CHI00FA040

NTSB accident investigation · Cessna 525 · Branson, MO · December 9, 1999

Accident · FatalField investigationFinal report
Date
December 9, 1999, 15:12 local (21:12 UTC)
Place
Branson, MO
Injuries
6 fatal
Damage
Destroyed
Phase of flight
Approach
Aircraft
N525KLCessna 525
Weather
Instrument (IMC) · Day
Status
Completed · report June 12, 2001
Report
Approved by Office Director
FAA report
19991209042939A
Case key
48515

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 descended below the minimum altitude for the segment of the GPS approach. Factors relating to the accident were low ceilings, rain, and pilot fatigue.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

In flight collision with terrain/waterApproach - faf/outer marker to threshold (ifr)
Proper altitude - not maintainedPilot in commandCause
Fatigue(lack of sleep)Pilot in commandFactor
Weather condition - low ceilingFactor
Use of inappropriate medication/drugPilot in command
Weather condition - rainFactor
Pressure induced by othersFaa inspector

Analysis

Prior to takeoff from Lambert Field/St. Louis International Airport, St. Louis, Missouri, the pilot contacted the operations manager at M. Graham Clark Airport, Point Lookout, Missouri, and asked about the current weather conditions there. The operations manager told the pilot that the weather was "pretty poor." The airplane took off from St. Louis, at 1411 cst. At 1447:12 cst, the pilot checked in with Springfield Approach Control. The pilot was told to expect the ILS approach to runway 2 at the Springfield-Branson Regional Airport. At 1501:01 cst, the pilot requested to go to Point Lookout and shoot the GPS to runway 11. Springfield Approach instructed the pilot to descend to 3,000 feet msl and cleared him for the approach. At 1507:08 cst, Springfield radar showed the airplane crossing the initial waypoint at 3,000 feet msl, and turn to 116 degrees approach heading. At 1507:17 cst, the airplane descended to 2,500 feet msl. At 1508:51 cst, Springfield Approach cleared the pilot to change to advisory frequency. "Call me back with your cancellation or your miss." The pilot responded, "Okay we're, we're RAWBE inbound and we will call you on the miss or cancellation." The operations manager at M. Graham Clark Airport said that he heard the pilot on the airport's common frequency radio say, "Citation 525KL is RAWBE inbound on the GPS 11 approach." At 1509:01 cst, Springfield radar showed the airplane begin a descent out of 2,500 feet msl. The last radar contact was at 1509:48 cst. The airplane was five nautical miles from the airport on a 296 degree radial, at 2,100 feet msl. At 1530 cst, the operations manager heard Springfield approach trying to contact the airplane. The operations manager initiated a search for the airplane. At 1430 cst, the weather observation at the M. Graham Clark Airport was 300 feet overcast, rain and mist, 3/4 miles visibility, temperature 53 degrees F, winds variable at 3 knots, altimeter 29.92 inches HG. Approach minimum weather for the GPS RWY11 straight in approach to Point Lookout are a minimum ceiling of 600 feet and visibility of 1 mile for a category B aircraft. An examination of the airplane wreckage revealed no anomalies. The results of FAA toxicology testing of specimens from the pilot revealed concentrations of Doxepin in kidney and liver. The Physicians' Desk Reference states that "... drowsiness may occur with the use of this drug, patients should be warned of the possibility and cautioned against driving a car or operating dangerous machinery while taking the drug." The physician who prescribed the Doxepin to the pilot said that he was using it to treat the pilot's "irritable bowel" condition. According to his wife, the pilot had not slept well for several nights, up to the day of the accident, due to problems he was having with the FAA. A friend, who spoke with the pilot just before the accident flight, confirmed the pilot saying "I haven't slept for three days." The friend stated further that the pilot "wasn't himself that day."

Factual narrative

History of flight

On December 9, 1999, at 1512 central standard time (cst), a Cessna 525, N525KL, operated by an airline transport pilot, was destroyed when it impacted a hillside on the northwest edge of the city of Branson, Missouri, 4.3 statute miles from its destination, the M. Graham Clark Airport, Point Lookout, Missouri. A post-crash fire ensued. The pilot, pilot-rated passenger, and four passengers in the cabin section of the airplane, were fatally injured. Instrument meteorological conditions prevailed at the time of the accident. The business flight was being conducted under 14 CFR Part 91. An instrument flight plan was on file. The cross-country flight originated at St. Louis, Missouri, at 1411 cst.

At 1339 cst, the pilot contacted the Federal Aviation Administration Flight Service Station at St. Louis, Missouri, by telephone, and obtained a preflight weather briefing for an instrument flight rules (IFR) flight from St. Louis to Point Lookout. Following the briefing, he filed an IFR flight plan.

The operations manager at M. Graham Clark Airport said that the pilot, while on the ground at St. Louis, contacted him by telephone, at 1348 cst, inquiring what the weather was at the airport. The operations manager told the pilot that the weather was pretty poor and gave him the most-recent observation, which he took a few hours earlier. "He (the pilot) asked me if I could listen for him to call on the CTAF (common traffic advisory frequency) and take a weather observation at that time for him. About 2:40 [p.m. cst] he called me on CTAF and said he was about 10 or 15 minutes out. He asked me if I could call him back with a current weather in about 10 minutes." At this time, another pilot departing the airport in a Cessna 421, N1527G, gave the pilot a pilot report (PIREP) for the field.

The Cessna 421 pilot told the pilot of N525KL that the clouds were approximately 1,200 feet mean sea level (msl). The pilot of N525KL radioed the airport manager and told him to disregard the observation; he was going to Springfield, Missouri.

At 1411 cst, the Air Traffic Control Tower at Lambert Field/St. Louis International Airport, cleared N525KL for takeoff. One minute later, the pilot was instructed to contact departure control.

At 1447:12 cst, N525KL checked in with Springfield Air Traffic Control Tower (ATCT) Approach Control (henceforth, referenced as Springfield Approach Control), and stated that he was descending at pilot's discretion to 10,000 feet msl. Springfield Approach Control told the pilot to maintain 10,000 feet msl and expect the ILS approach to runway 2 at the Springfield-Branson Regional Airport.

At 1449:29 cst, Springfield Approach Control cleared N525KL to 6,000 feet msl. N525KL responded, "okay we're down to six thousand..."

At 1455:48 cst, Springfield Approach Control instructed N525KL to turn left to a heading of 200 degrees. N525KL acknowledged the instruction.

At 1456:30 cst, Springfield Approach Control issued to N525KL, "pilot's discretion descend and maintain four thousand." N525KL responded, "discretion to four thousand for Kilo Lima."

At 1501:01 cst, Springfield Approach Control instructed N525KL to descend and maintain 3,000 feet msl, and turn right to a heading of 280 degrees. N525KL responded, "Okay we have a request. Can you give us, we would like to try Point Lookout, the weather doesn't look that bad here now, and then, if we miss, we'll come back up with you." The Springfield Approach controller asked N525KL's pilot what kind of approach did he want. The pilot responded, "We'll take the GPS to [runway] one-one."

At 1501:32 cst, Springfield Approach Control instructed N525KL to "descend and maintain three thousand until RAWBE, cleared [for the] GPS [runway] one-one approach." N525KL responded, "Okay, we're down to three [thousand], and we're direct RAWBE, and we're programming that now."

At 1507:08 cst, the display of ASR-8 radar at Springfield Approach Control showed N525KL cross the RAWBE waypoint at 3,000 feet msl, and turn to a heading of 116 degrees magnetic.

At 1507:17 cst, Springfield Approach Control radar showed N525KL descending out of 3,000 feet msl.

At 1508:04 cst, Springfield Approach Control radar showed N525KL level off at 2,500 feet msl.

At 1508:51 cst, Springfield Approach Control said, "Citation five Kilo Lima, change to advisory frequency approved. Call me back with your cancellation or your miss." N525KL responded, "Okay we're, we're RAWBE inbound and we will call you on the miss or cancellation."

The operations manager at M. Graham Clark Airport said that he was at his desk in the airport operations office when he heard the pilot on the airport's common frequency radio say, "Citation 525KL is RAWBE inbound on the GPS 11 approach." The operations manager said he went to the door of the building to see if he could hear the airplane go missed approach. The weather was no better than it had been earlier. He listened for about 15 to 20 minutes, then went back in. He said that he thought he must have missed hearing the airplane and that the airplane probably went back to Springfield.

At 1509:01 cst, Springfield Approach Control radar showed N525KL begin a descent out of 2,500 feet msl.

At 1509:46 cst, N1101U, contacted Springfield Approach Control and inquired if N525KL had cancelled yet, or if he was still on the approach? Springfield Approach Control answered, "Still on the approach, I show him just at the final approach fix now."

At 1509:48 cst, Springfield Approach Control's last radar contact position for N525KL, showed the airplane 5 nautical miles (nm) from the M. Graham Clark Airport on a 296 degree radial from the airport, at 2,100 feet msl.

Personnel information

The pilot held an airline transport pilot certificate with airplane single and multi-engine land, and instrument ratings.

The pilot also held a certified flight instructor certificate (CFI) with privileges to instruct in single and multi-engine land, instrument airplanes.

The pilot was also designated by the FAA as a pilot-examiner for the private pilot, commercial pilot, airline transport pilot, and flight instructor certificates in single and multi-engine, instrument airplanes.

According to insurance records provided by the College of the Ozarks, and dated May 6, 1999, the pilot reported having approximately 10,150 hours total flying hours. Trip reports, also provided by the college, showed the pilot had logged 328 hours in the Cessna 525.

According to FAA airman records, a type rating in the Cessna 525 was added to the pilot's airline transport pilot certificate on August 13, 1998. The FAA reported that the pilot had successfully completed a biennial flight review, in conjunction with the renewal of his pilot examiner authority, in a Beech BE-58, on November 10, 1999.

The pilot held a current second class medical certificate, with limitations. According to the Airman Medical Examiner's report, dated August 9, 1999, the pilot's medical certificate contained the statement, "Shall wear corrective lenses."

The pilot-rated passenger held a commercial pilot certificate with airplane single and multi-engine land, and instrument ratings. Federal Aviation Administration airman records showed the addition of the multi-engine rating on October 10, 1997.

The pilot-rated passenger also held a certified flight instructor certificate (CFI) with privileges to instruct in single and multi-engine land, instrument airplanes. The last reported renewal of this certificate was on November 8, 1997.

According to insurance records provided by the College of the Ozarks, and dated October 7, 1999, the pilot-rated passenger reported having approximately 965 hours total flying hours. The records also showed the pilot-rated passenger as having 75 hours in the Cessna 525.

The pilot-rated passenger held a current first class medic

Aircraft

Registration
N525KL
Reported as
Cessna 525
Category
Airplane
Serial number
525-0136
Airframe hours
783
Engine
Williams Intl FJ44-1A, 1,900 lbs thrust, turbo jet
Damage
Destroyed
Fire
On-Ground
Flight
Business · Part 91
Registered owner
College Of The Ozarks
Airworthiness certificate
Standard, Normal
Last inspection
Continuous airworthiness · October 30, 1999 · 30 hours before
Departed
STL · St. Louis, MO
Destination
PLK · Point Lookout, MO
Flight plan
IFR
Airport
PLK · M. Graham Clark Airport, runway 11, 3,739 × 100 ft, asphalt

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
54
Certificates
Flight instructor, Airline transport
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 2, Valid Medical--w/ waivers/lim
Seat
Left
Toxicology
Performed
Flight hours
10,150 total · 328 in this make and model · 9,950 as pilot in command · 2 in the last 24 hours

Weather

Conditions
Instrument (IMC) · Day
Wind
100° at 6 knots
Visibility
2 statute miles
Lowest ceiling
200 ft broken
Temperature
127 °F, dew point 127 °F
Altimeter
29.00 inHg
Observed at
HRO, 25 nm away

Docket · 53

The files NTSB released with the investigation on April 3, 2001, on NTSB’s docket system: statements, records, photos and specialists’ reports. 22.8 MB in all.

Supplement CItem 1 · .PDF · 501 KBSupplement DItem 2 · .PDF · 537 KBSupplement EItem 3 · .PDF · 124 KBSupplement SItem 4 · .PDF · 76 KBMaterials Laboratory Factual ReportItem 5 · .PDF · 68 KBMaterials Laboratory Factual Report Figure 1. Overall View of the Barometric Scale Shown as ReceovedItem 6 · .PDF · 35 KBFigure 2. Close View of the Fire Damage to the Front of the Drum Counters. (4X)Item 7 · .PDF · 31 KBFigure 3. Close View of the Reverse Side of the Drum Counters Showing the Partially Damaged Numbers. (4X)Item 8 · .PDF · 34 KBFigure 4. Close View of the Four Digits Visible on the Reverse Side of the Drum Counters. (7X)Item 9 · .PDF · 53 KBNTSB Medical Officer's Factual ReportItem 10 · .PDF · 96 KBWitness Statements & Record of InterviewsItem 11 · .PDF · 10.5 MBMaps and Wreckage DiagramItem 12 · .PDF · 795 KBAirfield DiagramItem 13 · .PDF · 98 KBWeather ReportsItem 14 · .PDF · 726 KBWeather Reports - Radar ImageItem 15 · .PDF · 35 KBWeather Reports ( Cont.)Item 16 · .PDF · 128 KBATC TranscriptsItem 17 · .PDF · 127 KBFAA Report on GPS Runway 11 Approach , Point Lookout, MO, M.Graham Clark AirportItem 18 · .PDF · 254 KBBranson Police Department Incident ReportItem 19 · .PDF · 226 KBReport From Williams InternationalItem 20 · .PDF · 86 KBIntegrated Avionics Computer Inspection ResultsItem 21 · .PDF · 39 KBFlight PlanItem 22 · .PDF · 78 KBApproach Plate GPS Runway 11, M. Graham AirportItem 23 · .PDF · 100 KBAircraft DiagramsItem 24 · .PDF · 467 KBAirplane Equipment and ConfigurationItem 25 · .PDF · 379 KBLetters Regarding FAA Action Toward Pilot, Joe BrinellItem 26 · .PDF · 596 KBFAA CDR ReadoutsItem 27 · .PDF · 198 KBExcerpts KLN 90B GPS ManualItem 28 · .PDF · 317 KBExcerpts Technical Standard Order (TSO) c129Item 29 · .PDF · 823 KBPilot's HistoryItem 30 · .PDF · 238 KBStatement of Party Representatives to NTSB InvestigationItem 31 · .PDF · 509 KBRelease of Aircraft Wreckage, NTSB Form 6120.15Item 32 · .PDF · 169 KBToxicological ReportItem 33 · .PDF · 134 KBPhoto 1. Accident Site, Aerial View ( Cessna Photo )Item 34 · .PDF · 117 KBPhoto 2. Accident Site, Aerial View ( Cessna Photo )Item 35 · .PDF · 215 KBPhoto 3. Accident Site, Ground Level ViewItem 36 · .PDF · 238 KBPhoto 4. Main Wreckage, Nose, Cockpit & Cabin Right Side ViewItem 37 · .PDF · 235 KBPhoto 5. Main Wreckage, Nose, Cockpit & Cabin Forward ViewItem 38 · .PDF · 240 KBPhoto 6. Main Wreckage, Cabin, Left Side View & Right WingItem 39 · .PDF · 223 KBPhoto 7. Main Wreckage, Aft Fuselage & Left EngineItem 40 · .PDF · 223 KBPhoto 8. Left Wing, Inboard Section, Trailing Edge & Left Wing FlapItem 41 · .PDF · 229 KBPhoto 9. Left Wing, Outboard SectionItem 42 · .PDF · 219 KBPhoto 10. Left Wing, Inboard Section, Leading Edge & Fir TreeItem 43 · .PDF · 212 KBPhoto 11. Aft Fuselage PiecesItem 44 · .PDF · 222 KBPhoto 12. Empennage and Right Engine, Forward ViewItem 45 · .PDF · 232 KBPhoto 13. Empennage and Right Engine, Left Side ViewItem 46 · .PDF · 228 KBPhoto 14. Empennage and Right Engine, Aft ViewItem 47 · .PDF · 209 KBPhoto 15. Rudder and T-TailItem 48 · .PDF · 201 KBPhoto 16. Right EngineItem 49 · .PDF · 168 KBPhoto 17. Tail ConeItem 50 · .PDF · 205 KBPhoto 18. Damaged Trees Preceding Accident SiteItem 51 · .PDF · 190 KBPhoto 19. Damaged Trees At Start of Main WreckageItem 52 · .PDF · 181 KBPhoto 20. Ground ScarItem 53 · .PDF · 239 KB

FAA reports on this event · 1

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