# NTSB CEN18FA387: Beech 200, N241CK, Oscoda, MI, September 25, 2018 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: September 25, 2018, 06:13 local (10:13 UTC) - Place: Oscoda, MI - Coordinates: 44.416667, -83.485832 - Nearby events: https://openairdocs.org/map.md?lat=44.4167&lon=-83.4858&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Defining event: [Approach-IFR final approach: Altitude deviation](https://openairdocs.org/ntsb-events/282) - Highest injury: Fatal - Injuries: 1 fatal - 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 - NTSB case key (mKey): 98348 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN18FA387 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/98348/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=98348 - Page: https://openairdocs.org/ntsb/CEN18FA387 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Action: incorrect action performance](https://openairdocs.org/ntsb-findings/02041015): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Beech 200, 1 case](https://openairdocs.org/ntsb-findings/02041015/cases.md?model=1152920), [All aircraft, 1,386 cases](https://openairdocs.org/ntsb-findings/02041015/cases.md) - [Performance/control parameters: altitude](https://openairdocs.org/ntsb-findings/01062012): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Beech 200, 2 cases](https://openairdocs.org/ntsb-findings/01062012/cases.md?model=1152920), [All aircraft, 1,310 cases](https://openairdocs.org/ntsb-findings/01062012/cases.md) - [Use of equip/info: use of policy/procedure](https://openairdocs.org/ntsb-findings/02063032): Personnel issues › Task performance · Pilot; cases with it: [Beech 200, 1 case](https://openairdocs.org/ntsb-findings/02063032/cases.md?model=1152920), [All aircraft, 191 cases](https://openairdocs.org/ntsb-findings/02063032/cases.md) - [Not determined](https://openairdocs.org/ntsb-findings/05000000): Not determined › Not determined · Unknown/Not determined (probable cause); cases with it: [Beech 200, 2 cases](https://openairdocs.org/ntsb-findings/05000000/cases.md?model=1152920), [All aircraft, 2,247 cases](https://openairdocs.org/ntsb-findings/05000000/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Approach-IFR final approach: Altitude deviation](https://openairdocs.org/ntsb-events/282) (defining event); cases with it: [Beech 200, 1 case](https://openairdocs.org/ntsb-events/282/sequence.md?model=1152920), [All aircraft, 104 cases](https://openairdocs.org/ntsb-events/282/sequence.md) - [Approach-IFR final approach: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Beech 200, 5 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=1152920), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) - [Post-impact: Fire/smoke (post-impact)](https://openairdocs.org/ntsb-events/170); cases with it: [Beech 200, 3 cases](https://openairdocs.org/ntsb-events/170/sequence.md?model=1152920), [All aircraft, 354 cases](https://openairdocs.org/ntsb-events/170/sequence.md) ## 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](https://openairdocs.org/deregistered/N241CK-2022-01-08), registration cancelled 2022-01-08, S/N BB272, built 1977 (OpenAirDocs) - Reported make and model: Beech 200 (Undesignat) - Registry model: [Beech 200](https://openairdocs.org/model/beech-200) (registry code 1152920) (OpenAirDocs) - Registry engine: [U/A Canada PT6A-41](https://openairdocs.org/engine/u-a-canada-pt6a-41) (registry code 61541, turbo-prop) (OpenAirDocs) - Category: Airplane - Serial number: BB272 - Year built: 1977 - Airframe hours: 13933.5 - Engines: Pratt & Whitney Canada PT6A-41 850 horsepower turbo prop; Pratt & 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 33; injuries: fatal; 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 ## 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 20180925009509A](https://openairdocs.org/incident/20180925009509A), Sep 25, 2018: Beech 200, Oscoda, MI, Destroyed, 1 fatal. On September 25, 2018 at 05:55 eastern daylight time (EDT), a Beechcraft, BE-200 aircraft, N241CK, registered to kalitta equipment LLC dba. And operated by an… ## Docket (10 files) The files NTSB released with the investigation on August 13, 2019, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=98348. 8.2 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 2.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40475082&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - N241CK, Initial Approach Plots. Plan View (item 2, .PDF, 470 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40475083&FileExtension=.PDF&FileName=N241CK,%20Initial%20Approach%20Plots.%20Plan%20View-Master.PDF - N241CK, Initial Approach Plots, Profile View (item 3, .PDF, 316 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40475084&FileExtension=.PDF&FileName=N241CK,%20Initial%20Approach%20Plots,%20Profile%20View-Master.PDF - N241CK, Radar Plots, YIP-OS (item 4, .PDF, 50 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40475085&FileExtension=.PDF&FileName=N241CK,%20Radar%20Plots,%20YIP-OS-Master.PDF - KFS85 Data Plots (Multiple Sensors) (item 5, .PDF, 73 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40475086&FileExtension=.PDF&FileName=KFS85%20Data%20Plots%20(Multiple%20Sensors)-Master.PDF - VOR 6 Approach Procedure with Accident Location Plotted (item 6, .PDF, 83 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40475087&FileExtension=.PDF&FileName=VOR%206%20Approach%20Procedure%20with%20Accident%20Location%20Plotted-Master.PDF - Wreckage Path, Google Earth (item 7, .PDF, 1 photo, 367 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40475088&FileExtension=.PDF&FileName=Wreckage%20Path,%20Google%20Earth-Master.PDF - Certification of Party Representative (item 8, .PDF, 152 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40475089&FileExtension=.PDF&FileName=Certification%20of%20Party%20Representative-Master.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 9, .PDF, 53 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40475090&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Master.PDF - Photos (item 10, .PDF, 12 photos, 4.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40475091&FileExtension=.PDF&FileName=Photos-Master.PDF 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.