# NTSB CHI93FA158: Beech E-18S, N80CB, Lone Rock, WI, May 4, 1993 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: May 4, 1993, 01:40 local (06:40 UTC) - Place: Lone Rock, WI - Coordinates: 43.180244, -90.199684 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=43.1802&lon=-90.1997&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed, report July 25, 1994 - Report: Approved by Office Director - NTSB case key (mKey): 9160 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CHI93FA158 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/9160/pdf - Page: https://openairdocs.org/ntsb/CHI93FA158 ## Probable cause was a pre-mature extension of the landing gear by the pilot which resulted in the inability of the pilot to maintain the minimum descent altitude. Factors related to the accident were the loose cylinder and loss of oil. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of engine power(total) - mech failure/malf, cruise - normal - 1 engine - engine assembly,cylinder - loose (contributing factor) - fluid,oil - loss,partial (contributing factor) - In flight collision with object, approach - faf/outer marker to threshold (ifr) - object - tree(s) - precautionary landing - attempted, pilot in command - gear extension - premature, pilot in command (cause) - minimum descent altitude - not possible, pilot in command (cause) - In flight collision with terrain/water, approach - faf/outer marker to threshold (ifr) - terrain condition - high terrain ## Analysis THE PILOT OF A TWIN-ENGINE CARGO AIRPLANE SHUT DOWN THE LEFT ENGINE AND FEATHERED THE PROPELLER DUE TO A LOSS OF ENGINE OIL. THE FAA ARTCC HANDLING THE FLIGHT VECTORED THE AIRPLANE TOWARD A VOR. DUE TO THE AIRPLANE'S ALTITUDE AND DISTANCE FROM THE CENTER'S RADAR, THE PILOT OF THE AIRPLANE HAD TO PERFORM A FULL INSTRUMENT APPROACH PROCEDURE. THE AIRPLANE MAINTAINED ITS ENROUTE ASSIGNED ALTITUDE UNTIL PASSING THE VOR OUTBOUND. NTAP READOUTS SHOW THE AIRPLANE DESCENDING THROUGHOUT THE PROCEDURE TURN AND INBOUND LEG OF THE APPROACH. THE AIRPLANE'S LAST RADAR CONTACT WAS 300 FEET BELOW THE INBOUND ALTITUDE FOR THE APPROACH WHILE OUTSIDE THE FINAL APPROACH FIX. THE AIRPLANE COLLIDED WITH TREES AND TERRAIN APPROXIMATELY 2 1/4 MILES FROM THE AIRPORT. THE VOR IS 5.5 MILES FROM THE AIRPORT. THE ON-SCENE INVESTIGATION REVEALED THE LEFT ENGINE'S PROPELLER HAD BEEN FEATHERED, ITS NUMBER NINE CYLINDER MOUNTING STUDS ON THE ENGINE'S CASE WERE CRUSHED DOWNWARD OR WERE BROKEN OFF AT THE CASE'S SURFACE, AND THE LANDING GEAR HAD BEEN EXTENDED. ## Factual narrative HISTORY OF FLIGHT On May 4, 1993, at 0140 central daylight time (CDT), a Beech E-18S, N80CB, operated by Viking Express, Incorporated, of Aurora, Illinois, and piloted by an airline transport rated pilot, was destroyed during a collision with trees and terrain while flying the inbound course of a VOR approach at the Tri-Counties Airport, Lone Rock, Wisconsin. Instrument meteorological conditions prevailed at the time of the accident. The 14 CFR Part 135 flight was operating on an instrument flight plan. The pilot received fatal injuries. The flight originated from Aurora, Illinois, at 0035 CDT. N80CB was part of a two-airplane cargo flight, flying between Aurora, Illinois, and Minneapolis, Minnesota. N80CB had been assigned an altitude of 6,000 feet mean sea level and confirmed reaching that altitude approximately 24 minutes after contacting air traffic control. During the flight, the pilot of N80CB radioed the pilot of the second airplane informing him that N80CB was losing oil from its left engine. According to the Federal Aviation Administration's (FAA) Chicago, Illinois', Air Route Traffic Control Center (ARTCC), the pilot of N80CB contacted the controller at 0119 CDT. During the following conversation the pilot requested routing from the airplane's present position to the nearest airport with an instrument approach. N80CB's pilot was advised he had two airports near him: Tri- County Regional Airport (Tri-County Airport), Lone Rock, Wisconsin, and Iowa County Airport, Mineral Point, Wisconsin. These airports were located 20 miles north and 5 miles southwest respectively of N80CB's position. After being informed of the nearest airports, the pilot advised ARTCC "...I'm gonna have an engine failure pretty quick." The pilot asked ARTCC the length of Tri-County Airport's runway. ARTCC advised the pilot to standby. At this time, an unidentified voice stated: "Come up on freak Jim." Approximately five seconds later ARTCC asked the pilot: "Ah did you copy that sir?" The pilot responded, "No." The pilot then stated, "Head me towards it right ah right now if you could can you give me a heading?" ARTCC gave the pilot Tri-County Airport data and instrument approach information. ARTCC advised the pilot that weather for the airport was not available. The pilot requested a radar vector to the VOR's final approach course. He was informed by ARTCC that the controller's radar screen did not have the VOR approach depicted. The ARTCC controller told the pilot he couldn't "...vector (him) around to the north side of the VOR... after (that) you'll don't have to do the full procedure turn if you'd like that sir." The pilot stated, "... that's my only choice I guess." ARTCC cleared N80CB to 3,300 feet, "... at your discretion." The pilot confirmed the clearance and assigned heading of 350 degrees. Approximately one minute after clearing N80CB to 3,300 feet, ARTCC advised the pilot, "Ah roger and the airport now is just ah (unintelligible) at your discretion maintain three thousand three hundred as you start your descent ah you you'll be right over the airport you might be able to get it in sight." N80CB's pilot acknowledged ARTCC's statement and was advised he was "... a mile south of the airport." The pilot asked ARTCC to repeat the statement and was advised: "...you're about five and half miles south of the VOR at this time and the airport is ah just off to your ah left side now and a quarter mile." Approximately four minutes later, ARTCC cleared N80CB for the VOR-A approach. The pilot of N80CB did not acknowledge ARTCC's clearance. While the pilot was talking with ARTCC he also spoke to the pilot of the second company airplane. According to the written statement of the second airplane's pilot, N80CB's pilot advised him "...that he was losing oil out of the engine and his oil pressure was dropping. He said that he was losing the engine and was going to talk to Center." This pilot stated he advised N80CB's pilot to divert to Lone Rock, Wisconsin, rather than Madison, Wisconsin. He said he advised the pilot to do this because Lone Rock was closer and, "At this point both engines were still running and the failing engine would only run until it ran out of oil." The pilot of the second airplane stated N80CB's pilot advised him that he was shutting the left engine down due to an overspeeding propeller while flying the outbound leg of the VOR approach. According to the written statement, N80CB's pilot advised he was 100 feet low approximately three miles outside the VOR during the inbound portion of the approach. N80CB's pilot then stated he was about 1 1/2 miles inside the VOR and had to overboost the engine to hold airspeed and altitude. After reminding the pilot to use a radio frequency appropriate for the airport, the pilot was no longer in contact with N80CB's pilot. The FAA ARTCC's National Track Analysis Program (NTAP) data showed N80CB maintained the assigned altitude of 6,000 feet within plus or minus 100 feet until it was approaching the Lone Rock VOR. As the airplane approached the Lone Rock VOR, its altitude was 5,300 feet MSL. Approximately two minutes later N80CB's altitude was 3,700 feet as it began its procedure turn outbound. At a point where it began its procedure turn inbound, N80CB's altitude was 2,800 feet; 100 feet below the established VOR crossing altitude. One minute and twenty seconds later, N80CB's altitude was 2,600 feet while it was northeast of the VOR. PERSONNEL INFORMATION Company records show the pilot began his employment on December 18, 1992, as pilot-in-command of a Piper PA-23-250. A review of the pilot's logbook concerning Beech 18 multi-engine training and pilot-in-command entries reveal two single-engine training activities. The logbook entries involving the Beech 18 show no instructor signature in the remark's section where the flight time is listed as "dual". On March 26, 1993, the pilot began flying the Beech 18 as pilot-in-command. Company training records show the pilot had one session of Beech 18 training dated March 26, 1993. The record reflects 2.5 hours of flight training and 8.0 hours of ground training. The record is signed by the check airman who is also the company's owner. This is the only formal training record associated with the pilot and Beech 18 that was found in the company's pilot training records. The company owner said that the training folder contained all the records applicable to the pilot. A review of FAA Form 8410.3, dated March 26, 1993, shows the pilot satisfactorily demonstrated all of the maneuvers listed on the form, except an NDB/ADF approach and use of auto-pilot which the pilot did not perform. The form shows a flight time of 2.1 hours and is signed by the same person signing the training record. The pilot's logbook record shows two entries for March 26, 1993. The first entry shows a flight time of 2.1 hours, the remarks section states: "...(check) ride 135 w/Bob Burwell (3 lndgs)." The second entry shows a cross country trip of 5.5 hours, of which 3.5 hours were at night. The company's "Pilot Duty Log" shows the pilot had a duty time of 8.5 hours, from 2200 to 0630 CDT, on March 26, 1993. During 14 duty days before the accident the pilot averaged approximately 7.1 hours duty time per day. The last logbook entry shows the pilot flew a 5.4 hour trip on May 2, 1993. Approximately five hours were flown in instrument meteorological conditions. AIRCRAFT INFORMATION N80CB was a Beech model E-18S that had been modified by an FAA approved supplemental type certificate (STC) number SA572WE on December 18, 1973. The STC was a product of the Hamilton Aircraft Company, Incorporated, of Tucson, Arizona. The addition of the STC allowed N80CB's gross takeoff weight (GTOW) to increase to 10,100 pounds rather than the original certificated weight of 9,600 pounds. Based upon the Type ## Aircraft - Registration: [N80CB](https://openairdocs.org/deregistered/N80CB-1993-10-07), registration cancelled 1993-10-07, S/N BA257 (OpenAirDocs) - Reported make and model: BEECH E-18S - Registry model: [Beech E18S](https://openairdocs.org/model/beech-e18s) (registry code 1151006) (OpenAirDocs) - Category: Airplane - Serial number: BA257 - Airframe hours: 15027 - Engines: P&W R-985-14B 450 horsepower reciprocating - Damage: Destroyed - Flight: Part 135 - Operator: Viking Express, Inc. - Registered owner: Robert R. Burwell - Airworthiness certificate: Standard, Normal - Last inspection: AAIP, April 2, 1993, 93 hours before - Departed: ARR, AURORA, IL - Destination: MSP, MINNEAPOLIS, MN - Flight plan: IFR - Airport: LNR, Tri-County Regional ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 26; commercial, airline transport, flight instructor; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 1, valid medical--no waivers/lim.; seat: left; toxicology performed; flight hours: 4,492 total, 310 in this make and model, 4,352 as pilot in command, 318 in the last 90 days, 112 in the last 30 days ## Weather - Conditions: Instrument (IMC), Night/dark - Wind: 140° at 10 knots - Visibility: 3 statute miles - Lowest ceiling: 900 ft overcast - Temperature: 59 °F, dew point 57 °F - Altimeter: 29.00 inHg - Observed at: MSN, 38 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 19930504015379A](https://openairdocs.org/incident/19930504015379A), May 4, 1993: Beech E18S, Lone Rock, WI, Destroyed, 1 fatal. Lost engine oil. Shutdown. Feathered. Descended into trees on procedure turn. Gear down. NR9 cylinder came loose. 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.