# NTSB DEN07FA059: Beech H-18, N45GM, Great Bend, KS, February 9, 2007 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: February 9, 2007, 08:50 local (14:50 UTC) - Place: Great Bend, KS - Coordinates: 38.335277, -98.868614 - Nearby events: https://openairdocs.org/map.md?lat=38.3353&lon=-98.8686&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed, report December 20, 2007 - Report: Approved by Office Director - Parties: Hawker Beechcraft Corporation, Federal Aviation Administration - NTSB case key (mKey): 65276 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=DEN07FA059 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/65276/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=65276 - Page: https://openairdocs.org/ntsb/DEN07FA059 ## Probable cause The pilot's failure to maintain aircraft control during the missed approach which resulted in an inadvertent stall and impact with terrain. A contributing factor was the icing conditions. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of control - in flight, missed approach (ifr) - aircraft control - not maintained, pilot in command (cause) - weather condition - icing conditions (contributing factor) - airspeed - not maintained, pilot in command - stall - inadvertent, pilot in command (cause) - In flight collision with terrain/water, descent - uncontrolled - terrain condition - ground ## Analysis Prior to the flight, the pilot obtained a weather briefing which included an AIRMET for IFR conditions and an AIRMET for icing that was "just off to the north." According to air traffic control (ATC) information, the en route portion of the flight was uneventful. ATC cleared the pilot for an ILS approach to runway 35, and the pilot acknowledged the approach clearance. When the airplane reached the outer marker ATC approved the pilot for a frequency change to the common traffic advisory frequency. The pilot acknowledged the frequency change, and no further communications were received from the pilot by ATC. Witnesses observed the observed the airplane approximately 200 feet above ground level (agl) on a northwesterly heading, west of runway 35. The airplane then entered a climbing left turn to the south and disappeared into the overcast cloud layer. Shortly thereafter, the witness observed the airplane in a "20 degree nose down, wings level attitude" on a southeasterly heading. The witness then lost sight of the airplane due to hangars obstructing his view. At the time of the accident, the witness stated that the ceiling was approximately 500 foot overcast with mist. The published missed approach procedure instructed the pilot to initiate a climbing left turn to a fix and hold. Examination of the accident site revealed the airplane impacted the terrain in a right wing, nose-low attitude. No ground impact marks were noted except in the immediate vicinity of the wing leading edges, engines, and propeller assemblies. The flaps and landing gear were in the extended position. The leading edge surfaces of the vertical and horizontal stabilizers revealed 1/4 to 1/2 inches of clear ice. The upper fuselage antenna displayed 1/4 to 1/2 inches of clear ice. Local authorities reported observing a "layer of ice" on the leading edges of both wings when they arrived to the accident site. Examination of the airframe and engines revealed no anomalies that would have precluded normal operations. ## Factual narrative HISTORY OF FLIGHT On February 9, 2007, approximately 0850 central standard time, a Beech H-18 twin-engine airplane, N45GM, was destroyed when it impacted terrain following a loss of control while maneuvering near Great Bend Municipal Airport (GBD), Great Bend, Kansas. The airplane was registered to a private individual and operated by Bygone Aviation, L.L.C., Guymon, Oklahoma. The airline transport pilot, who was the sole occupant, sustained fatal injuries. Instrument meteorological conditions (IMC) prevailed at the time of the accident. The unscheduled domestic cargo flight was being operated under the provisions of Title 14 Code of Federal Regulations (CFR) Part 135 under an instrument flight rules (IFR) flight plan. The flight departed the Wichita Mid-Continent Airport (ICT), Wichita, Kansas, approximately 0815, and was en route to GBD. Approximately 1 hour and 30 minutes prior to departure from ICT, the pilot contacted the Wichita Automated Flight Service Station (AFSS), Wichita, Kansas, to obtain a weather briefing for an IFR flight from ICT to GBD with a planned departure time of 0745. During the 5-minute briefing, the briefer informed the pilot of the weather conditions along her planned route which included an Airmen's Meteorological Information (AIRMET) for IFR conditions, an AIRMET for icing that was "just off to the north," and the current conditions at ICT and GBD. The pilot filed her flight plan with a planned true airspeed of 150 knots, an altitude of 8,000 feet mean sea level (msl), a time en route of 40 minutes, and ICT as an alternate destination airport. Prior to the end of the conversation, the briefer informed the pilot that a recent pilot weather report (PIREP) indicated the cloud tops out of ICT were at 5,500 feet msl and the reporting airplane accumulated moderate ice during the climb. The airplane then "lost the ice" at 6,500 feet msl. According to the Federal Aviation Administration (FAA) and the operator, at 0749, during the pilot's preflight checks of the airplane, a FAA inspector performed a ramp inspection on the pilot and the airplane. The ramp inspection included the following: verification of the pilot's medical and pilot certificates, and the airplane's airworthiness certificate, minimum equipment list, checklist, and flight manual. According to air traffic control information, the en route portion of the flight was uneventful. As the airplane approached GBD, FAA Kansas City Air Route Traffic Control Center (ARTCC) cleared the pilot for an instrument landing system (ILS) approach to runway 35 at GBD, and the pilot acknowledged the approach clearance. When the airplane reached the outer marker (BABSY), ARTCC approved the pilot for a frequency change to the common traffic advisory frequency at GBD. The pilot acknowledged the frequency change. No further communications were received from the pilot by ARTCC. A witness, who was located on the ramp at GBD, reported he observed the airplane approximately 200 feet above ground level (agl) on a northwesterly heading, west of runway 35. The airplane then entered a climbing left turn to the south and disappeared into the overcast cloud layer. Shortly thereafter, the witness observed the airplane in a "20 degree nose down, wings level attitude" on a southeasterly heading. The witness then lost sight of the airplane due to hangars obstructing his view. At the time of the accident, the witness stated that the ceiling was approximately 500 foot overcast with mist. Another witness, who was located at his residence adjacent to GBD, reported that he had heard the accident airplane "come in and out [of GBD] everyday." On the day of the accident, the witness heard "what sounded like the aircraft was making a turn...both engines sounded like they were running, slightly revving up." The witness then heard a "thump, no more noise." The witness reported "the visibility was poor" at the time of the accident. GBD airport personnel reported that a commercial passenger flight (Beech 1900 airplane) arrived at GBD from Kansas City, Kansas, approximately 0800. The Beech 1900's flightcrew provided statements to the NTSB investigator-in-charge (IIC) concerning the weather conditions they experienced during the flight. According to the statements, approximately 70 nautical miles from GBD, ARTCC cleared the flight from a cruise altitude of 12,000 feet to descend at the pilot's discretion to 6,000 feet. ARTCC notified the flightcrew of multiple icing reports encountered below 10,000 feet in the GBD area. The flightcrew requested the GBD runway 35 ILS approach. For approximately 20 miles, the captain flew the airplane at the cloud tops, 8,000 to 9,000 feet, "to avoid picking up any ice accumulation." The captain reported, "as soon as the flight descended into the clouds, the left wing began accumulating ice. I would characterize the icing as light clear or light mixed icing. I did not consider the accumulation rate as hazardous. We were IMC the entire time from the start of the descent into the cloud tops at [8,000] or 9,000 feet until the flight broke out at approximately 800 feet [above ground level] and gained visual with the runway. I would estimate the total accumulation during the time we were IMC and in the clouds at 1/8 of an inch." PERSONNEL INFORMATION The pilot, age 34, held an airline transport pilot (ATP) certificate, issued October 4, 2006, with an airplane multi-engine land rating, and commercial pilot privileges with an airplane single-engine land rating, and a flight instructor certificate with single-engine, multi-engine and instrument airplane ratings. The pilot's most recent FAA first-class airman medical certificate was issued on October 4, 2006, with no restrictions or limitations. The operator provided the pilot's personnel records to the NTSB IIC. A review of the pilot's flight time summary, dated October 17, 2006, indicated the pilot had accumulated 3,250 total flight hours of which 1,680 were in multi-engine airplanes, and 430 hours of actual instrument flight time. The operator reported the pilot had accumulated 255.5 hours in Beech 18 airplanes and 56 hours in Beech H-18 airplanes. The pilot's logbook was not located during the investigation. The personnel records revealed the operator hired the pilot in October 2006. The pilot completed the operator's "initial" training in the accident airplane make and model on December 8, 2006. The initial training consisted of ground school, which included: Basic Indoctrination, General Emergency, Situation and Hands-On Drill, Aircraft Ground, Aircraft Differences, and Hazmat. In addition to the ground school training, the pilot completed 5 training flights with the operator's chief pilot. During the third flight, steep turns, slow flight, stalls; clean, takeoff, and landing configurations, were conducted; during the fourth flight, emergency situations and procedures were conducted; and during the fifth flight, precision and non-precision approaches, missed approaches, and go around from rejected landings were conducted. The pilot satisfactorily completed the 5 training flights. On December 8, 2006, the pilot completed a Federal Aviation Regulations (FAR) Part 135 Airman Competency/Proficiency Check. The flight was conducted by the operator's check airman with a total flight time of 2.2 hours. A review of the operator's monthly time and duty log revealed the pilot had accumulated approximately 60 flight hours in the accident airplane make and model in the months of December and January. According to the operator's chief pilot, he had known the pilot for approximately 5 1/2 years. Approximately 3 years prior the pilot being hired by the operator, her employment with an air carrier was terminated due to a failed 6-month checkride. The pilot then flew with an on demand cargo company for a period of time. Between the previous on-demand cargo flig ## Aircraft - Registration: [N45GM](https://openairdocs.org/deregistered/N45GM-2010-12-27), registration cancelled 2010-12-27, S/N BA-717, built 1965 (OpenAirDocs) - Reported make and model: Beech H-18 - Registry model: [Beech H-18](https://openairdocs.org/model/beech-h-18) (registry code 1151012) (OpenAirDocs) - Category: Airplane - Serial number: BA-717 - Airframe hours: 7702 - Engines: Pratt & Whitney R-985-AN-14B 450 horsepower reciprocating - Damage: Destroyed - Flight: Part 135 - Operator: Bygone Aviation LLC - Registered owner: William Chase - Airworthiness certificate: Standard, Normal - Last inspection: Annual, November 1, 2006 - Departed: ICT, WICHITA, KS - Destination: GBD, GREAT BEND, KS - Flight plan: IFR - Airport: GBD, Great Bend Muni ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 34; injuries: fatal; flight instructor, commercial, airline transport; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 1, with waivers/limitations; last flight review December 1, 2006; seat: left; toxicology performed; flight hours: 3,250 total, 125 in this make and model, 2,300 as pilot in command, 125 in the last 90 days, 60 in the last 30 days, 1 in the last 24 hours ## Weather - Conditions: Instrument (IMC), Day - Wind: 40° at 6 knots - Visibility: 2 statute miles - Lowest ceiling: 500 ft overcast - Temperature: 25 °F, dew point 21 °F - Altimeter: 30.37 inHg - Observed at: GBD, 1 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 20070209001919A](https://openairdocs.org/incident/20070209001919A), Feb 9, 2007: Beech H18, Great Bend, KS, Destroyed, 1 fatal. (-23) At approximately 1455Z, 08:55 CST, February 9, 2007, a twin engine Beech model H-18-S, N45GM, was destroyed when it impacted terrain, following a loss of… ## Docket (27 files) The files NTSB released with the investigation on November 20, 2007, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=65276. 14.5 MB in all. - Meteorology 5 - Factual Report of Group Chairman (item 1, .PDF, 2.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40273625&FileExtension=.PDF&FileName=Meteorology%205%20-%20Factual%20Report%20of%20Group%20Chairman-Master.PDF - Witness Statements (item 2, .PDF, 547 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40285171&FileExtension=.PDF&FileName=Witness%20Statements-Redacted.PDF - Witness Flightcrew Report (item 3, .PDF, 462 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40285172&FileExtension=.PDF&FileName=Witness%20Flightcrew%20Report-Redacted.PDF - Wreckage Diagram (item 4, .PDF, 14 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40285173&FileExtension=.PDF&FileName=Wreckage%20Diagram-Master.PDF - FSS Transcript (item 5, .PDF, 152 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40285174&FileExtension=.PDF&FileName=FSS%20Transcript-Master.PDF - Airport Diagram (item 6, .PDF, 36 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40285175&FileExtension=.PDF&FileName=Airport%20Diagram-Master.PDF - ILS Rwy 35 Approach Plate (item 7, .PDF, 39 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40285176&FileExtension=.PDF&FileName=ILS%20Rwy%2035%20Approach%20Plate-Master.PDF - Pilot Records (item 8, .PDF, 458 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40285177&FileExtension=.PDF&FileName=Pilot%20Records-Redacted.PDF - Ramp Inspection (item 9, .PDF, 312 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40285178&FileExtension=.PDF&FileName=Ramp%20Inspection-Master.PDF - Cargo Manifest (item 10, .PDF, 412 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40285179&FileExtension=.PDF&FileName=Cargo%20Manifest-Master.PDF - Weight and Balance (item 11, .PDF, 358 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40285180&FileExtension=.PDF&FileName=Weight%20and%20Balance-Master.PDF - Airframe Logbook (item 12, .PDF, 410 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40285181&FileExtension=.PDF&FileName=Airframe%20Logbook-Redacted.PDF - Engine Logbook (item 13, .PDF, 458 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40285182&FileExtension=.PDF&FileName=Engine%20Logbook-Redacted.PDF - Excerpts of Flight Handbook (item 14, .PDF, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40285183&FileExtension=.PDF&FileName=Excerpts%20of%20Flight%20Handbook-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 15, .PDF, 54 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40285184&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Master.PDF - Toxicological Report (item 16, .PDF, 58 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40285185&FileExtension=.PDF&FileName=Toxicological%20Report-Master.PDF - 01 View of Accident Site (item 17, .PDF, 2.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40285188&FileExtension=.PDF&FileName=01%20View%20of%20Accident%20Site-Master.PDF - 02 View of Right Wing (item 18, .PDF, 438 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40285189&FileExtension=.PDF&FileName=02%20View%20of%20Right%20Wing-Master.PDF - 03 View of Accident Site (item 19, .PDF, 466 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40285190&FileExtension=.PDF&FileName=03%20View%20of%20Accident%20Site-Master.PDF - 04 View of Accident Site (item 20, .PDF, 488 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40285191&FileExtension=.PDF&FileName=04%20View%20of%20Accident%20Site-Master.PDF - 05 View of Accident Site (item 21, .PDF, 458 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40285192&FileExtension=.PDF&FileName=05%20View%20of%20Accident%20Site-Master.PDF - 06 View of Accident Site (item 22, .PDF, 497 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40285193&FileExtension=.PDF&FileName=06%20View%20of%20Accident%20Site-Master.PDF - 07 View of Left Wing (item 23, .PDF, 486 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40285194&FileExtension=.PDF&FileName=07%20View%20of%20Left%20Wing-Master.PDF - 08 View of Cockpit (item 24, .PDF, 441 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40285195&FileExtension=.PDF&FileName=08%20View%20of%20Cockpit-Master.PDF - 09 View of Left Engine (item 25, .PDF, 506 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40285196&FileExtension=.PDF&FileName=09%20View%20of%20Left%20Engine-Master.PDF - 10 View of Right Engine (item 26, .PDF, 477 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40285197&FileExtension=.PDF&FileName=10%20View%20of%20Right%20Engine-Master.PDF - 11 View of Ice on Left Horizontal Stabilizer (item 27, .PDF, 464 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40285198&FileExtension=.PDF&FileName=11%20View%20of%20Ice%20on%20Left%20Horizontal%20Stabilizer-Master.PDF 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.