SEA97FA188

NTSB accident investigation · Beech 1900C · Seattle, WA · August 14, 1997

Accident · Serious injuriesField investigationFinal report
Date
August 13, 1997, 19:13 local (Aug 14, 1997, 02:13 UTC)
Place
Seattle, WA
Injuries
1 serious
Damage
Destroyed
Phase of flight
Landing
Aircraft
N3172ABeech 1900C
Weather
Visual (VMC) · Day
Status
Completed · report June 11, 1999
Report
Approved by Office Director
FAA report
19970813022119A
Case key
42509

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

A stall/mush condition resulting from an aft center of gravity which was inaccurately provided to the pilot-in-command by contractual cargo-loading personnel. Additional causes were overloading of the aircraft's landing gear and fuel leakage resulting in a post-crash fire. Factors contributing to the accident were the pilot's improper lowering of flaps in an aft CG situation and the inadequate company procedures for cargo loading.

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.

Hard landingLanding - flare/touchdown
Stall/mushCause
Proper descent rate - not possiblePilot in command
Lowering of flaps - initiatedPilot in commandFactor
Aircraft weight and balance - inaccurateDispatcherCause
Procedure inadequateOther personFactor
Gear collapsedLanding - roll
Landing gear - overloadCause
FireStanding
Fuel system - leakCause
Fluid,fuel - fire

Analysis

The Beech 1900C cargo aircraft was loaded with more than 4,962 pounds of cargo during an approximate 20 minute period. No scale was available at the aircraft, forcing loaders to rely on tallying either waybill weights or estimates of total cargo weight and center of gravity (CG) during the brief loading period. Additionally, a strike had shut down a major cargo competitor at the time with substantial cargo overflow to the operator. Post-crash examination determined the cargo load was 656 pounds greater than that documented on the pilot's load manifest, and the CG was between 6.8 and 11.3 inches aft of the aft limit. The airplane behaved normally, according to the pilot, until he initiated full flaps for landing approaching the threshold of runway 34L at the Seattle-Tacoma International airport. At this time, the aircraft's airspeed began to decay rapidly and a high sink rate developed as the aircraft entered into a stall/mush condition. The aircraft then landed hard, overloading the nose and left-main landing gear which collapsed. A post-impact fuel system leak during the ground slide led to a post-crash fire.

Factual narrative

History of flight

On August 13, 1997, at 1913 Pacific daylight time, a Beech 1900C, N3172A, registered to and operated by Ameriflight, Inc., and being flown by an airline transport pilot, was destroyed when the aircraft's left main and nose landing gear collapsed following a loss of control and subsequent in-flight collision with the runway on landing at the Seattle Tacoma (SEATAC) International airport, Seattle, Washington. A post-crash fire ensued, damaging the center structure of the aircraft and wing root areas. The pilot, who was the sole occupant, sustained serious injuries. Visual meteorological conditions existed at the time, and an instrument flight rules (IFR) flight plan was in effect. The flight, which had originated from Portland, Oregon, was an unscheduled cargo run which was to have been operated under 14CFR135.

N3172A, call sign "AMFlight 262" (AMF262) departed Portland International airport at 1830 on the evening of August 13 en route to the SEATAC International airport. At 1859, the pilot of AMF262 contacted Seattle terminal radar approach control (TRACON) inbound, and advised he was at 10,000 feet. The aircraft was given vectors to SEATAC, a descent to 7,000 feet and, at 1904, was switched to Seattle approach (final) control on frequency 133.65 mHz (refer to ATTACHMENT T-I).

At 1905:11, Seattle TRACON (final) contacted AMF262 and requested that the aircraft reduce speed to 210 knots and descend to and maintain 6,000 feet. Over the next four minutes the pilot of AMF262 verified SEATAC airport in sight, was cleared for a visual approach to runway 34L, was advised of traffic preceding him by five miles for the same runway, and was asked to "maintain that speed if you can until about five mile final." At 1909, AMF262 was asked to contact SEATAC air traffic control tower (ATCT) (refer to ATTACHMENT T-II).

At 1909:50, the pilot of AMF262 contacted SEATAC ATCT reporting "over the mall for 34 left" (NOTE: "the mall" is located at the 7.5 nautical mile fix south of SEA VORTAC, which in turn, is located at the south end of the SEATAC airport runways). The local controller responded in part with "follow an airbus on a one mile final, caution wake turbulence, wind two seven zero at five, runway three four left cleared to land" and this was acknowledged by the pilot (refer to ATTACHMENTS T-III and RDR-I).

Four of the controllers in the SEATAC ATCT facility observed the aircraft crash and two of these controllers reported seeing the aircraft in an "unusual descent" (refer to attached statements C-I through C-IV).

Several other witnesses located on the SEATAC airport reported observing the accident. These witnesses reported seeing the aircraft "coming down at the wrong angle, too steep, like a helicopter," at "a high angle of attack and very low airspeed," "aircraft nose high, in approximately a 25 to 30 degree angle of descent, obviously stalled," and that "it looked like the aircraft stalled at about 300-400 ft. AGL (above ground level), and that the C.G. (center of gravity) appeared to be aft because the nose never dipped down after the stall, and the aircraft just pancaked in flat" (refer to attached statements S-I through S-IV).

The pilot-in-command (PIC) was interviewed on August 19, 1997, at Harborview Hospital, Seattle, Washington. The PIC reported no mechanical nor communication malfunctions during the flight to Seattle. During the PIC's interview, he reported that the takeoff from Portland was uneventful, the aircraft accelerated normally, becoming airborne after a reasonable ground roll, and the climb performance was as expected. He also reported that the flight to SEATAC was uneventful, he was cleared to land on runway 34L and that although visual conditions existed, he utilized the ILS and normally flew one-half to a full dot above glide slope to avoid potential wake vortex conditions.

The PIC reported that his intention was to touch down in the latter third of the touchdown area (the aircraft's destination was the cargo area in the northeast corner of the SEATAC airport - refer to DIAGRAM I). He further reported that his first indication of something out of the ordinary was somewhere between one quarter mile short of the threshold and the physical end of runway 34L. He stated that he had lowered full (landing) flaps and upon full extension noticed a decrease in airspeed below Vref (Vref is defined as any reference speed). Note: Vref speeds for flaps up and flaps landing at selected aircraft weights are provided to the pilot on the "Beech 1900 Normal Procedures Checklist" (refer to ATTACHMENT CL-I, page 2). He also reported that the pitch attitude of the aircraft did not change appreciably with flap extension, and the pitch change seemed to be normal for this event.

The PIC reported remembering trying to counteract the airspeed decay by applying nose down elevator but did not remember events beyond that time until attempting to exit the aircraft. He also reported that he did not recall hearing the stall warning horn prior to the accident, and that he was able to trim the aircraft throughout the flight and experienced no pitch trim difficulties.

The PIC reported that subsequent to the crash he recalled releasing his restraint system and unlatching and partially opening the cabin door. He observed AFFF (Aqueous Film Forming Foam, a fire fighting agent) entering the aircraft through the cabin door, and then reported that he allowed the door to rock back to a closed position. He also reported that there was smoke in the cockpit which prevented him from seeing the instrument panel.

The SEATAC Aircraft Rescue and Fire Fighting (ARFF) Fire Run Report showed that the ARFF crew was dispatched at 1913:25, responded at 1914:46 and arrived at the site at 1915:36. The fire was knocked down using a turret and hand lines and the pilot was extricated from the cockpit by two ARFF responders. The report also indicated that the forward cabin door was partially open upon arrival of the ARFF team, and that the forward cabin area and door was partially blocked by cargo.

Other damage

Several runway lights along the west edge of runway 34L were knocked out during the aircraft's ground slide. Additionally, small abrasions and gouges of the runway's paved surface were noted.

Personnel information

The 34 year old PIC had logged approximately 6,370 hours of flight time at the time of the accident, including 4,225 hours of multi-engine flight time and 4,359 hours of PIC time. He had been issued an airline transport pilot certificate June 8, 1997, with a type rating in the BE-1900 aircraft. His most recent medical examination was conducted September 4, 1996, and he was issued a first class certificate with no limitations.

The PIC had been hired by Horizon Air on October 2, 1995, and began flying as a first officer in the DeHavilland DHC-8, twin turboprop aircraft. He was subsequently issued a voluntary leave of absence on May 25, 1997, as Horizon Air faced potential reductions of pilots and requested volunteers for such absences. The leave of absence was projected to last six months. The PIC had been trained by Horizon Air in weight and balance procedures for the DHC-8 aircraft prior to his beginning line flights.

The PIC was hired by Ameriflight in late May of 1997, underwent Beech 1900 and company training, and began line flights on June 9, 1997. He had logged a total of 106 hours of flight time in the cargo version BE-1900C (all PIC) at the time of the accident.

Records maintained by Horizon Air showed the PIC as having logged a total of 1,230 hours of BE-1900 time (397 as pilot-in-command and 833 as second-in-command) as of June 26, 1995. This flight time was in scheduled FAR Part 135 passenger operations for GP Express in the 19 seat passenger version of the Be-1900.

The PIC reported during his interview that he had an estimated 1,500 total hours of BE-1900 time (both passenger and cargo versions)

Aircraft

Registration
N3172A
Reported as
Beech 1900C
Category
Airplane
Serial number
UB-47
Airframe hours
23,892
Engine
P&W PT6A-65B, 1,100 horsepower, turbo prop
Damage
Destroyed
Fire
On-Ground
Flight
Part 135
Registered owner
Ameriflight, Inc.
Airworthiness certificate
Standard, Normal
Last inspection
AAIP · July 25, 1997 · 33 hours before
Departed
PDX · Portland, OR
Destination
SEA
Flight plan
IFR
Airport
SEA · Seattle-Tacoma Intnl, runway 34L, 9,425 × 150 ft, concrete

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
34
Certificates
Airline transport, Commercial, Flight instructor
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--no waivers/lim.
Seat
Left
Toxicology
Performed
Flight hours
6,370 total · 106 in this make and model · 4,359 as pilot in command · 123 in the last 90 days · 53 in the last 30 days · 1 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
270° at 3 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
79 °F, dew point 61 °F
Altimeter
29.00 inHg
Observed at
SEA

Docket · 42

The files NTSB released with the investigation on January 11, 1999, on NTSB’s docket system: statements, records, photos and specialists’ reports. 7.0 MB in all.

Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1Item 1 · .PDF · 440 KBSupplement CItem 2 · .PDF · 442 KBSupplement DItem 3 · .PDF · 517 KBSupplement IItem 4 · .PDF · 265 KBAttachments C I-IV - ATC Personnel StatementsItem 5 · .PDF · 127 KBAttachments S I-IV - Record of Telephone CallsItem 6 · .PDF · 214 KBAttachment RI-I - Record of InterviewItem 7 · .PDF · 51 KBAttachments WB I-III - Records of Interview and InvestigationItem 8 · .PDF · 254 KBAttachment RDR-I - Seattle TRACONItem 9 · .PDF · 52 KBDiagram IItem 10 · .PDF · 188 KBCharts IItem 11 · .PDF · 103 KBAttachments T I-III - ATC TranscriptsItem 12 · .PDF · 186 KBAttachment CL - I - Ameriflight ChecklistItem 13 · .PDF · 207 KBAttachments MRA - FAA Major Repair and Alteration ReportItem 14 · .PDF · 148 KBAttachment CG - I - Weight and BalanceItem 15 · .PDF · 101 KBAttachment LPS - I - Ameriflight Load Planning SheetItem 16 · .PDF · 194 KBAttachments APV-I and II - Weight and Balance/Equipment ListItem 17 · .PDF · 118 KBAttachments IV-I thru III - StatementsItem 18 · .PDF · 231 KBAttachments AOM - I - Ameriflight Flight Operations ManualItem 19 · .PDF · 413 KBAttachment DHL-I - DHL Shipment BillItem 20 · .PDF · 150 KBAttachment WBC - Weight and Balance ComputationsItem 21 · .PDF · 139 KBAttachment CD - I - Notes from InspectionItem 22 · .PDF · 170 KBAttachment AA-I - Continuity and Operational TestItem 23 · .PDF · 45 KBAttachment SF-I - FAA Inspection of ComponentsItem 24 · .PDF · 60 KBAttachment AAR - 88/11Item 25 · .PDF · 154 KBAmeriflight Facsimile Message from John W. Hazlet, Jr. dated 4/29/99Item 26 · .PDF · 48 KBStatement of Party Representatives to NTSB InvestigationItem 27 · .PDF · 532 KBRelease of Aircraft Wreckage, NTSB Form 6120.15Item 28 · .PDF · 158 KBPhoto 1. A view of cargo removed from the center and aft areas of the fuselage. No Negative.Item 29 · .PDF · 91 KBPhoto 2. A view of cargo removed from the center and aft areas of the fuselage. No Negative.Item 30 · .PDF · 101 KBPhoto 3. A view of cargo removed from the forward area of the fuselage. No NegativeItem 31 · .PDF · 97 KBPhoto 4. A view of the interior of the cargo compartment subsequent to the removal of the cargo. No NegativeItem 32 · .PDF · 99 KBPhoto 5. A view looking at the initial ground impact (IGI) on runway 34L north to the aircraft's final resting place (FRP). No NegativeItem 33 · .PDF · 87 KBPhoto 6. Vew looking 335 drgrees magnetic at the IGI paint transfer smear on the RWY surface. Note the L and R tire marks on the RWY and the propeller slashes slightly north of each. Also note the hydraulic fluid spills nearItem 34 · .PDF · 90 KBPhoto 7. A view looking 160 degrees magnetic along the edge of the runway pavement. Note the runway distance to go marker "4" ( reverse side shows "5"). Also note the left inboard flap "F" and the nose gear strut "NS" on theItem 35 · .PDF · 84 KBPhoto 8. A view looking west at the aircraft. Note the rotational damage to the vertical stabilizer and the cargo removed through the main cargo door. No NegativeItem 36 · .PDF · 98 KBPhoto 9. A view looking north showing the separated nose and left main landing gear, left propeller damage and open cabin door. Note the cargo removed through the cabin door. No NegativeItem 37 · .PDF · 98 KBPhoto 10. A view looking east showing the attached right main landing gear and right propeller damage. No NegativeItem 38 · .PDF · 96 KBPhoto 11. A close up view of the right engine/wing showing the clockwise twisting deformation of the wing and the attached right main landing gear. Note the extended flap. No NegativeItem 39 · .PDF · 91 KBPhoto 12. A view looking south showing the fire damage along the right fuselage side aft of the wing. No NegativeItem 40 · .PDF · 105 KBPhoto 13. A view looking along the aircrafts longitudinal axis showing the crush area at the rear underside of the fusleage. No NegativeItem 41 · .PDF · 92 KBPhoto 14. A view showing the improperly placed Brownline "Z-net" deck hook attach fitting (arrow). No NegativeItem 42 · .PDF · 110 KB

FAA reports on this event · 1

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