FTW95FA087

NTSB accident investigation · Beech B95 · Hot Springs, AR · January 10, 1995

Accident · FatalField investigationFinal report
Date
January 10, 1995, 12:35 local (18:35 UTC)
Place
Hot Springs, AR
Injuries
3 fatal
Damage
Destroyed
Phase of flight
Approach
Aircraft
N673QBeech B95
Weather
Instrument (IMC) · Day
Status
Completed · report September 24, 1995
Report
Approved by Office Director
FAA report
19950110000249A
Case key
19204

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

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Probable cause

The pilot's failure to follow IFR and missed approach procedures.

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 collision with objectMissed approach (ifr)
Ifr procedure - not followedPilot in commandCause
Missed approach - not followedPilot in commandCause
Object - tower(marked)
In flight collision with terrain/waterDescent - uncontrolled

Analysis

Due to ATC workload, the controller could not provide vectors for the ILS runway 5. After being flown through the final approach course ATC cleared N673Q for the ILS and to proceed direct to the outer marker (hossy). This required an approximate 180 degree right turn. N673Q was also instructed to maintain 3,500 feet until hossy; glideslope intercept altitude at hossy was 2,300 feet. The pilot turned about 90 degrees inbound (left) at hossy rather than executing a procedure turn. According to recorded radar data, the airplane's flight path from hossy to the missed approach point was south (right) of the inbound course. Additionally, the radar data shows the airplane proceeding northbound beyond the terminal VOR. The missed approach procedure for the ILS runway 5 approach is a climbing right turn to 3000 feet. The right turn provides clearance from a mountain with towers north of the airport. A 3.5 foot section of the right wing was recovered 5 feet from the top of a 200 foot tower approximately 1.5 nautical miles north-northeast of the runway.

Factual narrative

History of flight

On January 10, 1995, at 1235 central standard time, a Beechcraft B95, N673Q, was destroyed during a missed approach near the Memorial Field Airport (HOT), Hot Springs, Arkansas. The instrument rated commercial pilot, and two passengers were fatally injured. The flight was on an instrument flight plan for the business cross country flight. Instrument meteorological conditions prevailed.

The pilot was on an IFR flight from Natchez, Mississippi (HEZ), to Hot Springs, Arkansas (HOT). The pilot was cleared for ILS Runway 5 approach to Hot Springs. A witness observed the airplane briefly through the clouds over runway 5, and "heard the aircraft apply go around power." A piece of the airplane's right wing was found 5 feet from the top of a 200 foot tower, approximately 1.5 nautical miles north northeast of runway 5.

Personnel information

The pilot's log books could not be located, therefore, instrument, single engine or multi engine flight time flown could not be determined. His last biennial flight review also could not be determined. According to Federal Aviation Administration records, the pilot reported 1,270 total hours on May 02, 1994, at the time of his class two medical examination.

Aircraft information

A review of the airframe and engine records did not reveal any anomalies or uncorrected maintenance defects.

Meteorological information

Prior to being cleared for the approach, Memphis Center issued the pilot the 1753 UTC Hot Springs weather observation. It was measured 300 feet variable overcast, visibility one mile and fog, wind 160 degrees at seven, altimeter 30.04, and the ceiling was three hundred variable to two hundred. About the time of the accident, at 1834 UTC, Hot Springs was a measured 400 feet overcast, visibility 1.5 mile variable fog, wind 130 degrees at five, altimeter 30.01, and visibility 1.25 variable 1.75. See the enclosed weather reports and observations.

Communications

Federal Aviation Administration (FAA) records revealed the pilot of N673Q called Greenwood Automated Flight Service Station (GWO AFSS) at 1614, and received an abbreviated briefing for an IFR flight from Natchez, Mississippi, to Hot Springs, Arkansas. He filed an IFR clearance from Natchez, Mississippi, to Hot Springs, Arkansas, at 6,000 feet. At 1704, the pilot called the Anniston, Alabama AFSS by telephone, and obtained an abbreviated pilot brief for an IFR flight from HEZ to HOT.

The pilot reported on the Houston Center frequency requesting an IFR clearance to Hot Springs at 1715. An IFR clearance to Hot Springs was issued. When nearing the destination airport, the pilot was given radar vectors to the final approach course for the ILS Runway 5 approach. According to an enclosed statement, after being flown through the final approach course Memphis Center, due to workload of the controller in another portion of the sector, was unable to provide vectors to the HOT ILS. Therefore, the pilot was instructed to proceed direct HOSSY, maintain 3,500 feet until the HOSSY locator outer marker (LOM), and cleared for the ILS Runway 5 approach to the HOT airport. Radar services were terminated and frequency change was approved.

Glide slope intercept altitude at Hossy inbound is 2,300 feet. Radar data indicates that after being cleared for the approach the pilot made a right turn of about 180 degrees, flew direct to Hossy, turned left inbound to HOT, and remained south of the inbound course until after the missed approach point. Additionally, the radar data shows the airplane proceeding northbound beyond the HOT terminal VOR. At 1833, the pilot reported missed approach and requested to try the ILS approach again. Memphis instructed the pilot to climb to and report reaching 3,000 feet. The pilot acknowledged the instructions. There was no further communication with the pilot. See the enclosed communication transcripts and radar flight path chart.

The operational equipment configuration for Sector 1 during this period was RDP, all radar sites operational, moving target indicator set at 100 miles, the video map in use was West Low, selected on a 75-mile range and centered approximately HOT331033, and all navigational aids were operating normally.

Aerodrome information

The published weather minimums for the ILS Runway 5 approach is 300 feet and 1/2-mile visibility. The missed approach procedure for the ILS Runway 5 approach is a climbing right turn to 3,000 feet via HOT vortac radial 123 to SOCKS intersection/HOT 10.3 DME and hold. The right turn provides clearance from a mountain with towers located north of the airport. The current approach plate for the ILS Runway 5 approach that was found during an examination of the aircraft, depicts towers north of the airport. See the enclosed approach plate.

Wreckage and impact information

The aircraft was located in the initial ground scar on a measured magnetic heading of 350 degrees. The left and right engines were buried in the ground at the initial scar. The empennage and fuselage were partially separated and displaced forward to the right. All flight controls were accounted for and were attached to their respective input devices. Due to the extent of damage, flight control continuity could not be established. A tree next to the left engine exhibited two slash marks 4-feet, 9-inches apart. A cut tree limb had aluminum transfer marks.

A 3 1/2-foot section of the right wing, with aileron attached, was recovered 5 feet from the top a 200 foot tower. The tower was located approximately 440 yards southwest of the main wreckage. The right wing tip was located north of tower at the bottom of the hill. See enclosed wreckage diagram for wreckage distribution details.

Medical and pathological information

The autopsy was performed by pathologist Charles E. Kokes, M.D. at the Arkansas State Crime Laboratory, Little Rock, Arkansas. Toxicological findings were negative.

Additional data

The wreckage was released to the owner's representative.

Aircraft

Registration
N673Q
Reported as
Beech B95
Category
Airplane
Serial number
TD-313
Airframe hours
8,114
Engine
Lycoming O-360-A1A, 180 horsepower, reciprocating
Damage
Destroyed
Flight
Business · Part 91
Registered owner
Kcs Lumber Company
Airworthiness certificate
Standard, Normal
Last inspection
Annual · January 3, 1995 · 5 hours before
Departed
HEZ · Natchez, MS
Destination
HOT
Flight plan
IFR

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

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
40
Certificate
Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 2, Valid Medical--no waivers/lim.
Seat
Left
Toxicology
Performed
Flight hours
1,270 total

Weather

Conditions
Instrument (IMC) · Day
Wind
130° at 5 knots
Visibility
1.5 statute miles
Lowest ceiling
400 ft overcast
Altimeter
30.00 inHg
Observed at
HOT, 2 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.