CEN18FA387

NTSB accident investigation · Beech 200 · Oscoda, MI · September 25, 2018

Accident · FatalField investigationFinal report
Date
September 25, 2018, 06:13 local (10:13 UTC)
Place
Oscoda, MI
Injuries
1 fatal
Damage
Destroyed
Phase of flight
Approach
Aircraft
N241CKBeech 200
Defining event
Approach-IFR final approach: Altitude deviation
Weather
Instrument (IMC) · Night
Status
Completed · report November 6, 2019
Report
Approved by Office Director
NTSB office
Central Region
Parties
Textron Aviation (Beech Aircraft), FAA Flight Standards District Office
FAA report
20180925009509A
Case key
98348

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 pilot's descent below minimum descent altitude during the nonprecision instrument approach for reasons that could not be determined based on the available information.

Findings · 4

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Action: incorrect action performancePersonnel issues › Action/decision · PilotBeech 200: 1 caseAll aircraft: 1,386 casesProbable cause
Performance/control parameters: altitudeAircraft › Aircraft oper/perf/capability · Not attained/maintainedBeech 200: 2 casesAll aircraft: 1,310 casesProbable cause
Not determinedNot determined › Not determined · Unknown/Not determinedBeech 200: 2 casesAll aircraft: 2,247 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The airline transport pilot of the multiengine airplane was cleared for the VOR approach. The weather at the airport was reported as 400 ft overcast with 4 miles visibility in drizzle. When the airplane failed to arrive at the airport as scheduled, a search was initiated, and the wreckage was located soon thereafter. Radar data indicated that the pilot was provided vectors to intercept the final approach course. The last radar return indicated that the airplane was at 2,200 ft and 8.1 miles from the runway threshold. It impacted terrain 3.5 miles from the runway threshold and left of the final approach course. According to the published approach procedure, the minimum descent altitude was 1,100 feet, which was 466 ft above airport elevation. Examination of the wreckage revealed that the airplane had impacted the tops of trees and descended at a 45° angle to ground contact; the airplane was destroyed by a postcrash fire, thus limiting the examination; however, no anomalies were observed that would have precluded normal operation. The landing gear was extended, and approach flaps had been set. Impact and fire damage precluded an examination of the flight and navigation instruments. Autopsy and toxicology of the pilot were not performed; therefore, whether a physiological issue may have contributed to the accident could not be determined. The location of the wreckage indicates that the pilot descended below the minimum descent altitude (MDA) for the approach; however, the reason for the pilot's descent below MDA could not be determined based on the available information.

Factual narrative

HISTORY OF FLIGHT On September 25, 2018, at 0613 eastern daylight time, a Beech 200, N241CK, collided with trees and terrain while on an instrument approach to Oscoda-Wurtsmith Airport (OSC), Oscoda, Michigan. The airline transport pilot was fatally injured, and the airplane was destroyed by impact forces and a post-impact fire. The airplane was registered to Kalitta Equipment LLC, and was operated by Kalitta Charters as a Title14 Code of Federal Regulations (CFR) Part 91 positioning flight. Instrument meteorological conditions prevailed at the accident site at the time of the accident, and an instrument flight rules (IFR) flight plan was filed for the flight which originated from Willow Run Airport (YIP), Ypsilanti, Michigan, about 0513. According to Kalitta personnel, the pilot was flying to OSC to pick up passengers and subsequently fly them to Memphis, Tennessee. The airplane departed YIP about 0513 and climbed to a cruise altitude of about 13,500 ft. The airplane en route airspeed was about 250 knots. At 0537, when the airplane was about 85 miles south of OSC, it began its initial descent. At 0548, the airplane was vectored to the right to intercept the final approach course and was cleared for the VOR runway 6 approach at OSC. The last radar return was at 0550 and indicated that the airplane was at an altitude of 2,200 ft and 8.1 miles from the runway threshold. It impacted terrain 4.6 miles past this point, about 3.5 miles from the runway threshold. According to the VOR runway 6 approach procedure, an altitude of 2,500 ft (or higher) is flown during the procedure turn. If the OSC altimeter setting is used, descent is made to 1,660 feet to Dogsy intersection, and then to 1,100 feet, the minimum descent altitude (MDA) to Au Sable (ASP) intersection. When the airplane failed to arrive at the airport as scheduled, Kalitta officials notified the Federal Aviation Administration (FAA0. The wreckage was subsequently located about 1030. PERSONNEL INFORMATION The 33-year-old pilot held an airline transport pilot certificate with an airplane multiengine land rating, type ratings in the Learjet, Dassault DA-20 Falcon, and Canadair 601 Challenger, and commercial privileges with an airplane single-engine land rating. He also held a flight instructor certificate with airplane single-engine, multiengine, and instrument ratings, and a ground instructor certificate with an instrument rating. His first-class FAA airman medical certificate, dated March 9, 2018, contained no restrictions or limitations. According to the operator, the pilot had logged 3,806 total hours of flight experience, of which 201 hours were in the Beech 200. The pilot's most recent Part 135 proficiency check was satisfactorily completed on August 31, 2018, in the Dassault DA-20. AIRCRAFT INFORMATION The accident airplane, serial number BB272, was manufactured in 1977. It was powered by two Pratt and Whitney PT6A-41 turboprop engines (serial numbers PCE80581 left, and PCE80282 right),each rated at 850 shaft horsepower, driving two Hartzell 3-blade, all-metal, full feathering, constant speed propellers (model HC-B3TN-3G). The airplane was maintained under an Approved Airworthiness Inspection Program (AAIP). The most recent inspection was performed on March 28, 2018, at an airframe time of 13,933.6 hours. At that time, the left engine had accrued 13,912.7 total hours and 7,742.2 hours since overhaul, and the right engine had accrued 12,802.5 total hours and 6,747.3 hours since overhaul. METEOROLOGICAL INFORMATION The following weather observations were recorded by the Automated Weather Observing System (AWOS): 0555: Wind from 180° at 7 knots; 5 miles visibility in light rain; 400 ft overcast ceiling; temperature, 18°C; dew point, 18°C; altimeter setting of 29.91 inches of mercury. 0615: Wind from 200° at 6 knots; 4 miles visibility in drizzle; 400 ft overcast ceiling; temperature, 19°C; dew point, 19°C; altimeter setting of 29.91 inches of mercury. 0635: Wind from 200° at 7 knots; 4 miles visibility in heavy drizzle; ceiling, 400 ft overcast ceiling; temperature, 19°C; dew point, 19°C; altimeter setting of 29.92 inches of mercury. WRECKAGE AND IMPACT INORMATION Examination of the accident site revealed that the airplane had impacted the tops of trees, then descended at a 45° angle to the ground. A postimpact fire consumed the cockpit and cabin area. There were numerous propeller contact marks in the trees. Examination of the wreckage revealed no evidence of mechanical malfunctions or anomalies. Actuator positions indicated that the landing gear was extended, and approach flaps had been set. Fire and impact damage precluded examination of the cockpit instruments. MEDICAL AND PATHOLOGICAL INFORMATION Due to the condition of the remains, autopsy and toxicology protocols were not performed.

Aircraft

Registration
N241CK
Reported as
Beech 200 (Undesignat)
Category
Airplane
Serial number
BB272
Built
1977
Airframe hours
13,933.5
Engines
Pratt & Whitney Canada PT6A-41, 850 horsepower, turbo propPratt & Whitney Canada PT6A-41, 850 horsepower, turbo prop
Damage
Destroyed
Fire
On-Ground
Flight
Business · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
AAIP · March 28, 2018
Departed
YIP · Ypsilanti, MI
Destination
OSC · Oscoda, MI
Flight plan
IFR
Airport
KOSC · Oscoda-Wurtsmith Airport, runway 06, 11,600 × 200 ft, concrete
Equipment
Auto-pilot, Electronic flight bag or handheld device, Electronic multifunction display, Stall warning system

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
33
Injuries
Fatal
Certificates
Commercial, Airline transport
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Last flight review
August 31, 2018
Seat
Left
Flight hours
3,806 total · 201 in this make and model · 2,687 as pilot in command · 72 in the last 90 days · 64 in the last 30 days · 6 in the last 24 hours

Weather

Conditions
Instrument (IMC) · Night
Wind
200° at 6 knots
Visibility
4 statute miles
Lowest ceiling
400 ft overcast
Temperature
66 °F, dew point 66 °F
Altimeter
29.90 inHg
Observed at
OSC, 6 nm away

Docket · 10

The files NTSB released with the investigation on August 13, 2019, on NTSB’s docket system: statements, records, photos and specialists’ reports. 8.2 MB in all.

FAA reports on this event · 1

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