DCA92MA011

NTSB accident investigation · Beech 400 · Rome, GA · December 11, 1991

Accident · FatalMajor investigationFinal report
Date
December 11, 1991, 09:41 local (14:41 UTC)
Place
Rome, GA
Injuries
9 fatal
Damage
Destroyed
Phase of flight
Enroute
Aircraft
N25BRBeech 400
Weather
Instrument (IMC) · Day
Status
Completed · report July 8, 1992
Report
Approved by Office Director
NTSB office
Major Investigations Division
Safety recommendations
Yes
FAA report
19911211055649A
Case key
15953

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 captain's decision to initiate visual flight into an area of known mountainous terrain and low ceilings and the failure of the flightcrew to maintain awareness of their proximity to the terrain.

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 encounter with weatherClimb
Terrain condition - high terrainFactor
Weather condition - cloudsFactor
Weather condition - low ceilingFactor
Weather condition - fogFactor
Vfr flight into imc - continuedPilot in commandCause
In flight collision with terrain/waterManeuvering - turn to reverse direction
Terrain condition - mountainous/hillyFactor
Clearance - not maintainedPilot in commandCause

Analysis

Before takeoff, an IFR flt plan was filed for a 15 min flt from Rome, GA, to huntsville, AL. Takeoff was commenced at 0937 EST with the coplt flying the acft. After a VFR takeoff, the capt contacted atlanta center to obtain an IFR clnc. The controller advised that other traffic was in the area & instructed the flt to remain VFR (while an IFR clnc was being arranged). At that time, the flt rprtd at 1300' in VFR conds. While waiting for an IFR clnc, the crew became concerned about higher terrain & low ceilings. At about 0940, the capt directed the coplt to fly 'back to the right.' Aprx 1 min later, the CVR stopped recording & radio contact was lost with the acft. Later, the acft was found where it had collided with the top of mt lavendar. Elevation of the crash site was aprx 1580' MSL. The acft was not equipped with a ground proximity warning sys. (For details see: summary report)

Aircraft

Registration
N25BR
Reported as
Beech 400
Category
Airplane
Serial number
RJ-57
Engine
P&W JT15D-5, 2,900 lbs thrust, turbo fan
Damage
Destroyed
Fire
On-Ground
Flight
Executive/Corporate · Part 91
Operator
Bruno'S Inc
Registered owner
B.R. Air Inc
Airworthiness certificate
Standard, Normal; Standard, Transport
Last inspection
Continuous airworthiness · October 17, 1991 · 17 hours before
Departed
RMG · Rome, GA
Destination
HSV · Huntsville, AL
Flight plan
IFR
Airport
RMG

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
59
Certificate
Airline transport
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--w/ waivers/lim
Seat
Right
Toxicology
Performed
Flight hours
17,000 total · 600 in this make and model

Weather

Conditions
Instrument (IMC) · Day
Wind
Calm
Temperature
-0 °F, dew point -0 °F
Altimeter
30.00 inHg
Observed at
RMG, 7 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.