# NTSB CHI05FA038: Hamburger Flugzeugbau HFB 320 Hansa, N604GA, Chesterfield, MO, December 1, 2004 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: November 30, 2004, 19:56 local (Dec 1, 2004, 01:56 UTC) - Place: Chesterfield, MO - Coordinates: 38.664443, -90.702499 - Nearby events: https://openairdocs.org/map.md?lat=38.6644&lon=-90.7025&mi=10 - Phase of flight: [Standing](https://openairdocs.org/ntsb-phases/150) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 2 fatal - Status: Completed, report May 30, 2006 - Report: Approved by Office Director - Parties: GE Aviation Engines, FAA, St. Louis FSDO, Grand Aire, Midcoast Aviation - NTSB case key (mKey): 60656 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CHI05FA038 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/60656/pdf - Page: https://openairdocs.org/ntsb/CHI05FA038 ## Probable cause The maintenance facility failed to properly install and inspect the elevator trim system resulting in the reversed elevator trim condition and the pilot's failure to maintain clearance with the terrain. Contributing factors included the dark night and low ceiling. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Miscellaneous/other, standing - pre-flight - elevator trim - reversed, other maintenance personnel (cause) - maintenance,inspection - inadequate, other maintenance personnel (cause) - In flight collision with terrain/water, takeoff - initial climb - altitude/clearance - not maintained, pilot in command (cause) - use of inappropriate medication/drug, pilot in command - inadequate training, copilot/second pilot - light condition - dark night (contributing factor) - weather condition - low ceiling (contributing factor) - terrain condition - water ## Analysis The Hansa 320, a corporate turbojet airplane departed runway 26L at night on a maintenance ferry flight at 1954 central standard time, and was destroyed when it impacted a river two miles west of the departure airport. Radar track data indicated that the airplane climbed to about 900 feet msl at about 180 knots before it began losing altitude and impacted the river. The current weather was: winds 270 degrees at 13 knots gusting to 19 knots, visibility 7 miles, light rain, 1,000 feet scattered ceiling, 1,800 feet broken, 2,400 feet overcast, temperature 2 degrees Celsius (C), dew point 2 degrees C, altimeter 29.90. The FAA had issued the pilot a Special Flight Permit for the flight. The limitations listed in the flight permit included the following limitations: Limitation number 6 stipulated, "IFR in VMC conditions approved, provided all equipment required for IFR flight is operational and certified iaw 14 CFR Part 91.413. If this equipment is NOT certified and operational, then VFR in VMC conditions ONLY." The ferry permit listed, "Additional Limitations: Engine power assurance runs, compass swing, and functional check of avionics equipment must be performed, and appropriate maintenance entries in the aircraft log prior to departure." The pilot was informed that none of the additional limitations had been performed prior to takeoff. The pilot had aborted a previous takeoff at about 1830 due to no airspeed indications. At the request of the pilot, maintenance personnel disconnected the lines to the pitot tubes and blew out the tubes, but no leak check, as required by FAR 91.411, was performed prior to the accident flight. The pilot performed a high-speed taxi to test the airspeed indicators prior to takeoff. The copilot did not have any ground school or flight time in a Hansa 320. The second-in-command requirements stated in FAR 61.55 9 (f) (1), required that the flight be conducted under day VFR or day IFR. The Toxicology report for the pilot indicated that 0.106 (ug/ml, ug/g) Diphenhydramine was detected in the blood. Diphenhydramine is an antihistamine commonly used in over-the-counter cold/allergy preparations. In therapeutic doses, the medication commonly results in drowsiness, and has measurable effects on performance of complex cognitive and motor tasks (e.g. flying an aircraft). The pilot's currency in the Hansa 320 expired on November 30, 2004, the day of the accident. He would be required to have an FAA checkride in a Hansa 320 to be a pilot-in-command (PIC) after November 30th. Engine teardown inspections revealed that both engines were developing power at the time of impact. The inspection of the elevator trim system revealed that the elevator trim cables were improperly installed when they were replaced to comply with an Airworthiness Directive (AD) 224-01-11. The maintenance manager who inspected the installation of the elevator trim cables did not perform an operational check of the elevator trim tabs. The maintenance manager signed the aircraft log stating the "Aircraft is approved for one time ferry flight from SUS to TOL," although all stipulations of the ferry permit had not been met, and that a leak check of the pitot-static system had not been performed after the pitot tubes had been blown out. ## Factual narrative HISTORY OF FLIGHT On November 30, 2004, at 1956 central standard time, a Hamburger Flugzeugbau, HFB Hansa 320, N604GA, operated by Grand Aire Express, was destroyed when it impacted the Missouri River near Chesterfield, Missouri, soon after departure from runway 26L (7,485 feet by 150 feet, concrete) at the Spirit of St. Louis Airport (SUS), Chesterfield, Missouri. The pilot and copilot sustained fatal injuries. The 14 CFR Part 91 ferry flight departed SUS en route to the Toledo Express Airport (TOL), Toledo, Ohio. Night visual meteorological conditions prevailed at the time of the accident. The flight was on an instrument flight rules (IFR) flight plan. The pilot contacted the St. Louis Automated Flight Service Station (AFSS) by telephone at 1504 to file a flight plan from SUS to TOL with a departure time of 1550. At 1615, the pilot contacted the St. Louis AFSS to amend the departure time to 1800. At 1733 and 1736, the pilot called the St. Louis AFSS to obtain information about a runway closure at TOL. The pilot contacted the St. Louis AFSS at 1934 to re-file the flight plan from SUS to TOL with a new departure time of 2000. The pilot filed for an airspeed of 400 knots with an en route altitude of 33,000 feet. The proposed time en route was 45 minutes, and the pilot indicated that there were 3 hours of fuel on board. When the St Louis AFSS briefer asked the pilot why the aircraft had not departed an hour earlier, the pilot responded, "We had to abort because the airspeed indicator didn't work, but ... it's fixed now." At 1943, N604GA contacted the SUS Air Traffic Control Tower (ATCT) and received its IFR clearance to TOL. N604GA reported to ATCT that the airplane was positioned at the Millionaire ramp and requested permission to do a high-speed back taxi on runway 26L. At 1950, ATCT authorized N604GA to perform a high-speed back taxi on the runway, and to position and hold on the runway once the back taxi was complete. At 1954, ATCT cleared N604GA for takeoff. At 1955, ATCT instructed N604GA to contact departure control, but there was no response from N604GA. The St. Louis Approach control radar recorded six "hits" of radar track data as N604GA departed to the west. The radar track data indicated that at 1955:33, N604GA initially climbed to about 900 feet mean sea level (msl) with a ground speed of about 180 kts. The radar track data indicated that the airplane continued on a westerly heading. The last recorded radar contact with N604GA at 1955:51 indicated the airplane's altitude was about 600 feet msl with a ground speed of about 190 kts. Witnesses who observed the airplane's departure reported that the engines sounded like they were at "full throttle" during the takeoff roll and climb. They reported seeing the airplane drift to the right during climbout and then the airplane started to lose altitude. The witnesses reported the engines continued to sound like they were at high power, and then there was silence followed by the sound of terrain impact. A search for N604GA was initiated immediately, but due to poor weather conditions and the dark night, the airplane was not located until about 0230 on December 1, 2004. The airplane wreckage was located about 2 nautical miles west of SUS along the riverbank of Howell Island, a heavily wooded wildlife sanctuary. PERSONNEL INFORMATION The pilot was the chief executive officer and president of Grand Aire Express, Inc. and TriCoastal Air, based in Toledo, Ohio. According to company records, he held an airline transport pilot certificate with an airplane multiengine rating, and a commercial certificate with a single-engine land rating. He was also a certified flight instructor with multiengine land and airplane instrument ratings and held a first-class medical certificate. He had about 11,500 hours of total flight time, including 10,500 hours in multiengine aircraft. He had about 2,500 hours in a Hansa 320, and had flown the Hansa 320 about 1.3 hours in the last 12 months and about 44.5 hours in the last 24 months. The pilot had a check ride in the Hansa 320 on October 24, 2002, in accordance with FAR 61.58. On November 13, 2004, the pilot had a check ride in a Learjet 35A simulator in accordance with FAR 135.293 and FAR 135.297. According to FAR 61.58, the pilot could not act as pilot-in-command of a Hansa 320 after November 30, 2004, without first passing a FAA check ride in a Hansa 320. The copilot was hired by TriCoastal Air on September 8, 2003. According to company records, he held an airline transport pilot certificate with an airplane multiengine rating, and a commercial certificate with a single-engine land rating. He was also a certified flight instructor with a single-engine land rating and held a first-class medical certificate. He had about 10,300 hours of total flight time, including 1,919 hours in multiengine aircraft. The copilot had not received any ground instruction in the Hansa 320 and had no flight time in the Hansa 320. FAR 61.55 states the requirements for second-in-command. FAR 61.55 (f) (1) states: "For the purpose of meeting the requirements of paragraph (b) of this section, a person may serve as second-in-command in that specific type aircraft, provided: (1) The flight is conducted under day VFR or day IFR, and (2) No person or property is carried on board the aircraft, other than necessary for conduct of the flight." AIRCRAFT INFORMATION The twin-engine Hamburger Flugzeugbau, HFB Hansa 320, serial number 1037, was manufactured in 1969. The maximum take-off weight was 20,280 pounds. The engines were General Electric CJ-610-5 engines that produced 2,850 pounds of static thrust each. Originally, the airplane had cabin seating for 7 or 8 passengers, but in October 9, 2002, the bench seat was removed per Supplementary Type Certificate (STC) SA01709CH, which configured the airplane to a four passenger corporate jet. The airplane was operated as a personal aircraft of the pilot. The airplane was being operated under FAR Part 91 regulations and was not listed on the FAR Part 135 operating certificate of TriCoastal Air. It was not equipped with a Cockpit Voice Recorder (CVR) or a Flight Data Recorder (FDR). A Federal Aviation Administration (FAA) airworthiness inspector reviewed the airplane's logbooks and records. The logbooks indicated that the aircraft was issued a Standard Airworthiness Certificate on January 30, 2000, during a recurrent certification. The aircraft had been operated in South America from 1987 to September 1999. The aircraft records did not indicate what inspection program the airplane was being inspected under as required by FAR 91.409 (e) (f). The logbooks indicated that the aircraft was inspected in accordance with the Hansa HFB-320 Inspection Method, and Grand Aire's Approved Aircraft Inspection Program (AAIP). The last 75/300 Hour inspection on the airframe was accomplished on July 10, 2003, with an airframe total time of 6,847.3 hours. The logbook entry signoff indicated that it was inspected in accordance with Grand Aire's AAIP program. The airplane had flown 28.7 hours since the inspection and had a total airframe time of 6,876 hours. The left engine, serial number E249-109, and the right engine, serial number 240B-249A, were installed on the airplane on March 10, 2004, at a total airframe time of 6,874.7 hours. The aircraft logbooks indicated that the altimeters, pitot static system, and transponders were recertified on March 10, 2004. A 1.3-hour functional test flight of the airplane's engines was conducted on March 23, 2004, when the airplane was flown from TOL to SUS. The airplane was not flown again until the accident flight on November 30, 2004. According to witnesses at SUS, the airplane was initially parked on the Thunder Aviation's satellite ramp. The airplane developed a fuel leak so the airplane was moved to another locatio ## Aircraft - Registration: [N604GA](https://openairdocs.org/deregistered/N604GA-2007-02-27), registration cancelled 2007-02-27, S/N 1037, built 1969 (OpenAirDocs) - Reported make and model: Hamburger Flugzeugbau (HFB) HFB 320 Hansa - Registry model: [Hamburger Flugzeugbau HFB 320 HANSA](https://openairdocs.org/model/hamburger-flugzeugbau-hfb-320-hansa) (registry code 4071204) (OpenAirDocs) - Registry engine: [GE CJ610-5&6](https://openairdocs.org/engine/ge-cj610-5-6) (registry code 30013, turbo-jet) (OpenAirDocs) - Category: Airplane - Serial number: 1037 - Airframe hours: 6875 - Engines: General Electric CJ-610-5 2850 lbs thrust turbo jet - Damage: Destroyed - Flight: Ferry, Part 91 - Registered owner: Grand Aire Express - Airworthiness certificate: Standard, Normal - Last inspection: AAIP, July 1, 2003, 27.4 hours before - Departed: SUS, Saint Louis, MO - Destination: TOL, Toledo, OH - Flight plan: IFR - Airport: SUS, Spirit of St. Louis, runway 26L, 7,485 × 150 ft, concrete ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 50; injuries: fatal; flight instructor, airline transport; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 1, with waivers/limitations; last flight review November 1, 2004; seat: left; toxicology performed; flight hours: 11,500 total, 2,500 in this make and model, 11,275 as pilot in command, 103 in the last 90 days - Co-pilot; age 43; injuries: fatal; flight instructor, airline transport; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 1, with waivers/limitations; last flight review November 1, 2004; seat: right; toxicology performed; flight hours: 10,377 total, 8,035 as pilot in command, 189 in the last 90 days ## Weather - Conditions: Instrument (IMC), Night/dark - Wind: 270° at 13 knots, gusting 19 - Visibility: 7 statute miles - Lowest ceiling: 1,800 ft overcast - Temperature: 36 °F, dew point 36 °F - Altimeter: 29.89 inHg - Observed at: SUS, 2 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 20041130031359A](https://openairdocs.org/incident/20041130031359A), Nov 30, 2004: Hamflu HFB320, St Louis, MO, Destroyed, 2 fatal. (-23) Approximately one hour prior to the accident, N604GA rejected a take-off attempt due to lack of airspeed indication on both the PIC and SIC airspeed… 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.