# NTSB NYC93LA161: Beech A23, N3552R, Morgantown, WV, August 18, 1993 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Limited investigation · Final report - Date: August 18, 1993, 05:57 local (09:57 UTC) - Place: Morgantown, WV - Coordinates: 39.630672, -79.939514 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=39.6307&lon=-79.9395&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Highest injury: Serious injuries - Injuries: 1 serious - Status: Completed, report September 13, 1994 - Report: Approved by Office Director - NTSB case key (mKey): 38636 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=NYC93LA161 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/38636/pdf - Page: https://openairdocs.org/ntsb/NYC93LA161 ## Probable cause The pilot's failure to follow IFR procedures in which he descended below the decision height without visual detection of the runway. Factors are the fog conditions, trees and the pilot's inattention to altitude. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - In flight collision with object, approach - faf/outer marker to threshold (ifr) - weather condition - fog (contributing factor) - ifr procedure - not followed, pilot in command (cause) - decision height - not maintained, pilot in command (cause) - inattentive, pilot in command (contributing factor) - object - tree(s) (contributing factor) ## Analysis THE PILOT WAS EXECUTING THE ILS RWY 18 APPROACH AND STRUCK TREES 3 MILES FROM THE APPROACH END OF THE RUNWAY AT APPROXIMATELY AIRPORT ELEVATION HEIGHT. WHEN INTERVIEWED, HE SAID THAT DUE TO THE FOG HE WAS LOOKING OUTSIDE FOR THE AIRPORT AND WHEN HE LOOKED BACK INSIDE HE REALIZED HE WAS LOW. HE SAID THAT WHEN HE ADDED POWER, THE AIRPLANE WAS ALREADY IN THE TREES. ## Factual narrative On Wednesday, August 18, 1993, at 0557 eastern daylight time, a Beech A23, N3552R, owned and operated by Benjamin F. Roush, of Point Pleasant, West Virginia, struck rising terrain while executing an ILS approach to Morgantown, West Virginia, airport for a landing. The pilot received serious injuries and the airplane received substantial damage. Instrument meteorological conditions prevailed and the pilot was operating on an instrument flight rules flight plan in accordance with 14 CFR 91. In the NTSB Accident Report, the pilot stated that while on final approach: ...looked at the approach plate to redetermine DH [Decision Height] 1440' [feet] and the next few seconds I heard slap, slap, --- smack, smack, and I was on the ground. Everything seemed to be functioning properly.... According to the map supplied by the FAA, the airplane flew into rising terrain, at an altitude of 1200 feet, 3 miles from the approach end of runway 18. The published airport elevation is 1248 feet. The minimum descent altitude on the ILS approach is 1440 feet. The glide slope at Morgantown is set at 3 degrees. In a telephone interview, Mr. Kenneth Leighton, of the Charleston, West Virginia, Flight Standards District Office said he traveled to the accident site. He said the onsite evidence indicated the engine was developing power while the airplane traveled through the trees. In addition, he said when he interviewed the pilot in the hospital, the pilot said he was looking outside the airplane for the airport and when he looked inside, he realized he was too low and added power, however, he was too late and was already in the trees. Although there is no record of the pilot checking weather prior to departure, according to the FAA Supplied transcript, he did receive, and acknowledged, the current Morgantown weather of an indefinite ceiling of 200 feet, sky obscured, visibility 2 miles with fog. ## Aircraft - Registration: [N3552R](https://openairdocs.org/deregistered/N3552R-1993-09-14), registration cancelled 1993-09-14, S/N M726 (OpenAirDocs) - Reported make and model: BEECH A23 - Registry model: [Beech A23](https://openairdocs.org/model/beech-a23) (registry code 1151204) (OpenAirDocs) - Category: Airplane - Serial number: M-726 - Airframe hours: 2558 - Engines: CONTINENTAL IO-346-A 165 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Registered owner: Benjamin F. Roush - Airworthiness certificate: Standard, Normal - Last inspection: Annual, September 23, 1992, 56 hours before - Departed: 3I2, POINT PLEASANT, WV - Destination: MGW, POINT MARION, PA - Flight plan: IFR - Airport: MGW, Morgantown Muni, runway 36, 5,199 × 150 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 57; flight instructor, commercial; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 2, valid medical--w/ waivers/lim; seat: left; flight hours: 4,050 total, 43 in this make and model, 3,874 as pilot in command, 25 in the last 90 days, 10 in the last 30 days, 2 in the last 24 hours ## Weather - Conditions: Instrument (IMC), Dawn - Wind: calm - Visibility: 2 statute miles - Lowest ceiling: 200 ft - Temperature: 68 °F, dew point 68 °F - Altimeter: 30.00 inHg - Observed at: MGW, 3 nm away ## 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 19930818029719A](https://openairdocs.org/incident/19930818029719A), Aug 18, 1993: Beech A23, Morgantown, WV, Substantial damage. Descended below dh and struck rising terrain on ILS approach. Was 240 feet below minimum descent altitude. ## Other investigations on N3552R (1) 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. - [NTSB NYC66D0364](https://openairdocs.org/ntsb/NYC66D0364), Nov 28, 1965: Beechcraft A-23 (N3552R), Doylestown, PA, substantial damage 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.