MIA02FA037

NTSB accident investigation · Cessna 208B · Bessemer, AL · December 1, 2001

Accident · FatalField investigationFinal report
Date
December 1, 2001, 01:43 local (07:43 UTC)
Place
Bessemer, AL
Injuries
2 fatal
Damage
Destroyed
Phase of flight
Approach
Aircraft
N499BACessna 208B
Weather
Instrument (IMC) · Night
Status
Completed · report March 30, 2004
Report
Approved by Office Director
Parties
FAA, MIDO, McCauley Propeller Systems, Shadin Company, Inc., Air Carriers, Inc., Honeywell, Inc., Cessna Aircraft Company, P&W Canada Corp., FAA Flight Standards District Office, FAA, FSDO, United Instruments, Inc.
FAA report
20011201031369A
Case key
53849

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 poor in-flight planning by the pilot-in-command for his initiation of the ILS approach to runway 05 with weather conditions below minimums for the approach contrary to the federal aviation regulations, and the failure of the pilot to maintain control of the airplane during a missed approach resulting in the in-flight collision with trees then terrain.

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 objectMissed approach (ifr)
Weather condition - fog
Weather condition - below approach/landing minimumsCause
In-flight planning/decision - poorPilot in commandCause
Ifr procedure - initiatedPilot in commandCause
Aircraft control - not maintainedPilot in commandCause
Object - tree(s)

Analysis

The flight departed from Little Rock, Arkansas, about 2356 cst, and approximately 49 minutes after takeoff, the FAA approved un-augmented Automated Weather Observing System (AWOS-3) installed at the destination airport began reporting the visibility as 1/4 statute mile; the visibility continued to be reported as that value for several hours after the accident. Title 14 CFR Part 135.225 indicates no pilot may begin an instrument approach procedure to an airport with an approved weather reporting facility unless the latest weather report issued by that weather reporting facility indicates that weather conditions are at or above the authorized IFR landing minimums for that airport. The listed minimums for the ILS approach to runway 05 was in part 3/4 mile visibility. A METAR taken at the destination airport approximately 2 minutes after the accident indicated overcast clouds existed at 100 feet, the temperature and dew point were 4 and 2 degrees Celsius, respectively, and the altimeter setting was 30.16 inHg. No precipitation was present across Arkansas, Mississippi, or Alabama, and no radar echoes were noted along the accident airplane's route of flight. The freezing level near the departure and destination airports at the nominal time of 0600 (4 hours 17 minutes after the accident) was 12000 and 14,500 feet mean sea level, respectively. A witness at the airport reported the fog was the thickest he had seen since working at the airport for the previous year. The flight was cleared for an ILS approach to runway 05, and the pilot was advised frequency change was approved. The witness waiting at the airport reported hearing a sound he associated with a shotgun report. Radar data indicated that between 0138:47, and 0142:11, the airplane was flying on a northeasterly heading and descended from 2,400 feet msl, to 900 feet msl. At 0142:11, the airplane was located .43 nautical mile from the approach end of runway 05. The next recorded radar target 24 seconds later indicated 1,000 feet msl, and was .20 nautical mile from the approach end of runway 05. The touchdown zone elevation for runway 05 is 700 feet msl. The airplane crashed in a wooded area located approximately 342 degrees and .37 nautical mile from the approach end of runway 05; the wreckage was located approximately 4 hours after the accident. Examination of trees revealed evidence the airplane was banked to the left approximately 24 degrees, and the descent angle from the trees to the ground was calculated to be approximately 22 degrees. All components necessary to sustain flight were either attached to the airplane or in close proximity to the main wreckage. There was no evidence of post crash fire and a strong odor of fuel was noted at the scene upon NTSB arrival. A 8-inch diameter pine tree located near the initial ground impact sight exhibited black paint transfer and a smooth cut surface that measured approximately 46 inches in length. The bottom portion of the cut was located 4 feet above ground level. The flap actuator was found nearly retracted; examination of the components of the flap system revealed no evidence of preimpact failure or malfunction. Examination of the flight control system for roll, pitch, and yaw revealed no evidence of preimpact failure or malfunction. Examination of the engine and engine components with TSB of Canada oversight revealed no evidence of preimpact failure of the engine or engine components. Examination of the propeller with FAA oversight revealed no evidence of preimpact failure or malfunction. Examination of the components of the autopilot system, selected avionics and flight instruments from the airplane with FAA oversight revealed no evidence of preimpact failure or malfunction. The pilot's attitude indicator had been replaced on October 14, 2001, and according to FAA personnel, the mechanic and facility that performed the installation did not have the necessary equipment to perform the operational checks required to return the airplane to service. The FAA flight checked the ILS approach to runway 05 two times after the accident and reported no discrepancies.

Factual narrative

History of flight

On December 1, 2001, about 0143 central standard time, a Cessna 208B, N499BA, registered to and operated by Air Carriers, Inc., using call sign "Fast Check 600", collided with trees then terrain during an instrument landing system (ILS) approach to runway 05, at Bessemer Airport, Bessemer, Alabama. Instrument meteorological conditions (IMC) prevailed at the time and an instrument flight rules (IFR) flight plan was filed for the 14 CFR Part 135, on-demand, non-scheduled, domestic, cargo flight from Little Rock, Arkansas, to the Bessemer Airport, Bessemer, Alabama. The airplane was destroyed and the commercial-rated pilot and a pilot-rated passenger (another company pilot) were fatally injured. The flight originated approximately 2356 from the Adams Field Airport, Little Rock, Arkansas.

Shortly after takeoff, the flight was radar identified and cleared to fly direct to the Bessemer Airport. At 0009, air traffic control (ATC) communications were transferred from the Little Rock Air Traffic Control Tower to the Memphis Air Route Traffic Control Center (Memphis ARTCC). The flight remained in contact with that facility from 0009 to 0122; radar data indicates that between 0011 and 0122, the flight was conducted at 9,000 feet mean sea level (msl). At 0055, the R13 sector controller provided the pilot the Birmingham altimeter setting of 30.17 inHg. At 0122, ATC communications were transferred to Birmingham Air Traffic Control Tower (KBHM ATCT).

According to a transcription of communications between the pilot of Fast Check 600 and the Birmingham ATCT, at 0122:51, the pilot contacted the facility and advised the controller that the flight was at 9,000 feet msl. The controller acknowledged the contact and advised the pilot "expect lower in one zero miles and visual approach Bessemer airport." The pilot responded with, "600." At 0126:41, the controller cleared the flight to descend and maintain 4,000 feet msl, which was acknowledged. At 0126:57, the pilot requested radar vectors for the instrument landing system approach, to which the controller responded initially roger, followed by, "maintain three thousand till brookwood cleared ILS runway five approach to Bessemer." The pilot acknowledged the descent clearance and at 0137:44, he advised the controller that the flight was "about to intercept", to which the controller replied, "fast check six hundred roger change to advisory frequency is approved report your cancellation in the air this frequency or on the ground clearance delivery frequency." The pilot acknowledged the transmission from the controller with, "fast check six hundred." There were no further recorded radio transmissions from the accident pilot, and there was no record that the Birmingham ATCT controller provided the pilot with an altimeter setting.

A witness who was on the airport waiting for the flight to arrive reported hearing the engine sound at a distance, and then heard a sharp sound he associated with a shotgun report north of runway 5. The witness reported heavy fog existed at the airport at the time of the accident.

Review of radar data from Atlanta Air Route Traffic Control Center (ARTCC) associated with the accident airplane revealed that between 0138:47, and 0142:11, the airplane was flying on a northeasterly heading and descended from 2,400 feet msl, to 900 feet msl. At 0142:11, the airplane was located at 33 degrees 18 minutes 12 seconds North latitude, and 086 degrees 56 minutes 22 seconds West longitude, or approximately 225 degrees and .43 nautical mile from the approach end of runway 05. The next recorded radar target 24 seconds later at 0142:35, was indicating 1,000 feet msl, and was located at 33 degrees 18 minutes 41 seconds North latitude, and 086 degrees 55 minutes 56 seconds West longitude, or 005 degrees and .20 nautical mile from the approach end of runway 05. The touchdown zone elevation for runway 05 is 700 feet msl.

A search for the airplane was conducted; the wreckage was located approximately 4 hours after the accident.

Personnel information

The pilot-in-command seated in the left front seat was the holder of a commercial pilot certificate, with airplane single and multi-engine land, and instrument airplane ratings. He was issued a second-class medical certificate on August 30, 2001, with the limitation, "Holder shall wear lenses that correct for distant vision and possess glasses that correct for near vision while exercising the privileges of his airman certificate."

Air Carriers, Inc., and BancServ Air, Inc., are owned by the same individual. Air Carriers, Inc., and BancServ Air, Inc., were assigned Air Carrier certificate number DKBA109S and VKSA957T, respectively. Air Carriers, Inc., and BancServ Air, Inc., were authorized by the Federal Aviation Administration (FAA) to conduct on-demand cargo only operations, and on-demand operations, respectively, in accordance with the certificates issued under Title 14 CFR Part 119.

Review of the pilot-in-command's Air Carriers, Inc., training file revealed he completed his initial new hire basic indoctrination training, and general emergency training in Cessna 206 and 210 airplanes on October 11, 2000. He completed initial hazardous materials training on October 12, 2000, and completed the initial new-hire equipment ground training for Cessna 210 airplanes on October 13, 2000. Initial new-hire equipment flight training that consisted of 3.1 hours in an undesignated type airplane was completed on October 14, 2000. He was assigned as pilot-in-command in Cessna 206 and 210 airplanes on October 16, 2000; he was not assigned as pilot-in-command on Cessna 208 airplanes. His last airman competency/proficiency check flight in accordance with 14 CFR Part 135.293, and 297 occurred on November 17, 2001, which consisted of a .8 hour flight in a Cessna 210 airplane. The result of the flight check was listed as "approved."

The pilot-in-command's training file with BancServ Air, Inc., indicates he received initial flight and ground training in Cessna 208 airplanes on February 27, 2001. An airman competency/proficiency check flight form dated February 28, 2001, indicates he passed the flight check that was flown in the accident airplane. He was assigned that same day as pilot-in-command on Cessna 208 airplanes for BancServ Air, Inc.

The pilot-rated passenger seated in the right front seat was the holder of a commercial pilot certificate, with ratings airplane single and multi-engine land, and instrument airplane. He was also the holder of a flight instructor certificate with ratings airplane single engine, multi-engine, instrument airplane, that was issued on January 16, 2001. He was issued a first class medical certificate with no limitations on June 21, 2001. He completed his ground and flight training with Air Carriers, Inc., on July 23, 2001, and was assigned to a fly as pilot-in-command Cessna 206 and 210 airplanes. He had not been trained in the Cessna 208 airplane. His last airman competency/proficiency check flight in accordance with 14 CFR Part 135.293, 297, and 299 occurred on July 21, 2001, which consisted of a 1.4 hours flight in a Cessna 210 airplane. The result of the flight check was listed as "approved."

Aircraft information

The airplane was a Cessna 208B, serial number 208B0689, manufactured in 1998. It was equipped with a 675 shaft horsepower Pratt & Whitney PT6A-114A engine, and a McCauley 3GFR34C703/106GA-0 propeller. The airplane was also equipped with a Shadin Key Data Recorder, a Bendix/King KFC-150 autopilot/flight director system, and an altitude preselector. BancServ Air, Inc., maintained the airplane in accordance with a Federal Aviation Administration (FAA) Approved Aircraft Inspection Program (AAIP). The last recorded altimeter, transponder, and static system checks were performed on May 10, 2000, by Southern Avionics.

The engine was last overhauled on April 3

Aircraft

Registration
N499BA
Reported as
Cessna 208B
Category
Airplane
Serial number
208B0689
Airframe hours
4,867
Engine
Pratt & Whitney Canada PT6A-114A, 675 horsepower, turbo prop
Damage
Destroyed
Flight
Part 135
Registered owner
Air Carriers, Inc.
Airworthiness certificate
Standard, Normal
Last inspection
AAIP · November 19, 2001 · 84.2 hours before
Departed
LIT · Little Rock, AR
Destination
KEKY · Bessemer, AL
Flight plan
IFR
Airport
KEKY · Bessemer Airport, runway 05

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
62
Injuries
Fatal
Certificate
Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 2, Valid Medical--w/ waivers/lim
Last flight review
November 17, 2001
Seat
Left
Toxicology
Performed
Flight hours
5,773 total · 990 in this make and model · 5,603 as pilot in command · 390 in the last 90 days · 130 in the last 30 days · 6 in the last 24 hours
Role
Other flight crew
Age
33
Injuries
Fatal
Certificates
Commercial, Flight instructor
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--no waivers/lim.
Seat
Right
Toxicology
Performed
Flight hours
1,675 total · 1,595 as pilot in command · 326 in the last 90 days · 77 in the last 30 days · 0 in the last 24 hours

Weather

Conditions
Instrument (IMC) · Night
Visibility
0.25 statute miles
Lowest ceiling
100 ft overcast
Temperature
39 °F, dew point 36 °F
Altimeter
30.15 inHg
Observed at
KEKY, 1 nm away

Docket · 66

The files NTSB released with the investigation on January 30, 2004, on NTSB’s docket system: statements, records, photos and specialists’ reports. 67.3 MB in all.

Meteorology 5 - Factual Report of Group ChairmanItem 1 · .PDF · 336 KBMeteorology 5 - Attachment 1Item 2 · .PDF · 586 KBPilot/Operator Aircraft Accident Report, NTSB Form 6120.1Item 3 · .PDF · 255 KBWitness StatementItem 4 · .PDF · 486 KBWeather Reports and RecordsItem 5 · .PDF · 7.2 MBTranscript of Radio CommunicationsItem 6 · .PDF · 155 KBReports from Federal AgenciesItem 7 · .PDF · 355 KBReport from Cessna Aircraft CompanyItem 8 · .PDF · 125 KBCessna annunciator panel reportItem 9 · .PDF · 3.1 MBReport from HoneywellItem 10 · .PDF · 1.9 MBReport from McCauley Propeller SystemsItem 11 · .PDF · 493 KBReport from Pratt & Whitney CanadaItem 12 · .PDF · 10.7 MBReport from United Instruments, Inc.Item 13 · .PDF · 4.6 MBReport from Shadin Company, Inc.Item 14 · .PDF · 2.8 MBStatement from Ernest C. MorrisItem 15 · .PDF · 362 KBExcerpts from Air Carriers, Inc., Operations SepcificationsItem 16 · .PDF · 1.0 MBExcerpts from BancServ Air, Inc., Operations SpecificationsItem 17 · .PDF · 109 KBFueling InformationItem 18 · .PDF · 312 KBFlight Progress StripItem 19 · .PDF · 20 KBPersonnel StatementsItem 20 · .PDF · 133 KBStatement from and Record of interview with Richard SappingtonItem 21 · .PDF · 277 KBExcerpt from U.S. Terminal Procedures, Southeast.Item 22 · .PDF · 1.9 MBTitle 14 CFR Part 135.225 regulationItem 23 · .PDF · 93 KBExcerpt from Airport Facility DirectoryItem 24 · .PDF · 1.7 MBExcerpt from Pilot's Operating Handbook and FAA Approved Airplane Flight ManualItem 25 · .PDF · 1.2 MBDocuments found in the wreckageItem 26 · .PDF · 1.6 MBExcerpts from Airframe Maintenance LogbooksItem 27 · .PDF · 4.1 MBExcerpts from Engine Maintenance RecordsItem 28 · .PDF · 2.5 MBExcerpts from Propeller LogbooksItem 29 · .PDF · 1.0 MBCargo InformationItem 30 · .PDF · 74 KBMaintenance RecordsItem 31 · .PDF · 1.7 MBTrend Monitoring Status Report and Oil Analysis ReportItem 32 · .PDF · 209 KBCescom DataItem 33 · .PDF · 532 KBPilot-in-command dataItem 34 · .PDF · 499 KBPilot-in-command dataItem 35 · .PDF · 153 KBPilot-in-command flight, duty, rest dataItem 36 · .PDF · 1.5 MBRight front seat occupant pilot data/informationItem 37 · .PDF · 525 KBExcerpts from maintenance recordsItem 38 · .PDF · 309 KBE-mail from FAA-IICItem 39 · .PDF · 26 KBFlight Check ReportsItem 40 · .PDF · 153 KBRecord of conversation with Tom TeplikItem 41 · .PDF · 61 KBRecord of conversation with Clive GaleItem 42 · .PDF · 61 KBRecord of conversation with L. Thomas "Tommy" MorrowItem 43 · .PDF · 30 KBRecord of conversation with Rasheed RedaItem 44 · .PDF · 28 KBRecord of conversations with Toshio KawawaItem 45 · .PDF · 40 KBAvionics/Flight Control System Installation Maintenance ManualItem 46 · .PDF · 307 KBRadar DataItem 47 · .PDF · 548 KBMaps of areaItem 48 · .PDF · 453 KBDocuments provided by Cessna Aircraft CompanyItem 49 · .PDF · 5.9 MBStatement of Party Representatives to NTSB InvestigationItem 50 · .PDF · 261 KBToxicological Report-O'NeillItem 51 · .PDF · 74 KBToxicological Report-TohovitisItem 52 · .PDF · 76 KBRelease of Aircraft Wreckage, NTSB Form 6120.15Item 53 · .PDF · 94 KBPhoto 1: Aerial view of wreckage area. Arrow points to location of main wreckage.Item 54 · .PDF · 180 KBPhoto 2: Aerial view of the main wreckage and the accident site area.Item 55 · .PDF · 274 KBPhoto 3:Aerial view of the main wreckage and the accident site area.Item 56 · .PDF · 295 KBPhoto 4: View of the wreckage at the accident site.Item 57 · .PDF · 291 KBPhoto 5: View of right aft side of wreckage.Item 58 · .PDF · 347 KBPhoto 6: View of the right forward portion of the wreckage. No negative.Item 59 · .PDF · 265 KBPhoto 7: View of the right side of engine. No negative.Item 60 · .PDF · 228 KB
All 66 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.