NYC08MA090

NTSB accident investigation · Raytheon C90A · Mount Airy, NC · February 1, 2008

Accident · FatalMajor investigationFinal report
Date
February 1, 2008, 11:28 local (16:28 UTC)
Place
Mount Airy, NC
Injuries
6 fatal
Damage
Substantial damage
Phase of flight
Approach
Aircraft
N57WRRaytheon C90A
Defining event
Approach-IFR missed approach: Aerodynamic stall/spin
Weather
Instrument (IMC) · Day
Status
Completed · report April 22, 2010
Report
Approved by Office Director
Parties
Hartzell Propeller, Hawker Beechcraft, FAA/FSDO, Pratt & Whitney Canada, TSBC
FAA report
20080201011039A
Case key
67450

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 failure to maintain control of the airplane in instrument meteorological conditions. Contributing to the accident were the pilot's improper decision to descend below the minimum descent altitude, and failure to follow the published missed approach procedure.

Findings · 8

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Use of equip/info: aircraft controlPersonnel issues › Task performance · PilotRaytheon C90A: 4 casesAll aircraft: 9,295 casesProbable cause
Ceiling/visibility/precip: low ceilingEnvironmental issues › Conditions/weather/phenomena · Decision related to conditionRaytheon C90A: 1 caseAll aircraft: 190 cases
Ceiling/visibility/precip: low visibilityEnvironmental issues › Conditions/weather/phenomena · Decision related to conditionRaytheon C90A: 1 caseAll aircraft: 175 cases
Ceiling/visibility/precip: drizzle/mistEnvironmental issues › Conditions/weather/phenomena · Decision related to conditionRaytheon C90A: 1 caseAll aircraft: 18 cases
Performance/control parametersAircraft › Aircraft oper/perf/capability · Not attained/maintainedRaytheon C90A: 1 caseAll aircraft: 1,269 casesProbable cause
Use of equip/info: use of policy/procedurePersonnel issues › Task performance · PilotRaytheon C90A: 2 casesAll aircraft: 191 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

While flying a nonprecision approach, the pilot deliberately descended below the minimum descent altitude (MDA) and attempted to execute a circle to land below the published circling minimums instead of executing the published missed approach procedure. During the circle to land, visual contact with the airport environment was lost and engine power was never increased after the airplane had leveled off. The airplane decelerated and entered an aerodynamic stall, followed by an uncontrolled descent which continued until ground impact. Weather at the time consisted of rain, with ceilings ranging from 300 to 600 feet, and visibility remaining relatively constant at 2.5 miles in fog. Review of the cockpit voice recorder (CVR) audio revealed that the pilot had displayed some non professional behavior prior to initiating the approach. Also contained on the CVR were comments by the pilot indicating he planned to descend below the MDA prior to acquiring the airport visually, and would have to execute a circling approach. Moments after stating a circling approach would be needed, the pilot received a sink rate aural warning from the enhanced ground proximity warning system (EGPWS). After several seconds, a series of stall warnings was recorded prior to the airplane impacting terrain. EGPWS data revealed, the airplane had decelerated approximately 75 knots in the last 20 seconds of the flight. Examination of the wreckage did not reveal any preimpact failures or malfunctions with the airplane or any of its systems. Toxicology testing detected sertraline in the pilot’s kidney and liver. Sertraline is a prescription antidepressant medication used for anxiety, obsessive-compulsive disorder, panic disorder, posttraumatic stress disorder, and social phobia. The pilot’s personal medical records indicated that he had been treated previously with two other antidepressant medications for “anxiety and depression” and a history of “impatience” and “compulsiveness.” The records also documented a diagnosis of diabetes without any indication of medications for the condition, and further noted three episodes of kidney stones, most recently experiencing “severe and profound discomfort” from a kidney stone while flying in 2005. None of these conditions or medications had been noted by the pilot on prior applications for an airman medical certificate. It is not clear whether any of the pilot’s medical conditions could account for his behavior or may have contributed to the accident.

Factual narrative

History of flight

On February 1, 2008, about 1128 eastern standard time, a Raytheon Aircraft Company C90A, N57WR, was substantially damaged when it impacted terrain during a missed approach following an instrument approach to the Mount Airy/Surry County Airport (MWK), Mount Airy, North Carolina. The certificated commercial pilot, pilot rated passenger, and four passengers were fatally injured. Instrument meteorological conditions prevailed, and an instrument flight rules (IFR) flight plan had been filed for the flight, which departed Polk County Airport/Cornelius Moore Field (4A4), Cedartown, Georgia. The personal flight was conducted under 14 Code of Federal Regulations (CFR) Part 91.

According to witness statements, rain, low ceilings, and fog were present in the local area. The pilot was first heard to check in on the MWK common traffic advisory frequency (CTAF), and announce “final 36, Mount Airy.” The airplane was then observed to “break out of the clouds” at approximately 500 feet above ground level (agl), in close proximity to the airport, and then descend “rapidly” for about 200 feet. It was then observed to “side step” to the left of the runway, and fly parallel to it for its entire length. The airplane then made a “hard” left turn at the end of the runway and climbed into the “fog.” A few minutes later, it came out of the bottom of the clouds in a nose down attitude, disappeared behind trees east of the airport and the sound of impact was heard.

According to Federal Aviation Administration (FAA) air traffic control (ATC) voice and radar data, the airplane departed 4A4 at approximately 1024 and arrived in the vicinity of MWK approximately 50 minutes later.

After arrival in the local area, the pilot contacted Greensboro Approach (GSO) and advised the controller that he was level at 4,000 feet above mean sea level (msl) on a northeast-bound track toward MWK. The GSO controller then instructed the pilot to maintain 4,000 feet msl until crossing the EDLIF waypoint, fly the Global Positioning System (GPS) approach to runway 36 at MWK, and switch to the CTAF for the airport.

Radar data obtained from the terminal radar approach control facility at GSO contained recorded radar targets for the accident airplane from 1112 until 1128. During the GPS approach to runway 36, the airplane was recorded tracking inbound to the airport. The last radar target on final approach was recorded at 1125:40, at 2000 feet, approximately 1.25 nautical miles (nm) from the runway 36 threshold. No more radar targets were recorded until 1127:49, when the target representing the airplane reappeared on radar on a left base leg at 2300 feet. The target continued to turn left to about a 020-degree heading, overfly the threshold of runway 36 at 2300 feet, and continue on a 020-degree heading for another 14 seconds. The last target was recorded to the east of the airport, .6 nm south of the accident site, at 2,700 feet.

The accident occurred during the hours of daylight. The wreckage was located at 36 degrees, 27.797 minutes north latitude, 80 degrees, 33.042 minutes west longitude, at an elevation of 1,219 feet msl.

Personnel information

According to FAA records, the pilot held a commercial pilot certificate with ratings for airplane multiengine land, airplane single engine land, and instrument airplane. He reported 780 total hours of flight experience on his most recent application for a FAA second-class medical certificate, dated August 6, 2007.

According to FAA records, the pilot-rated passenger held a private pilot certificate with ratings for airplane single engine land and instrument airplane. According to pilot records, he had accrued 1082.8 total hours of flight experience. His most recent application for a FAA second-class medical certificate was dated November 9, 2006.

Aircraft information

According to FAA and maintenance records, the airplane was manufactured in 2005. The airplane’s most recent manufacturer’s recommended inspection program, phase inspection, was completed on November 9, 2007. At that time the airplane had accrued 799.7 total hours of operation.

Meteorological information

According to National Weather Service (NWS) analysis charts, a surface occluded/cold front was moving eastward across western North Carolina during the late morning of February 1. Also, the charts indicated that a warm front over southern/eastern North Carolina was moving northward. A low-level cold wedge was situated between the fronts over north-central North Carolina (including MWK). The cold wedge was characterized by light easterly/northeasterly low-level flow near the surface and a strong inversion at about 5,000 feet. At and above the inversion, strong southerly-south southwesterly winds with speeds exceeding 50 knots were indicated over central North Carolina.

Widespread IFR conditions with scattered rain and drizzle were prevalent in the cold wedge.

Cloud Conditions on Approach

Infrared satellite images for the nominal times of 1110 and 1132 indicated cloud-top radiative temperatures in the vicinity of MWK ranged between +4 and –6 degrees Celsius (C). Upper air data implied cloud tops in this temperature range were 7,200 and 13,000 feet msl.

Surface Weather Conditions

An Automated Weather Observing System-3 (AWOS-3) recorded and disseminated official weather observations at MWK.

A weather observation taken about 3 minutes before the accident included: calm winds, visibility 2 and 1/2 miles in drizzle, overcast clouds at 600 feet, temperature 1 degrees C, dew point 0 degrees C, and an altimeter setting of 29.90 inches of mercury.

A weather observation taken about 13 minutes after the accident included: calm winds, visibility 2 and 1/2 miles in heavy drizzle, broken clouds at 300 feet, overcast at 600 feet, temperature 1 degrees C, dew point 0 degrees C, and an altimeter setting of 29.90 inches of mercury.

A review of surrounding weather observations by a NTSB meteorologist and post-accident certification of the equipment indicated that the AWOS-3 was reporting current weather conditions within the design specifications of the system.

Airport information

According to the Airport Facility Directory, MWK was a public use airport. It had one runway, oriented in an 18/36 configuration. Runway 36 was asphalt, in good condition. It was 4,300 feet long by 75 feet wide. The runway had non-precision markings that were in good condition. It was equipped with runway end identifier lights, medium intensity runway edge lights, and a 2-light precision approach path indicator.

Flight recorders

During examination of the wreckage, it was discovered that the airplane was equipped with an L-3 Communications FA 2100-1010 Cockpit Voice Recorder (CVR). Examination of the recorder by the NTSB's vehicle recorders laboratory revealed that the CVR had recorded 31 minutes and 3 seconds of useable audio.

The following is a summary of the recorded events:

The recording began at 10:57:23, prior to the pilot being cleared for the approach. Review of the audio revealed that the private pilot passenger who was seated in the front right seat of the airplane was assisting the pilot during the flight.

At 10:57:49, a discussion ensued between the pilot and pilot-rated passenger regarding a possible diversion if needed to another airport that was 25 miles from MWK. At that time the pilot asked the pilot-rated passenger if he remembered how to shoot an instrument landing system (ILS) approach in “this thing.”

At 10:58:08, the pilot rated passenger advised him that he thought he could.

At 11:00:58, the pilot began to sing to the passengers, "Save my life I'm going down for the last time." This continued until 11:01:22, when the pilot began a commentary to the passengers stating, "If anybody back there believes in the good Lord, I believe now would be a good time to hit your knee

Aircraft

Registration
N57WR
Reported as
Raytheon C90A
Category
Airplane
Serial number
LJ-1678
Airframe hours
800
Engines
Pratt & Whitney Aircraft of Ca PT6A-21, 550 horsepower, turbo propPratt & Whitney Aircraft of Ca PT6A-21, 550 horsepower, turbo prop
Damage
Substantial damage
Flight
Personal · Part 91
Operator
Blue Sky Airways Inc
Registered owner
Blue Sky Airways Inc
Airworthiness certificate
Standard, Normal
Last inspection
Continuous airworthiness · November 9, 2007
Departed
4A4 · Cedartown, GA
Destination
MWK · Mount Airy, NC
Flight plan
IFR
Airport
MWK · Mt. Airy/Surry County Airport, runway 36, 4,301 × 75 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
50
Injuries
Fatal
Certificates
Private, Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 2, With waivers/limitations
Last flight review
November 17, 2006
Seat
Left
Toxicology
Performed
Flight hours
780 total · 392 as pilot in command

Weather

Conditions
Instrument (IMC) · Day
Wind
Calm
Visibility
2 statute miles
Lowest ceiling
300 ft broken
Temperature
34 °F, dew point 32 °F
Observed at
MWK

Docket · 28

The files NTSB released with the investigation on December 15, 2009, on NTSB’s docket system: statements, records, photos and specialists’ reports. 12.2 MB in all.

St. Petersburg FCF/AFSS InformationItem 1 · .PDF · 195 KBNashville FCF/AFSS InformationItem 2 · .PDF · 287 KBWeather Reports and RecordsItem 3 · .PDF · 86 KBMeteorology 5 - Factual Report of Group ChairmanItem 4 · .PDF · 2.4 MBMeteorology 5 - Attachment 1Item 5 · .PDF · 140 KBMeteorology 5 - Attachment 2Item 6 · .PDF · 87 KBATC 3 - ATC Radar StudyItem 7 · .PDF · 1.6 MBEGPWS Factual ReportItem 8 · .PDF · 290 KBEGPWS Factual Report - Attachment 1Item 9 · .CSV · 5 KBAirworthiness Factual Report of Group ChairmanItem 10 · .PDF · 706 KBWitness StatementsItem 11 · .PDF · 407 KBMaps or Charts of Accident Area, Wreckage DiagramsItem 12 · .PDF · 1.3 MBMedical Records InformationItem 13 · .PDF · 15 KBToxicological Report - Pilot-Rated PassengerItem 14 · .PDF · 54 KBToxicological Report, PilotItem 15 · .PDF · 56 KBEstimated Weight and Balance at Time of AccidentItem 16 · .PDF · 45 KBStatement of Party Representatives to NTSB InvestigationItem 17 · .PDF · 65 KBExcerpt from Honeywell KTA970/KMH980 Pilot's GuideItem 18 · .PDF · 137 KBExcerpt from King Air C90A POH - Airspeed LimitationsItem 19 · .PDF · 31 KBExcerpt from King Air C90A POH - Balked Landing ProcedureItem 20 · .PDF · 29 KBExcerpt from King Air C90A POH - Stall Warning SystemItem 21 · .PDF · 61 KBExcerpt from King Air C90A POH - Seatbelts and Shoulder HarnessesItem 22 · .PDF · 118 KBRelease of Aircraft Wreckage, NTSB Form 6120.15Item 23 · .PDF · 80 KBApproach Chart - GPS Rwy 36 KMWKItem 24 · .PDF · 22 KBPhotograph of Accident Site and Runway - NTSBItem 25 · .PDF · 1.3 MBPhotograph of Accident Site - NTSBItem 26 · .PDF · 1.2 MBPhotograph (High Angle) of Main Wreckage - NTSBItem 27 · .PDF · 1.3 MBCockpit Voice Recorder 12 - Factual Report of Group ChairmanItem 28 · .PDF · 94 KB

FAA reports on this event · 1

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