MIA96FA051

NTSB accident investigation · Cessna 550 · East Naples, FL · December 31, 1995

Accident · FatalField investigationFinal report
Date
December 31, 1995, 12:25 local (17:25 UTC)
Place
East Naples, FL
Injuries
2 fatal
Damage
Destroyed
Phase of flight
Approach
Aircraft
N91MJCessna 550
Weather
Instrument (IMC) · Day
Status
Completed · report January 8, 1997
Report
Approved by Office Director
FAA report
19951231042749A
Case key
37889

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 pilot's disregard for the MDA for a specific segment of the VOR/DME approach which resulted in the inflight collision with a guy wire of an antenna and separation of 8.5 feet of the left wing.

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 objectApproach - faf/outer marker to threshold (ifr)
Object - guy wire
Minimum descent altitude - disregardedPilot in commandCause
In flight collision with terrain/waterDescent - uncontrolled
Terrain condition - open field

Analysis

The flight was cleared for the VOR/DME approach to runway 17 at the Marco Island Airport. The CVR recorded conversation between the pilot and co-pilot reference to the approach, specifically the MDA both in mean sea level and absolute altitude for a straight-in-approach to runway 17. The flight crew announced that the flight was landing on runway 35. The flight crew did not discuss the missed approach procedure nor the circling minimums. The flight continued and the co-pilot announced that the flight was 5 miles from the airport to descend to the MDA to visually acquire the airport. While descending about 8.5 feet of the left wing of the airplane was severed by a guy wire about 587 feet above ground level from an antenna that was 3.36 nautical miles from the threshold of runway 17. The tower is listed on the approach chart that was provided to the flight crew. The airplane then rolled left wing low, recovered to wings level, then was observed to roll to the left, pitch nose down, and impacted the ground. A fireball was then observed by witnesses. The altimeters, air data computer, and pilot's airspeed indicator were last calibrated about 8 months before the accident. The co-pilots altimeter was found set .01 high from the last known altimeter setting provided to the flight crew. The CVR did not record any conversation pertaining to failure or malfunction of either the pilot or co-pilot's HSI, the DME or Altimeters. There were no alarms from the VOR/DME monitoring equipment the day of the accident. The flight crew of another airplane executed the same approach about 30 minutes before the accident and they reported no discrepancies with the approach. The MDA for the segment of the approach between where the tower is located is no lower than 974 feet above ground level.

Factual narrative

History of flight

On December 31, 1995, about 1225 eastern standard time, a Cessna 550, N91MJ, registered to and operated by Moran Foods, Inc., collided with a guy wire from an antenna then collided with the ground near East Naples, Florida. Instrument meteorological conditions prevailed at the time and an IFR flight plan was filed for the 14 CFR Part 91 corporate flight. The airplane was destroyed and the airline transport-rated pilot and copilot were fatally injured. The flight originated about 0824 central standard time from the St. Louis Downtown-Parks Airport, Cahokia/St. Louis, Illinois.

The flight from St. Louis to the descent while in range was uneventful. There were no reported discrepancies of altitudes or headings flown as requested by Air Traffic Control (ATC) facilities during the flight.

Readout of the aircraft cockpit voice recorder (CVR) revealed that at 1156.45, the flightcrew monitored the Naples Airport, Airport Terminal Information Service (ATIS).

At 1206.16, the copilot contacted Fort Myers Approach Control and the flightcrew was given the altimeter setting of 30.00 inHg and told to expect the VOR runway 17 approach to the Marco Island Airport. The copilot acknowledged this then stated, "one forty eights inbound, huh" and the pilot-in-command responded in the affirmative. At 1206.53, the CVR recorded the copilot to state "three fifty four on your doohickey over there." The flightcrew was later advised to descend to 7,000 and at 1209.29, the CVR recorded the copilot to state, "obviously try to land to the north if we can." The flight was later cleared to descend to 5,000 feet and to contact approach control on a different frequency. The copilot contacted the approach controller on the new frequency and at 1214.30, the controller advised the flightcrew to expect the VOR/DME approach to runway 17. The copilot acknowledged this.

At 1218.29, the copilot stated "got a capture" and at 1219.55, 5 minutes 25 seconds after the controller advised the flightcrew to expect the VOR approach, the CVR recorded the PIC to ask what the MDA for the approach was. The copilot stated "...three sixty." The copilot then stated "two thousand till established and once you pass the VOR you can come down to 1,600 maintain (to or possible for) 5 miles thence" and the PIC responded "down to three." At 1220.34, the copilot stated "after five miles come down" and the PIC stated "three sixty." The PIC then asked the copilot to contact the approach controller to inquire if the flight was cleared for the approach and the controller stated in part, "...very shortly." At 1221.41, the copilot stated "it, its more than five miles and it will be down to nine eighty."

At about 1221.51, the approach controller advised the flightcrew that the flight was 4 miles from TIOFF, maintain 1,600 until established final approach course, cleared for the VOR/DME runway 17 approach Marco Island. The copilot acknowledged the approach clearance with the approach controller and about 4 seconds later the PIC requested approach flaps. The copilot then stated "looks like we need about 10 right" followed by "one down at nine eighty" with a sound one second later similar to the altitude alert signal. At 1223.15, the flightcrew was advised that radar service was terminated and to contact to the airport advisory frequency which the copilot acknowledged. About 3 seconds later the co-pilot advised on the Marco Island Airport Common Traffic Frequency (CTAF) that the flight was "6 north inbound on the approach will be landing on runway 35. At 1223.34, the copilot stated "yeah you otta be in good shape if you don't mind sneaking around a little bit yeah within 5 miles of the airport there you can come on down to three sixty." At 1223.57, the copilot stated "ah the airports a little bit to your left" then "about ten left looks like about one fifty five heading will take you right to it four miles out get her right down so we can sees it." The copilot then stated "three miles" and 4 seconds later, a sound of impact was heard. Conversation between the flightcrew about controlling the airplane occurred and at 1224.39, the copilot stated "...gotta find somewhere to land this keep the power in" to which the PIC responded "I got it." At 1224. 54, the PIC stated "one hundred thirty knots" and at 1225.04, the copilot stated "its dropping on you Hal." There was no further pertinent conversation from the flightcrew and at no time during the time recorded by the CVR did they report seeing the ground. Further review of the CVR that stopped recording at 1225.07 hours revealed that the flightcrew did not discuss the missed approach procedure, nor the MDA and visibility minimums for a circle to land approach.

Numerous witnesses on the ground near the tower reported that the top of the tower was obscured by clouds and the airplane was observed to descend below the base of the clouds then collided with a guy wire of the antenna. A section of the airplane was observed to fall to the ground and the airplane rolled to left nearly inverted then rolled wings level while descending flying in an easterly direction. Witnesses closer to the accident site observed the airplane roll to the left, pitch nose down, then impact the ground and a fireball was observed.

Personnel information

Both pilots were issued an Airline-Transport Pilot certificate with a type rating in Cessna 500 aircraft. The first pilot's name was listed as the pilot in the IFR flight plan. Review of his pilot logbook revealed that he had logged 11.7 hours actual instrument time with corresponding 15 instrument approaches during the preceding 6 months all in the airplane category. During the preceding 90 days he logged eight takeoff's and landings in the accident airplane and he was given a checkride in accordance with 14 CFR Part 135.297 and 135.299 on October 26, 1995. On March 2, 1994, he was also given a checkride in a Cessna 501 airplane. Additional information pertaining to the first pilot may be obtained in the NTSB Factual Report on page 3.

Review of the second pilot's logbook revealed that he had logged about 93 hours within the preceding 90 days of which about 68 hours were in the accident airplane. During that same time he logged about 17 hours actual instrument time and 17 instrument approaches. Also during that time he logged 61 hours as pilot-in-command and last attended Flight Safety on January 12-14, 1995, for recurrent Citation II flight training. Additional information pertaining to the second pilot may be found the NTSB Supplement E.

Aircraft information

Review of the maintenance records revealed that both altimeters, the air data computer, and the pilot's airspeed indicator were calibrated and leak checked on April 10, 1995. Additionally, the last recorded VOR test was performed on September 14, 1995.

Meteorological information

The Naples Airport ATIS "Q" that was monitored by the flightcrew before initiating the approach indicated that the recorded ceiling at 1155 was measured one thousand two hundred broken, with 6 miles of visibility in fog. The wind was from 150 degrees at 8 knots and the altimeter was 30.00 inHg. The Naples Airport is located about 11 nautical miles and 331 degrees magnetic from the Marco Island Airport.

According to the office assistant at the Marco Island Airport who was monitoring the CTAF at the time of the accident, one flightcrew member of the accident airplane reported that the flight was inbound to runway 35. The assistant broadcast to the flightcrew that runway 17 was the active but there was no response. The flightcrew member did not ask for the wind or altimeter setting. The flightcrew of an another airplane that landed at the Marco Island Airport about 30 minutes before the accident reported executing the VOR/DME approach to runway 17. They did not

Aircraft

Registration
N91MJ
Reported as
Cessna 550
Category
Airplane
Serial number
550-0101
Airframe hours
6,025
Engine
P&W JT15D-4, 2,500 lbs thrust, turbo fan
Damage
Destroyed
Fire
On-Ground
Flight
Executive/Corporate · Part 91
Registered owner
Moran Foods, Inc.
Airworthiness certificate
Standard, Normal
Last inspection
Continuous airworthiness · April 13, 1995 · 142 hours before
Departed
CPS · Cahokia/St Loui, IL
Destination
MKY · Marco Island, FL
Flight plan
IFR
Airport
MKY · Marco Island

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
57
Certificates
Flight instructor, Airline transport, Commercial
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--w/ waivers/lim
Seat
Left
Toxicology
Performed
Flight hours
13,026 total · 2,500 in this make and model · 11,753 as pilot in command · 87 in the last 90 days · 41 in the last 30 days · 3 in the last 24 hours

Weather

Conditions
Instrument (IMC) · Day
Wind
150° at 12 knots
Visibility
6 statute miles
Lowest ceiling
800 ft broken
Temperature
73 °F, dew point 66 °F
Altimeter
29.00 inHg
Observed at
APF, 7 nm away

Docket · 33

The files NTSB released with the investigation on November 8, 1996, on NTSB’s docket system: statements, records, photos and specialists’ reports. 7.9 MB in all.

Supplement CItem 1 · .PDF · 325 KBSupplement DItem 2 · .PDF · 368 KBSupplement EItem 3 · .PDF · 99 KBSupplement KItem 4 · .PDF · 628 KBSupplement TItem 5 · .PDF · 93 KBPilot/Operator Aircraft Accident Report, NTSB Form 6120.1Item 6 · .PDF · 318 KBFactual Report of each Group Chairman/Specialist-Cockpit Voice RecorderItem 7 · .PDF · 535 KBFactual Report of each Group Chairman/Specialist-Sound Spectrum StudyItem 8 · .PDF · 82 KBWitness StatementsItem 9 · .PDF · 1.1 MBMaps or Charts of Accident Area, Wreckage DiagramsItem 10 · .PDF · 27 KBTranscript of Radio CommunicationsItem 11 · .PDF · 156 KBReports from State Agencies-FCC Inspection Report and CorrespondenceItem 12 · .PDF · 429 KBReports from Parties to the InvestigationItem 13 · .PDF · 1.7 MBOther Pertinent Forms and Reports-Maintenance RecordsItem 14 · .PDF · 167 KBOther Pertinent Forms and Reports-Jeppesen Approach Chart.Item 15 · .PDF · 61 KBOther Pertinent Forms and Reports- Flight Plan InformationItem 16 · .PDF · 67 KBOther Pertinent Forms and Reports-Airman Proficiency and Training DocumentsItem 17 · .PDF · 199 KBOther Pertinent Forms and Reports-Ground Check of the CYY VOR.Item 18 · .PDF · 347 KBOther Pertinent Forms and Reports- Correspondence from the Chief Engineer in Charge of Maintenance for the Tower.Item 19 · .PDF · 157 KBOther Pertinent Forms and Reports- FAA Standard Instrument Approach ProcedureItem 20 · .PDF · 79 KBStatement of Party Representatives to NTSB InvestigationItem 21 · .PDF · 103 KBRelease of Aircraft Wreckage, NTSB Form 6120.15Item 22 · .PDF · 101 KBToxicological ReportItem 23 · .PDF · 299 KBPhoto 1: Initial Impact Crater. Note Left Wing Components.Item 24 · .PDF · 62 KBPhoto 2: View of the Horizontal and Vertical Stabilizers.Item 25 · .PDF · 55 KBPhoto 3: View of the Right Wing.Item 26 · .PDF · 61 KBPhoto 4: Thrust Levers.Item 27 · .PDF · 73 KBPhoto 5: JEPPESEN REVISION PAGES.Item 28 · .PDF · 35 KBPhoto 6: SEVERED LEFT WING.Item 29 · .PDF · 31 KBPhoto 7: PILOT'S ALTIMETER.Item 30 · .PDF · 41 KBPhoto 8: CO-PILOT'S ALTIMETER.Item 31 · .PDF · 49 KBPhoto 9: VIEW OF THE UPPER SECTION OF THE TOWER. NOTE THE DISPLACEMENT TO THE RIGHT. UPPERMOST WIRE ON THE LEFT WRAPPED AROUND OTHER WIRES.Item 32 · .PDF · 25 KBPhoto 10: PAINT COMPARISON NEAR BASE OF TOWER.Item 33 · .PDF · 27 KB

FAA reports on this event · 1

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