# NTSB BFO93FA016: Beech C-45G, N7770B, Elkridge, MD, December 10, 1992 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: December 10, 1992, 15:35 local (20:35 UTC) - Place: Elkridge, MD - Coordinates: 39.239421, -76.680458 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=39.2394&lon=-76.6805&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed, report September 28, 1993 - Report: Approved by Office Director - NTSB case key (mKey): 11864 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=BFO93FA016 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/11864/pdf - Page: https://openairdocs.org/ntsb/BFO93FA016 ## Probable cause FAILURE OF THE PILOT TO PROPERLY SECURE THE CARGO, WHICH ALLOWED A SHIFT IN THE CENTER OF GRAVITY DURING A MISSED APPROACH MANEUVER AND RESULTED IN SUBSEQUENT LOSS OF AIRCRAFT CONTROL AND FLYING SPEED. A FACTOR RELATED TO THE ACCIDENT WAS FAILURE OF THE PILOT TO ASSURE THE AIRPLANE WAS LOADED WITHIN ITS PROPER WEIGHT AND BALANCE LIMITATIONS. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Cargo shift, missed approach (ifr) - security of cargo - inadequate, pilot in command (cause) - aircraft weight and balance - improper, pilot in command (contributing factor) - weather condition - gusts - weather condition - turbulence - cargo/baggage - not secured - tie down - inadequate, pilot in command - Loss of control - in flight, missed approach (ifr) - stall/mush - uncontrolled - In flight collision with terrain/water, descent - uncontrolled ## Analysis THE PILOT SUPERVISED THE LOADING OF THE AIRPLANE. ACCORDING TO INFO FROM A PERSON THAT HELPED LOAD THE PLANE, THE BILL OF LADING, AND ACTUAL WEIGHTS AND MEASUREMENTS OF THE CARGO AFTER THE ACCIDENT, THE PLANE WAS LOADED TO A GROSS WEIGHT OF 11,979 LBS WITH THE CG 2.7 INCHES BEHIND THE AFT LIMIT. AT THE DESTINATION, THE FLIGHT WAS VECTORED FOR AN ILS RUNWAY 10 APPROACH. ABOUT 3 MI FROM THE RUNWAY, THE PILOT WAS TOLD TO MAKE A MISSED APPROACH DUE TO INADEQUATE SEPARATION FROM TRAFFIC. THE PILOT ACKNOWLEDGED, BUT SOON THEREAFTER, RADAR CONTACT WITH THE PLANE WAS LOST. WITNESSES SAW THE PLANE DESCEND FROM A LOW CLOUD LAYER BEFORE IT CRASHED. ONE WITNESS SAID ITS WINGS WERE MOVING FROM SIDE TO SIDE AND THE PLANE WAS FALLING FASTER THAN IT WAS MOVING FORWARD. THERE WAS EVIDENCE THE PLANE HAD IMPACTED IN A FLAT ATTITUDE WITH LITTLE FORWARD MOVEMENT. FOUR CARGO STRAPS WERE FOUND LOOSE WITH NO SIGN OF TENSILE OVERLOAD; 3 OTHERS AND A RESTRAINING BOARD WERE FOUND LOOSE AS IF THEY HAD NOT BEEN USED. NO PREIMPACT MECHANICAL PROBLEM WAS FOUND. THE WIND WAS FROM 090 DEG AT 21 GUSTING 32 KTS. ## Aircraft - Registration: [N7770B](https://openairdocs.org/deregistered/N7770B-1999-03-10), registration cancelled 1999-03-10, S/N AF-320 (OpenAirDocs) - Reported make and model: BEECH C-45G - Registry model: [Beech C-45G](https://openairdocs.org/model/beech-c-45g) (registry code 1151014) (OpenAirDocs) - Category: Airplane - Serial number: AF-320 - Airframe hours: 26436 - Engines: GARRETT TPE-331-1-101 620 horsepower turbo prop - Damage: Destroyed - Fire: On-Ground - Flight: Part 135 - Operator: Kalitta Flying Service - Registered owner: Kalitta Flying Service - Airworthiness certificate: Standard, Normal - Last inspection: AAIP, January 2, 2000 - Departed: DAY, DAYTON, OH - Destination: BWI, BALTIMORE, MD - Flight plan: IFR - Airport: BWI, Balt-Wash Int'L, runway 1, 9,452 × 200 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 33; airline transport, commercial, flight instructor; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 1, valid medical--no waivers/lim.; seat: left; toxicology performed; flight hours: 2,658 total, 657 in this make and model, 1,560 as pilot in command, 180 in the last 90 days, 90 in the last 30 days, 3 in the last 24 hours ## Weather - Conditions: Instrument (IMC), Day - Wind: 90° at 21 knots, gusting 32 - Visibility: 3 statute miles - Lowest ceiling: 900 ft broken - Temperature: 43 °F, dew point 43 °F - Altimeter: 29.00 inHg - Observed at: BWI, 4 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 19921210049559A](https://openairdocs.org/incident/19921210049559A), Dec 10, 1992: Beech STCC45, Baltimore, MD, Destroyed, 1 fatal. Indicates a stall mush to flat upright attitude prior impact. Near gross aft CG. Load was not secured. Shifted. ## Other investigations on N7770B (1) 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. - [NTSB OAK71DJW04](https://openairdocs.org/ntsb/OAK71DJW04), Jul 27, 1970: Beech G18S (N7770B), Bac Lieu, VM, substantial damage 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.