# NTSB DCA92MA011: Beech 400, N25BR, Rome, GA, December 11, 1991

- Type: NTSB accident investigation
- Classification: Accident · Fatal · Major investigation · Final report
- Date: December 11, 1991, 09:41 local (14:41 UTC)
- Place: Rome, GA
- Coordinates: 34.23949, -85.170951 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=34.2395&lon=-85.1710&mi=10
- Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping)
- Highest injury: Fatal
- Injuries: 9 fatal
- Status: Completed, report July 8, 1992
- Report: Approved by Office Director
- NTSB office: Major Investigations Division
- Safety recommendations: Yes
- NTSB case key (mKey): 15953
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=DCA92MA011
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/15953/pdf
- Page: https://openairdocs.org/ntsb/DCA92MA011

## 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

In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf).

- In flight encounter with weather, climb
  - terrain condition - high terrain (contributing factor)
  - weather condition - clouds (contributing factor)
  - weather condition - low ceiling (contributing factor)
  - weather condition - fog (contributing factor)
  - vfr flight into imc - continued, pilot in command (cause)
- In flight collision with terrain/water, maneuvering - turn to reverse direction
  - terrain condition - mountainous/hilly (contributing factor)
  - clearance - not maintained, pilot in command (cause)

## 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](https://openairdocs.org/deregistered/N25BR-1992-06-25), registration cancelled 1992-06-25, S/N RJ57 (OpenAirDocs)
- Reported make and model: BEECH 400
- Registry model: [Beech 400](https://openairdocs.org/model/beech-400) (registry code 1155400) (OpenAirDocs)
- Category: Airplane
- Serial number: RJ-57
- Engines: P&W JT15D-5 2900 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

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 59; 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 (OpenAirDocs).

- [Accident 19911211055649A](https://openairdocs.org/incident/19911211055649A), Dec 11, 1991: Beech 400BEECH, Rome, GA, Destroyed, 11 fatal. Departed VFR with low ceilings into known mountainous terrain crashed into side of mountain obscured by clouds.

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.