LAX02FA108

NTSB accident investigation · Beech E90 · Reno, NV · March 14, 2002

Accident · Serious injuriesField investigationFinal report
Date
March 13, 2002, 19:40 local (Mar 14, 2002, 03:40 UTC)
Place
Reno, NV
Injuries
1 serious, 5 minor
Damage
Destroyed
Phase of flight
Approach
Aircraft
N948CCBeech E90
Weather
Instrument (IMC) · Night/dark
Status
Completed · report March 2, 2004
Report
Approved by Office Director
Parties
Raytheon (Beech) Aircraft Company, Federal Aviation Administration, Pratt & Whitney Canada
FAA report
20020313004909A
Case key
54341

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 inadequate approach airspeed for the existing adverse meteorological conditions followed by his delayed remedial action to avert stalling and subsequent loss of airplane control. Contributing factors were the pilot's reduced visibility due to the inclement weather and the icing conditions.

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.

Loss of control - in flightApproach - faf/outer marker to threshold (ifr)
Weather condition - low ceiling
Weather condition - icing conditionsFactor
Airspeed - not maintainedPilot in commandCause
Weather condition - snowFactor
Remedial action - delayedPilot in commandCause
Airspeed(vs) - not maintainedPilot in commandCause
Stall/mush - inadvertentPilot in command
In flight collision with objectApproach - faf/outer marker to threshold (ifr)
Object - building(nonresidential)

Analysis

During an instrument approach, upon descending to the prescribed minimum descent altitude, about 1/2 mile from the missed approach point, the pilot failed to maintain flying airspeed. The airplane stalled, rolled left, and in an uncontrolled descent collided with a commercial building 0.96 nm from the runway's displaced threshold. The accident occurred during the return portion of a round trip flight, while on final approach to the pilot's alternate airport due to a weather-induced diversion. Moderate intensity snow showers and freezing fog existed. During the initial approach, the reported visibility was 1 1/2 miles. About the time the pilot passed the final approach fix, the visibility decreased to 1/2 mile, but the pilot was not informed of the decrease below his 1-mile minimum requirement. The pilot had maintained the recommended 140-knot approach speed in the icing conditions until about 3 1/2 miles from the runway. Thereafter, the airplane's speed gradually decreased until reaching about 75 knots. After the airplane started vibrating, the pilot increased engine power, but his action was not timely enough to avert stalling. Company mechanics maintained the airplane. On previous occasions overheat conditions had occurred wherein the environmental ducting melted and heat was conducted to the adjacent pneumatic tube that provides deice air to the empennage boots. During the accident investigation, the deice tube was found completely melted closed, thus rendering all of the empennage deice boots dysfunctional.

Factual narrative

History of flight

On March 13, 2002, about 1940 Pacific standard time (PST), a Beech E90, N948CC, descended into an unoccupied commercial building during an in-flight loss of control, about 1 mile south-southeast of the Reno/Tahoe International Airport, Reno, Nevada. Pilot Services Corporation, d.b.a. Regent Air Service, Inc., Truckee, California, operated the airplane. The accident occurred during a nighttime instrument approach in instrument meteorological conditions. The airline transport certificated pilot and four passengers sustained minor injuries, and a fifth passenger sustained a serious injury. The airplane was destroyed. The flight was operated under the provisions of 14 CFR Part 135 as an on-demand air taxi flight, which departed from Durango, Colorado, about 1625 mountain standard time (1525 PST).

Earlier in the day, about 0518 PST, the pilot and passengers had departed from the Truckee-Tahoe Airport, Truckee, California, for the planned round trip flight to Durango. The pilot landed in Durango about 0850 mountain standard time (0750 PST).

The pilot reported to National Transportation Safety Board investigators that thereafter, he ate lunch and retired at the prearranged crew-rest hotel. The pilot further indicated that the airplane was refueled, and he did not observe any discrepancies with the airplane during his preflight inspection for the planned nonstop return flight.

According to the pilot, the flight was uneventful until he attempted to land at the Truckee-Tahoe Airport, his home base. At 1905 PST, the pilot received a clearance to perform an instrument approach to the Truckee-Tahoe Airport. Prior to commencement of the approach, the pilot activated the airplane's anti-ice systems, and they remained on throughout the remainder of the flight. The pilot activated the pneumatic wing deice boots prior to reaching the final approach fix.

The pilot indicated that he initiated the approach but could not land because of his inadequate visibility; it was snowing. The pilot executed a missed approach at 1919. Thereafter, he requested and received a clearance with radar vectors to proceed to the Reno/Tahoe International Airport.

The pilot further reported that snow showers also existed at Reno, and on only one occasion did he activate the deice boots during the approach. That occurred while on a vector to intercept the localizer, distance measuring equipment (DME), back course instrument approach to runway 34L. The pilot stated that he never observed an appreciable amount of ice on the leading edge of the wing, but he felt that there was enough to activate the boots. The pilot stated that when he activated the boots, "a little (ice) came off." He could see ice on the side of the wing's stall strip. There was some thin ice on the boot, but it did not extend beyond the boot.

At 1925:27, the pilot was cleared to perform the instrument approach. During the Safety Board investigator's subsequent interview with the pilot, he indicated that it was his belief that, upon reaching the final approach fix, the airport's reported weather was at or above his landing minimums. At 1936:44, the pilot made his last recorded radio transmission during which he acknowledged being cleared to land.

The pilot stated that everything on the approach was normal outside of the 2-mile DME fix. However, control of the airplane became difficult inside the 2-mile DME fix.

The pilot further reported to Safety Board investigators that the airplane's approach was initially stabilized upon reaching the minimum descent altitude (MDA). At the MDA, he increased engine torque (power) to 800 foot-pounds per engine in order to maintain altitude. According to the pilot, a torque value between 700 and 900 foot-pounds is normal.

The pilot indicated that some ice was visible on the wing's leading edge stall strip, but opined it was "way less than 1/4-inch" in depth. He stated that the ice did not extend beyond the aft portion of the wing's deicing boot.

According to the pilot, during the final seconds of flight, the controls started vibrating and he felt a yawing moment. The pilot said that he instantly looked at the indicated airspeed, which was between 111 and 115 knots. Thereafter, the airplane started to shake. Previously, the airplane had been flying at 140 knots, the recommended approach speed for icing conditions. The pilot said that he applied full engine power; however, the airplane still shook and yawed. He recalled that the rudder pedals appeared to move freely. Although the vibration varied in intensity, once it started it never stopped.

The pilot further reported that he pitched forward on the yoke, and he did not believe the airplane was stalling because the indicated airspeed was still near the "blue line." The pilot reported that he felt the airplane sink. While the airplane was sinking he noticed that the stall warning light was illuminated, and he attempted to stop the airplane's descent. He did not "yank back or push forward" on the yoke; he just maintained a level attitude. The pilot looked outside and saw buildings "coming up." The engine power was full, but the airplane was not climbing. The pilot reported thinking that he was going to hit the building and that he had to reduce the impact. Therefore, he pulled the yoke full back. The left wing stalled, and the airplane banked left.

The pilot stated that there might have been ice on the tail because the tail "felt really weird." He said "something made the airplane go down when it shouldn't have."

The airplane's last recorded radar position was at 1939:53. At this time, the airplane had descended to about 4,500 feet, as indicated by its Mode C altitude reporting transponder. The accident site's elevation is approximately 4,470 feet msl.

Personnel information

Certification and Experience.

The pilot held an airline transport pilot certificate with an airplane multiengine land rating. He had commercial privileges in single engine land and sea airplanes. The pilot also possessed a certified flight instructor certificate with airplane single engine, multiengine, and instrument airplane privileges. He possessed advanced ground school instructor and aircraft dispatcher certificates. The pilot's last first-class aviation medical certificate was issued without limitations on May 14, 2001.

The pilot's total flight time was 1,610 hours, of which 608 hours were flown in the model of the accident airplane. During the 30- and 90-day periods preceding the accident, the pilot had flown the accident model of airplane as pilot-in-command for 40 and 105 hours, respectively, of which 8 and 22 hours were in actual instrument meteorological conditions.

Regent Air, Inc., hired the pilot in August 2000. In July 2001, he began flying the Beech E90 as pilot-in-command. The pilot's last FAR Part 135 competency, instrument proficiency, and line checks were performed by a Federal Aviation Administration (FAA) inspector in February 2002. All of the checks were completed satisfactorily.

Aircraft information

The Beech Aircraft Company began manufacturing the model E90 series of airplanes in 1972, with serial number LW-1. The accident airplane, serial number LW-236, was manufactured in 1977. Beech discontinued production of this model of airplane in 1981, with serial number LW-347. According to the Raytheon Aircraft Company participant, the interior configurations of these airplanes varied. As of April 2, 2002, FAA registration records indicated that 247 E90s were registered.

Flight Manual and Check List Information.

The FAA approved Airplane Flight Manual (AFM) contained the following statements regarding flight in icing conditions:

"CAUTION Stalling airspeeds should be expected to increase when ice has accumulated on the airplane due to the distortion of the wing airfoil. For the same reason, stall warn

Aircraft

Registration
N948CC
Reported as
Beech E90
Category
Airplane
Serial number
LW-236
Airframe hours
8,773
Engine
Pratt & Whitney PT6A-28, 550 horsepower, turbo prop
Damage
Destroyed
Flight
Part 135
Registered owner
Pilot Services Corporation
Airworthiness certificate
Standard, Normal
Last inspection
AAIP · February 28, 2002 · 26 hours before
Departed
DRO · Durango, CO
Destination
RNO · Reno, CA
Flight plan
IFR
Airport
RNO · Reno, runway 34L, 11,000 × 150 ft, concrete

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
25
Injuries
Minor
Certificates
Flight instructor, Airline transport
Airplane ratings
Multi-engine land, Single-engine sea, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--no waivers/lim.
Last flight review
February 22, 2002
Seat
Left
Flight hours
1,610 total · 608 in this make and model · 1,210 as pilot in command · 138 in the last 90 days · 54 in the last 30 days · 7 in the last 24 hours

Weather

Conditions
Instrument (IMC) · Night/dark
Wind
300° at 10 knots
Visibility
0.5 statute miles
Lowest ceiling
700 ft broken
Temperature
28 °F, dew point 27 °F
Altimeter
30.04 inHg
Observed at
RNO, 2 nm away

Docket · 67

The files NTSB released with the investigation on May 18, 2004, on NTSB’s docket system: statements, records, photos and specialists’ reports. 33.0 MB in all.

Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1Item 1 · .PDF · 321 KBMeteorology 5 - Factual Report of Group ChairmanItem 2 · .PDF · 258 KBMeteorology 5 - Attachment 1 - Surface Analysis ChartItem 3 · .PDF · 220 KBMeteorology 5 - Attachment 2 - Weather Depiction ChartItem 4 · .PDF · 203 KBMeteorology 5 - Attachment 3 - Radar Summary ChartItem 5 · .PDF · 173 KBMeteorology 5 - Attachment 4 - Constant Pressure Chart - 850mbItem 6 · .PDF · 3.1 MBMeteorology 5 - Attachment 5 - Constant Pressure Chart - 700mbItem 7 · .PDF · 3.1 MBMeteorology 5 - Attachment 6 - Constant Pressure Chart - 500mbItem 8 · .PDF · 3.0 MBMeteorology 5 - Attachment 7 - Weather ObservationsItem 9 · .PDF · 397 KBMeteorology 5 - Attachment 8 - SoundingItem 10 · .PDF · 328 KBMeteorology 5 - Attachment 9 - Radar 0343ZItem 11 · .PDF · 109 KBMeteorology 5 - Attachment 10-1 Radar SequenceItem 12 · .PDF · 126 KBMeteorology 5 - Attachment 10-2 Radar SequenceItem 13 · .PDF · 127 KBMeteorology 5 - Attachment 10-3 Radar SequenceItem 14 · .PDF · 124 KBMeteorology 5 - Attachment 10-4 Radar SequenceItem 15 · .PDF · 123 KBMeteorology 5 - Attachment 10-5 Radar SequenceItem 16 · .PDF · 119 KBMeteorology 5 - Attachment 10-6 Radar SequenceItem 17 · .PDF · 120 KBOperations 2 - Factual Report of Group ChairmanItem 18 · .PDF · 5.0 MBMeteorology 5 - Attachment 10-7 - Radar SequenceItem 19 · .PDF · 124 KBMeteorology 5 - Attachment 10-8 Radar SequenceItem 20 · .PDF · 119 KBMeteorology 5 - Attachment 10-9 Radar SequenceItem 21 · .PDF · 138 KBMeteorology 5 - Attachment 11 - Satellite 1R 0300ZItem 22 · .PDF · 134 KBMeteorology 5 - Attachment 12 - Satellite 1R 0330ZItem 23 · .PDF · 133 KBMeteorology 5 - Attachment 13 - Satellite 1R 0400ZItem 24 · .PDF · 131 KBMeteorology 5 - Attachment 14-1 IIDA 0300ZItem 25 · .PDF · 111 KBMeteorology 5 - Attachment 14-2 IIDA 0300ZItem 26 · .PDF · 87 KBMeteorology 5 - Attachment 14-3 IIDA 0300ZItem 27 · .PDF · 109 KBMeteorology 5 - Attachment 14-4 IIDA 0300ZItem 28 · .PDF · 103 KBMeteorology 5 - Attachment 14-5 IIDA 0300ZItem 29 · .PDF · 95 KBMeteorology 5 - Attachment 15-1 IIDA 0400ZItem 30 · .PDF · 110 KBMeteorology 5 - Attachment 15-2 IIDA 0400ZItem 31 · .PDF · 83 KBMeteorology 5 - Attachment 15-3 IIDA 0400ZItem 32 · .PDF · 108 KBMeteorology 5 - Attachment 15-4 IIDA 0400ZItem 33 · .PDF · 103 KBMeteorology 5 - Attachment 15-5 IIDA 0400ZItem 34 · .PDF · 91 KBMaintenance Records 11 - Factual Report of Group ChairmanItem 35 · .PDF · 1.9 MBSpecialist's Report of Recorded Aircraft Radar and Performance StudyItem 36 · .PDF · 1.0 MBAircraft Performance 13 - Addendum 1 - The attached errata page includes a revised radar plot that corrects Attachment 3D entitled "Origin Plot of Aircraft Ground Track"Item 37 · .PDF · 329 KBWitness StatementItem 38 · .PDF · 32 KBPersonnel Statements from FAA Reno ATCT/TRACONItem 39 · .PDF · 441 KBStatements from FAA InspectorsItem 40 · .PDF · 413 KBStatement from St. Louis University Chief Pilot with NTSB CorrespondenceItem 41 · .PDF · 139 KBWreckage DiagramsItem 42 · .PDF · 45 KBWeather ReportItem 43 · .PDF · 17 KBTranscript of Radio CommunicationsItem 44 · .PDF · 246 KBDrawings (King Air Parts Catalog)Item 45 · .PDF · 376 KBFAA Daily Record of Facility OperationItem 46 · .PDF · 50 KBReport from FAA ATC FacilitiesItem 47 · .PDF · 85 KBReport from Pratt & Whitney CanadaItem 48 · .PDF · 159 KBReport from Raytheon Aircraft CompanyItem 49 · .PDF · 134 KBStatement of Party Representatives to NTSB InvestigationItem 50 · .PDF · 338 KBRelease of Aircraft Wreckage, NTSB Form 6120.15Item 51 · .PDF · 137 KBCorrespondence Between NTSB and RaytheonItem 52 · .PDF · 155 KBFAA Flight PlanItem 53 · .PDF · 41 KBReno LOC/DME BC RWY 34L Approach PlatesItem 54 · .PDF · 201 KBPhoto 1. Aerial view looking 340 degrees of crash site (foreground) and Rwy 34L (background). Photo by Washoe County Sheriff.Item 55 · .PDF · 1.2 MBPhoto 2. Aerial view showing airplane in building. Photo by Washoe County Sheriff.Item 56 · .PDF · 1.2 MBPhoto 3. Bottom view of separated left wing.Item 57 · .PDF · 314 KBPhoto 4. Airplane being hoisted from roof.Item 58 · .PDF · 710 KBPhoto 5. Engine (left) suspended by cables from airplane.Item 59 · .PDF · 326 KBPhoto 6. Engine (right) on floor, NW corner of building.Item 60 · .PDF · 326 KB
All 67 files on NTSB’s docket

FAA reports on this event · 1

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