# NTSB ATL93FA143: Beech C-90, N90BP, Augusta, GA, August 7, 1993 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: August 7, 1993, 15:15 local (19:15 UTC) - Place: Augusta, GA - Coordinates: 33.350742, -81.970123 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=33.3507&lon=-81.9701&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 4 fatal - Status: Completed, report August 17, 1994 - Report: Approved by Office Director - NTSB case key (mKey): 3188 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ATL93FA143 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/3188/pdf - Page: https://openairdocs.org/ntsb/ATL93FA143 ## Probable cause WAS THE PILOT'S FAILURE TO ADEQUATELY EVALUATE INFLIGHT WEATHER CONDITIONS WHICH RESULTED IN A LOSS OF CONTROL WHEN THE AIRPLANE ENCOUNTERED A THUNDERSTORM. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - In flight encounter with weather, approach - faf/outer marker to threshold (ifr) - weather condition - thunderstorm (cause) - in-flight planning/decision - inadequate, pilot in command (cause) - weather evaluation - poor, pilot in command (cause) - Loss of control - in flight, approach - faf/outer marker to threshold (ifr) - In flight collision with object, descent - uncontrolled - object - tree(s) ## Analysis THE INSTRUMENT FLIGHT WAS CLEARED FOR AN ILS APPROACH TO THE DESTINATION AIRPORT. WHILE MANEUVERING FOR THE FINAL APPROACH COURSE, THE FLIGHT ENCOUNTERED CONVECTIVE ACTIVITY (THUNDERSTORMS). THE PILOT WAS QUESTIONED BY THE TOWER CONCERNING HIS POSITION ON THE APPROACH COURSE. THE TOWER RADAR PLACED THE FLIGHT'S POSITION 1/4 TO 1/2 MILE EAST OF THE FINAL APPROACH COURSE. THE PILOT STATED THAT HE WAS ON THE LOCALIZER. SUBSEQUENT FUNCTIONAL CHECKS OF THE ILS SYSTEM BY AIR WAYS FACILITIES, FAILED TO REVEAL A PROBLEM WITH THE ILS APPROACH SYSTEM. THE AIRPLANE COLLIDED WITH TREES ABOUT ONE AND ONE HALF MILES NORTHEAST OF THE AIRPORT AND ONE HALF MILE EAST OF THE APPROACH COURSE. WEATHER REPORTS RECORDED LEVEL FOUR THUNDERSTORM ACTIVITY WITHIN THE IMMEDIATE VICINITY OF THE DESTINATION AIRPORT. WRECKAGE EXAMINATION FAILED TO DISCLOSE ANY MECHANICAL PROBLEMS WITH THE AIRPLANE. THE AIR TRAFFIC CONTROLLERS PROVIDED THE PILOT WITH CURRENT WEATHER CONDITIONS AT THE AIRPORT THROUGHOUT THE FINAL MINUTES OF THE FLIGHT, THEREFORE THE PILOT WAS AWARE OF THE THUNDERSTORM ACTIVITY NEAR AND AT THE AIRPORT. ## Factual narrative HISTORY OF FLIGHT On August 7, 1993, at 1515 eastern daylight time, a Beech C-90, N90BP, collided with trees during final approach to Bush Field, Augusta, Georgia. The airplane was operated by Critical Care Medflight, Inc., as Lifeguard N909BP, under instrument flight rules and 14 CFR Part 135. Instrument weather conditions prevailed at the time of the accident, and the flight was issued a valid instrument flight clearance. The commercial pilot, two medical personnel and an infant were fatally injured. The airplane was destroyed by impact forces and a post impact fire. The flight departed Adel, Georgia, at 1423 hours. The purpose of the flight was to transport the one day old infant from Adel to the Medical College of Georgia in Augusta for treatment. At 1052, the pilot filed an instrument flight plan from Adel, Georgia, via Direct User Access Terminal Services (DUATS). At 1423, N90BP departed Adel, and was issued an instrument flight clearance to Augusta. Air Traffic Control procedures and instrument handling were routine throughout the flight. At 1456, the pilot established radio contact with Augusta Approach Control, and told the Air Traffic Controller that he had Automatic Terminal Information Service (ATIS) information "Quebec." The pilot also requested and was given approval to deviate around weather. Approach Control advised the pilot to expect the ILS Approach to runway 17. At 1508, the pilot was advised of a thunderstorm moving over the airport with winds 220 degrees at 21 knots. The pilot rogered the information, and stated that he was out of the worst of the weather. At 1509, the pilot requested and was given a 060 degree heading; the pilot was told to expect a tight turn at the marker. At 1510, the controller reported that visibility at the airport was down to two miles; the pilot reported that he was in good visual weather conditions. At 1511, four and one half miles from the marker, the flight was cleared for an ILS Approach to runway 17; at 1513, the flight was cleared to land. The controller again informed the pilot of the reduced visibility at the airport, (the Runway Visual Range (RVR) was 2000 feet), and that rain showers were still over the airport. At 1514, the controller questioned the pilot about his position on the approach course, which appeared to have been one quarter to one half mile east of the final approach course. At 1515, the pilot replied that he was on the localizer (see attached transcription of communications). Seconds later, two emergency locator beeps were heard. The flight crew on a Delta Air Lines' flight waiting for takeoff never made visual contact with the approaching aircraft. Additionally, the Delta flight crew observed the approaching airplane on the aircraft's Traffic and Collision Avoidance System (TCAS) radar; TCAS contact was maintained until the airplane descended to 400 feet. PERSONNEL INFORMATION Information on the pilot is included in this report at the data field labeled, First Pilot Information. The pilot's flight experience information was provided by the operator. A review of the pilot's data disclosed that, on November 8, 1991, the pilot was hired by Critical Care Medflight as a Piper PA-31 captain. On March 17, 1993, the pilot completed 14 CFR Part 135 requirements and was upgraded to a captain on the Beech 90 aircraft. According to the operator, the pilot's personal flight logs were not availabe for review, and the pilot flight experience information examined was from company records. The Director of Operation further stated that there is no requirement to record actual instrument flight time, but all Part 135 flights are conducted under instrument flight rules. The flight time recorded on the Operator Accident Report Form (NTSB Form 6120.1/2) within the last 90 days reflects instrument flight experience. AIRCRAFT INFORMATION Information on the aircraft is contained in this report at the data field labeled, Aircraft Information. Examination of historical maintenance recorded revealed that the aircraft inspection program, approved by the FAA, was accomplished within the prescribed intervals. According to the operator, the life support equipment onboard the airplane was not part of the aircraft equipment list, but supplied by the hospital in Adel for this flight. METEOROLOGICAL INFORMATION Meteorological information is contained in this report at the data field labeled Weather Information. Instrument weather conditions prevailed at the time of the accident. A weather study further revealed that, the 1400 surface weather map, prepared by the National Weather Service, showed a stationary front extending east-west from central Mississippi through north-central Alabama and Georgia to central South Carolina. An outflow boundary was indicated from western Florida curving northeast through south- central Georgia. The 1700 surface map showed that the front had moved further north and was oriented east-west across northern Alabama, northern Georgia, and north-central South Carolina. The outflow boundary was indicated from northern Florida curving northeastward into the vicinity of Augusta, Georgia. The Augusta Surface Weather Observations forms indicated that thunderstorms began at Augusta at 1440. The location of the thunderstorm was south of the airport and was moving northeast. At 1506, the observer stated that the thunderstorm was overhead through south of the airport. At 1511, the observer indicated that the thunderstorm had increased to moderate intensity and the visibility had decreased to 2 miles. The observer indicated that he checked the weather radar at 1513 and observed light to moderate thunderstorms in the local area. The observer further stated that he was notified of the aircraft mishap at 1518. Radar photographs were taken of the Athens plan position indicator (PHI) scope at approximately five-minute intervals around the time of the accident. The photograph taken at 1506 shows a cell with a maximum VIP level of four located over and just to the south of the Augusta (Bush Field) airport. The photograph taken about 1518 showed that the cell moved northeast and was centered four nautical miles northeast of Bush Field. The maximum intensity of the cell remained at level four. The Terminal Forecasts (FTs) for Augusta (Bush Field) issued on August 7, at 1236 hours, valid from August 7, 1300 to August 8, 1300, forecasted 1,500 feet scattered, 4,500 feet scattered, ceiling 9,000 feet broken, wind 230 degrees at six knots; occasional ceiling 4,500 feet broken, visibility five miles, light rain showers fog. The 1600 forecast called for 1,500 feet scattered ceiling 4,500 feet broken, wind 250 degrees at eight knots; occasional ceiling 400 feet overcast, visibility 3 miles, moderate rain showers and fog; a chance of visibility 1 mile, thunderstorm with heavy rain showers. Personnel at the Augusta Air Traffic Control Tower (ATCT) made Automatic Terminal Information Service (ATIS) recordings on August 7. A review of air traffic data disclosed that, N90BP reported on Augusta Approach Control frequency at 1456 and advised that the airplane was descending with Information Quebec. The ATIS Quebec information incorporated the 1440 Special Weather Observations. Weather observations were transmitted from the NWS office to the Augusta ATCT by means of the Automated Weather Information System (AWIS). Transmission times follow: Weather Observation Transmission Time AGS SP 1440 1443 AGS SA 1453 1456 AGS SP 1507 * 1509 AGS SP 1511 1513 AGS L 1520 1525 * The correct observation time as listed on the Surface Weather Observations forms was 1506 WRECKAGE AND IMPACT INFORMATION Wreckage debris was scattered over an area 325 ## Aircraft - Registration: [N90BP](https://openairdocs.org/deregistered/N90BP-1996-02-28), registration cancelled 1996-02-28, S/N LJ718 (OpenAirDocs) - Reported make and model: BEECH C-90 - Registry model: [Beech C90](https://openairdocs.org/model/beech-c90) (registry code 1152913) (OpenAirDocs) - Category: Airplane - Serial number: LJ-718 - Airframe hours: 3301 - Engines: P&W PT6A-21 550 horsepower turbo prop - Damage: Destroyed - Fire: On-Ground - Flight: Part 135 - Operator: Critical Care Medflight - Registered owner: Air Medical Leasing - Airworthiness certificate: Standard, Normal - Last inspection: AAIP, June 18, 1993, 59 hours before - Departed: 15J, ADEL, GA - Flight plan: IFR - Airport: AGS, Bush Field, runway 17, 8,000 × 150 ft, concrete ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 36; commercial; airplane ratings: multi-engine land; instrument ratings: airplane; medical: class 1, valid medical--no waivers/lim.; seat: left; toxicology performed; flight hours: 1,875 total, 300 in this make and model, 62 in the last 90 days, 32 in the last 30 days, 1 in the last 24 hours ## Weather - Conditions: Instrument (IMC), Day - Wind: 310° at 6 knots, gusting 22 - Visibility: 2 statute miles - Lowest ceiling: 1,100 ft broken - Temperature: 73 °F, dew point 72 °F - Altimeter: 30.00 inHg - Observed at: AGS, 2 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 19930807027889A](https://openairdocs.org/incident/19930807027889A), Aug 7, 1993: Beech C90, Augusta, GA, Destroyed, 4 fatal. Flew into thunderstorm activity on ILS. Off course struck trees off side runway. Was aware of thunderstorm activity 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.