FTW03FA089

NTSB accident investigation · Cessna 208B · San Angelo, TX · January 24, 2003

Accident · Serious injuriesField investigationFinal report
Date
January 24, 2003, 10:15 local (16:15 UTC)
Place
San Angelo, TX
Injuries
2 serious
Damage
Destroyed
Phase of flight
Maneuvering
Aircraft
N944FECessna 208B
Weather
Visual (VMC) · Day
Status
Completed · report December 20, 2007
Report
Approved by Office Director
Parties
Cessna Aircraft Company, Federal Aviation Administration, Pratt & Whitney Canada, McCauley Propeller Systems, Federal Express, Barron Aviation Services
FAA report
20030124001119A
Case key
56394

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 flight crew's failure to cycle the deice boots prior to conducting a simulated forced landing and their failure to maintain adequate airspeed during the maneuver, which resulted in an inadvertent stall and subsequent loss of control. A contributing factor was the ice accumulation on the leading edges of the airfoils.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

In flight encounter with weatherManeuvering
Weather condition - icing conditionsFactor
Loss of control - in flightApproach - vfr pattern - base leg/base to final
Anti-ice/deice system - not activatedCause
Airspeed - not maintainedFlightcrewCause
Stall - inadvertentFlightcrewCause
In flight collision with terrain/waterDescent - uncontrolled
Terrain condition - ground

Analysis

The airplane impacted a dirt field and a power line following a loss of control during a simulated engine failure while on a Part 135 proficiency check flight. Both pilots were seriously injured and could not recall any details of the flight after the simulated engine failure. Witnesses observed the airplane flying on a westerly heading at an altitude of 100 to 200 feet, and descending. They heard the sound of an engine “surging” and observed the airplane’s wings bank left and right. The airplane continued to descend and impacted the ground and power lines before becoming inverted. A pilot-rated witness reported that he observed about ¼ inch of clear and rime ice on the airplane’s protected surfaces (deice boots) and about ½ inch of ice on the airplane’s unprotected surfaces. An NTSB performance study of the accident flight based on radar data indicated that the airplane entered a descent rate of 1,300 feet per minute (fpm) about 1,100 feet above the ground. This rate of descent was associated with a decrease in airspeed from 130 knots to 92 knots over a span of 30 seconds. The airplane’s rate of descent leveled off at the 1,300 fpm rate for 45 seconds before increasing to a 2,000 fpm descent rate. The true airspeed fluctuated between a low of 88 knots to 102 knots during the last 45 seconds of flight. According to the aircraft manufacturer, the clean, wing flaps up stall speed was 78 knots. However, after a light rime encounter, the Pilot’s Operating Handbook (POH) instructed pilots to maintain additional airspeed (10 to 20 KIAS) on approach “to compensate for the increased pre-stall buffet associated with ice on the unprotected areas and the increased weight.” With flaps up, a minimum approach speed of 105 KIAS was recommended. The POH also stated that a significantly higher airspeed should be maintained if ½ inch of clear ice had accumulated on the wings.

Factual narrative

History of flight

On January 24, 2003, about 1015 central standard time, a Cessna 208B single-engine airplane, N944FE, was destroyed when it impacted terrain while landing at Ducote Airpark (TS65), San Angelo, Texas. The airplane was registered to Federal Express Corporation, Inc., of Memphis, Tennessee, and was operated by Baron Aviation Services, Inc., of Vichy, Missouri. The check airman, who held an airline transport pilot certificate, and the pilot who was receiving a Part 135 proficiency check and also held an airline transport pilot certificate, sustained serious injuries. Visual meteorological conditions prevailed, and a flight plan was not filed for the 14 Code of Federal Regulations Part 91 instructional flight. The local flight originated at 0832 from the San Angelo Regional Airport/Mathis Field (SJT), San Angelo, Texas, and was destined for Ducote Airpark.

According to the check pilot, the purpose of the flight was to administer an FAR Part 135 proficiency check. He stated that the last event he could remember of the flight was when he had simulated an engine failure while on approach to Ducote Airpark. According to communication and aircraft radar data provided by the Midland's Air Traffic Control Tower (ATCT) approach sector and Terminal Radar Approach Control (TRACON), the flight was practicing instrument approaches at SJT. At the completion of the VOR (Very high Omni-directional Range navigational aid) 21 approach, the flight crew requested a visual transition to Ducote Airport (which is located about 5 miles west of SJT). After conducting the missed approach, the flight departed the SJT airport area and proceeded west toward TS65. No further air traffic control communications were received.

Witnesses at Ducote Airpark stated that they heard the sound of an airplane engine "surging" and observed the airplane approaching the airport on a westerly heading. They observed the airplane about 100 to 200 feet above ground level in a descent. They observed the airplane’s wings bank left and right and the airplane then contacted the ground and struck power lines before coming to rest inverted. Witnesses stated that they smelled jet fuel fumes at the accident site. One pilot-rated witness reported that he observed about ¼ inch of clear and rime ice on the airplane’s protected surfaces and about ½ inch on the airplane’s unprotected surfaces.

An aircraft performance study was conducted by the NTSB's Vehicle Performance Division utilizing radar data from the Federal Aviation Administration's (FAA) Continuous Data Recording at the San Angelo, Texas, Airport Surveillance Radar (ASR-9). The study was derived from ASR data assuming steady, coordinated flight and did not account for any ice accumulations. Approximately 3 minutes before the accident, the flight crew indicated that they would proceed to Ducote. The study revealed that around 1008:30, while the airplane was at a pressure altitude of 3,100 feet (1,100 feet above the ground) the airplane's computed true airspeed began decreasing from 130 knots, to 92 knots at 1009:00. This decrease in airspeed was associated with a relatively rapid descent rate that began at 1008:45, from a 300-foot/minute (fpm) climb to a 1,300 fpm descent. The rate of descent remained at 1,300 fpm for about 45 seconds, before increasing to its maximum of 2,000 fpm prior to impacting the ground. The true airspeed further decreased to about 82 knots and fluctuated for the last 40 seconds of flight between 82 and 102 knots.

Personnel information

Check Airman

The pilot who was acting as the check airman held an airline transport pilot certificate with a multi-engine airplane rating. He also held commercial and flight instructor certificates with single-engine and instrument airplane ratings. He was issued a second-class medical certificate, with no restrictions or limitations, on November 4, 2002.

The operator hired the pilot on August 31, 1998. He was approved as a check airmen in the Cessna 208 series of aircraft on July 2, 2001 by the company's principal operations inspector. A review of the pilot's annual resume, dated January 7, 2003, revealed that he had accumulated a total time of 4,356 hours.

He last obtained Cessna 208 training at Pan Am International Flight Academy between August 1 and 3, 2002, where he underwent 11 hours of ground training and 6 hours of simulator training. On October 25, 2002, the pilot passed an Anti-ice/Deicing Exam for Corporate Pilots following a review of a National Aeronautics and Space Administration (NASA) icing training video.

Second Pilot

The pilot receiving the Part 135 proficiency check also held an airline transport pilot certificate with a multi-engine airplane rating. He also held a commercial pilot certificate with a single-engine airplane rating. He was issued a second-class medical certificate, with no restrictions or limitations, on November 19, 2002.

The operator hired the pilot in April 1990. His latest annual resume, dated March 25, 2002, indicated that he had accumulated a total of 13,884 hours of flight time.

He last underwent Cessna 208 training at Pan Am International Flight Academy between June 27 and 29, 2002, where he received 11 hours of ground training and 5.5 hours of simulator training.

Aircraft information

The 1987-model airplane was equipped with a 675-horsepower PT6A-114 Pratt & Whitney turboprop engine, and a 3-bladed C-300 McCauley propeller. The airplane was also equipped with a flight into known icing package that included pneumatic deicing boots on the wings, wing struts, main landing gear struts, cargo pod, and the horizontal and vertical stabilizers.

The airplane was maintained on Baron Aviation's 12-Phase Approved Aircraft Inspection Program (AAIP), and the company utilized Cessna's CESCOM program to track, schedule and report maintenance activity. A phase is completed every 200 hours with a 100-hour mini-check conducted in between each phase. On January 4, 2003, the airframe, engine, and propeller underwent a Phase I Inspection. At that time the airframe and engine had accumulated a total of 7,493.5 hours and 6,808 cycles, and the propeller had accumulated a total of 2,792.5 hours. At the time of the accident the airplane/engine accumulated a total of 7,503.7 hours and 6,818 cycles.

There was only one discrepancy recorded in the flight log during the 9 previous flights, which stated that a Phase I inspection was due. The flight log page for the accident flight was not recovered from the accident site.

Meteorological information

At 1053, the weather observation facility at SJT reported the following weather conditions: wind from 100 degrees at 7 knots, visibility 10 statute miles, an overcast ceiling at 2,300 feet agl, temperature -02 degrees Celsius, dew point -11 degrees Celsius, and an altimeter setting of 30.43 inches of mercury.

Wreckage and impact information

On-scene documentation of the wreckage at the accident site was conducted by FAA inspectors from the San Antonio Flight Standard District Office (FSDO), and representatives from Cessna Aircraft Company, FedEx, and Baron Aviation. According to photographs and information supplied by those entities, the accident site was located at 31 degrees 20.99 minutes north latitude and 100 degrees 36.78 minutes west longitude, approximately ¼ mile from the approach end of TS65 runway 35 at an elevation of 1,203 feet mean sea level (msl). The wreckage path was oriented along a magnetic heading of 300 degrees for about 300 feet, where at the 170-foot mark, the airplane impacted a fence and a power line. The left wing created a 170-foot furrow in the dirt field leading up to the fence/power line.

The fuselage came to rest inverted. The left wing was separated from the fuselage but remained attached to the airframe via the aileron control cables. The empennage was partially separated from the airframe and came to

Aircraft

Registration
N944FE
Reported as
Cessna 208B
Category
Airplane
Serial number
208B0044
Airframe hours
7,503.3
Engine
Pratt & Whitney Canada PT6A-114A, 675 horsepower, turbo prop
Damage
Destroyed
Flight
Instructional · Part 91
Operator
Baron Aviation Services Inc.
Registered owner
Federal Express Corporation
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · January 1, 2003 · 7,493 hours before
Departed
SJT · San Angelo, TX
Destination
TS65 · San Angelo, TX
Airport
TS65 · Ducote Airpark, runway 35, 3,700 × 30 ft, asphalt

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
Check pilot
Age
42
Injuries
Serious
Certificates
Airline transport, Commercial, Flight instructor
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 2, Without waivers/limitations
Last flight review
March 1, 2002
Seat
Right
Flight hours
4,356 total
Role
Pilot
Age
63
Injuries
Serious
Certificates
Airline transport, Commercial
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 2, With waivers/limitations
Last flight review
January 1, 2002
Seat
Left
Flight hours
13,884 total

Weather

Conditions
Visual (VMC) · Day
Wind
100° at 7 knots
Visibility
10 statute miles
Lowest ceiling
2,300 ft overcast
Temperature
28 °F, dew point 12 °F
Altimeter
30.43 inHg
Observed at
SJT

Docket · 23

The files NTSB released with the investigation on December 12, 2007, on NTSB’s docket system: statements, records, photos and specialists’ reports. 13.8 MB in all.

FAA reports on this event · 1

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