CHI07FA068

NTSB accident investigation · Cessna 208B · Alliance, NE · February 8, 2007

Accident · Serious injuriesField investigationFinal report
Date
February 8, 2007, 02:25 local (09:25 UTC)
Place
Alliance, NE
Injuries
1 serious
Damage
Substantial damage
Phase of flight
Approach
Aircraft
N1116YCessna 208B
Weather
Instrument (IMC) · Night
Status
Completed · report April 30, 2008
Report
Approved by Office Director
Parties
Honeywell, Suburban Air Freight Inc., Pratt & Whitney Canada, Federal Aviation Administration, Cessna Aircraft Company
FAA report
20070208002919A
Case key
65267

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's descent below minimum descent altitude while on a nonprecision approach. A contributing factor was a 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 objectApproach
Weather condition - low ceilingFactor
Minimum descent altitude - belowPilot in commandCause
Object - building(nonresidential)
In flight collision with terrain/waterDescent - uncontrolled
Terrain condition - ground
Object - pole

Analysis

The pilot was dispatched on a nonscheduled cargo flight to an airport other than his usual destination because it had a precision instrument approach, while his usual destination airport did not. The pilot elected to fly to his usual airport, and attempted a nonprecision instrument approach. The airport had both a VOR and an NDB approach. The NDB approach was noted as being out of service, although there was still a radio signal coming from the navigation aid. The pilot was cleared for the VOR approach, although instrumentation inside the cockpit was found set for the NDB approach, and radar track data disclosed that the flight path was consistent with the NDB approach path, not the VOR's. The airport's reported weather was 1.25 miles visibility, with a 200-foot overcast in mist. The airport's minimum NDB approach altitude is 652 feet above touchdown height. The airplane did not reach the runway, and collided with a pole and a building. Inspection of the airplane disclosed no evidence of any preimpact mechanical malfunctions.

Factual narrative

History of flight

On February 8, 2007, about 0225 mountain standard time, a Cessna 208B, N1116Y, operated by Suburban Air Freight Inc., sustained substantial damage on impact with a building and terrain during a non-precision approach to runway 12 at the Alliance Municipal Airport (AIA), near Alliance, Nebraska. The non-scheduled domestic cargo flight was operating under 14 CFR Part 135. Night instrument meteorological conditions prevailed at the time of the accident. An instrument flight rules (IFR) flight plan was on file and was activated. The commercial pilot sustained serious injuries and was hospitalized. The flight originated from Eppley Airfield (OMA), near Omaha, Nebraska, about 2345, and was dispatched to the Western Nebraska Regional Airport/William B. Heilig Field (BFF), near Scottsbluff, Nebraska.

The operator's accident report, in part, stated:

Scheduled U.S. Mail route operating AIA - LBF [North Platte,

Nebraska] - OMA, OMA - AIA. Due to low IFR conditions and

preceding night's aircraft diverting to, and remaining at CDR,

(Chardon, Nebraska), and being unable to position into AIA for the

evening departure, decision was made to leave the first [airplane] at

CDR overnight, and simply fly a [second airplane] from OMA - BFF

where [weather] was suitable for ILS [instrument landing system]

approach. Only non-precision approaches, with higher minimums,

are available at AIA. Thus, the accident [airplane] was dispatched

to take mail directly to BFF, which has precision approaches (ILS),

and the U.S. Mail truck was to meet the aircraft at BFF. That is a

normal procedure for occasions when AIA is below non-precision

landing conditions. All scheduled flights operate on "canned" flight

plans which are on file. ... The flight from OMA to either BFF or

AIA proceeds along the identical route until west of North Platte,

Nebraska. ... The change is typically only requested after handoff

from [Minneapolis] Center to [Denver] Center, west of North Platte. ...

Since the direct route from OMA - BFF passes literally over, or

almost over, the procedure turn for the AIA approach procedures,

there is always the option for a pilot to check weather at AIA, and if

it has unexpectedly improved so as to allow landing at AIA, certainly,

then he may land. However, in this case, the mission was not to go to

AIA, land, and remain for the next evening's return, but rather to simply

proceed to BFF, execute the precision approach, drop off the mail, and

return to OMA empty immediately.

An excerpt from a Federal Aviation Administration's (FAA) Air Route Traffic Control Center (ARTCC) transcript follows:

Agencies Making Transmissions Abbreviations

Denver ARTCC, Sector 35R Radar Controller ZDV35R

Suburban Air Freight, INC. (Omaha, NE) SUB22

...

0846:46 ZDV35R sub air two two denver center

0846:52 SUB22 denver center sub air two two level eight thousand

0846:55 ZDV35R sub air two two denver center roger the uh alliance

altimeter is three zero one seven and do you have the uh

alliance weather yet

0847:10 SUB22 three zero one seven sub air two two uh we are

requesting the uh v o r runway one two

0847:18 ZDV35R sub air two two roger

0848:09 ZDV35R sub air two two do you have the uh weather and notam

information for alliance

0849:17 SUB22 sub air two two i have the uh alliance awos and notams

0849:22 ZDV35R sub air two two roger

0854:15 SUB22 denver center sub two two request

0854:17 ZDV35R sub air two two go ahead

0854:20 SUB22 roger sub air two two would like to uh uh amend my uh

request for the uh v o r runway three zero at alliance

and uh in the event uh i have to go missed approach i'll

be uh planning to uh head over to scottsbluff

0854:36 ZDV35R sub air two two roger maintain seven thousand until

alliance v o r outbound cleared for v o r runway three

zero approach to the alliance airport

0854:48 SUB22 sub air two two departing eight for seven thousand

maintaining seven thousand until established cleared v o r

runway three zero alliance thank you

0857:11 SUB22 sub air two two copies all switching to advisory and i'll

close out my flight plan with columbus radio or i'll contact

you later if i have to uh divert to Scottsbluff

0857:21 ZDV35R sub air two two roger

0857:57 ZDV35R sub air two two radar service terminated change to

advisory frequency approved report your uh arrival with

columbus radio or you can report back to me if you uh

have to go missed approach there

0908:41 SUB22 denver center sub air two two request

0908:52 ZDV35R alpine or correction uh sub air two two go ahead

0908:56 SUB22 (unintelligible) sir sub air two two looks like i'm gonna

have to uh flr the v o r runway one two after all request

uh v o r runway one two at alliance

0909:08 ZDV35R sub air two two roger uh cleared for v o r runway one

two approach to the alliance airport maintain seven

thousand until established on a published segment of the

approach

0909:20 SUB22 sub air two two maintaining seven thousand until

established cleared v o r runway one to alliance thank

you sir- - - and uh switching back to advisory

0909:29 ZDV35R sub air two two roger change to advisory frequency

approved

0909:34 SUB22 sub air two two

A witness, who was a train engineer in a standing locomotive about a quarter mile from the impact site, reported that he felt a shock wave against his locomotive and thought it was impacted by something. He went out to inspect the locomotive. The train had collected a coating of ice and the weather was foggy according to the engineer. He stated that he saw a leaning power pole across the roadway and saw steam rising from the ditch across the roadway. He went to investigate, saw the airplane, and called 911.

FAA inspectors interviewed the pilot and he reported that he did not recall the accident.

Personnel information

According to FAA records, the pilot was issued a commercial pilot certificate with an airplane multiengine land limited to center thrust and instrument airplane ratings on October 25, 1977, based on military competence provisions allowed under 14 CFR Part 61.73 Military Pilots or Former Military Pilots: Special Rules. On December 14, 1977, he added an airplane single-engine land rating to his commercial certificate following a check ride in a Cessna 172. On August 25, 1978, he was reissued his commercial certificate without the center thrust limitation based on his military competence in the KC-135A airplane. On June 22, 1982, he was issued a type rating in the Boeing 707 and 720 airplanes based on his military competence in the KC-135A airplane. On August 22, 1982, he was issued an airplane single-engine certified flight instructor certificate following a check ride in a Piper PA-28R-200. On June 19, 1989, he was issued a type rating in the McDonnell Douglas DC-10 based on his military competence in a KC-10A airplane.

The pilot's last medical examination was completed on July 10, 2006, and the pilot was issued a second-class medical certificate with a limitation to wear corrective lenses.

According to the operator's report, the pilot reported a total flight time of 4,863 hours. The operator reported that the pilot had flown 523 hours in the Cessna 208. The operator reported that the pilot had flown 203 hours during the last 90 days and 64 hours during the last 30 days.

On October 2, 2006, the pilot attended and completed the airplane manufacturer's winter operations training seminar. The pilot attended recurrent ground training for the Cessna 208 aircraft on January 17, 2007. The pilot's last FAA Airman Competency/Proficiency Check was completed on January 18, 2007, and he was approved for 14 CFR Part 135 pilot-in-command operations i

Aircraft

Registration
N1116Y
Reported as
Cessna 208B
Category
Airplane
Serial number
208B0368
Airframe hours
7,299.6
Engine
Pratt & Whitney Canada PT6A-114A, 675 horsepower, turbo prop
Damage
Substantial damage
Flight
Part 135
Registered owner
Suburban Air Freight Inc
Airworthiness certificate
Standard, Normal
Last inspection
AAIP · January 1, 2007 · 51.3 hours before
Departed
OMA · Omaha, NE
Destination
AIA · Alliance, NE
Flight plan
IFR
Airport
AIA · Alliance Muni, runway 12, 9,202 × 150 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
52
Injuries
Serious
Certificate
Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 2, With waivers/limitations
Last flight review
January 1, 2007
Seat
Left
Toxicology
Performed
Flight hours
4,863 total · 523 in this make and model · 3,853 as pilot in command · 1 in the last 24 hours

Weather

Conditions
Instrument (IMC) · Night
Wind
50° at 4 knots
Visibility
1.25 statute miles
Lowest ceiling
200 ft overcast
Temperature
21 °F, dew point 19 °F
Altimeter
30.17 inHg
Observed at
AIA, 6 nm away

Docket · 31

The files NTSB released with the investigation on March 31, 2008, on NTSB’s docket system: statements, records, photos and specialists’ reports. 23.0 MB in all.

Meteorology 5 - Factual Report of Group ChairmanItem 1 · .PDF · 1.5 MBPilot/Operator Aircraft Accident Report, NTSB Form 6120.1Item 2 · .PDF · 798 KBChief Pilot's StatementItem 3 · .PDF · 77 KBCourier's StatementItem 4 · .PDF · 122 KBWitness StatementItem 5 · .PDF · 85 KBCessna Supplied Wreckage Site DiagramItem 6 · .PDF · 1.5 MBApproaches at AIAItem 7 · .PDF · 128 KBCessna Supplied Approaches with Overlaid Radar DataItem 8 · .PDF · 297 KBFAA TranscriptItem 9 · .PDF · 195 KBAAIP InspectionItem 10 · .PDF · 51 KBAirman Competency Proficiency CheckItem 11 · .PDF · 92 KBPilot Information and RecordsItem 12 · .PDF · 321 KBService Bulletin CAB06-11Item 13 · .PDF · 186 KBStatement Regarding Out of Service NBDItem 14 · .PDF · 35 KBDispatch RecordItem 15 · .PDF · 73 KBNOTAMItem 16 · .PDF · 53 KBAF Form 711Item 17 · .PDF · 103 KB61.73 ExcerptItem 18 · .PDF · 199 KBMedical Records InformationItem 19 · .PDF · 10 KBPrevious AccidentItem 20 · .PDF · 371 KBStatement of Party Representatives to NTSB InvestigationItem 21 · .PDF · 447 KBRelease of Aircraft Wreckage, NTSB Form 6120.15Item 22 · .PDF · 72 KBPhoto 1. Accident SiteItem 23 · .PDF · 1.3 MBPhoto 2. Building with Outboard Flap SectionItem 24 · .PDF · 1.2 MBPhoto 3. Propeller with Ice on BootItem 25 · .PDF · 1.4 MBPhoto 4. Ice on Right Strobe LightItem 26 · .PDF · 1.2 MBPhoto 5. Attitude Indicator Gyro with Rub Witness MarksItem 27 · .PDF · 1.2 MBPhoto 6. Propeller Anti Ice SwitchItem 28 · .PDF · 1.3 MBPhoto 7. RMIItem 29 · .PDF · 1.1 MBPhoto 8. ADFItem 30 · .PDF · 3.6 MBPhoto 9. Stand By Alternator TestItem 31 · .PDF · 4.1 MB

FAA reports on this event · 1

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

Other investigations on N1116Y · 1

Matched to the same aircraft by N-number and date.