NYC05FA042

NTSB accident investigation · Embraer EMB-110P1 · Swanzey, NH · January 14, 2005

Accident · FatalField investigationFinal report
Date
January 13, 2005, 22:15 local (Jan 14, 2005, 03:15 UTC)
Place
Swanzey, NH
Injuries
1 fatal
Damage
Destroyed
Phase of flight
Enroute
Aircraft
N49BAEmbraer EMB-110P1
Weather
Instrument (IMC) · Night
Status
Completed · report July 30, 2008
Report
Approved by Office Director
Parties
Pratt and Whitney Canada, Embraer, CENIPA, FAA/FSDO, TSB Canada
FAA report
20050113000719A
Case key
60854

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 improper decision to attempt a single-engine missed approach with the airplane in a slow airspeed, full flap configuration, which resulted in a minimum control speed (Vmc) roll. Contributing factors included an inoperative engine for undetermined reasons, the pilot's in-flight decision to divert to an airport with low ceilings and visibility while better conditions existed elsewhere, the pilot's failure to advise or seek assistance from air traffic control or his company, and the low cloud ceilings, fog, and night lighting 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 engine powerCruise
1 engineFactor
Reason for occurrence undetermined
Proper assistance - not obtainedPilot in commandFactor
Loss of control - in flightMissed approach (ifr)
In-flight planning/decision - improperPilot in commandCause
Airspeed(vmc) - not maintainedPilot in command
Weather condition - fogFactor
Flaps - excessivePilot in command
Weather condition - low ceilingFactor
Maneuver - inadvertentPilot in command
Weather evaluation - incorrectPilot in commandFactor
Light condition - nightFactor
In flight collision with terrain/waterDescent - uncontrolled
Terrain condition - runway

Analysis

En route to the company's home airport, the twin-engine airplane either experienced a loss of power to the right engine, or the pilot decided to shut the engine down. Although the home airport had night visual meteorological conditions, and there was no evidence of any malfunction with the remaining engine, the pilot opted to fly a night precision instrument approach to an airport 45 nautical miles closer, with a 1-mile visibility and a 100-foot ceiling. Unknown to the pilot, there was also fog at the airport. The pilot did not advise or seek assistance from air traffic control or the company. When the airplane broke out of the clouds, it was not stable. Approaching the runway, at full flaps and exceeding the 25 percent maximum for a go-around, the pilot added full power to the left engine. The high power setting, slow airspeed, and full flaps combination resulted in a minimum control speed (Vmc) roll. No determination could be made as to why the right engine was inoperative, and there were no mechanical or fuel-related anomalies found that would have precluded normal operation.

Factual narrative

History of flight

On January 13, 2005, about 2215 eastern standard time, an Embraer EMB-110P1, N49BA, operated by Business Air, Incorporated as AirNow flight 2352, was destroyed when it impacted the runway at Dillant Hopkins Airport (EEN), Swanzey, New Hampshire. The certificated airline transport pilot was fatally injured. Night instrument meteorological conditions prevailed, and an instrument flight rules flight plan was filed for the flight that departed Bangor International Airport (BGR), Bangor, Maine. The non-scheduled cargo flight was conducted under 14 Code of Federal Regulations Part 135.

According to the operator's dispatch telephone log, at 1831, the pilot contacted the operator from Bangor, and discussed the weather. At 2018, the flight departed and proceeded towards Manchester. The log entry, at 2144, indicated that the pilot was unable to land at Manchester, and was holding. After discussions with company personnel, it was agreed the pilot would proceed to Bennington, Vermont, where the company was based. Bennington visibility at the time was 10 statute miles and the ceiling was 2,900 feet.

According to air traffic control transcript excerpts, at 2148, the pilot contacted Boston Consolidated Terminal Radar Approach Control, and confirmed "when able, direct bennington." Two minutes later, the pilot reported that he was level at 6,000 feet.

At 2155, the pilot began a series of transmissions with the controller, requesting to land at Keene, rather than Bennington, as "it's right on the way i believe to bennington." The controller provided a vector to Keene, and about 3 minutes later, had the pilot switch to another frequency. During the initial contact with the next controller, the pilot advised that he was "looking for the i-l-s." The controller provided a vector for the approach, cleared the pilot to descend to 5,000 feet, provided an altimeter setting of 29.92, and requested that the pilot "advise with the weather at keene." The pilot responded, "twenty three fifty two has the weather at keene."

The controller subsequently provided an adjustment to the vector, and at 2208, advised the pilot that his company wanted to speak to him, which the pilot acknowledged. One minute later, the pilot advised the controller, "we'd like to keep it in tight if we can," and the controller provided the pilot a new vector and cleared him to descend to 3,000 feet, which the pilot acknowledged.

At 2211, the controller provided the pilot a final vector, and advised him to maintain 3,000 feet until established on the approach, "cleared for the i-l-s two keene."

At 2211:59, the pilot reported "established inbound," and the controller advised that radar service was terminated, "cancel with me or flight service, change to advisory good night," which the pilot acknowledged.

No further transmissions were received from the airplane, and according to the transcript and the telephone log, at no time did the pilot report any mechanical malfunctions.

A witness, who had pulled off the road adjacent to approach end of runway 02 to make a cell phone call, stated that she saw the approach lights illuminate. The witness then observed the airplane, with its landing lights illuminated, appear from the clouds. The wings were rocking up and down so far that the witness thought a wing would strike the ground, once the airplane landed. As the airplane continued towards the airport, it flew in and out of low-lying clouds. The witness's attention became diverted momentarily, until she heard the engine noise from the airplane increase to "very loud." The witness looked back towards the airport, and observed a large fireball. The witness added that the weather at the time of the accident was "foggy".

Personnel information

The pilot held an airline transport pilot certificate with a rating for multi-engine land airplanes and a commercial pilot certificate for single-engine land and sea airplanes. His most recent application for a Federal Aviation Administration (FAA) second-class medical certificate was dated January 31, 2004.

According to the pilot's logbook, he had accumulated about 2,292 hours of total flight experience, with about 338 hours in make and model. The pilot had also accumulated about 360 hours of multi-engine flight experience, 520 hours of night flying experience, and 160 hours of actual instrument flight experience.

Aircraft information

The airplane was a 1980 Embraer (EMB)-110P1 Bandeirante, powered by two Pratt and Whitney Canada PT6A-34 engines. The airplane had been converted from a passenger configuration to a cargo configuration and was being operated by a single pilot, with no autopilot, under an approved Supplemental Type Certificate (STC). The airplane's maintenance was performed according to an FAA Approved Aircraft Inspection Program (AAIP), and it was carrying small packages at the time of the accident.

According to the right engine maintenance logbook, on November 13, 2000, the engine was "continue time inspected I/A/W Pratt and Whitney Canada Overhaul Manual," and converted to a PT6A-36 engine. Time since overhaul on that date was listed as 0.0 hours. On February 6, 2001, at 15.3 hours since overhaul, the engine was converted back to a PT6A-34 engine. The engine was then installed on the left side of another EMB-110P1 on February 21, 2001. On June 29, 2003, the engine was removed, and installed on the right side of the accident airplane at 45 hours since overhaul. Time since overhaul, as of January 13, 2005, was listed as 429.3 hours.

Airport information

Runway 02 was 6,201 feet long and 100 feet wide. Touchdown zone elevation was 488 feet.

Keene was about 35 nautical miles from Manchester, approximately en route to Bennington, which was about 80 nautical miles from Manchester.

The instrument landing system runway 02 (ILS RWY 02) approach minimum for the straight in approach was 1 statute mile of visibility, and the decision altitude was 823 feet mean sea level [msl] (335 feet above ground level [agl]). The missed approach procedure was to climb to 1,600 feet, via a heading of 006 degrees, then a climbing left turn to 3,000 feet, direct to the EEN VOR, and hold. The EEN VOR was located about 5.7 miles south of the airport.

According to an FAA inspector, the ILS RWY 02 system was "ground checked" the day after the accident, with no anomalies noted.

Meteorological information

The weather, reported at the airport at 2215, included winds from 350 degrees true at 3 knots, 1 statute mile of visibility, an overcast cloud layer at 100 feet agl, temperature 2 degrees Celsius, dew point 1 degree Celsius, and an altimeter setting of 29.91 inches of mercury.

A law enforcement officer, who responded to the accident within 3 minutes, stated that the weather at the airport was "so foggy that I could not see the flashing blue lights from my patrol car which was parked 15 feet from the accident site."

Wreckage and impact information

The airplane came to rest inverted on runway 02, about 90 feet from the approach end.

The wreckage was examined on January 14, 2005, at the accident site. The main fuselage was oriented on an approximate heading of 060 degrees, and all major components of the airplane were accounted for at the accident site.

A post crash fire consumed the main cabin and a majority of the cockpit area. Both the left and right wings were oriented at a 90-degree angle to the ground, with the leading edges resting on the runway surface.

The outboard section of the left wing leading edge was crushed rearward about 16 inches, with the damage becoming progressively less on the inboard section of the wing. The left wing fuel tank was ruptured. The left wing landing gear assembly was observed in the extended position, and the flap position was verified in the "full flap" position. The left engine came to rest under its respective wing, and was separated from its mounts.

T

Aircraft

Registration
N49BA
Reported as
Embraer EMB-110P1
Category
Airplane
Serial number
110-301
Airframe hours
39,466
Engine
Pratt & Whitney Canada PT6A-36, 750 hp, turbo prop
Damage
Destroyed
Fire
On-Ground
Flight
Part 135
Registered owner
Business Air Inc.
Airworthiness certificate
Standard, Transport
Last inspection
AAIP · August 1, 2004 · 139 hours before
Departed
BGR · Bangor, ME
Destination
EEN · Swanzey, NH
Flight plan
IFR
Airport
EEN · Dillant-Hopkins, runway 02, 6,201 × 100 ft, asphalt

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
46
Injuries
Fatal
Certificate
Airline transport
Airplane ratings
Single-engine sea, Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 2
Last flight review
October 1, 2004
Seat
Left
Flight hours
2,292 total · 338 in this make and model · 2,217 as pilot in command · 120 in the last 90 days · 40 in the last 30 days · 3 in the last 24 hours

Weather

Conditions
Instrument (IMC) · Night
Wind
350° at 3 knots
Visibility
1 statute miles
Lowest ceiling
100 ft overcast
Temperature
36 °F, dew point 34 °F
Altimeter
29.90 inHg
Observed at
EEN

Docket · 20

The files NTSB released with the investigation on May 22, 2008, on NTSB’s docket system: statements, records, photos and specialists’ reports. 3.5 MB in all.

FAA reports on this event · 1

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