# NTSB IAD03FA043: Beechcraft B200, N257CG, Leominster, MA, April 4, 2003 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: April 4, 2003, 09:35 local (14:35 UTC) - Place: Leominster, MA - Coordinates: 42.536945, -71.73944 - Nearby events: https://openairdocs.org/map.md?lat=42.5369&lon=-71.7394&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 6 fatal, 1 serious, 1 minor; on the ground: 1 minor - Status: Completed, report September 1, 2004 - Report: Approved by Office Director - Parties: Raytheon Aircraft Company, Pratt & Whitney Engines, FAA/FSDO, Commonwealth of Massachusetts - NTSB case key (mKey): 56750 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=IAD03FA043 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/56750/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=56750 - Page: https://openairdocs.org/ntsb/IAD03FA043 ## Probable cause The pilot's low altitude maneuver using an excessive bank angle, and his failure to maintain airspeed which resulted in an inadvertent stall and subsequent collision with a building. A factor was the pilot's impairment from prescription medications. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of control - in flight, circling (ifr) - low altitude flight/maneuver - performed, pilot in command (cause) - physical impairment(stroke), pilot in command (contributing factor) - airspeed - not maintained, pilot in command (cause) - stall - inadvertent, pilot in command - In flight collision with object, descent - uncontrolled - object - building(nonresidential) ## Analysis While on approach to the airport, the airplane entered a left turn, which the surviving passenger described as "almost completely upside down." The airplane briefly leveled, then entered another left turn with a bank angle of the same severity. The airplane seemed to roll level, then entered a steep dive, until it impacted a building. The passenger reported that the engines were running normally throughout the entire flight, and the steep turns performed by the pilot did not concern her, as she had flown with him before and knew he "liked to make sharp turns." Examination of the airplane and engines revealed no pre-impact mechanical anomalies, and weather at the time of the accident included a broken cloud ceiling of 1,100 feet, with 3 miles visibility in mist. According to the FAA, Airplane Flying Handbook,"...[An] airplane will stall at a higher indicated airspeed when excessive maneuvering loads are imposed by steep turns, pull-ups, or other abrupt changes in its flightpath." A review of the "Stall Speeds - Power Idle" chart from the POH revealed that with approach flaps selected, at a bank angle of 60 degrees, the airplane would stall at about 123 knots. Radar data indicated the airplane descended along the approach course at an average speed of 120 knots. Toxicology testing performed on the pilot revealed imipramine and carbamazepine in the pilot's urine and blood, and morphine in the pilot's urine. According to the pilot's medical and pharmacy records, he suffered from a severe neurological disorder, possibly a seizure disorder, which resulted in frequent, unpredictable episodes of debilitating pain. Additionally, approximately three months prior to the accident, the pilot was diagnosed with viral meningitis, and a severe skin infection with multiple abscesses on his extremities. The pilot had been prescribed imipramine, an antidepressant that has detrimental effects on driving skills and other cognitive functions. He had also been prescribed carbamazepine, typically used to control seizures or treat certain chronically painful conditions. Carbamazepine has measurable impairment of performance on a variety of psychomotor tests. Morphine, a prescription opiate painkiller, is also a metabolite of heroin and many prescription medications, such as codeine, used to control moderate pain. No indication was observed in the pilot's medical records that he was recently prescribed any opiates. Neither the pilot's medical condition, nor the medication he was routinely taking was reported on his application for an airman medical certificate. ## Factual narrative HISTORY OF FLIGHT On April 4, 2003, at 0935 eastern standard time, a Beechcraft B200, N257CG, was substantially damaged when it impacted a building in Leominster, Massachusetts, while on approach to Fitchburg Municipal Airport (FIT), Fitchburg, Massachusetts. The certificated airline transport pilot, the pilot-rated passenger, and four additional passengers were fatally injured. One passenger was seriously injured, and one person inside the building received minor injuries. Instrument meteorological conditions prevailed, and an instrument flight rules (IFR) flight plan had been filed for the flight that departed LaGuardia International Airport (LGA), Flushing, New York, at 0831. The personal flight was conducted under 14 CFR Part 91. The accident flight departed the Laurence G. Hanscom Field (BED), Bedford, Massachusetts at 0700, and flew to LaGuardia with only the pilot and pilot-rated passenger onboard. At LaGuardia, five additional passengers boarded the airplane, which subsequently departed on an IFR flight plan to Bedford. While en route, the crew amended the destination to Fitchburg. According to the surviving passenger, the intent was to drop off two passengers at Fitchburg, then continue on to the Martha's Vineyard Airport, Vineyard Haven, Massachusetts, with the remaining passengers. According to air traffic control (ATC) transcripts provided by the Federal Aviation Administration (FAA), the pilot contacted the Bridgeport Flight Service Station (FSS), about 2050, on the evening prior to the accident. The pilot stated that he would be departing Bedford the following morning, at 0700, and requested specific weather for Bedford, Martha's Vineyard, and LaGuardia. The forecasts were provided, and the pilot stated that he would call back in the morning. The pilot again called the Bridgeport FSS on the morning of the accident, at 0616, and requested specific weather for Fitchburg, and LaGuardia. He also requested Pilot Weather Reports (PIREPS) for icing and turbulence. The FSS specialist provided him with the requested weather. At the same time, 0616, the pilot-rated passenger called the Burlington FSS and obtained a preflight weather briefing for an IFR flight from Bedford to Nantucket, Massachusetts, then to LaGuardia. The pilot-rated passenger also obtained several outlook briefings for possible flights between Nantucket and LaGuardia. A review of ATC communications revealed that the pilot contacted Boston TRACON at 0918, and requested the GPS RWY 14 approach at Fitchburg. At 0921, the airplane was cleared for the approach. At 0923, the controller asked N257CG, "you just gonna ah go to the v o r and turn inbound on the approach" The pilot responded, "affirm seven charlie golf," and at 0923, stated, "actually I suppose direct ah with that adiss would be okay." The pilot was asked to repeat his transmission, and he again stated, "direct adiss or whatever you call it would be fine too." At 0925, the pilot was asked if he had the weather at Fitchburg, and he replied "affirmative." At 0927, the pilot stated, "and ah king air two five seven Charlie golf on the way to whatever its called." The pilot was instructed to repeat his transmission and at 0928 stated, "direct canat for seven charlie golf." At 0928, the pilot was advised to "change to advisory and report cancellation in the air or promptly on the ground with Bridgeport FSS." At 0929, the pilot responded, "it will probably be on the ground, thanks seven charlie golf." No further transmissions were received, by ATC, from the airplane. A review of radar data revealed that a target emitting the same transponder code as the accident airplane descended along the GPS RWY 14 final approach course at an average groundspeed of 120 knots. The target descended from 2,800 feet at the final approach fix, to 1,600 feet at the missed approach point (MAP). After crossing the MAP at 0932, the target maintained approximately the same course, and continued to descend, passing over the approach end of runway 02 at an altitude of about 1,300 feet. It continued along the same course, until the last radar return was recorded at an altitude of 800 feet, at 0934. The last radar return was positioned to the left of course, and was located at 42 degrees, 32 minutes north latitude, 71 degrees, 44 minutes west longitude, on a magnetic heading of 165 degrees, approximately 1 nautical mile from the threshold of runway 32. According to the surviving passenger, "everything seemed fine" during the flight, until her father reported they were circling the airport and were "close to landing." The passenger subsequently felt the airplane enter a left turn, in which the airplane became "almost completely upside down." The airplane briefly straightened out, then entered another left turn with a bank angle of the same severity. The airplane then seemed to roll level "just for a second," then entered a dive "straight down" until it impacted the building. The passenger also noted that the engines were running "normally" throughout the entire flight, and did not recall any unusual sounds. In addition, the steep turns did not concern her, as she had flown with the accident pilot before and knew he "liked to make sharp turns." The passenger further noted that she was unable to see the ground during the sequence of turns, but saw it briefly "just a split second before the impact." In a written statement, a witness who was working at the airport at the time of the accident, reported hearing the flightcrew of the accident airplane call in on the Unicom frequency, and ask about runway conditions. Airport personnel responded that the braking action was "fair." The flightcrew then asked if there was any additional traffic in the pattern or vehicles on the runway, which the airport personnel replied "negative." The flightcrew then stated, "Well, if there is anyone on the runway, tell them to get off because we're coming in!" The witness further recalled hearing the flight being vectored by air traffic control, over the radio. The flightcrew was vectored for the GPS Runway 14 approach at Fitchburg, and reported accepting a vector for the "whatever approach fix." After hearing the radio transmissions from the flight, the witness walked outside and observed the airplane approaching the airport directly over runway 14 "going in and out of low scattered clouds." The airplane turned slightly to the right to join a left downwind for runway 32, "in close, and very slow and low." The airplane continued on a close tight downwind, making a slight left turn, then a steep left base-to-final turn, "90-degrees wings up." The witness then observed the airplane disappear behind the tree line in a left wing-down attitude. Several other witnesses observed the airplane during the accident sequence. One witness, who was familiar with the airport traffic pattern, observed the airplane at an altitude of approximately 450 feet as it made a "continual" left base-to-final turn. The nose of the airplane was "being held level, until the airplane stalled and descended to the ground." A second witness observed the airplane make a turn "so sharp that the wings were vertical," then enter a "nose-dive." A third witness observed the airplane flying east, "just above the tree line and just below the cloud deck." The airplane's landing gear were down and both propellers were turning. The airspeed was "extremely slow," and the airplane appeared to be flying with "not enough lift." In addition, the weather conditions were "extremely poor," with a low cloud deck and freezing rain. The accident occurred during the hours of daylight at 42 degrees, 32 minutes north latitude, and 71 degrees, 44 minutes west longitude, about 1 nautical miles from the approach end of runway 32. PERSONNEL INFORMATION The pilot held an airline transport pilot certificate, an ## Aircraft - Registration: [N257CG](https://openairdocs.org/deregistered/N257CG-2004-04-19), registration cancelled 2004-04-19, S/N BB-1739 (OpenAirDocs) - Reported make and model: Beechcraft B200 - Registry model: [Raytheon B200](https://openairdocs.org/model/raytheon-b200) (registry code 7150006) (OpenAirDocs) - Category: Airplane - Serial number: BB-1739 - Airframe hours: 359 - Engines: Pratt & Whitney Canada PT6A-42 850 horsepower turbo prop; Pratt & Whitney Canada PT6A-42 850 horsepower turbo prop - Damage: Substantial damage - Fire: On-Ground - Flight: Personal, Part 91 - Registered owner: FS Corsair Inc. - Airworthiness certificate: Standard, Normal - Last inspection: 100 hour, December 6, 2002, 53 hours before - Departed: LGA, New York, NY - Destination: FIT, Fitchburg, MA - Flight plan: IFR - Airport: FIT, Fitchburg Municipal Airport, runway 32, 4,510 × 100 ft ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 49; injuries: fatal; airline transport, flight instructor; airplane ratings: multi-engine land; instrument ratings: airplane; medical: class 2, valid medical--w/ waivers/lim; last flight review April 24, 2002; seat: left; toxicology performed; flight hours: 6,100 total, 1,334 in this make and model, 52 in the last 90 days, 13 in the last 30 days - Co-pilot; age 30; injuries: fatal; commercial; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 1, valid medical--w/ waivers/lim; last flight review June 18, 2002; seat: right; toxicology performed; flight hours: 1,080 total, 4 in this make and model, 960 as pilot in command, 61 in the last 90 days, 21 in the last 30 days, 0 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 70° at 9 knots - Visibility: 3 statute miles - Lowest ceiling: 1,100 ft broken - Temperature: 28 °F, dew point 27 °F - Altimeter: 30.14 inHg - Observed at: FIT, 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 (OpenAirDocs). - [Accident 20030404005269A](https://openairdocs.org/incident/20030404005269A), Apr 4, 2003: Beech 200BEECH, Fitchburg, MA, Destroyed, 6 fatal. (-23) On April 4, 2003 the pilot of the aircraft attempted to execute a gpsapproach to runway 14 at Fitchburg Municipal Airport (fit), Fitchburg, MA. The… ## Docket (17 files) The files NTSB released with the investigation on June 17, 2004, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=56750. 5.3 MB in all. - Cockpit Voice Recorder 12 - Factual Report of Specialist (item 1, .PDF, 51 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40202280&FileExtension=.PDF&FileName=Cockpit%20Voice%20Recorder%2012%20-%20Factual%20Report%20of%20Specialist-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 2, .PDF, 40 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40357158&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - GPS RWY 14 Approach Plate (item 3, .PDF, 28 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40211744&FileExtension=.PDF&FileName=GPS%20RWY%2014%20Approach%20Plate-Master.PDF - FAA Flight Check Report (item 4, .PDF, 117 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40357159&FileExtension=.PDF&FileName=FAA%20Flight%20Check%20Report-Redacted.PDF - Witness Statements (item 5, .PDF, 317 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40357160&FileExtension=.PDF&FileName=Witness%20Statements-Redacted.PDF - Radar Data Plot (item 6, .PDF, 25 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40211752&FileExtension=.PDF&FileName=Radar%20Data%20Plot-Master.PDF - ATC Transcript (item 7, .PDF, 128 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40357163&FileExtension=.PDF&FileName=ATC%20Transcript-Redacted.PDF - Pilot Operator Report (item 8, .PDF, 190 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40357164&FileExtension=.PDF&FileName=Pilot%20Operator%20Report-Redacted.PDF - Photo - rear of aircraft (item 9, .PDF, 938 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40211757&FileExtension=.PDF&FileName=Photo%20-%20rear%20of%20aircraft-Master.PDF - Photo - right side of aircraft (item 10, .PDF, 853 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40211758&FileExtension=.PDF&FileName=Photo%20-%20right%20side%20of%20aircraft-Master.PDF - Photo - from inside building (item 11, .PDF, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40211760&FileExtension=.PDF&FileName=Photo%20-%20from%20inside%20building-Master.PDF - Photo - left side of aircraft (item 12, .PDF, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40211780&FileExtension=.PDF&FileName=Photo%20-%20left%20side%20of%20aircraft-Master.PDF - Tox Report - Pilot (item 13, .PDF, 43 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40357165&FileExtension=.PDF&FileName=Tox%20Report%20-%20Pilot-Redacted.PDF - Tox Report - Passenger (item 14, .PDF, 34 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40357166&FileExtension=.PDF&FileName=Tox%20Report%20-%20Passenger-Redacted.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 15, .PDF, 46 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40357167&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - Medical Records Information (item 16, .PDF, 10 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40213822&FileExtension=.PDF&FileName=Medical%20Records%20Information-Master.PDF - Meteorology Study (item 17, .PDF, 288 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40357168&FileExtension=.PDF&FileName=Meteorology%20Study-Redacted.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.