# NTSB GAA19CA001: Cessna 340, N89AM, Keokuk, IA, October 1, 2018 - Type: NTSB accident investigation - Classification: Accident · No injuries · Data collection · Final report - Date: October 1, 2018, 03:30 local (08:30 UTC) - Place: Keokuk, IA - Coordinates: 40.459999, -91.452224 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=40.4600&lon=-91.4522&mi=10 - Phase of flight: [Landing](https://openairdocs.org/ntsb-phases/550) (OpenAirDocs' grouping) - Defining event: [Landing: Collision during takeoff/land](https://openairdocs.org/ntsb-events/490) - Highest injury: No injuries - Injuries: 3 uninjured - Status: Completed, report June 5, 2019 - Report: Approved by Office Director - NTSB office: General Aviation Accidents - Parties: FAA - NTSB case key (mKey): 98396 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=GAA19CA001 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/98396/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=98396 - Page: https://openairdocs.org/ntsb/GAA19CA001 ## Probable cause The pilot's failure to correctly identify the runway environment during an instrument approach at night in instrument meteorological conditions because he mistook building lights for runway lights, which resulted in landing short of the runway. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Performance/control parameters: descent/approach/glide path](https://openairdocs.org/ntsb-findings/01062040): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Cessna 340, 1 case](https://openairdocs.org/ntsb-findings/01062040/cases.md?model=2076404), [All aircraft, 809 cases](https://openairdocs.org/ntsb-findings/01062040/cases.md) - [Perception/orientation/illusion: perception](https://openairdocs.org/ntsb-findings/02022040): Personnel issues › Psychological · Pilot (probable cause); cases with it: [Cessna 340, 1 case](https://openairdocs.org/ntsb-findings/02022040/cases.md?model=2076404), [All aircraft, 61 cases](https://openairdocs.org/ntsb-findings/02022040/cases.md) - [Approach aid coverage/avail: glideslope](https://openairdocs.org/ntsb-findings/03012025): Environmental issues › Operating environment · Compliance w/ procedure (probable cause); cases with it: [Cessna 340, 1 case](https://openairdocs.org/ntsb-findings/03012025/cases.md?model=2076404), [All aircraft, 1 case](https://openairdocs.org/ntsb-findings/03012025/cases.md) - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Cessna 340, 5 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=2076404), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Ceiling/visibility/precip: drizzle/mist](https://openairdocs.org/ntsb-findings/03035050): Environmental issues › Conditions/weather/phenomena · Effect on personnel; cases with it: [Cessna 340, 1 case](https://openairdocs.org/ntsb-findings/03035050/cases.md?model=2076404), [All aircraft, 18 cases](https://openairdocs.org/ntsb-findings/03035050/cases.md) - [Ceiling/visibility/precip: low visibility](https://openairdocs.org/ntsb-findings/03035015): Environmental issues › Conditions/weather/phenomena · Effect on personnel; cases with it: [Cessna 340, 3 cases](https://openairdocs.org/ntsb-findings/03035015/cases.md?model=2076404), [All aircraft, 175 cases](https://openairdocs.org/ntsb-findings/03035015/cases.md) - [Light condition: dark](https://openairdocs.org/ntsb-findings/03036020): Environmental issues › Conditions/weather/phenomena · Effect on operation; cases with it: [Cessna 340, 1 case](https://openairdocs.org/ntsb-findings/03036020/cases.md?model=2076404), [All aircraft, 448 cases](https://openairdocs.org/ntsb-findings/03036020/cases.md) - [Object/animal/substance](https://openairdocs.org/ntsb-findings/03022000): Environmental issues › Physical environment · Contributed to outcome; cases with it: [Cessna 340, 1 case](https://openairdocs.org/ntsb-findings/03022000/cases.md?model=2076404), [All aircraft, 224 cases](https://openairdocs.org/ntsb-findings/03022000/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Landing: Landing area undershoot](https://openairdocs.org/ntsb-events/370); cases with it: [Cessna 340, 1 case](https://openairdocs.org/ntsb-events/370/sequence.md?model=2076404), [All aircraft, 201 cases](https://openairdocs.org/ntsb-events/370/sequence.md) - [Landing-aborted after touchdown: Wrong surface or wrong airport](https://openairdocs.org/ntsb-events/284); cases with it: [Cessna 340, 1 case](https://openairdocs.org/ntsb-events/284/sequence.md?model=2076404), [All aircraft, 56 cases](https://openairdocs.org/ntsb-events/284/sequence.md) - [Landing: Collision during takeoff/land](https://openairdocs.org/ntsb-events/490) (defining event); cases with it: [Cessna 340, 2 cases](https://openairdocs.org/ntsb-events/490/sequence.md?model=2076404), [All aircraft, 1,309 cases](https://openairdocs.org/ntsb-events/490/sequence.md) ## Analysis The pilot reported that, while conducting an instrument approach at night in instrument meteorological conditions, about 50 ft above the decision altitude of 921 ft, he mistook building lights for runway lights. He inadvertently touched down the airplane in a soybean field about 3/4 mile short of the runway. He then increased engine power to full, and the airplane climbed "a couple hundred feet." Once he established visual contact with the runway lights, he landed the airplane on the runway without further incident. The pilot added that the lateral guidance from the localizer was "dead center" but that he could not recall the position of the vertical guidance needle. The airplane sustained substantial damage to the left wing. The pilot reported that there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation. The airport’s automated weather observation station reported that, about 5 minutes after the accident, the wind was from 030° at 3 knots, visibility was 1/2 statute mile with mist, overcast at 200 ft above ground level (agl), temperature 57°F, and dew point 57°F. The pilot reported that the airport ceiling was overcast at 300 ft agl with fog and rain and that visibility was 1 mile. ## Factual narrative The pilot reported that while conducting the RNAV GPS RNY 08 instrument approach, at night in instrument meteorological conditions, about 50 feet above the decision altitude of 921 feet, he mistook building lights for runway lights. He inadvertently touched down in a soybean field, about ¾ mile short of the runway. He then increased engine power to full, climbed "a couple hundred feet", established visual contact with the runway lights, and landed without further incident. The pilot added that the lateral guidance from the localizer was "dead center" but he could not recall the position of the vertical guidance needle. The airplane sustained substantial damage to the left wing. The pilot reported that there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation. The automated weather observation station located on the airport reported that, about 5 minutes after the accident, the wind was from 030° at 3 knots, visibility at 1/2 statute miles with mist, overcast at 200 ft above ground level (AGL), temperature 57°F, dew point 57°F. The pilot reported that the airport ceiling was overcast at 300 ft AGL, with fog and rain, and visibility was one mile. ## Aircraft - Registration: [N89AM](https://openairdocs.org/deregistered/N89AM-2022-03-05), registration cancelled 2022-03-05, S/N 340-0545, built 1975 (OpenAirDocs) - Reported make and model: Cessna 340 (Undesignat) - Registry model: [Cessna 340](https://openairdocs.org/model/cessna-340) (registry code 2076404) (OpenAirDocs) - Registry engine: [Continental TSIO-520-N](https://openairdocs.org/engine/continental-tsio-520-n) (registry code 17264, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 340-0545 - Year built: 1975 - Engines: Continental TIO-550 310 horsepower reciprocating; Continental TIO-550 310 horsepower reciprocating - Damage: Substantial damage - Flight: Executive/Corporate, Part 91 - Operator: Windy Point Aviation Llc - Registered owner: Windy Point Aviation Llc - Airworthiness certificate: Standard, Normal - Departed: ORD, Chicago, IL - Destination: MPZ, Mount Pleasant, IA - Flight plan: IFR - Airport: EOK, Keokuk Muni, runway 08, 5,500 × 100 ft, concrete - Equipment: Electronic multifunction display, Electronic primary flight display, Onboard weather, Stall warning system, ADS-B, Auto-pilot, Electronic flight bag or handheld device ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 31; injuries: none; commercial; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 2, with waivers/limitations; last flight review October 8, 2017; seat: left; restraint: 3-point; flight hours: 2,700 total, 215 in this make and model, 3,624 as pilot in command, 45 in the last 90 days, 15 in the last 30 days, 5 in the last 24 hours ## Weather - Conditions: Instrument (IMC), Night/dark - Wind: 30° at 3 knots - Lowest ceiling: 200 ft overcast - Temperature: 57 °F, dew point 57 °F - Altimeter: 30.14 inHg - Observed at: KEOK ## 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 20181001016609A](https://openairdocs.org/incident/20181001016609A), Oct 1, 2018: Cessna 340, Keokuk, IA, Substantial damage. On October 1, 2018 around 0330 CDT, while conducting the RNAV 08 approach into Keokuk, IA (keok), a Cessna 340, N89AM, struck the ground about ¾ of a mile… ## Docket (3 files) The files NTSB released with the investigation on March 11, 2019, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=98396. 1.1 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 841 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40470935&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Accident Photos (item 2, .PDF, 2 photos, 193 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40470936&FileExtension=.PDF&FileName=Accident%20Photos-Master.PDF - FAA Record of Conversation (item 3, .PDF, 64 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40470937&FileExtension=.PDF&FileName=FAA%20Record%20of%20Conversation-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.