CHI94FA050

NTSB accident investigation · Mitsubishi MU-300 · Goodland, KS · December 15, 1993

Accident · FatalField investigationFinal report
Date
December 15, 1993, 13:05 local (20:05 UTC)
Place
Goodland, KS
Injuries
3 fatal
Damage
Destroyed
Phase of flight
Approach
Aircraft
N710MBMitsubishi MU-300
Weather
Instrument (IMC) · Day
Status
Completed · report October 20, 1994
Report
Approved by Office Director
FAA report
19931215046889A
Case key
9365

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-in-command's inadvertent stall of the airplane. A factor associated with the accident is the pilot-in-command's poor IFR procedures.

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.

Loss of control - in flightApproach
Ifr procedure - poorPilot in commandFactor
Airspeed - not maintainedPilot in command
Stall - inadvertentPilot in commandCause
In flight collision with terrain/waterDescent - uncontrolled

Analysis

The flight was cleared for the ILS approach to runway 30. The flying pilot was the pilot-in-command. According to the cockpit voice recorder transcripts, the flying pilot had difficulty making a stabilized approach. During the initial descent the airplane entered an over-speed condition and the airplane flew through the localizer. During his attempt to re-establish the airplane on the localizer, the pilot allowed the airspeed to decrease to the point where the prestall 'stick-shaker' activated. The stick shaker continued until the airplane departed controlled flight and impacted terrain. No evidence of any preimpact mechanical anomalies were discovered during the investigation.

Factual narrative

History of flight

On December 15, 1993, at 1305 mountain standard time, a Mitsubishi MU-300, N710MB, registered to Frank E. Whitham, and operated by a crew of two pilots, impacted the terrain one mile east of the Shugr Locator Outer Marker(LOM), after being cleared for the ILS runway 30 approach at Goodland Municipal, Goodland, Kansas. The airplane was destroyed by the impact and post- accident fire. The crew of two and the one passenger aboard received fatal injuries. The corporate/executive flight was operating under provisions of 14 CFR Part 91 on an IFR flight plan. Instrument meteorological conditions existed at the Goodland, Kansas airport, at the time of the accident. The flight departed Scott City, Kansas, at 1248 with the intended destination of Glasgow, Montana, with an intermediate stop at Goodland, Kansas.

According to transcripts from Federal Aviation Administration (FAA) records, the pilot-in-command called the Wichita Automated Flight Service station on four occasions on the date of the accident for weather briefings, to file an IFR flight plan, and to obtain an IFR clearance between 0845 and 1239.

A cockpit voice recorder (CVR) transcript from the accident airplane began at 1233, contained voices of the pilot-in-command and the second pilot along with anomalous cockpit noises.

At the beginning of the recording the flight crew members were heard discussing the proposed flight, setting navigation equipment, and preparing for the flight. They continued through a checklist, with liftoff occurring at 1248.

Radar contact was established with FAA Denver Air Route Traffic Control Center (ARTCC) at 1251, four miles southeast of Scott City, while climbing through 9,500 feet mean sea level (msl).

The clearance called for a direct route from Scott City, to Goodland, Kansas, at an altitude of 16,000 msl. The direct flight distance between the two airports is approximately 69 nautical miles.

At 1258:30 the flight was cleared for the ILS approach to runway 30 at Goodland.

A radar plot at 1259 indicated the accident airplane to be 26 nautical miles south of runway 30 at Goodland, and nine nautical miles west of the centerline of the ILS for runway 30, at 15,400 feet msl.

At 1301:19 the last reported radar plot for the airplane was 16 nautical miles southeast of runway 30 at Goodland, and two miles east of the centerline of the ILS for runway 30, at 9,400 feet msl.

The CVR recorded a "sound of warbling" starting at 1301:17 and commented on by the second pilot, "Airspeed."

At 1301:21 the CVR picked up a "sound of pulsating tone similar to over-speed warning."

At 1301:24, the second pilot asked "Speed brakes?"

At 1301:56, the "sound of pulsating tone similar to over-speed warning ended."

During the next three minutes the flaps were extended ten degrees, the landing gear were lowered, a landing check list was started, but interrupted by a conversation about intercepting the localizer, and a conversation with the Goodland Airport UNICOM concerning wind and runway conditions.

At 1305:26 conversation continued about intercepting the ILS, and at 1305:35 the second pilot stated, "That's a shaker,.. ." followed two seconds later by, "Shaker, power power... ."

At 1305:39 the CVR picked up a, "sound of a horn similar to altitude alert," and at 1305:43 a statement from the second pilot for, "Full power." At 1305:47 the second pilot stated, "Get your nose down... . Get your nose down. Let's get it, get it to flying."

The recording ended five seconds later.

There are no known eye witnesses to the impact. One resident of the area was in his residence approximately two miles to the east of the impact site. He indicated that about the time of the accident he walked into his bedroom where there was a window facing the west. He stated that he observed a bright flash which he thought was lightning, but heard nothing. Another resident who lived approximately one mile to the south of the accident site, stated that he was not looking in the direction of the accident site, however around the time of the impact he recalled hearing a loud noise, which he associated with the sound of thunder.

When the pilots of the airplane did not cancel the IFR flight plan and the airplane did not land at the Goodland airport a search was initiated to find the airplane. The wreckage was located about 1800.

Personal information

The pilot-in-command was born January 15, 1928. He held a commercial pilot's certificate with privileges for airplane single and multi-engine land, rotorcraft-helicopter, and instrument airplane. He held type ratings for CE-500, MU-300 and BE-400 airplanes. His most recent second class medical certificate was issued on January 11, 1993, with the restriction, "Must wear lenses for distant and possess glasses for near vision." No personal log books were located; however, Federal Aviation Administration (FAA) records revealed that he had a total pilot time of 17,635 hours, as of June 2, 1993. His total time in the type of airplane involved in the accident was approximately 80 hours, as determined from training records, FAA records, and maintenance records. His most recent biennial flight review was satisfied by the issuance of the MU-300 and BE- 400 type certification on June 2, 1993. His most recent instrument currency could not be verified. Flight training records from Flight Safety International for this pilot's training, in the MU-300 are included as an addendum to this report.

The second pilot was born January 6, 1946. He held a commercial pilot's certificate with privileges for airplane single and multi-engine land, instrument airplane. His most recent second class medical certificate was issued March 17, 1993, with the restriction, "Must have available glasses for near vision." No personal log books were located: however, FAA records revealed that he had a total pilot time of 1,725 hours, as of March 17, 1993. His most recent biennial flight review and instrument currency could not be verified. His experience in the MU-300 could not be determined.

Aircraft information

The airplane was a Mitsubishi MU-300, serial number A078 S. A. At the time of the accident, the airframe had accumulated a total time of 2,593 hours time in service with 110 hours since the last inspection conducted on April 23, 1993.

Communications

A transcript of conversations with the pilot or pilot's of N710MB is attached as an addendum to this report. This includes a telephone conversation with Wichita Automated Flight Service Station, and Denver Air Route Traffic Control Center.

Flight recorders

The airplane was not equipped with a flight data recorder; however a cockpit voice recorder (CVR) was installed and functioning during the accident flight. A complete transcription of the conversations recorded on the CVR is attached to this report.

Wreckage and impact information

Ground impact marks indicate that the airplane impacted in a shallow descent, right wing down, in an open field. The initial ground scar,consistent with the right wing leading edge reached a depth of 18 inches. The debris scattered out from the initial impact scar on a magnetic heading of 037 degrees in a fan shaped pattern. There was a general disintegration of the airplane in the debris trail and the wreckage was distributed from the initial impact point to a distance of 1,060 feet. The impact site was located one mile east of the Shugr LOM.

Impact scars indicate a flap extension of unknown value at impact. The landing gear was found extended. The speed brake was stowed, as were the thrust reversers.

The extensive destruction of the airplane prevented a continuity verification of engine and flight controls. Likewise no specific determination of instrumentation, flight director and auto-pilot components was possible. One airspeed was located with a reading of 280 knots, another was found wit

Aircraft

Registration
N710MB
Reported as
Mitsubishi MU-300
Category
Airplane
Serial number
A078 S.A.
Airframe hours
2,593
Engine
P&W JT15D-4, 2,500 lbs thrust, turbo fan
Damage
Destroyed
Fire
On-Ground
Flight
Executive/Corporate · Part 91
Registered owner
Whitham, Frank E.
Airworthiness certificate
Standard, Normal
Last inspection
AAIP · April 23, 1993 · 110 hours before
Departed
2K9 · Scott City, KS
Flight plan
IFR
Airport
GLD · Goodland Muni, runway 30, 5,499 × 100 ft, concrete

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
65
Certificate
Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 2, Valid Medical--w/ waivers/lim
Seat
Left
Toxicology
Performed
Flight hours
17,635 total · 80 in this make and model · 17,100 as pilot in command

Weather

Conditions
Instrument (IMC) · Day
Wind
150° at 14 knots
Visibility
10 statute miles
Lowest ceiling
400 ft broken
Temperature
28 °F, dew point 28 °F
Altimeter
29.00 inHg
Observed at
GLD, 6 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.