# NTSB ERA21LA124: Cessna 441, N44776, Belvidere, TN, February 7, 2021 - Type: NTSB accident investigation - Classification: Accident · Fatal · Class 3 · Limited · Final report - Date: February 7, 2021, 16:47 local (22:47 UTC) - Place: Belvidere, TN - Coordinates: 35.086901, -86.072045 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=35.0869&lon=-86.0720&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Defining event: [Approach-IFR final approach: Controlled flight into terr/obj (CFIT)](https://openairdocs.org/ntsb-events/120) - Highest injury: Fatal - Injuries: 2 fatal - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO, Textron Aviation, Honeywell Aerospace - NTSB case key (mKey): 102609 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA21LA124 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/102609/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=102609 - Page: https://openairdocs.org/ntsb/ERA21LA124 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Performance/control parameters: altitude](https://openairdocs.org/ntsb-findings/01062012): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Cessna 441, 1 case](https://openairdocs.org/ntsb-findings/01062012/cases.md?model=2076020), [All aircraft, 1,310 cases](https://openairdocs.org/ntsb-findings/01062012/cases.md) - [Action: incorrect action performance](https://openairdocs.org/ntsb-findings/02041015): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Cessna 441, 3 cases](https://openairdocs.org/ntsb-findings/02041015/cases.md?model=2076020), [All aircraft, 1,386 cases](https://openairdocs.org/ntsb-findings/02041015/cases.md) - [Ceiling/visibility/precip: obscuration](https://openairdocs.org/ntsb-findings/03035030): Environmental issues › Conditions/weather/phenomena · Contributed to outcome (probable cause); cases with it: [Cessna 441, 1 case](https://openairdocs.org/ntsb-findings/03035030/cases.md?model=2076020), [All aircraft, 45 cases](https://openairdocs.org/ntsb-findings/03035030/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Approach-IFR final approach: Controlled flight into terr/obj (CFIT)](https://openairdocs.org/ntsb-events/120) (defining event); cases with it: [Cessna 441, 1 case](https://openairdocs.org/ntsb-events/120/sequence.md?model=2076020), [All aircraft, 1,074 cases](https://openairdocs.org/ntsb-events/120/sequence.md) ## 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](https://openairdocs.org/deregistered/N44776-2021-10-23), registration cancelled 2021-10-23, S/N 4410121, built 1978 (OpenAirDocs) - Reported make and model: CESSNA 441 - Registry model: [Cessna 441](https://openairdocs.org/model/cessna-441) (registry code 2076020) (OpenAirDocs) - Registry engine: [AiResearch TPE331 series](https://openairdocs.org/engine/airesearch-tpe331-series) (registry code 01514, turbo-prop) (OpenAirDocs) - Category: Airplane - Serial number: 4410121 - Year built: 1978 - Airframe hours: 9860 - Engines: AIRESEARCH TPE 331-8 715 horsepower turbo prop; AIRESEARCH 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 78; injuries: fatal; 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 - Pilot-rated passenger; age 58; injuries: fatal; 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 ## 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 20210207003419A](https://openairdocs.org/incident/20210207003419A), Feb 7, 2021: Cessna 441, Belvidere, TN, Destroyed, 2 fatal. On 2-7-21 two pilots crashed on top of a mountain on the final approach into kbgf. The trip was from kbgf-klou-ktvi-kbgf. The pireps indicate that icing… ## Docket (33 files) The files NTSB released with the investigation on June 14, 2023, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=102609. 119 MB in all. - Excerpts - aircraft logbook (item 1, PDF, 5 pages, 3.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15584969&FileExtension=pdf&FileName=Excerpts%20-%20Aircraft%20Logbook_Redacted-Rel.pdf - Excerpts - left engine logbook (item 2, PDF, 3 pages, 2.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15056237&FileExtension=pdf&FileName=Excerpts%20-%20Left%20Engine%20Logbook_Redacted-Rel.pdf - Excerpts - right engine logbook (item 3, PDF, 3 pages, 1.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15056247&FileExtension=pdf&FileName=Excerpts%20-%20Right%20Engine%20Logbook_Redacted-Rel.pdf - Maintenance information provided by owner's family (item 4, PDF, 3 pages, 412 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15056124&FileExtension=pdf&FileName=Maintenance%20Information%20Provided%20by%20Owner%27s%20Family_Redacted-Rel.pdf - Weather factual report (item 5, PDF, 20 pages, 1.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12195418&FileExtension=pdf&FileName=ERA21LA124_weatherfactualSuffernfinal-Rel.pdf - Fuel record (item 6, PDF, 1 page, 1.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15055540&FileExtension=pdf&FileName=Fuel%20Truck%20Inventory-Rel.pdf - Weather attachment 1 (item 7, GIF, 16.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12195860&FileExtension=gif&FileName=attachment1_animationSAT_VIS_2101to2301utc_CODNEXLAB-GOES-East-local-Tennessee-02-23_01Z-20210207_map-id_-25-1n-10-100-Rel.gif - Weather attachment 2 (item 8, PDF, 5 pages, 2.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12196387&FileExtension=pdf&FileName=attachment2_GFAimagedata-Rel.pdf - Weather attachment 3 (item 9, PDF, 10 pages, 279 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12196052&FileExtension=pdf&FileName=attachment3_N44776_Redacted-Rel.pdf - Weather attachment 4 (item 10, PDF, 63 pages, 226 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12196397&FileExtension=pdf&FileName=attachment4_N44776_02-07-2021-1524Z_Route_Standard_Briefing_KBGF_KLOU_Flight_Services-Rel.pdf - Weather attachment 5 (item 11, PDF, 63 pages, 226 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12196407&FileExtension=pdf&FileName=attachment5_N44776_02-07-2021-1526Z_Route_Standard_Briefing_KBGF_KLOU_Flight_Services-Rel.pdf - Weather attachment 6 (item 12, PDF, 123 pages, 408 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12196658&FileExtension=pdf&FileName=attachment6_N44776_02-07-2021-1530Z_Route_Standard_Briefing_KLOU_KTVI_Flight_Services-Rel.pdf - Weather attachment 7 (item 13, PDF, 80 pages, 279 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12196062&FileExtension=pdf&FileName=attachment7_N44776_02-07-2021-1536Z_Route_Standard_Briefing_KTVI_KBGF_Flight_Services-Rel.pdf - Weather attachment 8 (item 14, PDF, 145 pages, 473 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12195870&FileExtension=pdf&FileName=attachment8_N44776_02-07-2021-1543Z_Route_Standard_Briefing_KBGF_KBGF_Flight_Services-Rel.pdf - Weather attachment 9 (item 15, WAV, 36.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12196336&FileExtension=wav&FileName=attachment9_N44776-1543Z-Rel.wav - Weather attachment 10 (item 16, WAV, 3.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12195880&FileExtension=wav&FileName=attachment10_N44776-2115Z-Rel.wav - Weather attachment 11 (item 17, ZIP, 14.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12196678&FileExtension=zip&FileName=attachment11_GFA-Rel.zip - Weather attachment 12 (item 18, PDF, 2 pages, 117 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12196072&FileExtension=pdf&FileName=attachment12_foreflightinfoera21la124_Redacted-Rel.pdf - ADS-B data (item 19, XLSX, 7.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15056014&FileExtension=xlsx&FileName=20210207_A5680A_446307687_ADSB-Rel.xlsx - ADS-B track kmz file (item 20, KMZ, 326 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15056533&FileExtension=kmz&FileName=20210207_A5680A_446307687-Rel.kmz - ADS-B track with approach fixes (item 21, PDF, 1 page, 392 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15056442&FileExtension=pdf&FileName=Aircraft%20Track%20with%20Approach%20Fixes-Rel.pdf - Accident site location with ADS-B track (item 22, PDF, 1 page, 417 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15584949&FileExtension=pdf&FileName=Accident%20Site%20and%20ADS-B%20Track-Rel.pdf - FAA form 8020-6 - report of aircraft accident (item 23, PDF, 5 pages, 700 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15056543&FileExtension=pdf&FileName=Excerpts%20-%20ATC%20Package-Rel.pdf - Approach procedure - RNAV (GPS) runway 36 at bgf (item 24, PDF, 1 page, 295 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15584959&FileExtension=pdf&FileName=RNAV%20GPS%20RWY%2036%20BGF-Rel.pdf - Photo array N44776 (item 25, PDF, 10 pages, 9.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15689887&FileExtension=pdf&FileName=Photo%20Array%20ERA21LA124-Rel.pdf - Wreckage diagram courtesy of Textron aviation (item 26, PDF, 1 page, 255 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15056745&FileExtension=pdf&FileName=Wreckage%20Path-Rel.pdf - NTSB examination summaries (item 27, PDF, 5 pages, 408 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15614385&FileExtension=pdf&FileName=NTSB%20Examination%20Summaries-Rel.pdf - Textron technical report (item 28, PDF, 9 pages, 3.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15690684&FileExtension=pdf&FileName=Tech%20Report%20441-0121_Redacted-Rel.pdf - Mccauley propeller teardown inspection report (item 29, PDF, 3 pages, 184 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15057062&FileExtension=pdf&FileName=McCauley%20Propeller%20Teardown%20Inspection%20Report_Redacted-Rel.pdf - NTSB memorandum for record - autopsy results (item 30, PDF, 1 page, 122 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15608796&FileExtension=pdf&FileName=Memorandum%20for%20Record%20508%20Autopsy%20Findings-Rel.pdf - Statement of party representatives to NTSB investigation (item 31, PDF, 16 pages, 7.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15056666&FileExtension=pdf&FileName=Party%20Forms_Redacted-Rel.pdf - Release of aircraft wreckage, NTSB form 6120.15 (item 32, PDF, 1 page, 863 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15585891&FileExtension=pdf&FileName=Release%20N44776_Redacted-Rel.pdf - Evidence control (item 33, PDF, 2 pages, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15586102&FileExtension=pdf&FileName=Evidence%20Control%20N44776-Rel.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.