MIA98FA091

NTSB accident investigation · Cessna 208B · Clarksville, TN · March 5, 1998

Accident · FatalField investigationFinal report
Date
March 5, 1998, 05:20 local (11:20 UTC)
Place
Clarksville, TN
Injuries
1 fatal
Damage
Destroyed
Phase of flight
Enroute
Aircraft
N840FECessna 208B
Weather
Instrument (IMC) · Night/dark
Status
Completed · report February 16, 2001
Report
Approved by Office Director
FAA report
19980305002709A
Case key
38390

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 did not maintain control of the airplane due to undetected airframe ice, resulting in an inadvertent stall, and subsequent impact with the ground. Factors in this accident were; flight into clouds, below freezing temperatures, and the inability of the pilot to detect ice, due to the lack of an ice detection system to determine ice build up on portions of the airframe that are not visible from the cockpit.

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 encounter with weatherCruise - normal
Light condition - dark night
Flight into known adverse weather - encounteredPilot in command
Weather condition - cloudsFactor
Weather condition - temperature,lowFactor
Weather condition - icing conditionsFactor
Anti-ice/deice system - inadequate
Acft/equip inadequate,visual restrictionProduction/design personnelFactor
Inadequate certification/approvalFaa(organization)
Loss of control - in flightDescent - uncontrolled
Airspeed - not maintainedPilot in command
Aircraft control - not maintainedPilot in commandCause
Stall - inadvertentPilot in commandCause
In flight collision with terrain/waterDescent - uncontrolled
Terrain condition - rough/uneven
Terrain condition - ground

Analysis

The flight was in radio contact with air traffic controllers at the FAA Memphis Air Route Traffic Control Center (ARTCC), and was level at 9,000 feet, when the pilot checked in on frequency. The last radio contact with the flight was at 0447. At 0520, radar contact was lost. The airplane impacted in rough terrain, at a steep angle of impact. Two other company pilots flying in trail of the accident aircraft said, they had radio contact with the pilot of N840FE about 5 minutes before the accident. They said he sounded fine and did not say anything about any problems. Radar data showing the flight's ground speed indicated that at 0512, the ground speed was 158 knots (182 mph). The ground speed then decreased to 153 (176 mph), 143 (165 mph), 138 (159 mph), and 132 (152 mph), until at 0519:40, when the ground speed of the flight was 125 knots (144 mph). After the radar read out at 0519:40, the next radar hit was coast (no information), and then the flight disappeared from the radar scope. The airplane's heading and altitude did not change during the decrease in ground speed. According to the NTSB Radar Data Study, calculated flight parameters indicated the airplane "...experienced a slow reduction of airspeed in the final 8 minutes of flight at altitude, and then abruptly exhibited a sharp nose down pitch attitude with a rapid increase in airspeed." About the time of the reduction in airspeed, pitch angle began to slowly increase also. When radar contact was lost, the calculated airspeed had reduced to less then 102 knots [118 mph], and calculated body angle of attack [AOA] had increased to 8.8 degrees. A large reduction in pitch angle, angle of attack, and flight path angle as the airspeed increases after peak AOA was reached. Examination of the engine Power Analyzer and Recorder (PAR) revealed that no exceedences were in progress at the time power was removed from the PAR. It was determined that no caution timing events were in progress. The PAR computer appeared to be operating correctly until power was removed at impact. Examination of the airplane's autopilot were not conclusive due to impact damage. Determination of whether the autopilot was engaged or not engaged at the time of the accident could not be determined. The NTSB Meteorological Factual Report revealed that at 0515, about 7 minutes before the flight was lost on radar, the radiative temperature in an area centered at Clarksville (4 kilometer resolution data), showed that the Mean Radiative Temperature was -6.26 degrees C (21F). The Minimum Radiative Temperature was -6.66 degrees C (19F). The Maximum Radiative Temperature was -6.06 degrees C (21F). According to the Archive Level II Doppler weather radar tape for a beginning sweep time of 0508:10, showed that N840FE had tracked into a weather echo from 0510:34, to 0516:28. The Doppler Weather Radar data, revealed that N840FE, had entered a weak weather echo about the same time that the airspeed of the airplane started to decrease, at an altitude of about 9,000 feet, and the airplane was in the weak weather echo for a few minutes. Based on the weather data, it was determined that in-flight airplane icing conditions were encountered by N840FE. Cessna Aircraft Company Airworthiness Directive (AD) 96-09-15; Amendment 39-9591; Docket No. 96-CE-05-AD, applicable to this airplane and complied with by the company, on December 12, 1996, stated: "...to minimize the potential hazards associated with operating the airplane in severe icing conditions by providing more clearly defined procedures and limitations associated with such conditions...operators must initiate action to notify and ensure that flight crewmembers are apprised of this change...revise the FAA-approved Airplane Flight Manual (AFM) by incorporating the following into the Limitation Section of the AFM. This may be accomplished by inserting a copy of this AD in the AFM...." The airplane was equipped with leading edge deicing boots on the wings, elevators, struts, and had a cargo pod deicing capability. Lights were installed to illuminate the leading edge of the wings, to aid the pilot in detecting ice on the leading edges of the wings during night operations. The airplane was not equipped with an ice detection device.

Factual narrative

History of flight

On March 5, 1998, about 0520 central standard time, a Cessna 208B, N840FE, registered to Federal Express Inc., and operated by Baron Aviation Services, Inc., as flight SM8315 (call sign Show Me), was destroyed after impact with the ground, near Clarksville, Tennessee. The commercial-rated pilot was fatally injured. Instrument meteorological conditions (IMC) prevailed in the vicinity, and an IFR (instrument flight rules) flight plan had been filed. The scheduled domestic cargo flight from Memphis, Tennessee, to Bowling Green, Kentucky, was being conducted in accordance with Title 14 CFR Part 135. The flight had departed Memphis, at 0413.

The pilot of SM8315 was in radio contact with air traffic controllers at the FAA Memphis Air Route Traffic Control Center (ARTCC) and was level at an altitude of about 9,000 feet, on the Nashville VOR 315-degree radial, about 25 nautical miles, when radio and radar contact was lost. Witnesses in the area reported hearing the sound of the crash and the wreckage was located a short time later. The crash site was located on the Nashville VOR 315-degree radial about 35 nautical miles, or about 5 miles southeast of Clarksville.

The last radio communication with the pilot of SM8315 was at 0447, when he checked in on frequency with the Memphis ARTCC, and reported at 9,000 feet. About 0520, radar contact was lost. At 0521, the controller attempted to re-establish radio contact with the pilot, and said he had lost his transponder. No response from the pilot was received, and no further radar contacts were made. The airplane impacted in rough terrain, at a steep angle of impact.

Two other company pilots flying in the same vicinity at the time of the accident said they were at 7,000 feet msl (SM8314), and 5,000 feet msl (SM8316). They said they were in and out of the clouds. The pilot of SM8314 indicated that the outside air temperature (OAT) at 7,000 feet was between 0 degrees C (32F) and -1 degree C (30F). The pilot of SM8316 indicated that the OAT at 5,000 feet was between 3 degrees C (37F) and 5 degree C (41F). The other two company pilots also said they had radio contact with the pilot of SM8315 about 5 minutes before the accident. They said he sounded fine and did not say anything about any problems. A third company pilot flying about 100 miles behind SM8315, said he was at 9,000 feet and had picked up some ice crystals. The third pilot landed at Nashville, about 50 miles south of the crash site.

Radar data showing the flight's ground speed indicated that at 0512, the ground speed was 158 knots (182 mph). The ground speed then decreased to 153 (176 mph), 143 (165 mph), 138 (159 mph), and 132 (152 mph), until at 0519:40, when the ground speed of the flight was 125 knots (144 mph). After the radar readout at 0519:40, the next radar hit was "coast," no information, and then the flight disappeared from the radar scope. The sweep of the radar scope was 12-second intervals. During the change in ground speed the airplane's heading and altitude did not change.

The NTSB Office of Research and Engineering's Radar Data Study revealed that radar trajectory studies indicated the flight was cruising at about 9,200 feet msl (mean sea level) altitude and at roughly 135 knots (156 mph) calibrated airspeed (KCAS) en route from Memphis to Bowling Green. According to the NTSB Radar Data Study, calculated flight parameters indicated the airplane "...experienced a slow reduction of airspeed in the final 8 minutes of flight at altitude, and then abruptly exhibited a sharp nose down pitch attitude with a rapid increase in airspeed."

Radar plots showed that SM8315, "...maintained a steady altitude at 9,400 feet-msl, at an airspeed of close to 135 knots, and flying on heading 040 [degrees]. About 10 minutes before the upset...the aircraft's airspeed began to slightly reduce to close [to] 125 knots [144 mph] as the pitch angle and flight path remained steady. Five minutes before radar contact was lost, [the] airspeed began to further reduce at an increased rate, with a corresponding increase in angle of attack. About the time of the increased reduction in airspeed, pitch angle began to slowly increase also. When radar contact was lost, the calculated airspeed had reduced to less then 102 knots [118 mph], and calculated body angle of attack [AOA] had increased to 8.8 degrees. A large reduction in pitch angle, angle of attack, and flight path angle as the airspeed increases after peak AOA was reached." (See the NTSB Radar Data Study an attachment to this report.)

A witness, who had an aviation background, was located at his home about 1 mile south of the crash site. He told investigators he heard an aircraft directly above his house "at approximately 200 feet, having engine trouble. " He described the sound from the airplane as like the sound of a "pilot changing the prop setting [pitch angle]." He then heard the airplane crash.

The accident occurred during the hours of darkness approximately 36 degrees, 28 minutes north, and 087 degrees, 13 minutes west.

Personnel information

Information on the pilot is contained in this report on page 3, under First Pilot Information. The pilot had been employed by Baron Aviation Services Inc., for 7 1/2 years, with a date of hire of August 13, 1990. The company reported it was common practice for their pilots to fly the same route, and the majority of this pilot's time with the company was flying the same route as the accident flight. The duty time of the pilot on the day before the accident, March 4, 1998, was 7 hours 51 minutes. On the day of the accident, March 5, 1998, the pilot had a duty time of 6 hours 23 minutes. The pilot had a total flight time in this make and model airplane of 5,198 hours. His last check ride before the accident was February 26, 1998.

Aircraft information

At the time of the accident the total time on the airframe was 4,078.5 hours. The maximum gross weight was 8,750 pounds. The airplane was equipped with leading edge deicing boots on the wings, elevators, struts, and had a cargo pod deicing capability. Lights were installed to illuminate the leading edge of the wings, to aid the pilot in detecting ice on the leading edges of the wings during night operations. The airplane was not equipped with an ice detection device.

Meteorological information

Meteorological information is contained in this report on page 3, under Weather Information. A preliminary weather study for the accident area showed that at 9,000 feet the temperature was minus 4 degrees C (24.8 F), and the tops of the clouds were from 10,000 to 11,000 feet. There was also an AIRMET (Airman's Meteorological Information) issued that covered the area around the crash site that called for icing conditions.

The following AIRMET was found in the wreckage; "AIRMET ICE...Tennessee, Mississippi, Alabama...FROM TRI TO CHA TO 50W ATL TO GWO TO DYR TO TRI, LGT OCNL MOD RIME ICGIC BTN 060 160. CONDS OVR NRN MS /WRN TENN, SPRDG TO RMNDR AREA BY 09Z...CONS CONTG BTD 09Z THUR 15Z."

[From Bristol/Johnson/Kingsport, Tennessee, to Chattanooga, Tennessee, to 50 miles west of Atlanta, Georgia, to Greenwood, Mississippi, to Dyersburg, Tennessee, to Bristol/Johnson/Kingsport, Tennessee, light occasional moderate rime icing between 6,000 feet msl and 16,000 feet msl. Conditions over northern Mississippi/ western Tennessee, spreading to the remainder of the area by 0900 UTC (0300)...conditions continuing beyond 0900 UTC thru 1500 UTC (0900).] A map trace of this AIRMET, showed that it included the flight path area, times and altitudes associated with the flight of SM8315.

The pilot of SM8314 said that his flight conditions at 7,000 were, "...IMC [instrument meteorological conditions] with an outside air temperature of 0 degrees C (32F) to -1 degree C (30 F), but no ice was forming on my airplane at any time."

At

Aircraft

Registration
N840FE
Reported as
Cessna 208B
Category
Airplane
Serial number
C208B-0142
Airframe hours
4,079
Engine
P&W PT6A-114, 600 horsepower, turbo prop
Damage
Destroyed
Flight
Part 135
Operator
Baron Aviation Services Inc., doing business as Federal Express
Registered owner
Federal Express Corp.
Airworthiness certificate
Standard, Normal
Last inspection
AAIP · January 15, 1998 · 88 hours before
Departed
MEM · Memphis, TN
Destination
BWG · Bowling Green, KY
Flight plan
IFR

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
45
Certificate
Commercial
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 2, Valid Medical--no waivers/lim.
Seat
Left
Toxicology
Performed
Flight hours
8,398 total · 5,198 in this make and model · 7,000 as pilot in command · 160 in the last 90 days · 50 in the last 30 days · 3 in the last 24 hours

Weather

Conditions
Instrument (IMC) · Night/dark
Wind
180° at 5 knots
Visibility
5 statute miles
Lowest ceiling
2,000 ft overcast
Temperature
109 °F, dew point 97 °F
Altimeter
30.00 inHg
Observed at
HOP, 5 nm away

Docket · 46

The files NTSB released with the investigation on July 28, 1999, on NTSB’s docket system: statements, records, photos and specialists’ reports. 26.1 MB in all.

Supplement CItem 1 · .PDF · 416 KBSupplement DItem 2 · .PDF · 495 KBSupplement KItem 3 · .PDF · 435 KBHazardous Materials Factual ReportItem 4 · .PDF · 2.6 MBMaterials Laboratory Factual ReportItem 5 · .PDF · 105 KBMeteorology Factual Report and AddendumItem 6 · .PDF · 1.4 MBRadar Data StudyItem 7 · .PDF · 245 KBPilot/Operator Aircraft Accident Report, NTSB Form 6120.1/2Item 8 · .PDF · 2.3 MBWitness StatementsItem 9 · .PDF · 592 KBMaps or Charts of Accident Area, Wreckage DiagramsItem 10 · .PDF · 706 KBWeather Reports, Airmets and RecordsItem 11 · .PDF · 820 KBTranscript of Radio CommunicationsItem 12 · .PDF · 1.2 MBReports from Parties to the Investigation - FedEx, Cessna, PAR Avionics Specialties, P&W, and Allied SignalItem 13 · .PDF · 6.8 MBStatement of Party Representatives to NTSB InvestigationItem 14 · .PDF · 90 KBRelease of Aircraft Wreckage, NTSB Form 6120.15Item 15 · .PDF · 93 KBToxicological ReportItem 16 · .PDF · 68 KBMiscellaneousItem 17 · .PDF · 3.2 MBPhoto 1. General view of the wreckage. Photo taken opposite the direction of travel.Item 18 · .PDF · 178 KBPhoto 2. Wing and tail section.Item 19 · .PDF · 178 KBPhoto 3. Photo taken in the direction of travel. The arrow points to the impact creator.Item 20 · .PDF · 182 KBPhoto 4. Re-construction of the wreckage.Item 21 · .PDF · 170 KBPhoto 5. Engine.Item 22 · .PDF · 161 KBPhoto 6. Propeller blades.Item 23 · .PDF · 149 KBPhoto 7. Switches. The following switches were found in the up [on] position at impact; pitot static heat, stall heat, de-ice/anti wing light, w/s [windshield].Item 24 · .PDF · 178 KBPhoto 8. Same as photo No. 7.Item 25 · .PDF · 178 KBPhoto 9. Autopilot panel. The AP on/off switch was found in the up [on] position [arrow].Item 26 · .PDF · 168 KBPhoto 10. Impact creator found just aft of the wreckage.Item 27 · .PDF · 230 KBPhoto 11. Photo provided and taken by the FAA [no negative].Item 28 · .PDF · 187 KBPhoto 12. Photo provided and taken by the FAA [no negative].Item 29 · .PDF · 227 KBPhoto 13. Photo provided and taken by the FAA [no negative].Item 30 · .PDF · 224 KBPhoto 14. Photo provided and taken by the FAA [no negative].Item 31 · .PDF · 158 KBPhoto 15. Photo provided and taken by the FAA [no negative].Item 32 · .PDF · 161 KBPhoto 16. Photo provided and taken by the FAA [no negative].Item 33 · .PDF · 228 KBPhoto 17. Photo provided and taken by the FAA no negative].Item 34 · .PDF · 144 KBPhoto 18. Photo provided and taken by the FAA [no negative].Item 35 · .PDF · 155 KBPhoto 19. Photo provided and taken by the FAA [no negative].Item 36 · .PDF · 83 KBPhoto 20. Photo provided and taken by Cessna [no negative].Item 37 · .PDF · 162 KBPhoto 21. Photo provided and taken by Cessna [no negative].Item 38 · .PDF · 116 KBPhoto 22. Photo provided and taken by Cessna [no negative].Item 39 · .PDF · 119 KBPhoto 23. Photo provided and taken by Cessna [no negative].Item 40 · .PDF · 106 KBPhoto 24. Photo provided and taken by Cessna [no negative].Item 41 · .PDF · 104 KBPhoto 25. Photo provided and taken by Cessna [no negative].Item 42 · .PDF · 105 KBPhoto 26. Photo provided and taken by Cessna [no negative].Item 43 · .PDF · 116 KBPhoto 27. Photo provided and taken by Cessna [no negative].Item 44 · .PDF · 118 KBPhoto 28. Photo provided and taken by Cessna [no negative].Item 45 · .PDF · 100 KBPhoto 29. Photo provided and taken by Cessna [no negative].Item 46 · .PDF · 105 KB

FAA reports on this event · 1

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