CEN22FA032

NTSB accident investigation · Beech E-90 · Boyne City, MI · November 15, 2021

Accident · FatalClass 3 · FieldFinal report
Date
November 15, 2021, 12:45 local (17:45 UTC)
Place
Boyne City, MI
Injuries
2 fatal
Damage
Destroyed
Phase of flight
Approach
Aircraft
N290KABeech E-90
Defining event
Approach-IFR final approach: Loss of control in flight
Weather
Instrument (IMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Central Region
Parties
McCauley Propeller Systems, Textron Aviation, Honeywell Aerospace, FAA - AVP-100
FAA report
20211115018219A
Case key
104245

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 NTSB’s determination of the probable cause, and any contributing factors.

The pilot’s failure to maintain sufficient airspeed and his exceedance of the airplane’s critical angle of attack while in icing conditions, which resulted in an aerodynamic stall and subsequent ground impact.

Findings · 2

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings.

Analysis

While on final approach, the airplane gradually slowed to near its stall speed. About 600 ft beyond the last recorded data, the airplane impacted the ground in a nose down attitude that was consistent with a stall. Postaccident examination revealed no preaccident mechanical failures or malfunctions that would have contributed to the accident. Witnesses near the accident site reported very heavy sleet with low visibility conditions, whereas a witness located near the final approach flightpath, about 2 miles before the accident site observed the airplane fly by below an overcast cloud layer with no precipitation present. Based on the witness accounts and weather data, the airplane likely entered a lake effect band of heavy sleet during the final portion of the flight. The airplane was modified with 5-bladed propellers, and other pilots reported it would decelerate rapidly, especially when the speed/propeller levers were moved to the high rpm (forward) position. The pilot usually flew a larger corporate jet and had not flown the accident airplane for 8 months. The passenger was a student pilot with an interest in becoming a professional pilot. The pilot’s poor airspeed control on final approach was likely influenced by a lack of recency in the turboprop airplane. The workload of inflight deicing tasks may have also contributed to the poor airspeed control. The aerodynamic effects of the heavy sleet that was encountered near the accident site likely contributed to the stall to some degree.

Factual narrative

The factual narrative1,059 words

The airplane had been modified numerous times since 1973 and was equipped with Honeywell TPE331-10 engines, McCauley 5-bladed propellers, and Garmin avionics. The aircraft was the original test vehicle for the Honeywell engine and McCauley propeller supplemental type certificate (STC) development. The airplane was the first of two modified by the STC. The owner/pilot of the second STC airplane reported that a rapid deceleration on final approach would occur when propeller levers were moved to the high rpm (forward) position, so he normally waited until the airplane was on short final to do so. A different pilot who flew the accident airplane observed it rapidly decelerate from 135 to 100 knots during level off on one occasion. This pilot normally flew jets and the rapid deceleration was surprising to him. Another pilot who flew the accident airplane stated he normally landed with partial engine power on to avoid the airplane decelerating prematurely. According to FAA flight testing that was conducted in conjunction with the STC, the stall speed with landing gear down and 0° flaps was 89 knots indicated airspeed. Flight testing results were determined to be satisfactory. The airplane flight manual included the following caution about icing: Stalling airspeeds should be expected to increase when ice has accumulated on the airplane due to distortion of the wing airflow. Keep a comfortable margin of airspeed above the normal stall airspeed with ice on the airplane. Maintain a minimum of 140 knots during icing conditions to prevent ice accumulation on unprotected surfaces of the wing. On November 15, 2021, about 1245 eastern standard time, a Beech E-90, N290KA, was destroyed when it was involved in an accident near Boyne City, Michigan. The airline transport pilot and passenger sustained fatal injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 business flight. A review of automatic dependent surveillance-broadcast (ADS-B) data revealed the airplane departed Oakland County International Airport (PTK), Pontiac, Michigan, at 1150 and climbed to a cruise altitude of 16,000 ft mean sea level (msl) enroute to Boyne City Municipal Airport (N98), Boyne City, Michigan. The airplane descended toward N98 and air traffic control cleared the pilot for the RNAV GPS Rwy 27 approach. While established on final approach, the airplane gradually slowed from 129 to 88 knots groundspeed over a period of one minute. The last recorded ADS-B data showed the airplane at 88 knots groundspeed, about 3.2 nautical miles from the runway, and about 600 ft above ground level. The airplane impacted the ground about 600 ft beyond the last recorded ADS-B data. The nearest surface winds located about 12 miles north were 360° at 3 knots. An airman’s meteorological information (AIRMET) for moderate icing was valid for the accident location, which the pilot received during a weather briefing from Leidos. The accident site was influenced by northwesterlywinds flowing across the Great Lakes that resulted in increased moisture. When combined with the low-level trough, bands of lake effect rain and snow shower activity were occurring. The destination did not have weather reporting capability. The observations of the nearest airports indicated visual flight rules (VFR) to marginal VFR conditions with scattered snow. Visibility conditions were reported as low as ¼ mile when areas of snow moved across the region during the early morning of the accident. Two witnesses located about ¼ mile southeast of the accident site heard the airplane fly overhead, followed by a loud thud of the accident. The witnesses observed very heavy sleet with low visibility conditions for about 10 minutes prior to and after the accident. The sleet had a high liquid content and would melt quickly after ground impact. Another witness located near the final approach flightpath, about 2 miles before the accident site observed the airplane fly past his position below an overcast cloud deck. The witness reported that no precipitation was present as the airplane flew by his position. The pilot primarily flew a Bombardier Challenger 604 jet, although he had not flown this airplane since June 2021 due to maintenance work on the engines. The pilot completed Challenger 601 recurrency training with CAE in a flight simulator from November 5-8, 2021. The pilot flew about 700 hours in Beech E-90 airplanes. About 3 years prior to the accident, the pilot started managing the accident airplane, and he last flew the airplane during recurrent flight training on March 22, 2021. The airplane required one pilot to be operated. The passenger in the cockpit’s right seat was a student pilot interested in becoming a professional pilot and was along for the ride. The airplane impacted into forested terrain on a westerly heading, with broken tree limbs indicating a steep descent of about 70°. The nose was crushed aft and the tail was bent up and over the top of the fuselage like a scorpion. A postimpact fire did not occur. Multiple propeller-cut tree limbs were found immediately east of the accident site. The power levers, speed/propeller levers, and fuel cutoff levers were found at the accident site in the full forward position. The position of the cockpit deice switches were unable to be determined due to impact damage. The landing gear was in the down position. Three of the four flap actuators indicated a flaps 5° position. No preimpact anomalies were observed with flight control continuity. Examination at a recovery location revealed the impeller vanes of both engines were bent in the direction opposite of rotation, consistent with ingestion of foreign debris during engine operation. The third stage turbine shrouds of both engines were rotationally scored and the nozzles vanes of both engines displayed metal spray deposits on the convex side of the vanes, consistent with engine rotation, normal internal airflow and an existent combustion process.Witness marks on both propellers indicated blade angles were 20° to 40° during ground impact. The blade bending, twisting, and overall assembly damage of both propellers was consistent with deformation during the impact sequence. Left and right propeller mounting holes were elongated, the direction of which was consistent with the correct rotational direction. The deicing system was examined at the recovery location, and the bleed air regulator valve, de-ice distributor valve, and an 8-inch section of the left wing surface de-ice manifold assembly were removed for further testing. No preaccident mechanical failures or malfunctions were observed that would have contributed to the accident.

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident.

Aircraft

Registration
N290KA
Reported as
Beech E-90
Category
Airplane
Serial number
LW59
Built
1974
Airframe hours
10,491
Engines
Honeywell TPE331-10-511KA, 715 horsepower, turbo propHoneywell TPE331-10-511KA, 715 horsepower, turbo prop
Damage
Destroyed
Flight
Business · Part 91
Operator
N290ka LLC
Registered owner
N290ka LLC
Airworthiness certificate
Standard, Normal
Last inspection
Continuous airworthiness · October 13, 2021 · 11 hours before
Departed
PTK · Pontiac, MI
Destination
N98 · Boyne City, MI
Flight plan
IFR
Airport
N98 · Boyne City Muni, runway 27, 4,001 × 75 ft, asphalt
Equipment
Stall warning system, ADS-B, Auto-pilot

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
61
Injuries
Fatal
Certificates
Airline transport, Private
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 2, With waivers/limitations
Last flight review
November 8, 2021
Seat
Left
Restraint
4-point
Toxicology
Performed
Flight hours
13,000 total · 700 in this make and model

Weather

Conditions
Instrument (IMC) · Day
Wind
360° at 3 knots
Visibility
10 statute miles
Lowest ceiling
2,400 ft broken
Temperature
36 °F, dew point 34 °F
Altimeter
29.95 inHg
Observed at
KMGN, 13 nm away
METAR
KMGN 151735Z AUTO 36003KT 10SM SCT012 BKN024 OVC042 02/01 A2995 RMK AO2 T00290012

Docket · 30

The files NTSB released with the investigation on April 5, 2023, on NTSB’s docket system: statements, records, photos and specialists’ reports. 96.8 MB in all.

Witness interview - hunters located near accident siteItem 1 · PDF · 1 page · 133 KBWitness statement - located 2 miles east of accident siteItem 2 · PDF · 1 page · 130 KBInterviews of pilots - summariesItem 3 · PDF · 2 pages · 108 KBInterview of owner-pilot of the other STC aircraftItem 4 · PDF · 1 page · 89 KBPilot recurrent training - king airItem 5 · PDF · 1 page · 2.6 MBPilot recurrent training - challengerItem 6 · PDF · 9 pages · 765 KBFlight manual - excerpt on icingItem 7 · PDF · 1 page · 315 KBFlight manual supplementItem 8 · PDF · 27 pages · 2.0 MBFAA flight testing - excerptItem 9 · PDF · 1 page · 172 KBWeather report - factualItem 10 · PDF · 36 pages · 4.1 MBWeather report - attachment 1Item 11 · PDF · 2 pages · 52 KBWeather report - attachment 2Item 12 · GIF · 18.6 MBWeather report - attachment 3Item 13 · GIF · 12.3 MBWeather report - attachment 4Item 14 · PDF · 5 pages · 2.2 MBWeather report - attachment 5Item 15 · PDF · 4 pages · 75 KBWeather report - attachment 6Item 16 · PDF · 48 pages · 194 KBWeather report - attachment 7Item 17 · ZIP · 3.7 MBWeather report attachment 8Item 18 · WAV · 6.1 MBWeather report - attachment 9Item 19 · PDF · 3 pages · 156 KBWeather report - attachment 10Item 20 · ZIP · 29.0 MBFAA air traffic control report - excerptItem 21 · PDF · 4 pages · 492 KBADS-B data fileItem 22 · CSV · 4.5 MBADS-B google earthItem 23 · KMZ · 80 KBADS-B - graphic of flight path and accident siteItem 24 · PDF · 1 page · 115 KBWreckage examination summaryItem 25 · PDF · 12 pages · 3.0 MBSystems factual reportItem 26 · PDF · 19 pages · 1.4 MBToxicological report - pilotItem 27 · PDF · 2 pages · 473 KBAutopsy memorandumItem 28 · PDF · 1 page · 62 KBStatement of party representatives to NTSB investigationItem 29 · PDF · 3 pages · 3.8 MBRelease of aircraft wreckage, NTSB form 6120.15Item 30 · PDF · 1 page · 123 KB

FAA reports on this event · 1

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