# NTSB IAD05MA006: Beech 200, N501RH, Stuart, VA, October 24, 2004 - Type: NTSB accident investigation - Classification: Accident · Fatal · Class 1 · Major · Final report - Date: October 24, 2004, 12:35 local (16:35 UTC) - Place: Stuart, VA - Coordinates: 36.706111, -80.192222 - Nearby events: https://openairdocs.org/map.md?lat=36.7061&lon=-80.1922&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 10 fatal - 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 - NTSB case key (mKey): 60415 - NTSB case page: https://www.ntsb.gov/investigations/Pages/IAD05MA006.aspx - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/60415/pdf - Board report AAB0601 (PDF): https://www.ntsb.gov/investigations/AccidentReports/Reports/AAB0601.pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=60415 - Page: https://openairdocs.org/ntsb/IAD05MA006 ## 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 In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - In flight collision with terrain/water, missed approach (ifr) - ifr procedure - not complied with, flightcrew (cause) - in-flight planning/decision - inadequate, flightcrew (contributing factor) - 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](https://openairdocs.org/deregistered/N501RH-2012-08-29), registration cancelled 2012-08-29, S/N BB-805, built 1981 (OpenAirDocs) - Reported make and model: Beech 200 - Registry model: [Beech 200](https://openairdocs.org/model/beech-200) (registry code 1152920) (OpenAirDocs) - Registry engine: [U/A Canada PT6A series](https://openairdocs.org/engine/u-a-canada-pt6a-series) (registry code 61508, turbo-prop) (OpenAirDocs) - Category: Airplane - Serial number: BB-805 - Airframe hours: 8078 - Engines: Pratt & Whitney Canada PT6A41 850 horsepower turbo prop; Pratt & 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 51; injuries: fatal; 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 - Co-pilot; age 31; injuries: fatal; 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 ## 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 20041024035159A](https://openairdocs.org/incident/20041024035159A), Oct 24, 2004: Beech 200BEECH, Stuart, VA, Destroyed, 10 fatal. (-23) On October 24, 2004, at 1235 eastern daylight time, a Beech 200 king air, N501RH, operated by hendrick motorsports incorporated, was destroyed when it… ## Docket (26 files) The files NTSB released with the investigation on February 3, 2006, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=60415. 12.5 MB in all. - Operations 2 - Factual Report of Group Chairman (item 1, .PDF, 1.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40456715&FileExtension=.PDF&FileName=Operations%202%20-%20Factual%20Report%20of%20Group%20Chairman-Master.PDF - Toxicological Report - Pilot (item 2, .PDF, 52 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40255655&FileExtension=.PDF&FileName=Toxicological%20Report%20-%20Pilot-Redacted.PDF - Toxicological Report - Copilot (item 3, .PDF, 51 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40255654&FileExtension=.PDF&FileName=Toxicological%20Report%20-%20Copilot-Redacted.PDF - Meteorology 5 - Factual Report of Group Chairman (item 4, .PDF, 2.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40223908&FileExtension=.PDF&FileName=Meteorology%205%20-%20Factual%20Report%20of%20Group%20Chairman-Master.PDF - Airworthiness Factual Report of Group Chairman (item 5, .PDF, 18 photos, 3.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40226620&FileExtension=.PDF&FileName=Airworthiness%20Factual%20Report%20of%20Group%20Chairman-Master.PDF - ATC 3 - Factual Report of Group Chairman (item 6, .PDF, 99 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40229172&FileExtension=.PDF&FileName=ATC%203%20-%20Factual%20Report%20of%20Group%20Chairman-Master.PDF - ATC 3 - Attachment 1 - Controller Interview (item 7, .PDF, 105 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40229173&FileExtension=.PDF&FileName=ATC%203%20-%20Attachment%201%20-%20Controller%20Interview-Master.PDF - ATC 3 - Attachment 2 - ATC Transcript (item 8, .PDF, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40456716&FileExtension=.PDF&FileName=ATC%203%20-%20Attachment%202%20-%20ATC%20Transcript-Master.PDF - ATC 3 - Attachment 3 - Controller Statements (item 9, .PDF, 729 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40456717&FileExtension=.PDF&FileName=ATC%203%20-%20Attachment%203%20-%20Controller%20Statements-Master.PDF - ATC 3 - Attachment 4 - MTV Localizer Runway 30 Approach Diagram (item 10, .PDF, 108 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40229176&FileExtension=.PDF&FileName=ATC%203%20-%20Attachment%204%20-%20MTV%20Localizer%20Runway%2030%20Approach%20Diagram-Master.PDF - ATC 3 - Attachment 5 - Radar Plots (item 11, .PDF, 1.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40229177&FileExtension=.PDF&FileName=ATC%203%20-%20Attachment%205%20-%20Radar%20Plots-Master.PDF - ATC 3 - Attachment 6 - Radar Graphics (item 12, .PDF, 176 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40229178&FileExtension=.PDF&FileName=ATC%203%20-%20Attachment%206%20-%20Radar%20Graphics-Master.PDF - ATC 3 - Attachment 9 - GSO MSAW Diagram for MTV (item 13, .PDF, 64 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40229181&FileExtension=.PDF&FileName=ATC%203%20-%20Attachment%209%20-%20GSO%20MSAW%20Diagram%20for%20MTV-Master.PDF - Aircraft Performance 13 - Factual Report of Group Chairman (item 14, .PDF, 880 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40224900&FileExtension=.PDF&FileName=Aircraft%20Performance%2013%20-%20Factual%20Report%20of%20Group%20Chairman-Master.PDF - Memorandum for Record-Interview, Chief of Maintenance (item 15, .PDF, 25 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40456718&FileExtension=.PDF&FileName=Memorandum%20for%20Record-Interview,%20Chief%20of%20Maintenance-Master.PDF - Memorandum for Record - Interview,Chief Pilot (item 16, .PDF, 73 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40456719&FileExtension=.PDF&FileName=Memorandum%20for%20Record%20-%20Interview,Chief%20Pilot-Master.PDF - Memorandum for Record - Interview, Witness 1 (item 17, .PDF, 31 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40456720&FileExtension=.PDF&FileName=Memorandum%20for%20Record%20-%20Interview,%20Witness%201-Master.PDF - Memorandum for Record - Interview, Witness 2 (item 18, .PDF, 26 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40456721&FileExtension=.PDF&FileName=Memorandum%20for%20Record%20-%20Interview,%20Witness%202-Master.PDF - Memorandum for Record - Interview, Witness 3 (item 19, .PDF, 27 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40456722&FileExtension=.PDF&FileName=Memorandum%20for%20Record%20-%20Interview,%20Witness%203-Master.PDF - Memorandum for Record - Interview, Witness 4 (item 20, .PDF, 29 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40456723&FileExtension=.PDF&FileName=Memorandum%20for%20Record%20-%20Interview,%20Witness%204-Master.PDF - Memorandum for Record - Interview, Witness 5 (item 21, .PDF, 26 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40456724&FileExtension=.PDF&FileName=Memorandum%20for%20Record%20-%20Interview,%20Witness%205-Master.PDF - Memorandum for Record - Interview ASI TSB Canada (item 22, .PDF, 23 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40456725&FileExtension=.PDF&FileName=Memorandum%20for%20Record%20-%20Interview%20ASI%20TSB%20Canada-Master.PDF - FAA Flight Inspection Reports (item 23, .PDF, 354 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40456726&FileExtension=.PDF&FileName=FAA%20Flight%20Inspection%20Reports-Master.PDF - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 24, .PDF, 252 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40456727&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 25, .PDF, 65 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40456728&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Master.PDF - Wreckage Release (item 26, .PDF, 33 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40456729&FileExtension=.PDF&FileName=Wreckage%20Release-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.