CHI01FA083

NTSB accident investigation · Swearingen SA227-AT · Beaver Island, MI · February 9, 2001

Accident · FatalField investigationFinal report
Date
February 8, 2001, 19:20 local (Feb 9, 2001, 00:20 UTC)
Place
Beaver Island, MI
Injuries
2 fatal, 2 serious, 2 minor
Damage
Destroyed
Phase of flight
Approach
Aircraft
N318DHSwearingen SA227-AT
Weather
Instrument (IMC) · Night/dark
Status
Completed · report July 2, 2002
Report
Approved by Office Director
Parties
Honeywell - Engines and Systems, Fairchild Aerospace, FAA-Grand Rapids, Michigan-FSDO, Dowty Propellers, National Air Traffic Controllers Association
FAA report
20010208000749A
Case key
51699

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 flightcrew not maintaining altitude/clearance during the circling instrument approach. Factors were the pilot in command initiating the flight without proper weather reporting facilities at the destination, the flightcrew not flying to an alternate destination, the flightcrew not following company and FAA procedures/directives, the lack of certification of the second pilot, the operator not following company and FAA procedures/directives, and the dark night and the low ceiling.

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 objectCircling (ifr)
Flt with inadqt en route/destn facilities - initiatedPilot in commandFactor
Not performedFlightcrewFactor
Procedures/directives - not followedFlightcrewFactor
Light condition - dark nightFactor
Altitude/clearance - not maintainedFlightcrewCause
Weather condition - low ceilingFactor
Lack of certificationCopilot/second pilotFactor
Procedures/directives - not followedCompany/operator managementFactor

Analysis

The airplane was on an on-demand air-taxi flight operating under 14 CFR Part 135 and was destroyed when it impacted trees and terrain while circling to land during a non-precision instrument approach at night. The airplane came to rest 1.74 nautical miles and 226 degrees magnetic from the intended airport. A weather briefing was obtained and instrument meteorological conditions were present along the route of flight at the time of the briefing. Weather conditions for the two reporting stations closest to the destionation were obtained by the airplane prior to executing the approach. The weather reports listed ceilings and visibilities as 400 to 500 feet overcast and 5 to 7 statute miles. The airport elevation is 669 feet and the minimum descent altitude for the approach was listed as 1,240 feet. There was no weather reporting station at the destination airport at the time of the accident. According to the operators General Operations Manual, the pilot was responsible for the dispatch of the airplane including flight planning, and confirming departure, en-route, arrival and terminal operations compliance. The manual also states, "For airports without weather reporting, the area forecast and reports from airports in the vicinity must indicate that the weather conditions will be VFR [visual flight rules] at the ETA so as to allow the aircraft to terminate the IFR operations and land under VFR. (Note: a visual approach is not approved without weather reporting)." For 14 CFR Part 135 instrument flight operations conducted at an airport, federal regulations require weather observations at that airport. Furthermore, the regulations state that, for 14 CFR Part 135 operations, an instrument approach cannot be initiated unless approved weather information is available at the airport where the instrument approach is located, and the weather information indicates that the weather conditions are at or above the authorized minimums for the approach procedure. The commercial pilot held a type rating for the accident airplane. The right seat occupant was a commercial pilot employed by the operator and did not hold an appropriate type rating for the accident airplane. The pitch trim selector switch was found set to the co-pilot side. The regulations state that 14 CFR Part 135 operators cannot use the services of any person as an airman unless that person is appropriately qualified for the operation for which the person is to be used. The circling approach was made over primarily unlit land and water. An FAA publication states that during night operations, "Distance may be deceptive at night due to limited lighting conditions. A lack of intervening references on the ground and the inability of the pilot to compare the size and location of different ground objects cause this. This also applies to the estimation of altitude and speed. Consequently, more dependence must be placed on flight instruments, particularly the altimeter and the airspeed indicator." No anomalies were found with respect to the airframe, engines, or systems that could be associated with a pre-impact condition.

Factual narrative

History of flight

On February 8, 2001, about 1920 eastern standard time (all times herein are est), a Swearingen SA227-AT, N318DH, operated by Northern Illinois Flight Center (NIFC) and piloted by a commercial pilot, was destroyed when it impacted trees and terrain 1.74 nautical miles and 226 degrees magnetic from the Beaver Island Airport (SJX), Beaver Island, Michigan. The 14 CFR Part 135 on-demand air-taxi flight was operating in instrument meteorological conditions and was on an instrument flight rules (IFR) flight plan. The pilot and pilot rated front seat occupant were fatally injured. Two passengers received minor injuries and two passengers received serious injuries. There were a total of six persons on board the aircraft. The flight departed the Chicago Midway Airport (MDW), Chicago, Illinois, at 1810, with SJX as the intended destination.

According to a certified re-recording from the Kankakee, Illinois, Automated Flight Service Station, a call was received about 1738 to file an IFR flight plan for the accident airplane. During the call, the flight service station specialist issued the current weather conditions for the two reporting stations closest to the destination were given. The weather at Charlevoix, Michigan was given as: Wind 110 at 9 knots; Visibility 10 statute miles; Ceiling 1,100 feet overcast; Temperature 1 degree Celsius; Dew point -1 degree Celsius. The weather at Pellston, Michigan was given as: Wind 110 at 10 knots; Visibility 8 statute miles; Ceiling 900 feet overcast; Temperature 0 degrees Celsius; Dew point -1 degree Celsius.

The airplane was cleared for takeoff from MDW at 1810. The airplane proceeded to fly to SJX. At 1841, the pilot established communications with the Minneapolis Air Route Traffic Control Center (ARTCC). At 1908, the controller cleared the airplane for the instrument approach to SJX.

Aircraft radar track data was obtained from 1833:58 to 1919:53. The last recorded radar return was at 1919:53. The radar data was plotted on the instrument approach procedure chart and on a sectional aeronautical chart using commercial software. These plots are appended to this report. The last recorded radar position was at 45 degrees, 41 minutes, 03 seconds north latitude and 85 degrees, 32 minutes, 12 seconds west longitude. The last radar position is about 1.3 nautical miles and 110 degrees magnetic from SJX.

The chief pilot for the airplane operator stated in a telephone conversation that the pilot of the accident airplane was informed that the flight was only to be executed if visual meteorological weather conditions existed at the destination airport.

Personnel information

The pilot held commercial pilot and flight instructor certificates with airplane multiengine land, airplane single engine land, and instrument airplane ratings. The pilot was type-rated in BE-1900 and SA227 aircraft. The pilot held a second-class aviation medical certificate issued on August 17, 2000. The medical certificate listed the restriction, "Must wear corrective lenses."

A written report submitted by the airplane operator states that the pilot had accumulated 6,500 hours total flight time, of which 3,500 hours were in multi-engine airplanes and 250 hours in the same make and model as the accident airplane.

The pilot-rated front seat occupant held a commercial pilot certificate with airplane multiengine land, airplane single engine land, and instrument airplane ratings. He also held a flight instructor certificate with an airplane single engine rating. He was not type-rated in the SA227. He held a first-class aviation medical certificate issued on November 14, 2000. The medical certificate listed the restriction, "Must wear corrective lenses."

A written report submitted by the airplane operator states that the pilot-rated front seat occupant had accumulated 800 hours total flight time, of which 10 hours were in multi-engine airplanes. In a telephone conversation, the chief pilot for the operator stated that the front seat occupant was not a required crew-member and was on the airplane for observation purposes only.

Aircraft information

The airplane was a Swearingen model SA227-AT, serial number AT469, manufactured in 1981. The SA227-AT is a twin-engine turboprop aircraft. The fuselage is a semi-monocoque structure. The interior of the airplane was configured to accommodate 12 passengers in addition to the two crew stations. Two Honeywell model TPE331-11U-611G engines, each producing 1,000 shaft-horsepower, powered the airplane.

Maintenance records supplied by the operator state that the airplane had accumulated 7,280.5 hours of flight time. The maintenance records further state that the right and left engines had accumulated 4,222.2 and 4,359.5 hours, respectively, since overhaul.

The NIFC Operations Specifications state that the operator was authorized to use the airplane and its autopilot system in lieu of a second-in-command pilot, provided that the pilot has satisfactorily completed the proficiency check requirements, and the autopilot system is operational.

Documents regarding the seating configuration of the airplane were provided to the NTSB. In a letter to NIFC, a representative of Fairchild Aerospace, the airplane type certificate holder, stated, "We, Fairchild Aerospace, have no technical objections with your plan for an Alternate Configuration B: 9 passenger with couch placarded, not to be occupied for take off and landing." In a letter to the FAA, NIFC stated, "The aircraft will be configured for 9 passengers in accordance with the letter from Fairchild." A letter from the FAA to NIFC stated, "This aircraft must be operated in a factory authorized configuration of 9 passenger seats or less."

Meteorological information

At the time of the accident, SJX did not have a weather reporting station. According to the instrument approach procedure chart for the NDB or GPS runway 27 approach at SJX, the Pellston altimeter setting is to be used for the approach.

The Pellston, Michigan, surface weather observation station, KPLN, located about 100 degrees true and 35 nautical miles from the accident site recorded the following observations:

Time-1854; type-METAR; wind-130 degrees at 12 knots; visibility-5 miles;

present weather-mist; sky condition-overcast 500 feet; temperature-00

degree Celsius; dew point-00 degree Celsius; altimeter setting-30.09

inches hg.

Time-1954; type-METAR; wind-110 degrees at 11 knots; visibility-5 miles;

present weather-mist; sky condition-overcast 500 feet; temperature-00

degree Celsius; dew point-00 degree Celsius; altimeter setting-30.01

inches hg.

The Mackinac Island, Michigan, surface weather observation station, KMCD, located about 075 degrees true and 42 nautical miles from the accident site recorded the following observations:

Time-1855; type-METAR; wind-120 degrees at 4 knots gusting 14 knots;

visibility-4 miles; present weather-mist; sky condition-overcast 300

feet; temperature-00 degree Celsius; dew point-00 degree Celsius;

altimeter setting-30.08 inches hg.

Time-1955; type-METAR; wind-130 degrees at 10 knots gusting 21 knots

wind 110 degrees variable 190 degrees; visibility-10 miles; present

weather-none; sky condition-overcast 500 feet; temperature-00 degree

Celsius; dew point-minus 01 degree Celsius; altimeter setting-30.00

inches hg.

The Newberry, Michigan, surface weather observation station, KERY, located about 039 degrees true and 39 nautical miles from the accident site recorded the following observations:

Time-1855; type-METAR; wind-110 degrees at 10 knots gusting 16 knots;

visibility-2 1/2 miles; present weather-mist; sky condition-overcast 400

feet; temperature-minus 03 degree Celsius; dew point-minus 05 degree

Celsius; altimeter setting-30.07 inches hg.

Aircraft

Registration
N318DH
Reported as
Swearingen SA227-AT
Category
Airplane
Serial number
AT469
Airframe hours
7,207
Engines
Allied Signal TPE331, 1,000 horsepower, turbo propAllied Signal TPE331, 1,000 horsepower, turbo prop
Damage
Destroyed
Fire
On-Ground
Flight
Part 135
Registered owner
Northern Illinois Flight Center
Airworthiness certificate
Standard, Normal
Last inspection
AAIP · November 2, 2000 · 74 hours before
Departed
MDW · Chicago, IL
Destination
SJX · Beaver Island, MI
Flight plan
IFR
Airport
SJX · Beaver Island, runway 27, 4,000 × 50 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 · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
52
Injuries
Fatal
Certificates
Commercial, Flight instructor
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 2, Valid Medical--w/ waivers/lim
Last flight review
September 22, 2000
Seat
Left
Toxicology
Performed
Flight hours
6,500 total · 250 in this make and model · 6,400 as pilot in command · 100 in the last 90 days · 40 in the last 30 days · 0 in the last 24 hours
Role
Other flight crew
Age
23
Injuries
Fatal
Certificates
Flight instructor, Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--w/ waivers/lim
Last flight review
June 8, 2000
Seat
Right
Toxicology
Performed
Flight hours
800 total · 750 as pilot in command · 195 in the last 90 days · 76 in the last 30 days · 1 in the last 24 hours

Weather

Conditions
Instrument (IMC) · Night/dark
Wind
110° at 11 knots
Visibility
5 statute miles
Lowest ceiling
500 ft overcast
Temperature
32 °F, dew point 32 °F
Altimeter
30.01 inHg
Observed at
PLN, 35 nm away

Docket · 40

The files NTSB released with the investigation on June 17, 2002, on NTSB’s docket system: statements, records, photos and specialists’ reports. 20.9 MB in all.

Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1Item 1 · .PDF · 1.5 MBSupplement CItem 2 · .PDF · 384 KBSupplement SItem 3 · .PDF · 61 KBMeteorological Factual ReportItem 4 · .PDF · 651 KBMeteorological Factual Report-Attachment 1Item 5 · .PDF · 475 KBMeteorological Factual Report-Attachment 2Item 6 · .PDF · 4.9 MBMeteorological Factual Report-Attachment 3Item 7 · .PDF · 307 KBMeteorological Factual Report-Attachment 4Item 8 · .PDF · 12 KBMeteorological Factual Report-Attachment 4-Image 1Item 9 · .PDF · 17 KBMeteorological Factual Report-Attachment 4 (Cont.)Item 10 · .PDF · 229 KBMeteorological Factual Report-Attachment 5Item 11 · .PDF · 14 KBMeteorological Factual Report-Attachment 5-Image 1Item 12 · .PDF · 94 KBMeteorological Factual Report-Attachment 6Item 13 · .PDF · 12 KBMeteorological Factual Report-Attachment 6-Image 1Item 14 · .PDF · 82 KBMeteorological Factual Report-Attachment 7Item 15 · .PDF · 12 KBMeteorological Factual Report-Attachment 7-Image 1Item 16 · .PDF · 87 KBMeteorological Factual Report-Attachment 7-Image 2Item 17 · .PDF · 88 KBMeteorological Factual Report-Attachment 8Item 18 · .PDF · 380 KBMeteorological Factual Report-Attachment 9Item 19 · .PDF · 190 KBMeteorological Factual Report-Attachment 10Item 20 · .PDF · 155 KBMeteorological Factual Report-Attachment 11Item 21 · .PDF · 287 KBMeteorological Factual Report-Attachment 12Item 22 · .PDF · 658 KBWitness, Passenger Statements and Record of InterviewItem 23 · .PDF · 857 KBMemo of Conversation with Northern Illinois Flight Center Chief PilotItem 24 · .PDF · 59 KBExcerpts and Transcripts from FAA Accident PackageItem 25 · .PDF · 502 KBExcerpts From Search & Rescue ReportItem 26 · .PDF · 324 KBExcerpt From Honeywell Engine Teardown ReportItem 27 · .PDF · 1.2 MBDowty Propeller Examination ReportItem 28 · .PDF · 250 KBCorrespondence Regarding Seat Configuration of AirplaneItem 29 · .PDF · 143 KBAircraft and Flight Information Found at Accident SiteItem 30 · .PDF · 2.9 MBExcerpt From NIFC Ground Operations ManualItem 31 · .PDF · 368 KBRadar Data PlotsItem 32 · .PDF · 402 KBApproach InformationItem 33 · .PDF · 127 KBFAA-H-8083-3 ExcerptItem 34 · .PDF · 1.5 MBToxicological ReportItem 35 · .PDF · 513 KBPhoto 1. View of Airplane FuselageItem 36 · .PDF · 226 KBPhoto 2. View of Airplane TailItem 37 · .PDF · 214 KBPhoto 3. View of Wreckage Path From Wreckage SiteItem 38 · .PDF · 222 KBPhoto 4. Overall View of WreckageItem 39 · .PDF · 223 KBPhoto 5. Overall View of WreckageItem 40 · .PDF · 223 KB

FAA reports on this event · 1

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