IAD05MA006

NTSB accident investigation · Beech 200 · Stuart, VA · October 24, 2004

Accident · FatalClass 1 · MajorFinal report
Date
October 24, 2004, 12:35 local (16:35 UTC)
Place
Stuart, VA
Injuries
10 fatal
Damage
Destroyed
Phase of flight
Approach
Aircraft
N501RHBeech 200
Weather
Instrument (IMC) · Day
Status
Completed · report February 7, 2006
Report
Board-adopted at Board Meeting
Investigation class
Class 1
Parties
AAI-100 ,, Hendrick Motorsports, Pratt and Whitney Canada, Raytheon
FAA report
20041024035159A
Case key
60415

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 properly execute the published instrument approach procedure, including the published missed approach procedure, which resulted in controlled flight into terrain. Contributing to the cause of the accident was the flight crew's failure to use all available navigational aids to confirm and monitor the airplane's position during the approach.

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 terrain/waterMissed approach (ifr)
Ifr procedure - not complied withFlightcrewCause
In-flight planning/decision - inadequateFlightcrewFactor
Weather condition - fog
Terrain condition - mountainous/hilly

Analysis

The Board's full report is available at http://www.ntsb.gov/publictn/publictn.htm

On October 24, 2004, about 1235 eastern daylight time (all times in this brief are eastern daylight time based on a 24-hour clock), a Beech King Air 200, N501RH, operated by Hendrick Motorsports, Inc., crashed into mountainous terrain in Stuart, Virginia, during a missed approach to Martinsville/Blue Ridge Airport (MTV), Martinsville, Virginia. The flight was transporting Hendrick Motorsports employees and others to an automobile race in Martinsville, Virginia. The two flight crewmembers and eight passengers were killed, and the airplane was destroyed by impact forces and postcrash fire. The flight was operating under the provisions of 14 Code of Federal Regulations (CFR) Part 91 on an instrument flight rules (IFR) flight plan. Instrument meteorological conditions (IMC) prevailed at the time of the accident.

Factual narrative

The Board's full report is available at http://www.ntsb.gov/publictn/publictn.htm

On October 24, 2004, about 1235 eastern daylight time (all times in this brief are eastern daylight time based on a 24-hour clock), a Beech King Air 200, N501RH, operated by Hendrick Motorsports, Inc., crashed into mountainous terrain in Stuart, Virginia, during a missed approach to Martinsville/Blue Ridge Airport (MTV), Martinsville, Virginia. The flight was transporting Hendrick Motorsports employees and others to an automobile race in Martinsville, Virginia. The two flight crewmembers and eight passengers were killed, and the airplane was destroyed by impact forces and postcrash fire. The flight was operating under the provisions of 14 Code of Federal Regulations (CFR) Part 91 on an instrument flight rules (IFR) flight plan. Instrument meteorological conditions (IMC) prevailed at the time of the accident.

The flight departed from Concord Regional Airport (JQF), Concord, North Carolina, about 1156. An examination of radar data and voice communications from the Federal Aviation Administration (FAA) revealed that, during the en route portion of the flight, a radar target identified as the accident airplane maintained all assigned altitudes and headings.

As the airplane approached MTV, an air traffic controller advised the flight crew that the airplane was second in line for the localizer runway 30 approach. The controller instructed the pilots to hold "as published" on the localizer course at 4,000 feet mean sea level (msl) (all altitudes and elevations in this brief are expressed as msl unless otherwise noted) and to expect a 28-minute delay in the holding pattern. The flight crew requested 5-mile legs in the holding pattern, and the controller approved 5- or 10-mile legs at the crew's discretion.

The localizer runway 30 approach procedure included an inbound course with a magnetic heading of 305 degrees. The minimum descent altitude for the intermediate section of the approach and the holding pattern southeast of the BALES locator outer marker (LOM) was 2,600 feet. The BALES LOM is located at 6 distance measuring equipment (DME) (1 DME equals 1 nautical mile) on the approach course. After crossing the BALES LOM on the inbound course, the minimum descent altitude on the final segment of the approach, for an airplane equipped with DME, was 1,340 feet. The missed approach point (MAP) was at 1 DME and near the approach end of the runway. The distance from the BALES LOM to the MAP was 5 nautical miles (nm). The published missed approach procedure instructed the pilot to make a "climbing right turn to 2,600 feet and proceed direct to BALES LOM and hold."

The accident airplane approached the BALES LOM from the south, crossed BALES at 4,000 feet, and turned right toward the outbound leg of the holding pattern. About that time, the flight crewmembers of the airplane that preceded the accident airplane on the approach announced that that they were canceling their IFR clearance after breaking out of the clouds during the approach and then proceeded to land at MTV.

At 1224:19, while the accident airplane was still turning right to the outbound leg of the holding pattern, the controller asked the flight crew if the airplane was established in the holding pattern, and the crew confirmed, "we're established." At 1224:26, the controller cleared the airplane for the localizer runway 30 approach and requested that the flight crew advise him when the airplane was inbound on the approach. The airplane then completed a continuous right turn toward the inbound course and crossed the BALES LOM at an altitude of 3,900 feet.

At 1226:53, the flight crew advised the controller that the airplane was "established inbound" on the approach. At 1227:04, the controller cleared the airplane for the approach and approved a radio frequency change from the approach control frequency to the common traffic advisory frequency (CTAF). (According to FAA Order 7110.65, "Air Traffic Control," paragraph 5-1-13, after a controller issues a frequency change to the CTAF, radar services are automatically terminated.) At 4 DME, or 2 nm after crossing the BALES LOM on the inbound course, the airplane started to descend from 4,000 feet. The airplane leveled off at 2,600 feet as it passed the MAP. About 1 nm past the MAP and over the runway, the airplane began a descent to 1,400 feet and continued on an approximate heading of 305 degrees.

The airplane leveled at 1,400 feet, about 4 nm beyond MTV and 5 nm beyond the MAP. The airplane maintained level flight between 1,400 and 1,500 feet for the next 1 minute 13 seconds. At 1232:13, about 8 nm beyond MTV, the airplane initiated a straight-ahead climb.

At 1233:08, the flight crew informed the controller, "we're going missed at this time." The controller asked the flight crew to repeat the radio transmission. The flight crew repeated the information, and the controller acknowledged the radio transmission. The controller received no further radio transmissions from the flight crew.

At 1233:21, the controller advised the flight crew to climb and maintain 4,400 feet. At 1233:24, the radar target was lost. The accident occurred on Bull Mountain in Stuart, Virginia, at an elevation of about 2,400 feet and near the extended centerline of the runway.

Witnesses at MTV said that they heard the airplane pass overhead but did not see it because of the cloud cover. They stated that the engine sound was smooth and continuous with no interruption. One witness said that the engines sounded as though they were at idle. Two witnesses stated that they heard no increase in engine sound at the time they perceived the airplane to be at a position that coincided with the MAP.

Two witnesses who were about 3 to 4 miles southeast of Bull Mountain saw an airplane fly past them at a low altitude. One of the witnesses said that the airplane was flying "flat and level" about 60 to 70 feet above ground level and was heading northwest. This witness also stated that, other than flying "very low," the airplane did not appear to be in distress, and the landing gear appeared to be up. The witness further stated that the speed of the airplane "wasn't extremely fast." In addition, the witness noted that the fog level was low but could not tell how much lower the airplane was from the fog.

A trooper with the Virginia State Police stated that, at the time of the accident and throughout the search and recovery efforts (which spanned throughout the day and evening), Bull Mountain was completely obscured by clouds and fog. The trooper stated that the visibility was between 0 and 0.25 mile.

Aircraft

Registration
N501RH
Reported as
Beech 200
Category
Airplane
Serial number
BB-805
Airframe hours
8,078
Engines
Pratt & Whitney Canada PT6A41, 850 horsepower, turbo propPratt & Whitney Canada PT6A41, 850 horsepower, turbo prop
Damage
Destroyed
Fire
On-Ground
Flight
Executive/Corporate · Part 91
Registered owner
Hendrick Motorsports, Inc
Airworthiness certificate
Standard, Normal
Last inspection
Continuous airworthiness · June 25, 2004 · 61 hours before
Departed
JQF · Concord, NC
Destination
MTV · Martinsville, VA
Flight plan
IFR
Airport
MTV · Blue Ridge, runway 30, 5,002 × 100 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
Pilot
Age
51
Injuries
Fatal
Certificates
Airline transport, Commercial
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--w/ waivers/lim
Last flight review
May 27, 2004
Seat
Left
Toxicology
Performed
Flight hours
10,733 total · 210 in this make and model · 67 in the last 90 days · 18 in the last 30 days · 1 in the last 24 hours
Role
Co-pilot
Age
31
Injuries
Fatal
Certificate
Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--no waivers/lim.
Last flight review
May 27, 2004
Seat
Right
Toxicology
Performed
Flight hours
2,090 total · 121 in this make and model · 67 in the last 90 days · 22 in the last 30 days · 1 in the last 24 hours

Weather

Conditions
Instrument (IMC) · Day
Wind
Calm
Visibility
5 statute miles
Lowest ceiling
600 ft overcast
Temperature
57 °F, dew point 55 °F
Altimeter
29.97 inHg
Observed at
MTV, 10 nm away

Docket · 26

The files NTSB released with the investigation on February 3, 2006, on NTSB’s docket system: statements, records, photos and specialists’ reports. 12.5 MB in all.

Operations 2 - Factual Report of Group ChairmanItem 1 · .PDF · 1.5 MBToxicological Report - PilotItem 2 · .PDF · 52 KBToxicological Report - CopilotItem 3 · .PDF · 51 KBMeteorology 5 - Factual Report of Group ChairmanItem 4 · .PDF · 2.0 MBAirworthiness Factual Report of Group ChairmanItem 5 · .PDF · 18 photos · 3.3 MBATC 3 - Factual Report of Group ChairmanItem 6 · .PDF · 99 KBATC 3 - Attachment 1 - Controller InterviewItem 7 · .PDF · 105 KBATC 3 - Attachment 2 - ATC TranscriptItem 8 · .PDF · 1.1 MBATC 3 - Attachment 3 - Controller StatementsItem 9 · .PDF · 729 KBATC 3 - Attachment 4 - MTV Localizer Runway 30 Approach DiagramItem 10 · .PDF · 108 KBATC 3 - Attachment 5 - Radar PlotsItem 11 · .PDF · 1.5 MBATC 3 - Attachment 6 - Radar GraphicsItem 12 · .PDF · 176 KBATC 3 - Attachment 9 - GSO MSAW Diagram for MTVItem 13 · .PDF · 64 KBAircraft Performance 13 - Factual Report of Group ChairmanItem 14 · .PDF · 880 KBMemorandum for Record-Interview, Chief of MaintenanceItem 15 · .PDF · 25 KBMemorandum for Record - Interview,Chief PilotItem 16 · .PDF · 73 KBMemorandum for Record - Interview, Witness 1Item 17 · .PDF · 31 KBMemorandum for Record - Interview, Witness 2Item 18 · .PDF · 26 KBMemorandum for Record - Interview, Witness 3Item 19 · .PDF · 27 KBMemorandum for Record - Interview, Witness 4Item 20 · .PDF · 29 KBMemorandum for Record - Interview, Witness 5Item 21 · .PDF · 26 KBMemorandum for Record - Interview ASI TSB CanadaItem 22 · .PDF · 23 KBFAA Flight Inspection ReportsItem 23 · .PDF · 354 KBPilot/Operator Aircraft Accident Report, NTSB Form 6120.1Item 24 · .PDF · 252 KBStatement of Party Representatives to NTSB InvestigationItem 25 · .PDF · 65 KBWreckage ReleaseItem 26 · .PDF · 33 KB

FAA reports on this event · 1

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