CEN19MA312

NTSB accident investigation · Convair 440 · Monclova, OH · September 11, 2019

Accident · FatalClass 3 · MajorFinal report
Date
September 11, 2019, 02:39 local (06:39 UTC)
Place
Monclova, OH
Injuries
2 fatal
Damage
Destroyed
Phase of flight
Approach
Aircraft
N24DRConvair 440
Defining event
Approach-IFR final approach: Collision with terr/obj (non-CFIT)
Weather
Visual (VMC) · Night
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Central Region
Parties
Convair Technical Support, Pratt & Whitney, TSB, FAA Flight Standards
FAA report
20190911012859A
Case key
100231

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

The flight crew’s failure to maintain the proper airspeed on final approach, which resulted in an inadvertent aerodynamic stall and impact with trees, and terrain. Contributing to the accident was the flight crew’s fatigue due to the overnight flight schedule.

Findings · 5

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.

Use of equip/info: aircraft controlPersonnel issues › Task performance · Flight crewConvair 440: 1 caseAll aircraft: 9,295 casesProbable cause
Performance/control parameters: airspeedAircraft › Aircraft oper/perf/capability · Not attained/maintainedConvair 440: 1 caseAll aircraft: 1,681 casesProbable cause
Performance/control parameters: angle of attackAircraft › Aircraft oper/perf/capability · Capability exceededConvair 440: 1 caseAll aircraft: 990 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 accident occurred during the second of a two-leg nonscheduled cargo flight. The initial leg of the flight departed the preceding evening. The pilots landed about 3.5 hours later for fuel and departed on the accident flight an hour after refueling. The flight entered a cruise descent about 39 miles from the destination airport in preparation for approach and landing. The pilots reported to air traffic control that they were executing a wide base and were subsequently cleared for a visual approach and landing. The landing clearance was acknowledged, and no further communications were received. No problems or anomalies were reported during the flight. The airplane was briefly established on final approach before radar contact was lost. The airplane impacted trees and terrain about 0.5 mile short of the runway and came to rest in a trucking company parking lot. A postimpact fire ensued. Damage to the landing gear indicated that it was extended at the time of impact. The position of the wing flaps could not be determined. Disparities in the propeller blade angles at impact were likely due to the airplane’s encounter with the wooded area and the impact sequence. No evidence of mechanical anomalies related to the airframe, engines, or propellers was observed. A review of air traffic control radar data revealed that the airplane airspeed decayed to about 70 to 75 kts on final approach which was at or below the documented aerodynamic stall speed of the airplane in the landing configuration. Although there was limited information about the flight crew’s schedules, their performance was likely impaired by fatigue resulting from both the total duration of the overnight flights and the approach being conducted in the window of the circadian low. This likely resulted in the flight crew’s failure to maintain airspeed and recognize the impending aerodynamic stall conditions.

Factual narrative

Glidepath information to runway 25 was provided by a four-light precision approach path indicator (PAPI) system and an instrument landing system (ILS). On September 11, 2019, at 0239 eastern daylight time, a Convair 440 airplane, N24DR, was destroyed when it was involved in an accident near Monclova, Ohio. Both pilots were fatally injured. The airplane was operated under Title 14 Code of Federal Regulations Part 125 as a nonscheduled cargo flight. The flight crew initially departed Laredo International Airport (LRD), Laredo, Texas, about 1838 central time the evening before the accident and arrived at Millington/Memphis Airport (NQA), Millington, Tennessee, about 2210 central time. The airplane was refueled before it departed NQA at 2314 for the accident flight. Air traffic control position data depicted the airplane proceed direct to Toledo Express Airport (TOL), Toledo, Ohio, after departure from NQA at a cruise altitude of 7,000 ft mean sea level. About 39 miles southwest of TOL, the airplane entered a cruise descent in preparation for approach and landing. At 0225, the flight was handed off to TOL tower and instructed to descend to 3,000 ft. At 0233, the TOL tower controller instructed the flight crew to descend and maintain 2,100 ft. At 0235, the flight crew informed the controller that they were flying a wide base, and the controller cleared the pilots for a visual approach to runway 25. The airplane was about 5 miles southeast of TOL at that time. At 0236, the controller cleared the pilots to land. The landing clearance was acknowledged, and no further communications from the airplane were received. No problems or anomalies were reported by the flight crew during the flight. The airplane became briefly established on final approach before radar contact was lost. The airplane impacted trees and terrain and came to rest in a trucking company parking lot short of the runway 25 arrival threshold. A review air traffic control radar data performed by a National Transportation Safety Board (NTSB) aircraft performance specialist revealed that the airplane airspeed decayed to about 70 to 75 kts on final approach. The data depicted a flight path consistent with small bank angles through the end of the data. The airplane flight manual noted the zero thrust (power off) aerodynamic stall speed for the airplane in the landing configuration (landing gear and wing flaps extended) was about 75 kts. The pilots’ logbooks were not available to the National Transportation Safety Board during the investigation. Flight times were obtained from their most recent Federal Aviation Administration medical certificate applications. Daily flight logs corresponding to the airplane, dated March 2018 to July 2019, indicated that the pilots were paired together for every flight during that time. The logs reflected 175.1 hours during the preceding 1 year, 3.9 hours within the preceding 90 days, and 0.2 hours within the 30 days preceding the accident. The pilots accumulatedan additional 6 hours of flight time during the flights from LRD to NQA to TOL. The airplane struck trees about 0.65 mile northeast of the runway arrival threshold. The initial strikes were about 55 ft above ground level and consistent with a right bank angle of about 20°. Multiple tree breaks were observed along the flightpath through the wooded area east of the accident site. The airplane flightpath was oriented on a westerly heading and continued through the wooded area. The airplane came to rest in a trucking company parking lot about 0.50 mile from the threshold and near the extended centerline of the runway. A postimpact fire ensued. The wreckage was intermingled with the trucks and trailers parked in the lot. The top and side of a parked tractor trailer exhibited propeller strikes. In addition, portions of airplane structure were located in the woods immediately east of the accident site and along the flightpath leading to the final wreckage location. The main fuselage and cargo area (including the cargo), portions of the right and left wings, main landing gear, nose landing gear structure, flight deck, engine nacelles, and left engine exhibited extensive postimpact fire damage. Damage to the landing gear indicated that it was extended at the time of impact. The position of the wing flaps could not be determined due to the impact and postimpact fire damage. An examination of the airframe revealed no evidence of a preimpact structural failure. The left (No. 1) engine and propeller assembly came to rest on the ground against the aft side of a semi-tractor trailer. Both the engine and propeller were damaged by impact forces and the postimpact fire. The fire consumed the portions of the engine accessories and multiple cylinders, which prevented a full engine teardown. However, there was no evidence of a preimpact failure in the crankcase or cylinders that remained intact. The left propeller blades exhibited bending opposite the direction of rotation. The left propeller assembly was disassembled and no anomalies consistent with a preimpact failure or malfunction were observed. The left propeller blade shim spider impacts indicate that the propeller blades were at angles between 41-44°. The presence of multiple propeller strike marks at the accident site after the airplane had encountered the wooded area, including propeller strikes on a semi-tractor trailer, was consistent with the engine producing power at the time of impact. The right (No. 2) engine was separated from the wing and came to rest in the trucking company parking area. The right propeller was separated from the engine consistent with impact forces and located in the main debris field. The fracture surfaces on the front case were jagged and dimpled consistent with overload failure. The right propeller blades exhibited bending opposite the direction of rotation, and teardown examination of the propeller assembly did not reveal any anomalies consistent with a preimpact failure ormalfunction. The right propeller blade spider shim impact marks indicated that the blades were at angles between 26-27° when the airplane impacted the trees/ground. The overload fracture of the engine accessory case and the low propeller blade angles at the time of impact are consistent with the engine producing power.

Aircraft

Registration
N24DR
Reported as
Convair 440 (No Series)
Category
Airplane
Serial number
393
Built
1957
Airframe hours
47,742.4
Engines
Pratt & Whitney R2800-52W, 2,200 horsepower, reciprocatingPratt & Whitney R2800-52W, 2,200 horsepower, reciprocating
Damage
Destroyed
Fire
On-Ground
Flight
Part 125
Airworthiness certificate
Standard, Transport
Last inspection
AAIP · February 23, 2019 · 39.2 hours before
Departed
NQA · Millington, TN
Destination
TOL · Toledo, OH
Flight plan
IFR
Airport
TOL · Toledo Express, runway 25, 10,599 × 150 ft, asphalt
Equipment
Stall warning system, Electronic multifunction display

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 · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
69
Injuries
Fatal
Certificate
Airline transport
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 2, With waivers/limitations
Last flight review
July 22, 2019
Seat
Left
Toxicology
Performed
Flight hours
8,000 total · 10 in the last 90 days · 6 in the last 30 days · 6 in the last 24 hours
Role
Co-pilot
Age
72
Injuries
Fatal
Certificate
Commercial
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 2, With waivers/limitations
Last flight review
July 22, 2019
Seat
Right
Toxicology
Performed
Flight hours
11,287 total · 10 in the last 90 days · 6 in the last 30 days · 6 in the last 24 hours

Weather

Conditions
Visual (VMC) · Night
Wind
230° at 4 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
75 °F, dew point 66 °F
Altimeter
30.13 inHg
Observed at
TOL, 1 nm away

Docket · 42

The files NTSB released with the investigation on August 24, 2022, on NTSB’s docket system: statements, records, photos and specialists’ reports. 1.3 GB in all.

Plot of airplane position dataItem 1 · PDF · 3 pages · 1.4 MBAccident photosItem 2 · PDF · 15 pages · 3.5 MBUAS aerial imageryItem 3 · PDF · 9 pages · 1.5 MBUAS imagery att 1 google earth kmzItem 4 · KMZ · 146 MBUAS imagery att 2 orthomosaicItem 5 · ZIP · 527 MBUAS aerial imagery att 3 overall point cloudItem 6 · ZIP · 283 MBUAS aerial imagery att 4 wreckage point cloudItem 7 · ZIP · 319 MBElectronic devices - specialist's factual reportItem 8 · PDF · 5 pages · 486 KBConversation summary -- captain's wifeItem 9 · PDF · 1 page · 51 KBConversation summary -- first officer's wifeItem 10 · PDF · 1 page · 49 KBFlight plan documentation -- foreflightItem 11 · PDF · 2 pages · 86 KBFlight release -- accident flightItem 12 · PDF · 1 page · 631 KBFueling records -- accident flightItem 13 · PDF · 3 pages · 986 KBAirplane flight logsItem 14 · PDF · 46 pages · 4.7 MBAirplane flight summaryItem 15 · PDF · 7 pages · 70 KBCheckride documentation -- captainItem 16 · PDF · 2 pages · 2.5 MBCheckride documentation -- first officerItem 17 · PDF · 2 pages · 2.7 MBAutopsy memoItem 18 · PDF · 1 page · 103 KBToxicological report -- captainItem 19 · PDF · 1 page · 196 KBToxicological report -- first officerItem 20 · PDF · 1 page · 177 KBAirworthiness group chairman's factual reportItem 21 · PDF · 35 pages · 34 photos · 3.9 MBPowerplants group chairman's factual reportItem 22 · PDF · 34 pages · 13.6 MBMaintenance records -- inspection recordItem 23 · PDF · 2 pages · 185 KBMaintenance records -- component listing/statusItem 24 · PDF · 51 pages · 913 KBMaintenance records -- AD listingItem 25 · PDF · 12 pages · 261 KBMaintenance records -- B1 inspection (June 2018)Item 26 · PDF · 43 pages · 3.0 MBMaintenance records -- AD inspection (July 2018)Item 27 · PDF · 7 pages · 443 KBMaintenance records -- ''a'' inspection (sept 2018)Item 28 · PDF · 16 pages · 1.2 MBMaintenance records -- ''B2'' inspection (oct 2018)Item 29 · PDF · 44 pages · 3.1 MBMaintenance records -- ''a'' inspection (dec 2018)Item 30 · PDF · 13 pages · 1.1 MBMaintenance records -- AD inspection (feb 2019)Item 31 · PDF · 3 pages · 236 KBMaintenance records -- ''B3'' inspection (feb 2019)Item 32 · PDF · 39 pages · 2.7 MBMaintenance records -- left engine maintenance (mar 2019)Item 33 · PDF · 2 pages · 226 KBMaintenance records -- AD inspection (may 2019)Item 34 · PDF · 9 pages · 951 KBMaintenance records -- right engine maintenance (may 2019)Item 35 · PDF · 1 page · 77 KBMaintenance records -- airframe inspection (jun 2019)Item 36 · PDF · 2 pages · 198 KBMaintenance records -- landing gear inspection (jun 2019)Item 37 · PDF · 10 pages · 989 KBMaintenance records -- airframe inspection (sep 2019)Item 38 · PDF · 1 page · 84 KBSurface weather observations -- toledo express airportItem 39 · PDF · 2 pages · 56 KBRelease of aircraft wreckage, NTSB form 6120.15Item 40 · PDF · 1 page · 4.6 MBPlot of airspeedItem 41 · PDF · 1 page · 1.6 MBFlight manual (excerpt) -- zero thrust stall speedItem 42 · PDF · 1 page · 1.6 MB

FAA reports on this event · 1

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