# NTSB NYC05FA042: Embraer EMB-110P1, N49BA, Swanzey, NH, January 14, 2005 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: January 13, 2005, 22:15 local (Jan 14, 2005, 03:15 UTC) - Place: Swanzey, NH - Coordinates: 42.898334, -72.23722 - Nearby events: https://openairdocs.org/map.md?lat=42.8983&lon=-72.2372&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed, report July 30, 2008 - Report: Approved by Office Director - Parties: Pratt and Whitney Canada, Embraer, CENIPA, FAA/FSDO, TSB Canada - NTSB case key (mKey): 60854 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=NYC05FA042 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/60854/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=60854 - Page: https://openairdocs.org/ntsb/NYC05FA042 ## 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 In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of engine power, cruise - 1 engine (contributing factor) - reason for occurrence undetermined - proper assistance - not obtained, pilot in command (contributing factor) - Loss of control - in flight, missed approach (ifr) - in-flight planning/decision - improper, pilot in command (cause) - airspeed(vmc) - not maintained, pilot in command - weather condition - fog (contributing factor) - flaps - excessive, pilot in command - weather condition - low ceiling (contributing factor) - maneuver - inadvertent, pilot in command - weather evaluation - incorrect, pilot in command (contributing factor) - light condition - night (contributing factor) - In flight collision with terrain/water, descent - 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](https://openairdocs.org/deregistered/N49BA-2007-11-15), registration cancelled 2007-11-15, S/N 110.301, built 1980 (OpenAirDocs) - Reported make and model: Embraer EMB-110P1 - Registry model: [Embraer EMB-110P1](https://openairdocs.org/model/embraer-emb-110p1) (registry code 3260122) (OpenAirDocs) - Registry engine: [U/A Canada PT6A-34](https://openairdocs.org/engine/u-a-canada-pt6a-34) (registry code 61534, turbo-prop) (OpenAirDocs) - Category: Airplane - Serial number: 110-301 - Airframe hours: 39466 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 46; injuries: fatal; 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 ## 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 20050113000719A](https://openairdocs.org/incident/20050113000719A), Jan 13, 2005: Emb EMB110P1, Keene, NH, Destroyed, 1 fatal. (-23) The aircraft crashed during an ILS to runway 02 at the Keene/Dillant-Hopkins Airport (een). The aircraft was in IMC conditions during the approach. The… ## Docket (20 files) The files NTSB released with the investigation on May 22, 2008, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=60854. 3.5 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 239 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40293105&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Excerpts, Partial Air Traffic Control Transcript (item 2, .PDF, 144 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40293101&FileExtension=.PDF&FileName=Excerpts,%20Partial%20Air%20Traffic%20Control%20Transcript%20-Redacted.PDF - Swanzey Fire Department Press Release (item 3, .PDF, 47 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40293208&FileExtension=.PDF&FileName=Swanzey%20Fire%20Department%20Press%20Release-Master.PDF - Excerpts, AirNow Telephone Logs (item 4, .PDF, 182 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40293104&FileExtension=.PDF&FileName=Excerpts,%20AirNow%20Telephone%20Logs-Master.PDF - Statements from Pilot of Flight RLR951 (item 5, .PDF, 90 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40293201&FileExtension=.PDF&FileName=Statements%20from%20Pilot%20of%20Flight%20RLR951-Redacted.PDF - Wreckage Diagram (item 6, .PDF, 19 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40293107&FileExtension=.PDF&FileName=Wreckage%20Diagram-Master.PDF - Excerpts, Right Engine Maintenance Logs (item 7, .PDF, 540 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40293199&FileExtension=.PDF&FileName=Excerpts,%20Right%20Engine%20Maintenance%20Logs%20-Redacted.PDF - Materials Laboratory Factual Report 05-020, EDS examination of fuel residue (item 8, .PDF, 117 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40226914&FileExtension=.PDF&FileName=Materials%20Laboratory%20Factual%20Report%2005-020,%20EDS%20examination%20of%20fuel%20residue-Master.PDF - Commercial Laboratory Fuel Test (item 9, .PDF, 154 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40293204&FileExtension=.PDF&FileName=Commercial%20Laboratory%20Fuel%20Test-Redacted.PDF - Fuel Load Worksheet (item 10, .PDF, 18 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40293206&FileExtension=.PDF&FileName=Fuel%20Load%20Worksheet-Master.PDF - Toxicological Report (item 11, .PDF, 56 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40293106&FileExtension=.PDF&FileName=Toxicological%20Report-Redacted.PDF - Statement of Party Representatives to NTSB Investigation (item 12, .PDF, 58 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40293207&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Embraer One-Engine Inoperative Landing and Go-Around Procedure (item 13, .PDF, 60 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40293108&FileExtension=.PDF&FileName=Embraer%20One-Engine%20Inoperative%20Landing%20and%20Go-Around%20Procedure%20-Master.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 14, .PDF, 46 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40293203&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - Photo - Wreckage Overview 1 (item 15, .PDF, 280 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40293112&FileExtension=.PDF&FileName=Photo%20-%20Wreckage%20Overview%201-Master.PDF - Photo - Wreckage Overview 2 (item 16, .PDF, 268 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40293113&FileExtension=.PDF&FileName=Photo%20-%20Wreckage%20Overview%202-Master.PDF - Photo - Left Engine Propeller/Hub (item 17, .PDF, 278 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40293114&FileExtension=.PDF&FileName=Photo%20-%20Left%20Engine%20Propeller%2FHub-Master.PDF - Photo - Left Engine Propeller Runway Marks (item 18, .PDF, 312 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40293115&FileExtension=.PDF&FileName=Photo%20-%20Left%20Engine%20Propeller%20Runway%20Marks-Master.PDF - Photo - Right Engine Propeller/Hub (item 19, .PDF, 295 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40293116&FileExtension=.PDF&FileName=Photo%20-%20Right%20Engine%20Propeller%2FHub-Master.PDF - Photo - Right Engine Propeller Runway Marks (item 20, .PDF, 284 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40293118&FileExtension=.PDF&FileName=Photo%20-%20Right%20Engine%20Propeller%20Runway%20Marks-Master.PDF From the NTSB's public API. 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