contributing factor)
  - ifr procedure - improper, copilot/second pilot (cause)
  - flight/navigation instrument(s) - improper use of, copilot/second pilot (cause)
  - climb - not maintained, copilot/second pilot (cause)
  - descent - not identified, copilot/second pilot (cause)
  - spatial disorientation, copilot/second pilot (contributing factor)
  - lack of total experience in type operation, copilot/second pilot (contributing factor)
  - supervision - inadequate, pilot in command (cause)
- In flight collision with object, other
  - object - tree(s)

## Aircraft

- Registration: CGDOV (not matched to a registry record)
- Reported make and model: HAWKER SIDDELEY HS.748 SERIES 2A (HS.748 SER)
- Category: Airplane
- Serial number: 1582
- Airframe hours: 35817
- Engines: Rolls-Royce DART-7/MK.534 2040 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.

- Pilot; age 37; 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

From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model.

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