# NTSB NYC03FA203: Cessna 402C, N405BK, Nantucket, MA, September 23, 2003 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: September 23, 2003, 05:23 local (09:23 UTC) - Place: Nantucket, MA - Coordinates: 41.248332, -70.06472 - Nearby events: https://openairdocs.org/map.md?lat=41.2483&lon=-70.0647&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 1 fatal, 1 serious - Status: Completed, report February 24, 2005 - Report: Approved by Office Director - Parties: Bost Flight Standards District Office, Continental Motors, Mass Aeronautics Commission, Cessna Aircraft Company - NTSB case key (mKey): 57976 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=NYC03FA203 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/57976/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=57976 - Page: https://openairdocs.org/ntsb/NYC03FA203 ## Probable cause The pilot's failure to maintain aircraft control during a missed approach. Factors in this accident were fog and the night light conditions. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of control - in flight, missed approach (ifr) - aircraft control - not maintained, pilot in command (cause) - weather condition - fog (contributing factor) - light condition - night (contributing factor) - In flight collision with terrain/water, missed approach (ifr) - terrain condition - ground ## Analysis The pilot was conducting an instrument landing system approach during night instrument meteorological conditions. The airplane was observed to descend toward the runway threshold to an altitude consistent with the approach decision height. A witness reported that he heard the airplane overhead, and assumed that the pilot had performed a missed approach. He described the engine noise as "cruise power" and did not hear any unusual sounds. Shortly thereafter, he received a call from airport operations stating that an airplane had crashed. The airplane impacted the ground about 1/4 mile to the left of the runway centerline, about 3,500 feet beyond the approach end of the runway. Examination of the airplane did not reveal any pre-impact mechanical malfunctions. A weather observation taken around the time of the accident, included a visibility 1/2 statue mile in fog, and an indefinite ceiling at 100 feet. The witness described the weather at the time of the accident as thick fog, and "pitch black." ## Factual narrative HISTORY OF FLIGHT On September 23, 2003, about 0523 eastern daylight time, a Cessna 402C, N405BK, operated by Island Airlines Inc., as flight 400, was substantially damaged when it impacted terrain, while on approach to the Nantucket Memorial Airport (ACK), Nantucket, Massachusetts. The certificated airline transport pilot was fatally injured, and a passenger was seriously injured. Night instrument meteorological conditions prevailed and an instrument flight rules (IFR) flight plan was filed for the flight that departed the Barnstable Municipal Airport (HYA), Hyannis, Massachusetts. The non-scheduled cargo flight was conducted under 14 CFR Part 135. According to air traffic control information obtained from the Federal Aviation Administration (FAA), the airplane departed HYA under visual flight rules about 0508. Shortly after takeoff, the pilot requested and received an IFR clearance. At 0516, the airplane was 12 miles from ACK, and was cleared for the ILS Runway 24 approach. At 0520:52, the airplane's radar track was observed at 1,000 feet, with a ground speed of 114 knots, as it descended toward runway 24. At 0522:02, the airplane was observed at an altitude of 300 feet, as it approached the runway threshold. The airplane crossed slightly to the right of the runway centerline, and then made a left turn, about 45 degrees to the runway. The airplane's last radar target was observed at 0522:42, and was consistent with the accident site location. The altitude of the last radar target was not recorded. According to an airport supervisor, the pilot called on the tower frequency, and asked if the runway lights were on. The airport supervisor confirmed that runway lights were illuminated and radioed the pilot; however, the pilot did not respond. He heard the airplane overhead, and assumed that the pilot had performed a missed approach. He described the engine noise as "cruise power" and did not hear any unusual sounds. Shortly thereafter, he received a call from airport operations stating that an airplane had crashed. The passenger was employed by Island Airlines as a ticket agent. She held a commercial pilot's license with an instrument rating. During an interview with a Federal Aviation Administration inspector, the passenger described the flight and approach as "normal." She recalled that the weather was IFR and foggy, and the pilot initiated a missed approach; however, she had no further memory of the flight. The accident occurred during the hours of darkness approximately 41 degrees, 14.9 minutes north latitude, and 70 degrees, 3.9 minutes west longitude. PERSONNEL INFORMATION The pilot held an airline transport pilot certificate, with an multi-engine land airplane rating. He also held a commercial pilot certificate with ratings for rotorcraft, and single engine land and sea airplanes. The pilot reported 14,000 hours of total flight experience on his most recent application for an FAA first class medical certificate, which was issued on April 16, 2003. Island Airlines reported that the pilot had accumulated about 4,000 hours of total flight experience in the same make and model as the accident airplane, which included 106 and 36 hours accumulated during the preceding 30 and 90 days, respectively. The pilot received and passed an airman competency check on May 6, 2003. According to company records, the pilot was not scheduled to work on September 20, and 21. On September 22, the pilot reported for duty at 0455, and reported off duty at 1200. He flew for 1.2 hours. On the date of the accident, the pilot reported for duty at 0450. AIRCRAFT INFORMATION The airplane was maintained under an approved airworthiness inspection program. The airplane had been operated for about 50 hours since it's most recent inspection, which was performed on September 2, 2003. At the time of the accident, the airplane had accumulated about 9,800 total airframe hours. The left engine was rebuilt by Teledyne Continental Motors, Mobile, Alabama, on September 29, 2001, and installed on the accident airplane on November 19, 2001. At the time of the accident, the left engine had accumulated about 1,430 hours since installation. The right engine was rebuilt by Teledyne Continental Motors, Mobile, Alabama, on November 12, 2001, and installed on the accident airplane on December 11, 2001. At the time of the accident, the right engine had accumulated about 1,370 hours since installation. According to an FAA inspector, the airplane was loaded with about 650 pounds of newspapers, which were placed in-between the passenger seats. METEOROLOGICAL INFORMATION A weather observation taken at ACK, at 0529, reported: Winds from 130 degrees at 10 knots, visibility 1/2 statue mile in fog, indefinite ceiling at 100 feet, temperature and dew point 61 degrees F, altimeter 30.04 in/hg. The airport supervisor described the weather at the time of the accident as thick fog, and "pitch black." AERODROME INFORMATION The Nantucket Memorial Airport was located at an elevation of 48 feet msl. Runway 24 was 6,303 feet-long, 150 feet-wide, and constructed of asphalt. In addition, runway 24, was equipped a simplified short approach lighting system with runway alignment indicator lights. Review of the approach diagram for the ILS Runway 24 approach revealed a decision height of 248 feet msl, and an approach minimum of 1/2 mile visibility. The published missed approach procedure included an initial climb to 700 feet, and then a climbing right turn to 2,500 feet. A post accident FAA flight inspection of the runway 24 instrument landing system did not revealed any equipment or signal malfunctions. WRECKAGE AND IMPACT INFORMATION The airplane impacted the ground about 1/4 mile to the left of the runway centerline, about 3,500 feet beyond the approach end of the runway. A debris path oriented on a 196 degree heading, began at a berm, and continued approximately 275 feet to the main wreckage. Approximately 3 feet of the airplane's left wing tip was located on the berm. In addition, 2 to 3 inch diameter trees, located near the berm, were cut at 45-degree angles, and contained black paint on the cut surfaces. The tops of the trees were cut at equal heights. All major portions of the airframe were accounted for at the accident site. The left wing, left engine, and the right wing outboard of the engine nacelle, were located approximately 125 feet from the initial impact point. The area leading to and around the wings was charred. The left wing was destroyed by impact and fire damage. The right wing was partially consumed by fire, forward of the inboard flap area. The aileron was charred and the wing tip was bent up about 45 degrees. The main wreckage came to rest upright on a 200 degree heading. There was no evidence of fire damage associated with the main wreckage. The left side of the airplane, forward of the empennage was absent, exposing the interior of the cabin. The inboard portion of the right wing remained attached to the airframe. The nose section, which contained the nose gear was located about 225 feet along the debris path. The remainder of the forward cockpit area was crushed to a point just forward of the wing leading edges. The horizontal stabilizer was intact, except for the left elevator counter weight, which was located near the beginning of the debris path. The horizontal stabilizer was inverted and remained attached to the empennage by elevator trim cables. The rudder was intact and remained connected to the airframe. Flight control continuity was confirmed from the forward cockpit area, through the aft cabin bulkhead to the rudder control surface. Due to impact damage the flight control cables to the elevator and aileron were not intact. Examination of the flap motor sprocket chain corresponded with a 0 degree flap setting. All landing gear were observed in a ## Aircraft - Registration: [N405BK](https://openairdocs.org/deregistered/N405BK-2006-06-14), registration cancelled 2006-06-14, S/N 402C0459, built 1981 (OpenAirDocs) - Reported make and model: Cessna 402C - Registry model: [Cessna 402C](https://openairdocs.org/model/cessna-402c) (registry code 207590R) (OpenAirDocs) - Registry engine: [Continental TSIO-520 series](https://openairdocs.org/engine/continental-tsio-520-series) (registry code 17040, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 402C-0459 - Airframe hours: 9795 - Engines: Continental TSIO-520-VB 325 horsepower reciprocating; Continental TSIO-520-VB 325 horsepower reciprocating - Damage: Substantial damage - Fire: On-Ground - Flight: Part 135 - Operator: Island Airlines Inc - Registered owner: B & K Leasing, Inc. - Airworthiness certificate: Standard, Normal - Last inspection: AAIP, September 2, 2003, 50 hours before - Departed: HYA, Hyannis, MA - Destination: ACK, Nantucket, MA - Flight plan: IFR - Airport: ACK, Nantucket Memorial, runway 24, 6,303 × 150 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 59; injuries: fatal; commercial, airline transport; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 1, valid medical--w/ waivers/lim; last flight review May 6, 2003; seat: left; toxicology performed; flight hours: 14,000 total, 4,000 in this make and model, 14,000 as pilot in command, 106 in the last 90 days, 36 in the last 30 days, 1 in the last 24 hours ## Weather - Conditions: Instrument (IMC), Night - Wind: 130° at 10 knots - Visibility: 0.5 statute miles - Lowest ceiling: 100 ft indefinitevv - Temperature: 61 °F, dew point 61 °F - Altimeter: 30.04 inHg - Observed at: ACK ## 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 20030923027679A](https://openairdocs.org/incident/20030923027679A), Sep 23, 2003: Cessna 402C, Nantucket, MA, Substantial damage, 1 fatal. (-23) [privacy data omitted] one fatality and one seriously injured when N405BK, CE-402-C, on an instrument flight rules flight plan, enroute from barnstable… ## Docket (13 files) The files NTSB released with the investigation on December 29, 2004, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=57976. 3.6 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 290 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40461001&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Air Traffic Control Summary and Transcripts (item 2, .PDF, 141 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40461002&FileExtension=.PDF&FileName=Air%20Traffic%20Control%20Summary%20and%20Transcripts-Master.PDF - Witness Statements and Interview Summaries (item 3, .PDF, 199 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40461003&FileExtension=.PDF&FileName=Witness%20Statements%20and%20Interview%20Summaries-Master.PDF - Maintenance Records (excerpts) (item 4, .PDF, 534 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40461004&FileExtension=.PDF&FileName=Maintenance%20Records%20(excerpts)-Master.PDF - Pilot Training Records (excerpts) and recent duty schedule (item 5, .PDF, 326 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40461005&FileExtension=.PDF&FileName=Pilot%20Training%20Records%20(excerpts)%20and%20recent%20duty%20schedule-Master.PDF - Weather Observations (item 6, .PDF, 32 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40461006&FileExtension=.PDF&FileName=Weather%20Observations-Master.PDF - FAA Flight Inspection Report (item 7, .PDF, 141 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40461007&FileExtension=.PDF&FileName=FAA%20Flight%20Inspection%20Report-Master.PDF - Astronomical Data (item 8, .PDF, 29 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40223112&FileExtension=.PDF&FileName=Astronomical%20Data-Master.PDF - FAA Toxicological Report (item 9, .PDF, 80 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40461008&FileExtension=.PDF&FileName=FAA%20Toxicological%20Report-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 10, .PDF, 185 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40461009&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Master.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 11, .PDF, 72 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40461010&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Master.PDF - Photograph # 1: View of right side of airplane, as it came to rest. (item 12, .PDF, 691 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40223127&FileExtension=.PDF&FileName=Photograph%20%23%201%3A%20View%20of%20right%20side%20of%20airplane,%20as%20it%20came%20to%20rest.%20%20-Master.PDF - Photograph # 2: View of front left side of airplane. (item 13, .PDF, 906 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40223130&FileExtension=.PDF&FileName=Photograph%20%23%202%3A%20View%20of%20front%20left%20side%20of%20airplane.%20%20-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.