ERA21LA124

NTSB accident investigation · Cessna 441 · Belvidere, TN · February 7, 2021

Accident · FatalClass 3 · LimitedFinal report
Date
February 7, 2021, 16:47 local (22:47 UTC)
Place
Belvidere, TN
Injuries
2 fatal
Damage
Destroyed
Phase of flight
Approach
Aircraft
N44776Cessna 441
Defining event
Approach-IFR final approach: Controlled flight into terr/obj (CFIT)
Weather
Instrument (IMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Eastern Region Aviation
Parties
FAA/FSDO, Textron Aviation, Honeywell Aerospace
FAA report
20210207003419A
Case key
102609

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

The pilot’s failure to follow the published instrument approach procedure by prematurely descending the airplane below the final approach fix altitude to fly under the low ceiling conditions, which resulted in controlled flight into terrain.

Findings · 3

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Performance/control parameters: altitudeAircraft › Aircraft oper/perf/capability · Not attained/maintainedCessna 441: 1 caseAll aircraft: 1,310 casesProbable cause
Action: incorrect action performancePersonnel issues › Action/decision · PilotCessna 441: 3 casesAll aircraft: 1,386 casesProbable cause
Ceiling/visibility/precip: obscurationEnvironmental issues › Conditions/weather/phenomena · Contributed to outcomeCessna 441: 1 caseAll aircraft: 45 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The pilot was conducting a cross-country flight and was beginning an instrument flight rules approach from the south. Weather conditions at the destination airport included a ceiling between 800 and 1,000 ft and light rime icing conditions in clouds; the pilot was aware of these conditions. Elevated, wooded terrain existed along the final approach course. Radar and automatic dependent surveillance-broadcast data revealed that the airplane crossed the intermediate approach fix at the correct altitude; however, the pilot descended the airplane below the final approach fix altitude about 4 miles before the fix. The airplane continued in a gradual descent until radar contact was lost. No distress calls were received from the airplane before the accident. The airplane crashed on a north-northwesterly heading about 5 miles south of the runway threshold. The elevation at the accident site was about 1,880 ft, which was about 900 ft higher than the airport elevation. Postaccident examination of the airframe, engines, and propellers revealed no evidence of a pre-existing mechanical failure or anomaly that would have precluded normal operation. Because of the weather conditions at the time of the final approach, the pilot likely attempted to fly the airplane under the weather to visually acquire the runway. The terrain along the final approach course would have been obscured in low clouds at the time, resulting in controlled flight into terrain.

Factual narrative

On February 7, 2021, about 1647 central standard time, a Cessna 441, N44776, was destroyed when it was involved in an accident near Belvidere, Tennessee. The airline transport pilot and the commercial pilot-rated passenger were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to automatic dependent surveillance-broadcast (ADS-B) data, radar, and voice communications obtained from the Federal Aviation Administration (FAA), the flight departed from Thomasville Regional Airport (TVI), Thomasville, Georgia, about 1527 with a destination of Winchester Municipal Airport (BGF), Winchester, Tennessee. The flight was cleared to flight level 220 after departing TVI. About 1616, the flight was cleared to begin the descent into BGF. About 1640, as the airplane was descending to 4,000 ft mean sea level (msl), the pilot established contact with the Bowling Green, Kentucky, radar controller. The flight was then cleared for the area navigation (RNAV) GPS runway 36 approach into BGF. The airplane crossed the intermediate fix at an altitude of about 4,000 ft. The approach procedure allowed the pilot to cross the intermediate fix at or above 4,000 ft and then descend to cross the final approach fix at or above 3,000 ft. The airplane was observed descending slowly from 3,000 ft when the airplane was about 4 nautical miles (nm) south of the final approach fix. As the airplane descended through 2,300 ft, its radar target disappeared, which was expected due to the limited radar coverage in the area. The last ADS-B target for the airplane showed that it was about 0.6 nm south of the final approach fix and at an altitude of 2,100 ft on a northerly heading. Shortly thereafter, the controller attempted to contact the pilot but received no response. The airplane subsequently impacted trees and terrain about 0.25 nm north-northeast of the final approach fix, which was about 5 nm south of the runway 36 threshold. A postcrash fire ensued. No distress calls were received. A dissipating cold frontal boundary stretched eastward from Arkansas to Georgia and then northeastward into the mid-Atlantic states. A trough stretched from northeastern Arkansas to northern Tennessee and West Virginia. The accident site was located to the north of the dissipating cold front on the cold side of the front. The station models surrounding the accident site depicted air temperatures in the low 30s (°F), dew point temperatures in the upper 20s (°F), temperature-dew point spreads of 2°F or less, an easterly wind at 5 knots, and overcast sky cover. The weather at BGF at 1635, about 12 minutes before the accident, included a ceiling of 800 ft overcast. The BGF weather at 1655, 8 minutes after the accident, included a ceiling of 1,000 ft overcast. The tops of the clouds were about 4,000 ft, and light rime icing conditions prevailed in the clouds. The pilot received a weather briefing before the flight. The briefing revealed thatthe pilot was comfortable with ceilings above 500 ft and that he was aware of the icing conditions at the destination. The pilot reported that he had deicing equipment and “onboard weather” on the accident airplane. The logbooks for the pilot and the pilot-rated passenger were not located after the accident. All flight times were obtained from FAA sources. The airplane impacted elevated, wooded terrain at an elevation of about 1,880 ft. The debris path was about 260 ft long. The first piece of wreckage found along the debris path was the left-wing tip lens. The farthest piece of wreckage was a light housing. The debris path was on a magnetic heading of about 342°. The fuselage was found inverted on a heading of 260°. Tree strikes indicated that the airplane impacted trees in a left-wing, nose-low attitude before rolling inverted and colliding with terrain. The postaccident fire consumed most of the cockpit, fuselage, inboard left wing, and outboard left horizontal stabilizer. All structural components of the airplane were found within the wreckage debris field. Flight control continuity was established from the control surfaces to the cockpit controls except in areas with tension overload failures. The preaccident position of the main landing gear and the wing flaps could not be determined due to impact and postaccident fire damage. The nose landing gear was in the extended position. The fuel system components were damaged during the postimpact fire. The left fuel cap was securely installed; the right fuel cap separated during the impact sequence. Postaccident examination of the airframe revealed no evidence of a pre-existing mechanical failure or anomaly that would have precluded normal operation. Teardown and examination of both engines found no evidence of a pre-existing malfunction or failure was found that would have precluded normal operation. Both engines exhibited internal signatures consistent with normal operation at impact, including rotational scoring and metal spray on internal components and compressor blades bent opposite the direction of engine rotation. Teardown and examination of both propeller assemblies also found no evidence of a pre existing malfunction or failure that would have precluded normal operation.

Aircraft

Registration
N44776
Reported as
Cessna 441
Category
Airplane
Serial number
4410121
Built
1978
Airframe hours
9,860
Engines
Airesearch TPE 331-8, 715 horsepower, turbo propAiresearch TPE 331-8, 715 horsepower, turbo prop
Damage
Destroyed
Fire
On-Ground
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Continuous airworthiness · December 10, 2020
Departed
TVI · Thomasville, GA
Destination
BGF · Winchester, TN
Flight plan
IFR
Airport
BGF · Winchester Muni, runway 36, 5,003 × 75 ft, asphalt
Equipment
Unknown

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 · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
78
Injuries
Fatal
Certificates
Flight instructor, Airline transport
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 2, Without waivers/limitations
Flight hours
18,800 total
Role
Pilot-rated passenger
Age
58
Injuries
Fatal
Certificates
Commercial, Flight instructor
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 2, With waivers/limitations
Flight hours
775 total

Weather

Conditions
Instrument (IMC) · Day
Wind
30° at 6 knots
Visibility
10 statute miles
Lowest ceiling
1,000 ft overcast
Temperature
32 °F, dew point 30 °F
Altimeter
30.14 inHg
Icing
Rime
Observed at
BGF, 6 nm away

Docket · 33

The files NTSB released with the investigation on June 14, 2023, on NTSB’s docket system: statements, records, photos and specialists’ reports. 119 MB in all.

Excerpts - aircraft logbookItem 1 · PDF · 5 pages · 3.2 MBExcerpts - left engine logbookItem 2 · PDF · 3 pages · 2.0 MBExcerpts - right engine logbookItem 3 · PDF · 3 pages · 1.9 MBMaintenance information provided by owner's familyItem 4 · PDF · 3 pages · 412 KBWeather factual reportItem 5 · PDF · 20 pages · 1.4 MBFuel recordItem 6 · PDF · 1 page · 1.0 MBWeather attachment 1Item 7 · GIF · 16.7 MBWeather attachment 2Item 8 · PDF · 5 pages · 2.7 MBWeather attachment 3Item 9 · PDF · 10 pages · 279 KBWeather attachment 4Item 10 · PDF · 63 pages · 226 KBWeather attachment 5Item 11 · PDF · 63 pages · 226 KBWeather attachment 6Item 12 · PDF · 123 pages · 408 KBWeather attachment 7Item 13 · PDF · 80 pages · 279 KBWeather attachment 8Item 14 · PDF · 145 pages · 473 KBWeather attachment 9Item 15 · WAV · 36.8 MBWeather attachment 10Item 16 · WAV · 3.5 MBWeather attachment 11Item 17 · ZIP · 14.3 MBWeather attachment 12Item 18 · PDF · 2 pages · 117 KBADS-B dataItem 19 · XLSX · 7.4 MBADS-B track kmz fileItem 20 · KMZ · 326 KBADS-B track with approach fixesItem 21 · PDF · 1 page · 392 KBAccident site location with ADS-B trackItem 22 · PDF · 1 page · 417 KBFAA form 8020-6 - report of aircraft accidentItem 23 · PDF · 5 pages · 700 KBApproach procedure - RNAV (GPS) runway 36 at bgfItem 24 · PDF · 1 page · 295 KBPhoto array N44776Item 25 · PDF · 10 pages · 9.6 MBWreckage diagram courtesy of Textron aviationItem 26 · PDF · 1 page · 255 KBNTSB examination summariesItem 27 · PDF · 5 pages · 408 KBTextron technical reportItem 28 · PDF · 9 pages · 3.8 MBMccauley propeller teardown inspection reportItem 29 · PDF · 3 pages · 184 KBNTSB memorandum for record - autopsy resultsItem 30 · PDF · 1 page · 122 KBStatement of party representatives to NTSB investigationItem 31 · PDF · 16 pages · 7.0 MBRelease of aircraft wreckage, NTSB form 6120.15Item 32 · PDF · 1 page · 863 KBEvidence controlItem 33 · PDF · 2 pages · 1.3 MB

FAA reports on this event · 1

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