# NTSB CHI07LA063: Raytheon B200, N777AJ, Cape Girardeau, MO, February 2, 2007 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: February 2, 2007, 09:30 local (15:30 UTC) - Place: Cape Girardeau, MO - Coordinates: 37.2252777777778, -89.5736111111111 - Nearby events: https://openairdocs.org/map.md?lat=37.2253&lon=-89.5736&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: No injuries - Injuries: 2 uninjured - Status: Completed, report November 20, 2008 - Report: Approved by Office Director - Parties: Federal Aviation Adminstration, PPG Aerospace, Raytheon Aircraft Company - NTSB case key (mKey): 65268 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CHI07LA063 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/65268/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=65268 - Page: https://openairdocs.org/ntsb/CHI07LA063 ## Probable cause The company pilot's poor judgment before and during the flight, including turning the oxygen system ready switch to the OFF position after he conducted the preflight inspection and using an unapproved checklist, which did not provide guidance for a fractured windshield and resulted in his depressurizing the airplane. Members Hersman and Sumwalt did not approve this probable cause. Member Hersman filed a dissenting statement, with which Member Sumwalt concurred. The statement can be found in the public docket for this accident. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Decompression, cruise - window,flight compartment window/windshield - cracked (contributing factor) - checklist - not followed, pilot in command (contributing factor) - improper use of procedure, pilot in command (cause) - checklist - not approved, pilot in command (contributing factor) - Loss of control - in flight, descent - uncontrolled - preflight planning/preparation - inadequate, pilot in command (contributing factor) - incapacitation(loss of consciousness), flightcrew (cause) - Abrupt maneuver, descent - uncontrolled ## Analysis The airplane was operated by a company pilot. A noncompany pilot, who had not attended or completed a training course or received a checkout for Raytheon Aircraft Company Beech King Air 200 airplanes, was asked by the pilot to accompany him on the flight so that the noncompany pilot could accumulate flight time. The flight only required one pilot. While the airplane was in cruise flight (27,000 feet mean sea level), the cockpit voice recorder (CVR) recorded the sound of the windshield fracturing. The CVR transcript indicated that the company pilot was not in the cockpit when the windshield fractured because he was emptying trash in the cabin. This action showed poor judgment considering the noncompany pilot was not qualified in the airplane. Although the windshield stayed in place, the company pilot stated that "within seconds" after it fractured, he depressurized the airplane because he was unsure about the windshield's "integrity." However, the Beech King Air Airplane Flight Manual (AFM) states to maintain cabin pressurization in the event of a fractured windshield and further states that the airplane can continue flight for up to 25 hours with the windshield fractured. During the on-scene examinations, an unapproved document (not derived from the AFM) that contained several checklists was found on the airplane. The company pilot stated that he used this document and that it "came with the airplane." The document did not include a checklist addressing a cracked or shattered windshield. The company pilot most likely was not aware that the airplane should not have been depressurized nor that it could operate for 25 hours after the fracture occurred and, therefore, that the fractured windshield did not present an in-flight emergency. The CVR transcript revealed that, after depressurizing the airplane, the pilots attempted to use the oxygen masks but were unable to receive any oxygen. (The pilots most likely did not turn the oxygen on once they needed it because they either forgot as a result of the emergency or because they did not have time to do so before they lost consciousness.) According to the company pilot, during his preflight inspection of the airplane, the oxygen system was functional. He stated that, after the inspection, he turned the oxygen system ready switch to the OFF position because he wanted to "save" the oxygen, which was not in accordance with the Before Start checklist in the AFM. Postaccident functional testing of the oxygen system revealed normal operation. The unapproved checklists document did not include the instruction to leave the oxygen system on. Regardless, the pilot stated that he knew the approved checklist stated to leave the oxygen system on but that he still chose to turn it off. The pilot exhibited poor judgment by using an unapproved, incomplete checklists document and by knowingly deviating from approved preflight procedures. About 1 minute after the pilots tried to get oxygen, the CVR recorded the last comment by either pilot. For about the next 7 minutes until it stopped recording, the CVR recorded the sounds of increased engine propeller noise, the landing gear and overspeed warning horns, and altitude alerts indicating that the airplane had entered an uncontrolled descent. (The CVR's 4-g impact switch was found in the open position during the on-scene examination, indicating that the airplane experienced at least 4 acceleration of gravity forces.) Further, a plot of two radar data points, recorded after the last pilot comment, showed that the airplane descended from 25,400 feet to 7,800 feet within 5 minutes. Shortly thereafter, the pilots regained consciousness and recovered from the uncontrolled descent. The airplane was substantially damaged by the acceleration forces incurred during the uncontrolled descent and subsequent recovery. Examination of the windshield revealed that a dense network of fractures was located on the inner glass ply; however, the windshield did not lose significant pieces of glass and maintained its structural integrity. Therefore, the fractures did not preclude safe continued flight. Postaccident examinations revealed evidence that the fracture initiated due to a design deficiency in the glass. The manufacturer redesigned the windshield in 2001 (the accident airplane was manufactured in 1998), and no known similar fractures have occurred in the newly designed windshield. The manufacturer chose not to issue a service bulletin for a retrofit of the new windshield design in airplanes manufactured before 2001 because the fracture of one pane of glass is not a safety-of-flight issue. Members Hersman and Sumwalt did not approve this brief. Member Hersman filed a dissenting statement, with which Member Sumwalt concurred. The statement can be found in the public docket for this accident. ## Factual narrative HISTORY OF FLIGHT On February 2, 2007, about 0930 central standard time, a Raytheon Aircraft Company B200, N777AJ, was substantially damaged due to acceleration forces incurred during an uncontrolled descent and recovery from cruise at flight level (FL) 270. Visual meteorological conditions prevailed at the time of the accident. The flight crew reported they depressurized the airplane after a cracked/shattered windshield. They then donned their oxygen masks but were unable to obtain oxygen from the oxygen system resulting in their loss of consciousness. They later regained consciousness, recovered from the descent, and landed without further incident at Cape Girardeau Regional Airport, Cape Girardeau, Missouri. The 14 CFR Part 91 business flight was operating on an instrument flight rules plan. The pilot and copilot were uninjured. The flight originated from Rogers Municipal Airport-Carter Field (ROG), Rogers, Arkansas, at 0839. The business flight was a positioning flight with no passengers aboard. The pilot had the copilot accompany him on the positioning flight so that the copilot could accumulate flight time. The copilot was not a company pilot and had not attended or completed an initial/recurrent training course for the airplane or received a checkout in the airplane. The pilot stated that he checked the oxygen system during his preflight checks but turned the system off for the accident flight because he wanted to "save" the oxygen within the oxygen system. He stated he didn't want the oxygen to deplete if the system were left on. He also stated that the windshield heater was in the OFF position and was not turned ON after departing from ROG. The pilot stated in a National Transportation Safety Board (NTSB) Pilot/Operator Report, that the left pilot windshield "shattered" but stayed in place. He stated that "within seconds," he began to depressurize the airplane because the integrity of the windshield was unknown. He instructed the copilot to don the oxygen mask. The pilot pulled the left oxygen handle and "it did not seem to engage properly." He then pulled the right oxygen handle and the oxygen masks deployed in the rear cabin. The oxygen still did not "seem" to be delivering to the crew masks because he had tunnel vision and was having trouble thinking clearly. The last thing he remembered was being in an emergency descent. He disengaged the autopilot and pitched down, but was not able to reduce power to idle or extend the landing gear. The pilot was interviewed a second time following the readout of the cockpit voice recorder (CVR). During the interview, the pilot stated that he was out of the pilot seat but had his leg on it while twisting around to empty trash. The NTSB Vehicle Recorders Laboratory read out the airplane CVR and transcribed the recording as follows: 0854:01, Memphis Center clears aircraft to FL 270 0857:06, the pilot makes comment about setting the pressurization. Climbing you look at the inner scale and descending you look at the outer scale 0905:42, the pilot leaves the cockpit to "fetch the trash can" 0905:56, comment heard only on the cockpit area microphone channel (CAM) from the pilot saying "don't tear it up while I'm gone" 0909:01, a sound of a very loud snap was heard on all CVR channels 0909:03, the copilot exclaims the pilot's first name. 0909:08, comment heard only on CAM channel from the pilot saying "what'd you # break" 0909:16, comment heard only on CAM channel from the pilot saying "gunna dump the cabin" 0909:38, the copilot exclaims "what the #" 0909:42, the copilot states, "we need to go on oxygen" 0909:43, the pilot says "yeah" 0910:06, Center instructs the airplane to change to Memphis Center frequency but the airplane never changes frequency and remains on Memphis Center for the remainder of the CVR recording 0910:12, loud right seat pilot breathing starts and continues to the end of the recording 0910:25, comment heard only on CAM channel from left seat pilot saying "can't get no oxygen" 0910:36, comment heard only on CAM channel from left seat pilot saying "I ain't getting no oxygen" 0910:46, comment heard only on CAM channel from the pilot saying, "you got oxygen" (last comment heard on CVR recording from either pilot). After this time the only crew noise was the sound of the copilot breathing erratically. 0914:55, change in background engine propeller noise starts and continues until the end of recording 0915:20, start of 500 hertz (Hz) beeping tone that continues until end of recording (landing gear warning horn) 0916:41, start of alternating high (1 Khz) low (500 Hz) tones beeping at 5 Hz rate and continues until end of recording (over speed warning horn) 0916:57, sound of one altitude alert tone 0917:05, alternating high low tone transition to steady (1 Khz) tone began and continued for approximately 4 seconds 0917:17, sound of one altitude alert tone 0917:23, alternating high low tone transition to steady (1 Khz) tone continued for approximately 6 seconds 0917:54, sound of increasing wind noise 0918:28, the recording stopped while the airplane was still airborne PERSONNEL INFORMATION Pilot The pilot held an airline transport pilot certificate with a multiengine airplane land and a commercial pilot certificate with an airplane single-engine landing rating. The pilot completed a flight review during B200 training at Simcom International on August 24, 2006. At the time of the accident, he accumulated a total aircraft time of 4,048 hours of which 110 hours were in B200 airplanes. According to Federal Aviation Administration (FAA) records, the pilot was involved in an incident on Oct 24, 2006, while flying N777AJ inbound to Adams Field Airport, Little Rock, Arkansas, in order to have scheduled maintenance performed on N777AJ. During the approach/landing, the pilot was unaware that the landing gear was not extended until queried by local air traffic control to check the airplane landing gear because it was not extended. The pilot then departed the airport traffic pattern and reportedly reset the circuit breaker and then landed without further incident. Post incident maintenance inspection of the airplane did not reveal any mechanical anomalies that would have precluded normal operation of the landing gear system. Copilot The copilot held a commercial pilot certificate with airplane single-engine land, airplane multiengine land and instrument airplane ratings. He also held a certified flight instructor certificate with single-engine land, multiengine land, and instrument airplane ratings. At the time of the accident, he accumulated a total aircraft time of 2,806 hours of which 28 hours were in B200 airplanes. AIRCRAFT INFORMATION The airplane was a 1998 Raytheon Aircraft Company B200, serial number BB-1638, which accumulated a total time in service of 1,834.8 hours at the time of the accident. The airplane was last inspected during phase 1 to 4 inspections, which were completed on August 29, 2006. The pilot windshield, model number 101-384025-21, serial number 98264H7442 was installed at the time of the airplane manufacture and subsequently had not been overhauled or repaired prior to the accident. The windshield had accumulated 1,834 hours of service and had no previous reports of delamination or cracking. The crew and cabin oxygen system controls are located on the cockpit control pedestal via left and right push-pull control handles. Actuation of the left push-pull control handle actuates the oxygen system shutoff valve and places the oxygen system in ready mode. The right push-pull control handle is the passenger manual override control that will manually deploy the passenger oxygen masks. Oxygen will flow to each passenger mask only if the oxygen tank shutoff valve is in an OPEN position. METEOROLOGICAL INFORMATION The Springfield, Missouri, upper air tempe ## Aircraft - Registration: [N777AJ](https://openairdocs.org/deregistered/N777AJ-2008-06-05), registration cancelled 2008-06-05, S/N BB-1638, built 1998 (OpenAirDocs) - Reported make and model: Raytheon Aircraft Company B200 - Registry model: [Raytheon B200](https://openairdocs.org/model/raytheon-b200) (registry code 7150006) (OpenAirDocs) - Registry engine: [Pratt & Whitney PT6A series](https://openairdocs.org/engine/pratt-whitney-pt6a-series) (registry code 52032, turbo-prop) (OpenAirDocs) - Category: Airplane - Serial number: BB 1638 - Airframe hours: 1834.8 - Engines: Pratt & Whitney PT6A-42 850 horsepower turbo prop; Pratt & Whitney PT6A-42 850 horsepower turbo prop - Damage: Substantial damage - Flight: Business, Part 91 - Registered owner: Hudson Timber Services Inc - Airworthiness certificate: Standard, Normal - Last inspection: Continuous airworthiness, August 1, 2006 - Departed: ROG, ROGERS, AR - Destination: SHD, Staunton, VA - Flight plan: IFR - Airport: CGI, Cape Girardeau ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 31; injuries: none; airline transport, commercial; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 2; last flight review August 1, 2006; seat: left; flight hours: 4,048 total, 110 in this make and model, 3,878 as pilot in command, 49 in the last 90 days, 11 in the last 30 days - Co-pilot; age 28; injuries: none; commercial, flight instructor, private; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 2; last flight review April 1, 2005; seat: right; flight hours: 2,806 total, 28 in this make and model, 2,737 as pilot in command, 72 in the last 90 days, 28 in the last 30 days, 1 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 330° at 11 knots - Visibility: 10 statute miles - Lowest ceiling: 3,300 ft broken - Temperature: 27 °F, dew point 14 °F - Altimeter: 30.02 inHg - Observed at: CGI ## 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 20070202001649A](https://openairdocs.org/incident/20070202001649A), Feb 2, 2007: Beech B200, Cape Girardeau, MO, Substantial damage. (-23) During cruise flight at FL270, the pilot's (l/s) windshield (inner panel) shattered. The windshield did not separate from the frame of the aircraft.… ## Docket (21 files) The files NTSB released with the investigation on March 28, 2008, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=65268. 13.3 MB in all. - Cockpit Voice Recorder 12 - Specialist's Factual Report of Investigation (item 1, .PDF, 33 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40288548&FileExtension=.PDF&FileName=Cockpit%20Voice%20Recorder%2012%20-%20Specialist%27s%20Factual%20Report%20of%20Investigation-Master.PDF - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (Pilot) (item 2, .PDF, 643 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40286481&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1%20(Pilot)-Master.PDF - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (Copilot) (item 3, .PDF, 638 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40286483&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1%20(Copilot)-Master.PDF - Weather Information (item 4, .PDF, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40286486&FileExtension=.PDF&FileName=Weather%20Information-Master.PDF - Airplane Oxygen System Description (item 5, .PDF, 135 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40286487&FileExtension=.PDF&FileName=Airplane%20Oxygen%20System%20Description-Master.PDF - Airplane Crew Windshield Parts Manual (item 6, .PDF, 232 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40286505&FileExtension=.PDF&FileName=Airplane%20Crew%20Windshield%20Parts%20Manual-Master.PDF - E-mail (item 7, .PDF, 71 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40376709&FileExtension=.PDF&FileName=E-mail-Redacted.PDF - CVR Diagram (item 8, .PDF, 55 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40286507&FileExtension=.PDF&FileName=CVR%20Diagram-Master.PDF - Radar Data Plots (item 9, .PDF, 2.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40286509&FileExtension=.PDF&FileName=Radar%20Data%20Plots-Master.PDF - Checklist Used By Pilot (item 10, .PDF, 87 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40286511&FileExtension=.PDF&FileName=Checklist%20Used%20By%20Pilot-Master.PDF - Airplane Checklists (item 11, .PDF, 316 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40286512&FileExtension=.PDF&FileName=Airplane%20Checklists-Master.PDF - Service Difficulty Reports (item 12, .PDF, 3.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40376710&FileExtension=.PDF&FileName=Service%20Difficulty%20Reports-Redacted.PDF - Statement of Party Representatives to NTSB Investigation (item 13, .PDF, 459 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40286515&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Master.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 14, .PDF, 60 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40291290&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Master.PDF - Photo 1. Left Wing (item 15, .PDF, 316 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40286525&FileExtension=.PDF&FileName=Photo%201.%20%20Left%20Wing-Master.PDF - Photo 2. Right Wing (item 16, .PDF, 341 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40286526&FileExtension=.PDF&FileName=Photo%202.%20%20Right%20Wing-Master.PDF - Photo 3. Horizontal Stab (item 17, .PDF, 352 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40286527&FileExtension=.PDF&FileName=Photo%203.%20%20Horizontal%20Stab-Master.PDF - Photo 4. Horizontal Stab (item 18, .PDF, 364 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40286528&FileExtension=.PDF&FileName=Photo%204.%20%20Horizontal%20Stab-Master.PDF - Photo 5. Horizontal Stabilizer (item 19, .PDF, 327 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40286529&FileExtension=.PDF&FileName=Photo%205.%20%20Horizontal%20Stabilizer-Master.PDF - Photo 6. Pilot Windshield (item 20, .PDF, 1.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40286530&FileExtension=.PDF&FileName=Photo%206.%20%20Pilot%20Windshield-Master.PDF - Dissenting Statement Notation 8036 (item 21, .PDF, 93 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40376707&FileExtension=.PDF&FileName=Dissenting%20Statement%20Notation%208036-Redacted.PDF 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.