CHI99FA075

NTSB accident investigation · Beech BE-55 · Elkhart, IN · January 22, 1999

Accident · FatalField investigationFinal report
Date
January 22, 1999, 18:40 local (23:40 UTC)
Place
Elkhart, IN
Injuries
2 fatal, 1 serious
Damage
Destroyed
Phase of flight
Approach
Aircraft
N40HCBeech BE-55
Weather
Instrument (IMC) · Night/dark
Status
Completed · report June 23, 2000
Report
Approved by Office Director
FAA report
19990122000679A
Case key
45751

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 failed to maintain a proper glidepath and obstacle clearance. Factors were the fog and dark night.

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 - fogFactor
Light condition - dark nightFactor
Proper glidepath - not maintainedPilot in commandCause
Altitude/clearance - not maintainedPilot in commandCause
In flight collision with terrain/waterDescent - uncontrolled

Analysis

The airplane was cleared for the ILS Rwy 27 approach. Radar data indicated the airplane had intercepted the inbound approach course of 271 degrees. The surviving passenger reported he heard the landing gear extension and saw the three landing gear indicator lights illuminate. He reported that he did not hear the airplane malfunction or hear any abnormal sounds. He reported he saw the glow of parking lot lights in the fog out the left rear window. He reported seeing the pilot looking out the left window and then looking to the front of the airplane. The airplane initially impacted two 40 foot pine trees about 800 feet from the wreckage site. The radar data hit was recorded when the airplane was about 1,300 feet msl and about 2.0 nm from the runway. It indicated the airplane's glide path was about 130 feet below the ILS Rwy 27's glide path. The reported weather was winds 120 at 7 knots, visibility 1/2 mile, light rain, mist, indefinite ceiling, 200 foot overcast, 9 degrees C, 29.77. A weather station 14 miles from the accident was reporting the temperature and dew point as 8 degrees C. Ground fog was reported in the area. The airplane did not exhibit any pre-impact anomalies.

Factual narrative

History of Flight

On January 22, 1999, at 1840 eastern standard time (All times EST), a Beech BE-55, N40HC, was destroyed when it impacted the terrain during an instrument approach. The 14 CFR Part 91 business flight had departed Worthington Municipal Airport (OTG), Worthington, Minnesota, at approximately 1540 en route to Elkhart Municipal Airport (EKM), Elkhart, Indiana. The airplane was executing the ILS 27 approach when it hit trees and impacted the ground about 190 feet from the middle marker. The pilot and one passenger received fatal injuries, and one passenger was seriously injured. Instrument meteorological conditions prevailed and an instrument flight plan had been filed.

Federal Aviation Administration (FAA) transcripts indicate the pilot contacted the Princeton, Minnesota, Automated Flight Service Station (AFSS) at 1504 by telephone to file an IFR flight plan for a flight from Worthington, Minnesota, to Elkhart, Indiana. The pilot also received a standard weather brief. At 1532, the pilot phoned the Princeton AFSS and received an IFR flight clearance. The flight was cleared to 7,000 feet altitude and it had a Void Time of 1548.

At 1547, the Air Traffic Controller who controlled Sector 33 at the Minneapolis ARTCC, called "in the blind" for N40HC. The pilot of N40HC contacted Sector 33 and reported the airplane had departed Worthington and was climbing through 3,500 feet mean sea level (msl). At 1549, the airplane continued its climb to its en route altitude of 7,000 feet msl.

At 1629, N40HC contacted Waterloo Approach Control and reported that the flight was at 7,000 feet msl. At 1636, the Waterloo Approach Control reported, "...I am receiving your transponder. Altitude indicates seven thousand."

The en route portion of the flight continued to Indiana. At 1817, N40HC was told to contact South Bend Approach Control (SBN).

At 1818:05, SBN reported, "Baron Four Zero Hotel Charlie, South Bend Approach. The weather at Elkhart is wind one two zero at seven, visibility one half, light rain, mist. Indefinite ceiling, two hundred overcast. Temperature niner. The altimeter two niner seven seven. And you can let me know what approach you would like please."

The radar data indicated that at 1818:08, N40HC's altitude was 7,000 feet mean sea level (msl).

At 1818:25, N40HC responded, "Ah, guess we have to try the ILS 27."

At 1818:29, SBN started issuing N40HC radar vectors for the ILS Rwy 27 approach into Elkhart, Indiana.

The radar track indicated that N40HC's flight path took N40HC approximately eight miles south of the Elkhart Municipal Airport as it continued heading east. N40HC continued heading east until SBN vectored it back to the north in order to intercept the ILS Rwy 27 inbound localizer course of 271 degrees.

At 1833:55, SBN transmitted, "Baron Four Zero Hotel Charlie, turn left to heading three six zero. Descend and maintain two thousand five hundred."

At 1834:00, N40HC responded, "Three six zero, twenty five hundred, Forty Hotel Charlie."

The radar data indicated that N40HC turned to the north and started descending in altitude.

At 1834:48, SBN transmitted, "Baron Zero Hotel Charlie, six miles from Sousa. Turn left heading three zero zero maintain two thousand five hundred til established on the localizer. Cleared ILS 27 approach to Elkhart."

At 1834:57, N40HC responded, "Three zero zero, twenty five hundred. Cleared for the approach, Four Zero Hotel Charlie."

The radar data indicated that at 1835:13, N40HC's altitude was 3,300 feet msl.

The radar data indicated that N40HC intercepted and turned inbound on the ILS Rwy 27 inbound course heading of 271 degrees.

At 1837:01, SBN transmitted, "Baron Four Zero Hotel Charlie, contact Elkhart Tower now on one one niner point five." The radar data indicated that at 1837:14, N40HC's altitude was 2,500 feet msl, and the ground speed was approximately 120 knots.

The transcript from the Elkhart Tower indicated that the Tower Controller transmitted the following instructions to N40HC at (1836:13) (The times indicated on Elkhart Tower's tape recording were not synchronized with SBN's tape or the radar data's time indications): "Hotel Charlie, report the marker. Wind is, ah, one two zero at seven. Altimeter two niner seven five."

At (1836:26), N40HC responded, "I got everything, (Unintelligible)."

At (1836:30), the Tower transmitted, "Cleared to land two seven."

At (1839:08), the Tower transmitted, "Hotel Charlie, Tower."

At (1839:16), the Tower transmitted, "Four Zero Hotel Charlie, Tower."

The transcripts from SBN and the Elkhart Tower indicate that both facilities tried to make radio contact with N40HC but without success. SBN contacted two aircraft that were flying in the Elkhart area to check if they were picking up any signals from an Emergency Locator Transmitter (ELT). Both aircraft indicated that they were receiving an ELT transmission.

The radar data indicated that at 1837:55, N40HC's altitude was 2,200 feet msl and was about 0.2 nautical miles east of Sousa, the ILS Rwy 27 Outer Marker.

The radar data indicated that there were eight radar "hits" between Sousa and the last radar hit recorded before radar contact with N40HC was lost due to altitude and terrain. The radar hits were recorded approximately every 10 seconds.

The last six radar hits indicate that N40HC's glide path was approximately 100 feet below the ILS Runway 27 glide path.

N40HC was approximately 2.0 nautical miles from the approach end of runway 27 when the last radar hit was recorded at 1839:16. The altitude indicated was 1,300 feet msl, which was approximately 130 feet below the ILS Runway 27 glide path.

A ground search for N40HC was initiated. At 2028, the airplane wreckage was located approximately 0.4 nautical miles east of the approach end, and near the centerline, of runway 27 at the Elkhart Municipal Airport. One passenger was found conscious and alert. The other passenger and pilot were found unconscious, and later pronounced deceased by Elkhart Fire Department paramedics. The ground search was hampered by fog and the dark night.

Personnel Information

The pilot was an airline transport rated pilot with single engine land and sea ratings and a multi-engine land rating. He was a Certified Flight Instructor with single engine land and multi-engine land and instrument instructor ratings. He held a Second Class medical certificate.

The pilot had a total of about 7,400 hours of flight time. A computerized pilot's log that dated back to September 1, 1987, was obtained. The pilot logbooks that pre-dated the computerized logs were not obtained. The computerized log indicated that the pilot had flown 2,687 hours between September 1, 1987, and December 19, 1998. The log indicated the pilot first flew N40HC on August 16, 1997, and had a total of approximately 135 flight hours in N40HC. In the last 90 days, the pilot had flown approximately 102 hours with about 20 hours in N40HC.

The pilot owned and operated a similar make and model airplane. The pilot operated his airplane from the Elkhart Municipal Airport.

A business associate of the pilot reported that she had flown with the pilot on numerous occasions. She reported that the pilot did not fly approaches with the autopilot engaged.

Aircraft Information

The airplane was a twin engine Beech BE-55 Baron, serial number TC-1974. The airplane seated five and had a maximum gross weight of 5,121 pounds. The engines were 260 horsepower Continental IO-470-L engines. The last annual inspection was conducted on November 4, 1998. The airplane had flown 141 hours since the last inspection and had a total time of 3,678 hours.

Meteorological Conditions

At 1818:05, the SBN Approach Control reported the weather at Elkhart, Indiana, was: winds 120 degrees at seven knots, visibility one half mile with light rain and mist. Ind

Aircraft

Registration
N40HC
Reported as
Beech BE-55
Category
Airplane
Serial number
TC-1974
Airframe hours
3,678
Engine
Continental IO-470-L, 260 horsepower, reciprocating
Damage
Destroyed
Flight
Business · Part 91
Registered owner
Ggt
Airworthiness certificate
Standard, Utility; Standard, Normal
Last inspection
Annual · November 4, 1998 · 141 hours before
Departed
OTG · Worthington, MN
Destination
EKM
Flight plan
IFR
Airport
EKM · Elkhart Municipal Airport, runway 27, 6,500 × 120 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
50
Certificate
Airline transport
Airplane ratings
Single-engine land, Single-engine sea, Multi-engine land
Instrument ratings
Airplane
Medical
Class 2, Valid Medical--w/ waivers/lim
Seat
Left
Toxicology
Performed
Flight hours
7,400 total · 102 in the last 90 days · 5 in the last 30 days · 5 in the last 24 hours

Weather

Conditions
Instrument (IMC) · Night/dark
Wind
120° at 7 knots
Visibility
0.5 statute miles
Lowest ceiling
200 ft
Temperature
48 °F
Altimeter
29.00 inHg
Observed at
EKM

FAA reports on this event · 1

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