# NTSB DCA94GA010: Beech 300/F, N82, Front Royal, VA, October 26, 1993

- Type: NTSB accident investigation
- Classification: Accident · Fatal · Class 1 · Final report
- Date: October 26, 1993, 15:52 local (19:52 UTC)
- Place: Front Royal, VA
- Coordinates: 38.920623, -78.180366 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=38.9206&lon=-78.1804&mi=10
- Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping)
- Highest injury: Fatal
- Injuries: 3 fatal
- Status: Completed, report March 30, 1995
- Report: Board-adopted at Board Meeting
- Investigation class: Class 1
- NTSB office: Major Investigations Division
- Safety recommendations: Yes
- NTSB case key (mKey): 10978
- NTSB case page: https://www.ntsb.gov/investigations/Pages/DCA94GA010.aspx
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/10978/pdf
- Board report AAR9403 (PDF): https://www.ntsb.gov/investigations/AccidentReports/Reports/AAR9403.pdf
- Page: https://openairdocs.org/ntsb/DCA94GA010

## Probable cause

the failure of the pilot-in-command to ensure that the airplane remained in visual meteorological conditions over mountainous terrain, and the failure of the Federal Aviation Administration executives and managers responsible for the FAA flying program to: 1)establish effective and accountable leadership and oversight of flying operations; 2)establish minimum mission and operational performance standards; 3)recognize and address performance-related problems among the organization's pilots; and 4) remove from flight operations duty pilots who were not performing to standards.

## Sequence of events

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

- In flight encounter with weather, maneuvering
  - weather condition - low ceiling (contributing factor)
  - vfr flight into imc - continued, pilot in command (cause)
  - inadequate surveillance of operation, faa(organization) (cause)
  - insufficient standards/requirements, faa(organization) (cause)
  - inadequate certification/approval, faa(organization) (cause)
- In flight collision with terrain/water, maneuvering
  - terrain condition - mountainous/hilly

## Analysis

The airplane was flying at 2,000 feet in the vicinity of high terrain when the airplane entered IMC conditions. The airplane struck the high terrain near the LINDEN VOR, while the PIC was awaiting an IFR clearance.

## Factual narrative

The airplane, used to inspect airways facilities, had departed nearby Winchester Regional Airport in visual meteorlogical conditions (VMC) on a routine point-to-point flight to Newport News/Williamsburg International Airport.  Witnesses described low clouds that were consistent with instrument meteorological conditions (IMC) in the area of the accident, which was about 15 south of the departure field.  An IFR flight plan was on file in the ATC system, but the flight plan had not been activated.  The flight was being conducted under 14 CFR 91.

At 1549, the PIC reported, "we're over the Linden VOR at 2,000 feet, can you get us a little higher, VFR on top and we'll be on our way."  The airplane struck high terrain at 2,000 feet.

## Aircraft

- Registration: [N82](https://openairdocs.org/deregistered/N82-1997-11-05), registration cancelled 1997-11-05, S/N FF17 (OpenAirDocs)
- Reported make and model: BEECH 300/F
- Registry model: [Beech 300](https://openairdocs.org/model/beech-300) (registry code 1152930) (OpenAirDocs)
- Category: Airplane
- Serial number: FF-17
- Airframe hours: 3353
- Engines: P&W PT6A-60A 1050 horsepower turbo prop
- Damage: Destroyed
- Fire: On-Ground
- Flight: Public aircraft, Part 91
- Operator: Federal Aviation Admin
- Registered owner: Federal Aviation Admin
- Airworthiness certificate: Standard, Normal
- Last inspection: Continuous airworthiness, September 30, 1993, 73 hours before
- Departed: W16, WINCHESTER, VA
- Destination: PHF, NEWPORT NEWS, VA

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 55; airline transport, flight instructor; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 1, valid medical--no waivers/lim.; seat: left; toxicology performed; flight hours: 6,700 total, 2,000 in this make and model, 108 in the last 90 days, 38 in the last 30 days

## Weather

- Conditions: Instrument (IMC), Day
- Lowest ceiling: 2,000 ft overcast
- Observed at: W16, 15 nm away

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.

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