# NTSB NYC97FA057: Beech E-18S, N54BT, Mabie, WV, March 6, 1997 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: March 6, 1997, 00:21 local (05:21 UTC) - Place: Mabie, WV - Location: 38.8765° N, 79.9831° W: Placed by OpenAirDocs: center of Mabie, WV, within about 6 miles (OpenAirDocs) - Nearby events: https://openairdocs.org/map.md?lat=38.8765&lon=-79.9831&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 2 fatal - Status: Completed, report April 24, 1998 - Report: Approved by Office Director - NTSB case key (mKey): 39269 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=NYC97FA057 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/39269/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=39269 - Page: https://openairdocs.org/ntsb/NYC97FA057 ## Probable cause The pilot's disregard of the preflight weather briefing for severe weather along his route of flight, and his departure into the known and forecasted severe weather. A factor in the accident was the inadequate FAA oversight of the operator, which fostered an attitude of rule bending. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of control - in flight, cruise - normal - light condition - night - weather condition - icing conditions - weather condition - thunderstorm - hazardous weather advisory - disregarded, pilot in command (cause) - flight into known adverse weather - performed, pilot in command (cause) - inadequate surveillance of operation, faa(organization) (contributing factor) - In flight collision with terrain/water, descent - uncontrolled ## Analysis The flight had been delayed due to severe weather over the departure airport. The preflight weather briefing received by the pilot included AIRMETS and SIGMETS for icing and severe thunderstorms, possible tornadoes, hail to 2 inches, and wind gusts to 70 knots near the ground. The Beech 18 was not equipped with a storm scope or weather radar. Prior to takeoff, a passenger stated to a witness that the weather was 'really really bad,' and that they would have to 'do some deviating to get around it.' After takeoff, the airplane cruised at 10,000 feet uneventfully for 1 hour and 50 minutes, when a center controller advised that radar contact was lost, which the pilot acknowledged. The next and last transmission occurred 13 minutes later when the controller received a 'Mayday' radio transmission that the airplane was 'going down.' The last radar target revealed a 6,000 foot per minute rate of descent. Training records revealed the pilot, also the company chief pilot, had flown solo 6.3 hours in the Beech 18 and credited it as dual flight instruction. He then passed a Part 135 evaluation with the FAA Principal Operations Inspector (POI), which lasted 1.6 hours. The next day the POI issued the pilot check airmen authorization for the Beech 18, all models. According to the POI, the airplane was not approved for Part 135 operations; however, the company had a bogus approval for the airplane, signed by the POI, that allowed the company to apply to Canadian Authorities for authorization to operate in Canada. The bogus approval had been used to justify the accident flight. ## Factual narrative HISTORY OF FLIGHT On March 6, 1997, at 0021 eastern standard time, a Beech E-18S, N54BT, owned and operated by Polaris Aviation, Sanford, North Carolina, was destroyed when it descended from cruise flight and impacted the ground near Mabie, West Virginia. The certificated airline transport pilot-in-command (PIC) and pilot rated passenger were fatality injured. Instrument meteorological conditions prevailed for the cargo flight that originated at the Sanford-Lee County Brick Field (W77), about 2217, destined for Detroit, Michigan. An instrument flight rules flight plan had been filed for the flight conducted under 14 CFR Part 135. During an interview with the Sanford Airport Manager, also the Director of Maintenance for Polaris Aviation, he stated that the PIC was the Chief Pilot and Director of Operations for Polaris Aviation, and the passenger was the General Manager (GM) for Polaris. The flight was scheduled to depart Sanford, about 2100, with 550 pounds of automobile parts. During the day, the PIC had used a direct satellite link and a computer program at W77, to obtain weather information. About 2100, when the Airport Manager was about to leave, the passenger/GM approached him and stated that the weather was "really really bad," and that they would have to "do some deviating to get around it." During the day, another pilot/witness not employed by Polaris, had spent the day at the airport with the PIC of the flight. The witness stated that the flight had been scheduled to depart about 2100, destined for Michigan, and was to return directly to Raleigh, North Carolina, for another cargo pick-up at 0600, the next morning. The witness stated that about 1900, he and the PIC had looked at a computer radar depiction of weather, which depicted a "squall line" just north of the Sanford area, with solid red areas. The witness stated that he had commented to the PIC, "you're not going to fly through that, are you?" The witness also commented to the PIC that the GM "wouldn't do that." The witness reported that the PIC responded that the GM would probably like the challenge. Prior to the flight, severe weather had passed north of the Sanford area, and the GM had sent three FAX messages to the cargo receiving facility in Michigan. The first indicated a departure time of 2140 from W77. The second FAX indicated a departure time of 2215 from W77, and had a written message which stated, "Severe WX delay for all aircraft. No clearances issued until 2200 EST per Raleigh clearance delivery." A third FAX indicated a departure time of 2220 from W77, with a printed text of "Taxiing out Now." According to Air Traffic Control (ATC) records, the PIC contacted the Raleigh Automated Flight Service Station (AFSS) by telephone at 2050, and filed an IFR flight plan from W77 to Detroit, Michigan, but did not request a preflight briefing. At 2112, the PIC contacted Raleigh AFSS by telephone and obtained a preflight pilot briefing for the flight, and at 2131, called back to Raleigh AFSS and requested the IFR clearance from W77 to Detroit, and was placed on hold. At 2142, the PIC was issued an expect departure clearance time of 15 minutes, and at 2159, was issued an IFR clearance by Fayetteville ATC, through Raleigh AFSS. After departure from W77, N54BT was instructed to climb to 10,000 feet, and to contact the Washington Air Route Traffic Control Center (ARTCC). According to the ARTCC transcripts and a review of the voice tape, all communications were routine until 0007, when the ARTCC controller advised N54BT that radar contact was lost, and requested that the airplane report over the Elkins VOR. The PIC acknowledged the call, and stated that he would report over the VOR. No other transmissions were received from N54BT, until 0020, when the controller received a radio transmission, "Mayday, Mayday, N54BT is going down, N54BT is going down." No further transmissions were received, and an emergency locator transmitter (ELT) was heard by other pilots about 55 seconds later. After several seconds, the ELT signal faded out. The last radar target of N54BT was recorded at 6,400 feet. The airplane was located in a wooded area, about 1/2 mile from the last reported radar target. The accident occurred during the hours of darkness approximately 38 degrees, 52 minutes north latitude, and 80 degrees, 01 minutes west longitude. PERSONNEL INFORMATION The pilot held an airline transport pilot certificate with a rating for airplane multiengine land, and a commercial pilot certificate with ratings for single engine land and instrument airplane. He also held a flight instructor certificate with ratings for airplane single and multiengine land and instrument airplane. His most recent Federal Aviation Administration (FAA) second class medical certificate was issued on December 30, 1996. Several pilot log books were located and reviewed. According to the log books and FAA records, the pilot obtained his commercial pilot certificate for airplane single engine land and instrument airplane, on January 7, 1994. He obtained his commercial pilot multiengine land rating on July 6, 1994, and he obtained his airline transport pilot certificate on April 1, 1996. The pilot's log book (Book Two), that covered the period from February 1992, to April 1996, was reviewed. The log book ended on April 30, 1996, with 1667.6 hours of total flight experience logged, of which 244 hours were in multiengine airplanes. It also revealed that of the 244 hours, 170 hours were logged while flying with one of several flight instructors from which the pilot had obtained training. The log book entries revealed that as of April 22, 1995, the pilot had logged 1,022.7 hours of total flight experience, of which 187.6 hours were in multiengine airplanes. The most recent pilot log book (Book Three) began on April 22, 1995, and ended on July 21, 1996, which overlapped Book Two by 12 months. This log book began with 1,145.7 hours of total flight experience, 123 hours more than logged in Book Two. It also began with 292.6 hours of multiengine experience, verses the 187.6 hours that had been logged in Book Two. When Book Three reached the end date of the Book Two (April 30, 1996), all additional entries and changes increased the pilot's total flight experience by 162 hours, to 1,839.5 hours, and increased his multi engine experience by 161 hours, to 409 hours. The pilot's log books, and his personal daily crew log which began July 1996, were used to determine the pilot's total flight experience. It was estimated that at the time of the accident, the pilot had accumulated about 2,000 hours of total flight experience, of which 450 hours were in multiengine airplanes, and 30 hours were in make and model. The pilot rated passenger, also the General Manager of Polaris, held a commercial pilot certificate with a rating for airplane multiengine land, and a Private Pilot Certificate with a rating for airplane single engine land. He was not instrument rated, and his certificate limitations included the statement, "Carrying passengers in airplanes for hire is prohibited at night and on cross country flight of more than 50 nautical miles." His most recent FAA second class medical certificate was issued on January 23, 1997. A review of the pilot's log book revealed that he had obtained his airplane multiengine rating on January 26, 1997. He had accumulated about 328 hours of total flying experience. The log book also revealed that he had accumulated a total of 97 hours of multiengine experience, of which all 97 hours were logged as dual instruction. The log book did not contain any flight experience in Beech 18 airplanes. AIRCRAFT INFORMATION. Company documents and airplane records were reviewed, and Polaris personnel were interviewed concerning the airworthiness of N54BT. According to the documents and personnel statem ## Aircraft - Registration: [N54BT](https://openairdocs.org/deregistered/N54BT-1998-05-19), registration cancelled 1998-05-19, S/N BA56 (OpenAirDocs) - Reported make and model: Beech E-18S - Registry model: [Beech E18S](https://openairdocs.org/model/beech-e18s) (registry code 1151006) (OpenAirDocs) - Category: Airplane - Serial number: BA-56 - Airframe hours: 11196 - Engines: P&W R-985-AN14B 450 horsepower reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Part 135 - Registered owner: Polaris Aviation - Airworthiness certificate: Standard, Normal; Standard, Utility - Last inspection: Annual, October 29, 1996, 38 hours before - Departed: W77, SANFORD, NC - Destination: DET, DETROIT, MI - Flight plan: IFR ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 44; flight instructor, commercial, airline transport; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 2, valid medical--no waivers/lim.; seat: left; toxicology performed; flight hours: 2,000 total, 30 in this make and model, 1,980 as pilot in command, 59 in the last 90 days, 20 in the last 30 days ## Weather - Conditions: Instrument (IMC), Night/dark - Wind: 280° at 26 knots, gusting 35 - Visibility: 6 statute miles - Lowest ceiling: 1,200 ft broken - Temperature: 46 °F, dew point 45 °F - Altimeter: 29.00 inHg - Observed at: EKN, 8 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 19970306002179A](https://openairdocs.org/incident/19970306002179A), Mar 6, 1997: Beech E18S, Elkins, WV, Destroyed, 2 fatal. Aircraft at 10000FT sent out two mayday calls, radar/radio contact lost, wreckage located in wooded area. Burned. (.4) the flight had been delayed due to… ## Docket (26 files) The files NTSB released with the investigation on March 5, 1998, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=39269. 12.9 MB in all. - Supplement A - Wreckage Documentation (item 1, .PDF, 297 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40079957&FileExtension=.PDF&FileName=Supplement%20A%20-%20Wreckage%20Documentation-Master.PDF - Supplement B - Cockpit Documentation (item 2, .PDF, 411 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40079958&FileExtension=.PDF&FileName=Supplement%20B%20-%20Cockpit%20Documentation-Master.PDF - Supplement E - Second Pilot Information (item 3, .PDF, 123 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40472132&FileExtension=.PDF&FileName=Supplement%20E%20-%20Second%20Pilot%20Information-Master.PDF - Supplement K - Occupant, Survival and Injury Information (item 4, .PDF, 872 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40079960&FileExtension=.PDF&FileName=Supplement%20K%20-%20Occupant,%20Survival%20and%20Injury%20Information-Master.PDF - NTSB Recorded Radar Study (item 5, .PDF, 364 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40472133&FileExtension=.PDF&FileName=NTSB%20Recorded%20Radar%20Study-Master.PDF - Radar Plots Provided By Raytheon Aircraft (item 6, .PDF, 275 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40079962&FileExtension=.PDF&FileName=Radar%20Plots%20Provided%20By%20Raytheon%20Aircraft-Master.PDF - Interview Summaries (item 7, .PDF, 66 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40472135&FileExtension=.PDF&FileName=Interview%20Summaries-Master.PDF - ATC Record of Events (item 8, .PDF, 626 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40079964&FileExtension=.PDF&FileName=ATC%20Record%20of%20Events-Master.PDF - ATC Transcript Of Radio Communnications (item 9, .PDF, 245 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40472134&FileExtension=.PDF&FileName=ATC%20Transcript%20Of%20Radio%20Communnications-Master.PDF - ATC Personnel Statements (item 10, .PDF, 83 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40472136&FileExtension=.PDF&FileName=ATC%20Personnel%20Statements-Master.PDF - Airplane Compliance Letters (item 11, .PDF, 125 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40472137&FileExtension=.PDF&FileName=Airplane%20Compliance%20Letters-Master.PDF - FAA FSDO POI Response to NTSB Questions (item 12, .PDF, 812 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40472138&FileExtension=.PDF&FileName=FAA%20FSDO%20POI%20Response%20to%20NTSB%20Questions-Master.PDF - Polaris OPSPECS (Excerpts) (item 13, .PDF, 212 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40472139&FileExtension=.PDF&FileName=Polaris%20OPSPECS%20(Excerpts)-Master.PDF - Polaris Company Personnel Responses (item 14, .PDF, 153 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40472140&FileExtension=.PDF&FileName=Polaris%20Company%20Personnel%20Responses-Master.PDF - Pilot Training Records (item 15, .PDF, 668 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40472141&FileExtension=.PDF&FileName=Pilot%20Training%20Records-Master.PDF - Pilot Crew Log (item 16, .PDF, 1.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40472142&FileExtension=.PDF&FileName=Pilot%20Crew%20Log-Master.PDF - Police Report (item 17, .PDF, 340 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40472143&FileExtension=.PDF&FileName=Police%20Report-Master.PDF - Polaris Fax To Penstar (item 18, .PDF, 114 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40472144&FileExtension=.PDF&FileName=Polaris%20Fax%20To%20Penstar-Master.PDF - Weather Data (item 19, .PDF, 4.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40079975&FileExtension=.PDF&FileName=Weather%20Data-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 20, .PDF, 361 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40472145&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Master.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 21, .PDF, 99 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40472146&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Master.PDF - Photo 1. View of wreckage as found, looking northwest. Arrow points to left wing. (item 22, .PDF, 56 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40079978&FileExtension=.PDF&FileName=Photo%201.%20%20View%20of%20wreckage%20as%20found,%20looking%20northwest.%20%20Arrow%20points%20to%20left%20wing.-Master.PDF - Photo 2. View of wreckage as found, looking southeast. Arrow points to right winng. (item 23, .PDF, 46 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40079979&FileExtension=.PDF&FileName=Photo%202.%20%20View%20of%20wreckage%20as%20found,%20looking%20southeast.%20%20Arrow%20points%20to%20right%20winng.-Master.PDF - Photo 3. View of wreckage as found, looking northeast. (item 24, .PDF, 51 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40079980&FileExtension=.PDF&FileName=Photo%203.%20%20View%20of%20wreckage%20as%20found,%20looking%20northeast.-Master.PDF - Photo 4. Pilot's airspeed indicator. (item 25, .PDF, 39 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40079981&FileExtension=.PDF&FileName=Photo%204.%20%20Pilot%27s%20airspeed%20indicator.-Master.PDF - Photo 5. Arrow "1" points to rotational scoring on gyro. Arrow "2" points to ccopilots airspeed indicator face plate. Arrow "3" poinnts to ELT. (item 26, .PDF, 44 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40079982&FileExtension=.PDF&FileName=Photo%205.%20%20Arrow%20%221%22%20points%20to%20rotational%20scoring%20on%20gyro.%20%20Arrow%20%222%22%20points%20to%20ccopilots%20airspeed%20indicator%20face%20plate.%20%20Arrow%20%223%22%20poinnts%20to%20ELT.-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.