# NTSB FTW03FA089: Cessna 208B, N944FE, San Angelo, TX, January 24, 2003 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Field investigation · Final report - Date: January 24, 2003, 10:15 local (16:15 UTC) - Place: San Angelo, TX - Coordinates: 31.358333, -100.612777 - Nearby events: https://openairdocs.org/map.md?lat=31.3583&lon=-100.6128&mi=10 - Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping) - Highest injury: Serious injuries - Injuries: 2 serious - 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 - NTSB case key (mKey): 56394 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=FTW03FA089 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/56394/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=56394 - Page: https://openairdocs.org/ntsb/FTW03FA089 ## 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 In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - In flight encounter with weather, maneuvering - weather condition - icing conditions (contributing factor) - Loss of control - in flight, approach - vfr pattern - base leg/base to final - anti-ice/deice system - not activated (cause) - airspeed - not maintained, flightcrew (cause) - stall - inadvertent, flightcrew (cause) - In flight collision with terrain/water, descent - 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](https://openairdocs.org/deregistered/N944FE-2003-01-30), registration cancelled 2003-01-30, S/N 208B0044, built 1987 (OpenAirDocs) - Reported make and model: Cessna 208B - Registry model: [Cessna 208B](https://openairdocs.org/model/cessna-208b) (registry code 2073701) (OpenAirDocs) - Registry engine: [Pratt & Whitney PT6A series](https://openairdocs.org/engine/pratt-whitney-pt6a-series) (registry code 52034, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 208B0044 - Airframe hours: 7503.3 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Check pilot; age 42; injuries: serious; 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 - Pilot; age 63; injuries: serious; 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 ## 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 20030124001119A](https://openairdocs.org/incident/20030124001119A), Jan 24, 2003: Cessna 208B, San Angelo, TX, Destroyed. (-23) The aircraft descended impacting ground at a steep angle of bank, striking the left wing tip then, proceeded until striking power lines and fence. The… ## Docket (23 files) The files NTSB released with the investigation on December 12, 2007, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=56394. 13.8 MB in all. - Witness Statement (item 1, .PDF, 304 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40285835&FileExtension=.PDF&FileName=Witness%20Statement-Redacted.PDF - Other Pertinent Forms and Reports - Check Pilot Records (item 2, .PDF, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40410910&FileExtension=.PDF&FileName=Other%20Pertinent%20Forms%20and%20Reports%20-%20Check%20Pilot%20Records-Redacted.PDF - Other Pertinent Forms and Reports - Pilot Records (item 3, .PDF, 1.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40410911&FileExtension=.PDF&FileName=Other%20Pertinent%20Forms%20and%20Reports%20-%20Pilot%20Records-Redacted.PDF - Maintenance Records (item 4, .PDF, 3.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40410912&FileExtension=.PDF&FileName=Maintenance%20Records%20-Redacted.PDF - Weather Reports and Records (item 5, .PDF, 33 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40285842&FileExtension=.PDF&FileName=Weather%20Reports%20and%20Records-Master.PDF - Flight Data Recorder PAR Report (item 6, .PDF, 347 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40285843&FileExtension=.PDF&FileName=Flight%20Data%20Recorder%20PAR%20Report-Master.PDF - Reports from Federal Agencies FAA FSDO Statement (item 7, .PDF, 304 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40285854&FileExtension=.PDF&FileName=Reports%20from%20Federal%20Agencies%20FAA%20FSDO%20Statement-Redacted.PDF - Reports from Parties to the Investigation - Pratt & Whitney Canada Extract (item 8, .PDF, 102 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40285852&FileExtension=.PDF&FileName=Reports%20from%20Parties%20to%20the%20Investigation%20-%20Pratt%20%26%20Whitney%20Canada%20Extract-Master.PDF - Reports from Parties to the Investigation - Cessna Aircraft (item 9, .PDF, 899 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40285844&FileExtension=.PDF&FileName=Reports%20from%20Parties%20to%20the%20Investigation%20-%20Cessna%20Aircraft-Redacted.PDF - Reports from Parties to the Investigation - McCauley Report (item 10, .PDF, 125 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40285845&FileExtension=.PDF&FileName=Reports%20from%20Parties%20to%20the%20Investigation%20-%20McCauley%20Report-Redacted.PDF - Statement of Party Representatives to NTSB Investigation (item 11, .PDF, 317 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40410914&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 12, .PDF, 137 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40410915&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - Photo 1 Initial impact Point (item 13, .PDF, 622 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40285856&FileExtension=.PDF&FileName=Photo%201%20Initial%20impact%20Point-Master.PDF - Photo 2 ground scar (item 14, .PDF, 604 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40285857&FileExtension=.PDF&FileName=Photo%202%20ground%20scar-Master.PDF - Photo 3 Propeller (item 15, .PDF, 699 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40285858&FileExtension=.PDF&FileName=Photo%203%20Propeller-Master.PDF - Photo 4 Front view (item 16, .PDF, 754 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40285859&FileExtension=.PDF&FileName=Photo%204%20Front%20view-Master.PDF - Photo 5 rear view (item 17, .PDF, 565 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40285860&FileExtension=.PDF&FileName=Photo%205%20rear%20view-Master.PDF - Photo 6 Instruments (item 18, .PDF, 902 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40285861&FileExtension=.PDF&FileName=Photo%206%20Instruments-Master.PDF - Photo 7 Throttle quadrant (item 19, .PDF, 441 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40285862&FileExtension=.PDF&FileName=Photo%207%20Throttle%20quadrant-Master.PDF - Photo 8 De-ice switches (item 20, .PDF, 544 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40285863&FileExtension=.PDF&FileName=Photo%208%20De-ice%20switches-Master.PDF - Aircraft Performance 13 - Factual Report of Group Chairman (item 21, .PDF, 357 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40285938&FileExtension=.PDF&FileName=Aircraft%20Performance%2013%20-%20Factual%20Report%20of%20Group%20Chairman-Master.PDF - Petition for Reconsideration (item 22, .PDF, 228 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40356832&FileExtension=.PDF&FileName=Petition%20for%20Reconsideration-Master.PDF - Response to Petition for Reconsideration (item 23, .PDF, 377 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40356833&FileExtension=.PDF&FileName=Response%20to%20Petition%20for%20Reconsideration-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.