ATL95FA057

NTSB accident investigation · Cessna 208B · Gainesville, GA · March 4, 1995

Accident · FatalField investigationFinal report
Date
March 3, 1995, 19:43 local (Mar 4, 1995, 00:43 UTC)
Place
Gainesville, GA
Injuries
2 fatal
Damage
Destroyed
Phase of flight
Approach
Aircraft
N227DMCessna 208B
Weather
Instrument (IMC) · Night/dark
Status
Completed · report October 26, 1995
Report
Approved by Office Director
FAA report
19950303003019A
Case key
3473

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 pilots failure to maintain the minimum descent altitude during the approach. The weather and dark night light condition were factors.

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 - faf/outer marker to threshold (ifr)
Weather condition - low ceilingFactor
Weather condition - rainFactor
Weather condition - fogFactor
Light condition - dark nightFactor
Minimum descent altitude - not maintainedPilot in commandCause

Analysis

The flight was executing the non-precision NDB rwy 4 approach, had reported procedure turn inbound, and was cleared to change to advisory frequency. Witnesses observed the airplane descend out of the base of the overcast clouds in a 10 deg nose down, 45 deg left wing down attitude. The airplane impacted terrain about 3/4 mi sse of the airport. Witnesses in the area reported that the weather was ceilings of about 100 ft and visibility of about 500 ft in light rain and fog. The minimum descent altitude for the approach is 465 feet AGL.

Factual narrative

History of flight

On March 3, 1995, at 1943 eastern standard time, a Cessna 208B, N227DM, was destroyed following a collision with terrain, and a post crash fire, during an instrument approach to the Gainesville, Georgia Airport. Both the airline transport/instructor pilot and the private/instrument rated pilot were fatally injured in the accident. The aircraft was being operated under the provisions of 14 Code of Federal Regulations Part 91 by D.M.C. Flying Service, at the time of the accident. Instrument meteorological conditions existed at the time of the accident, and an instrument flight rules flight plan was in effect for the flight. The flight departed Savannah, Georgia, at 1730.

All radio communications with the aircraft were reported to be normal. The flight had been cleared by the Atlanta Air Route Traffic Control Center for the Non-Directional Beacon (NDB) approach and cleared to change radio frequencies to the advisory channel. Witnesses reported observing the aircraft descend out of the base of the overcast clouds in a 10 degree nose down, 45 degree left wing down attitude. The aircraft impacted the trees and terrain about 3/4 mile south southeast of the airport. The trees and terrain at the impact area were approximately 1200 feet above mean sea level.

A pilot, flying on an instrument flight plan, and practicing instrument approaches in the area at the time of the accident, reported the following. He stated that at the time of the accident, he was in a holding pattern waiting for N227DM to complete the approach into Gainesville (GVL). He heard the conversations between Atlanta Approach Control, and the pilot of N227DM, and reported that all conversations were normal. He stated that he had departed Peachtree-Dekalb Airport (PDK), and executed several practice approaches into PDK. He reported that the cloud base at PDK was about 300 feet above ground level (AGL), and that the clouds were solid up to 5,000 feet above mean sea level (MSL). He said that there was no ice accumulation noted during his flight. He stated that during the approaches into PDK, he could see lights straight down below the aircraft about 500 feet AGL, but that there was no forward visibility through the clouds. He did not execute the approach into GVL, because N227DM did not report the approach complete. He stated that he did not expect to see the Gainesville Airport had he executed the approach, as the cloud base at PDK was below the minimum descent altitude for GVL.(See Record of Conversation With Mr. Johnny Masters Attached to This Report.)

Personnel information

The left seat pilot held an airline transport pilot certificate with airplane multiengine land rating, and commercial privileges airplane single engine land, and rotorcraft-helicopter ratings. He held a certified flight instructor certificate with airplane single and multiengine, instrument airplane, and rotorcraft-helicopter ratings. He held a first class medical certificate issued July 28, 1994 with a restriction for the use of corrective lenses. His pilot log book showed that he had obtained 2,005 hours of flight time, of which 201 hours were in the Cessna 208B aircraft. He had accumulated 221 hours of actual instrument flight time, and 99 hours of simulated instrument flight time. He had completed Flight Safety International's Cessna 208 Pilot Initial Training Course on February 21, 1994.

The right seat pilot held a private pilot certificate with airplane single and multiengine land, and instrument airplane ratings. The airplane multiengine land rating was limited to center line thrust. He held a third class medical certificate issued March 3, 1994, with a restriction for the use of corrective lenses. His pilot log book was not made available. On the last application for a medical certificate, he listed his civilian flight experience as 800 hours of flight time. He attended Flight Safety International's Cessna 208 Aircraft Systems Training Course. His Certificate of Training from Flight Safety remarks that there was no flight training, and that the aircraft simulator training was not completed.

Additional personnel information may be obtained in this report on Page 3 under the section titled First Pilot Information, and in Supplement E of this report.

Aircraft information

The Cessna 208B, N227DM, was a single engine, fixed gear, 10 place, turbo propeller airplane. The aircraft was configured for executive seating, and had a lavatory located in the aft section of the cabin.

The aircraft was purchased new in February of 1994 by D.M.C. Flying Service. The last annual inspection of the aircraft was accomplished on January 12, 1995. At the time of the last annual inspection the aircraft and engine had 201.5 hours in service. The amount of flight time the aircraft operated after the last annual could not be obtained.

Additional aircraft information may be obtained in this report on page 2 under section titled Aircraft Information.

Meteorological information

The Lee Gilmer Memorial Airport in Gainesville, Georgia was in the process of installing an automated weather observation station (AWOS). The AWOS had not been certified at the time of the accident, and the weather reported by the AWOS is not available by means of radio communication. The AWOS was operating at the time of the accident, and recorded the following weather at 2009. Ceiling 200 feet with overcast skies, visibility of one and one half miles. The temperature was reported as 45 degrees fahrenheit, and the dew point was 45 degrees fahrenheit. Winds were from 090 degrees at five nautical miles per hour, and the altimeter setting was 20.25 inches of mercury.

The ceilings in the area at the time were reported by the witnesses on the ground to be about 100 feet above the terrain, and the visibility to be about 500 feet in fog and rain.(See Statement of Mr. Stephen Simpson Attached to This Report.)

Additional Meteorological information may be obtained on page 4 of this report under section titled Weather Information.

Aids to navigation

The Lee Gilmer Memorial Airport in Gainesville, Georgia is served by a non directional beacon (NDB) instrument approach. The published minimum descent altitude for the NDB approach is 1740 feet above mean sea level and 465 feet above ground level. A pilot flying in the area at the time of the accident, stated that he was waiting for N227DM to complete the approach, in order to begin the NDB approach into Gainesville. He stated that he had the NDB tuned into his radio, and that the signal strength seemed to be normal and he was receiving the GVL identification.(See Record of Conversation with Mr. Johnny Masters Attached to This Report.)

Wreckage and impact information

The aircraft impacted the terrain in a wooded area about 3/4 of a mile south southeast of the Lee Gilmer Memorial Airport. The terrain elevation in the area of the accident site is about 1200 feet above mean sea level.(See Copy of Topographical Map of Area Attached to This Report).

The wreckage was distributed over an area about 319 feet in length, on a magnetic heading of 240 degrees. There were trees, eight inches in diameter at the base, about eighty feet in height located at the beginning of the wreckage path. The trees were broken off about 50 feet above ground level. The elevator trim tab and elevator counter weight were the first pieces of the aircraft wreckage located in the direction of impact from the broken trees. The elevator trim tab and counterweight were located 90 feet in the direction of impact from the beginning of the wreckage site. The trim tab had a "U" shaped indention on the outboard leading edge.

An outboard section of the right aileron, about three feet in length was located about 25 feet, in the direction of impact from the elevator trim tab. there was a "U" shaped indention in the aileron.

The aircraft engine displayed severe impact damage including complete se

Aircraft

Registration
N227DM
Reported as
Cessna 208B
Category
Airplane
Serial number
208B-0364
Engine
P&W PT6A-114A, 675 horsepower, turbo prop
Damage
Destroyed
Fire
On-Ground
Flight
Personal · Part 91
Registered owner
Dmc Flying Service
Airworthiness certificate
Standard, Normal
Last inspection
Annual · January 12, 1995
Departed
SAV · Savannah, GA
Destination
GVL
Flight plan
IFR
Airport
GVL · Lee Gilmer Memorial, runway 4, 4,999 × 100 ft, asphalt

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
46
Certificates
Flight instructor, Airline transport
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Helicopter, Airplane
Medical
Class 1, Valid Medical--w/ waivers/lim
Seat
Left
Toxicology
Performed
Flight hours
2,005 total · 201 in this make and model · 1,887 as pilot in command · 50 in the last 90 days · 5 in the last 30 days · 2 in the last 24 hours

Weather

Conditions
Instrument (IMC) · Night/dark
Wind
90° at 5 knots
Visibility
1.5 statute miles
Lowest ceiling
200 ft overcast
Temperature
45 °F, dew point 45 °F
Altimeter
30.00 inHg
Observed at
GVL, 1 nm away

Docket · 24

The files NTSB released with the investigation on October 1, 1995, on NTSB’s docket system: statements, records, photos and specialists’ reports. 3.1 MB in all.

Supplement CItem 1 · .PDF · 328 KBSupplement DItem 2 · .PDF · 375 KBSupplement EItem 3 · .PDF · 91 KBSupplement KItem 4 · .PDF · 608 KBRecord of Conversation with Mr. Johnny MastersItem 5 · .PDF · 51 KBWitness Statement of Mr. Stephen SimpsonItem 6 · .PDF · 41 KBNDB Approach Chart From Lee Gilmer Memorial Airport in Gainesville, GAItem 7 · .PDF · 56 KBWreckage Diagram for N227DMItem 8 · .PDF · 35 KBTopographical Map of Accident AreaItem 9 · .PDF · 293 KBTranscript of Radio Communications with the Pilots of N227DMItem 10 · .PDF · 469 KBCopy of Record of Cessna 208 Training for Mr. Don CottrellItem 11 · .PDF · 45 KBCopy of Record of Cessna 208 Training for Mr. Leon ReeseItem 12 · .PDF · 42 KBStatement of Party Representatives to NTSB InvestigationItem 13 · .PDF · 65 KBRelease of Aircraft Wreckage, NTSB Form 6120.15Item 14 · .PDF · 44 KBToxicological ReportsItem 15 · .PDF · 118 KBPhoto 1 - View of Aircraft Wreckage Looking in Direction of Impact From Initial Tree StrikeItem 16 · .PDF · 56 KBPhoto 2 - View of Wreckage Path Looking From Main Wreckage Opposite Direction of ImpactItem 17 · .PDF · 41 KBPhoto 3 - View of Section of Right Aileron (Note "U" Shaped Indentation).Item 18 · .PDF · 35 KBPhoto 4 - View of Propeller Hub and Blades (Note Chordwise Scratching of Blades).Item 19 · .PDF · 66 KBPhoto 5 - View of Section of Left WingItem 20 · .PDF · 56 KBPhoto 6 - Front View of Main Wreckage Looking From Propeller Impact PointItem 21 · .PDF · 60 KBPhoto 7 - View of Left Side of Main WreckageItem 22 · .PDF · 60 KBPhoto 8 - View of EmpennageItem 23 · .PDF · 54 KBPhoto 9 - View of Engine Compressor (Note Circumferential Rubbing Marks on Turbine Housing).Item 24 · .PDF · 33 KB

FAA reports on this event · 1

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