# NTSB SEA99FA028: Pacific Aviation Composites LC 40-550FG, N141LC, Portland, OR, January 9, 1999 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: January 8, 1999, 18:12 local (Jan 9, 1999, 02:12 UTC) - Place: Portland, OR - Coordinates: 45.509273, -122.689315 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=45.5093&lon=-122.6893&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 2 fatal - Status: Completed, report June 22, 2000 - Report: Approved by Office Director - NTSB case key (mKey): 45628 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=SEA99FA028 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/45628/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=45628 - Page: https://openairdocs.org/ntsb/SEA99FA028 ## Probable cause Aircraft control was not maintained and the pilot's lack of total experience in type operation. Weather conditions reported ceilings below approach/landing minimums and a dark night condition were factors. ## Analysis Radar data and air traffic communications indicated that the pilot initially contacted approach control while the airport was under night visual conditions. Shortly after the initial contact, the weather conditions deteriorated and instrument meteorological conditions became effective. The pilot was advised of the weather conditions and given vectors to intercept the ILS 10L approach. As the aircraft was turning inbound to intercept the localizer, the air traffic controller notified the pilot that it appeared that he was aligned for the ILS 10R approach. The pilot advised the controller that he had tuned in the wrong frequency and asked the controller for the correct frequency. The controller informed the pilot of the correct frequency for the ILS 10L approach. Due to other air traffic, the controller instructed the pilot to turn to a northerly heading for vectors to the ILS 10L approach. The pilot complied with the controllers instructions and shortly thereafter was aligned for the ILS 10L approach. After the aircraft was established on the localizer and cleared to land, the flight course maintained a constant descent rate, magnetic heading and airspeed. Approximately one mile short of the runway, the course heading began to turn to the northeast of runway centerline. The last radar targets indicated that the aircraft continued to turn to the northeast and descend below radar coverage. The weather reported at the time of the accident and shortly after the accident, indicated that the ceilings conditions were below the approach minimums and both ceilings and visibility were deteriorating. Documentation of the wreckage that was recovered, indicated that the aircraft impacted the river in a nose low attitude. The pilot's flight logbook indicated that the pilot had recently been signed off for an instrument competency check that was performed under simulated flight conditions. The logbook indicated that the last flight logged under actual conditions was performed approximately seven years prior to the accident. The last simulated instrument flight was logged approximately three years prior to the accident. ## Factual narrative HISTORY OF FLIGHT On January 8, 1999, approximately 1812 Pacific standard time, a Pacific Aviation Composites LC 40-550FG, N141LC, registered to and operated by Pacific Aviation Composites as a 14 CFR Part 91 personal flight, impacted the Columbia River about one mile west of Portland International Airport, Portland, Oregon, while on approach to runway 10L. Instrument meteorological conditions prevailed at the time and no flight plan was filed. The aircraft was destroyed and the commercial pilot and his passenger were fatally injured. The flight originated from Bend, Oregon, about one hour prior to the accident. Air Traffic Control (ATC) personnel reported that the pilot contacted Portland Approach and reported that he was 28 miles east of Portland International (PDX) for landing. Shortly after the initial contact, the controller notified the pilot that the airport was going to instrument conditions. The pilot then requested and received IFR instructions. The flight was cleared for the ILS runway 10L approach. As the aircraft was turning inbound to intercept the localizer, the controller notified the pilot that it appeared that he was lined up for runway 10R. The tower controller instructed the flight to go around to the north and the pilot was given vectors for the runway 10L approach. Radar data indicates that the aircraft was bracketing the runway 10L localizer and descending, when the aircraft dropped off radar coverage about one mile west of the runway. Shortly after the accident, search and rescue personnel located floating debris in the Columbia River. Witnesses located at various positions along the Columbia River reported to the Port of Portland Police what they saw or heard at about the time of the accident. One witness reported that she heard a "fast, low flying aircraft," and that the "engines sounded normal." This witness did not see or hear the aircraft crash. Another witness who was aboard a tug in the middle of the Columbia River at about 1815, reported that he heard and saw what appeared to be a little "Cessna" flying directly overhead. This witnesses stated that it sounded like the plane was "sputtering and missing on a continuous basis." The witness stated that the airplane appeared to be quite high in elevation. PERSONNEL INFORMATION At the time of the accident, the pilot held a commercial certificate for single and multi-engine land aircraft, and was rated for instrument flight. The pilot's flight logbooks indicate a total flight time of about 2,315 hours, with about 620 hours in the LC 40-550FG. The logbooks indicate that the pilot had accumulated a total of 11 hours of actual instrument flight time. About 86 hours had been accumulated under simulated conditions. The logbooks indicated that the last logged flight under actual instrument conditions was on February 11, 1992. The last logged simulated flight was on December 8, 1995. There were no other instrument flights logged until November 13, 1998, when the pilot flew with a flight instructor for about one hour and 36 minutes under simulated conditions. The flight consisted of VOR holding, a VOR-DME approach and an ILS approach. On December 22, 1998, the pilot flew another simulated instrument flight for one hour and 40 minutes. This flight consisted of VOR holding, an ILS approach and a VOR approach. On December 24, 1998, the pilot was signed off for an instrument competency flight after completing VOR holding, a VOR approach, and an ILS approach with a DME arc. This flight lasted one hour and 35 minutes. All of these flights were flown in the LC 40-550FG with an instructor on board. Company personnel reported that the pilot was the test pilot for the company and had been employed since June 1996. All of the flights, except the three flights previously described, were logged under visual conditions. METEOROLOGICAL INFORMATION At 0959, the pilot contacted McMinnville Flight Service Station (FSS) for a standard weather briefing from Bend, to Aurora, Oregon. The specialist asked if this was for an IFR flight. The pilot responded that he would prefer VFR, but that he could "shoot an approach in Aurora." The specialist reported that VFR was not recommended due to low IFR conditions at Aurora. The specialist asked the pilot for the time of the flight. The pilot responded in the next two hours. The specialist reported that the airmets for IFR were expected to improve by 1100, however, there was not much improvement for the surface reports. The area and terminal forecasts were improving by 1100. The specialist reported that west of the Cascades, there was a flight precaution for icing above 8,000 feet with moderate rime icing. The pilot responded that he would wait a little bit and call back later. The conversation concluded at 1001. There was no further contact between the pilot and McMinnville FSS. At 1759, the weather at Portland was reported as visibility of three miles and mist. The ceiling was overcast at 300 feet. The temperature was 37 degrees F. The altimeter was 30.49" Hg. The wind was from 170 degrees at five knots. At 1823, the weather at Portland was reported as visibility of one and one quarter miles, with 10R runway visual range of 4,500 feet, variable to 6,000 feet, with mist. The ceiling was 300 feet overcast. The temperature and dewpoint were 37 degrees F. The wind was from 180 degrees at six knots. The altimeter was 30.49" Hg. COMMUNICATIONS At 1740, the pilot contacted Portland Approach. The transmission was unreadable and the controller instructed the pilot to try again. At 1742, the pilot's second transmission was readable. The pilot reported that he was about 28 miles east of the airport and descending through 5,000 feet for landing at Portland. The controller gave the pilot a discrete transponder code and instructed the pilot to remain in visual conditions. At 1743, the controller informed the pilot that Portland was going to go to instrument conditions and asked the pilot if he was capable of instrument flight. The pilot acknowledged that he was. The controller instructed the pilot to remain in visual conditions and to proceed southwest bound. At 1744, the controller asked the pilot if he was requesting an instrument clearance at this time. The pilot responded that he would want a clearance only if visual conditions were not possible. At 1748, the pilot was cleared to the Portland Airport via radar vectors to the Instrument Landing System (ILS) runway 10L approach. The pilot was instructed to turn to a heading of 270 degrees and to climb to and maintain 4,000 feet. The pilot acknowledged by repeating that he was cleared via radar vectors to 10L approach and 4,000 feet. At 1749, the controller notified the pilot that Portland's weather was below basic VFR. The winds were from 170 degrees at nine knots. The altimeter was 30.49" Hg. The visibility was four miles and the ceiling was broken at 300 feet. The pilot acknowledged this information. At 1750, the pilot was instructed that he was to follow an MD-80 at his 12 o'clock position at three miles and descending out of 7,500 feet. The pilot acknowledged that he had the traffic in sight. The controller instructed the pilot to maintain visual separation from the traffic and to turn right to a heading of 280 degrees. The pilot acknowledged this instruction. At 1751, the pilot was instructed to reduce his speed to 130 knots. The pilot acknowledged this instruction. At 1753, the pilot continued to receive radar vectors and was requested to descend and maintain 3,000 feet. At 1757, a Cessna 182 reported to the controller that he needed runway 10R as runway 10L was below minimums. (location unknown) At 1758, the pilot was instructed to maintain 150 knots, and to descend to 2,500 feet. At 1759, the Portland Approach controller announced the current weather to all aircraft. The visibi ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - In flight collision with terrain/water, approach - faf/outer marker to threshold (ifr) - weather condition - below approach/landing minimums (contributing factor) - aircraft control - not maintained, pilot in command (cause) - lack of total experience in type operation, pilot in command (cause) - light condition - dark night (contributing factor) ## Aircraft - Registration: [N141LC](https://openairdocs.org/deregistered/N141LC-2017-07-14), registration cancelled 2017-07-14, S/N 40002, built 1997 (OpenAirDocs) - Reported make and model: Pacific Aviation Composites LC 40-550FG (LC 40-550F) - Registry model: [Pacific Aviation Composites US LC 40-550FG](https://openairdocs.org/model/pacific-aviation-composites-us-lc-40-550fg) (registry code 05603A4) (OpenAirDocs) - Registry engine: [Continental IO-550 series](https://openairdocs.org/engine/continental-io-550-series) (registry code 17042, reciprocating) (OpenAirDocs) - Category: Airplane, amateur-built - Serial number: 40002 - Airframe hours: 548 - Engines: Continental IO-550-N 310 horsepower reciprocating - Damage: Destroyed - Flight: Personal, Part 91 - Registered owner: Pacific Aviation Composites - Airworthiness certificate: Special, Experimental (Special) - Last inspection: Continuous airworthiness, December 24, 1998, 7 hours before - Departed: S07, BEND, OR - Airport: PDX, Portland International, runway 10L, 8,000 × 150 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 39; commercial; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 2, valid medical--w/ waivers/lim; seat: left; flight hours: 620 in this make and model, 3,215 as pilot in command, 52 in the last 90 days, 36 in the last 30 days ## Weather - Conditions: Instrument (IMC), Night/dark - Wind: 190° at 4 knots - Visibility: 3 statute miles - Lowest ceiling: 300 ft overcast - Temperature: 37 °F, dew point 37 °F - Altimeter: 30.00 inHg - Observed at: PDX, 1 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 19990108000249A](https://openairdocs.org/incident/19990108000249A), Jan 8, 1999: Amtr LANCAIR, Portland, OR, Destroyed, 2 fatal. (.19) On January 8, 1999, approximately 1812 pacific standard time, a pacific aviation composites lc 40-550FG, N141LC, registered to and operated by pacific… ## Docket (34 files) The files NTSB released with the investigation on September 2, 1999, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=45628. 4.6 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1/2 (item 1, .PDF, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40386027&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1%2F2-Redacted.PDF - Supplement A (item 2, .PDF, 246 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40110365&FileExtension=.PDF&FileName=Supplement%20A-Master.PDF - Supplement B (item 3, .PDF, 363 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40110366&FileExtension=.PDF&FileName=Supplement%20B-Master.PDF - Supplement S (item 4, .PDF, 48 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40110367&FileExtension=.PDF&FileName=Supplement%20S-Master.PDF - FAA Transcript of Radio Communications (item 5, .PDF, 535 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40386028&FileExtension=.PDF&FileName=FAA%20Transcript%20of%20Radio%20Communications-Redacted.PDF - ILS Runway 10L Approach Plate (item 6, .PDF, 129 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40110369&FileExtension=.PDF&FileName=ILS%20Runway%2010L%20%20Approach%20Plate-Master.PDF - Radar Data provided by Portland Tracon (item 7, .PDF, 361 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40110370&FileExtension=.PDF&FileName=Radar%20Data%20provided%20by%20Portland%20Tracon-Master.PDF - Technical Findings (item 8, .PDF, 302 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40386029&FileExtension=.PDF&FileName=Technical%20Findings-Redacted.PDF - Statement of Party Representatives to NTSB Investigation (item 9, .PDF, 407 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40386030&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 10, .PDF, 51 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40386031&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - Toxicological Report (item 11, .PDF, 68 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40386032&FileExtension=.PDF&FileName=Toxicological%20Report-Redacted.PDF - Photo 1. Right side view of aft cabin. No negatives for photos 1 - 23. (item 12, .PDF, 29 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40110375&FileExtension=.PDF&FileName=Photo%201.%20%20Right%20side%20view%20of%20aft%20cabin.%20%20No%20negatives%20for%20photos%201%20-%2023.-Master.PDF - Photo 2. Rear view of aft cabin and control tubing. (item 13, .PDF, 43 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40110376&FileExtension=.PDF&FileName=Photo%202.%20%20Rear%20view%20of%20aft%20cabin%20and%20control%20tubing.-Master.PDF - Photo 3. Top view of aft fuselage. (item 14, .PDF, 45 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40110377&FileExtension=.PDF&FileName=Photo%203.%20%20Top%20view%20of%20aft%20fuselage.-Master.PDF - Photo 4. Right rear view of empennage. (item 15, .PDF, 34 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40110378&FileExtension=.PDF&FileName=Photo%204.%20%20Right%20rear%20view%20of%20empennage.-Master.PDF - Photo 5. Left rear view of empennage. (item 16, .PDF, 37 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40110379&FileExtension=.PDF&FileName=Photo%205.%20%20Left%20rear%20view%20of%20empennage.-Master.PDF - Photo 6. Side view of horizontal stabilizer right side. (item 17, .PDF, 29 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40110380&FileExtension=.PDF&FileName=Photo%206.%20%20Side%20view%20of%20horizontal%20stabilizer%20right%20side.-Master.PDF - Photo 7. Aft view of right side horizontal stabilizer and elevator. (item 18, .PDF, 39 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40110381&FileExtension=.PDF&FileName=Photo%207.%20%20Aft%20view%20of%20right%20side%20horizontal%20stabilizer%20and%20elevator.-Master.PDF - Photo 8. View of elevator trim tab positioned about 30 degrees nose down attitude. (item 19, .PDF, 30 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40110382&FileExtension=.PDF&FileName=Photo%208.%20%20View%20of%20elevator%20trim%20tab%20positioned%20about%2030%20degrees%20nose%20down%20attitude.-Master.PDF - Photo 9. View of elevator trim mechanism. (item 20, .PDF, 25 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40110383&FileExtension=.PDF&FileName=Photo%209.%20%20View%20of%20elevator%20trim%20mechanism.-Master.PDF - Photo 10. View of right side elevator mass balance with impact damage. (item 21, .PDF, 33 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40110384&FileExtension=.PDF&FileName=Photo%2010.%20%20View%20of%20right%20side%20elevator%20mass%20balance%20with%20impact%20damage.-Master.PDF - Photo 11. View of right side elevator balance imprint. (item 22, .PDF, 29 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40110385&FileExtension=.PDF&FileName=Photo%2011.%20%20View%20of%20right%20side%20elevator%20balance%20imprint.-Master.PDF - Photo 12. View of left side horizontal stabilizer. (item 23, .PDF, 26 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40110386&FileExtension=.PDF&FileName=Photo%2012.%20%20View%20of%20left%20side%20horizontal%20stabilizer.-Master.PDF - Photo 13. View of elevator push rod bent to the left. (item 24, .PDF, 39 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40110387&FileExtension=.PDF&FileName=Photo%2013.%20%20View%20of%20elevator%20push%20rod%20bent%20to%20the%20left.-Master.PDF - Photo 14. Top view of vertical stabilizer and rudder . (item 25, .PDF, 24 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40110388&FileExtension=.PDF&FileName=Photo%2014.%20%20Top%20view%20of%20vertical%20stabilizer%20and%20rudder%20.-Master.PDF - Photo 15. View of bottom vertical stabilizer and rudder with rudder trim attached. (item 26, .PDF, 26 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40110389&FileExtension=.PDF&FileName=Photo%2015.%20%20View%20of%20bottom%20vertical%20stabilizer%20and%20rudder%20with%20rudder%20trim%20attached.-Master.PDF - Photo 16. Right side view of rudder and trim. (item 27, .PDF, 24 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40110390&FileExtension=.PDF&FileName=Photo%2016.%20%20Right%20side%20view%20of%20rudder%20and%20trim.-Master.PDF - Photo 17. View of rudder mechanism. (item 28, .PDF, 38 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40110391&FileExtension=.PDF&FileName=Photo%2017.%20%20View%20of%20rudder%20mechanism.-Master.PDF - Photo 18. View of cabin seats. (item 29, .PDF, 41 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40110392&FileExtension=.PDF&FileName=Photo%2018.%20%20View%20of%20cabin%20seats.-Master.PDF - Photo 19. View of top of cowling. (item 30, .PDF, 37 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40110393&FileExtension=.PDF&FileName=Photo%2019.%20%20View%20of%20top%20of%20cowling.-Master.PDF - Photo 20. View of upper skin, left wing. (item 31, .PDF, 28 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40110394&FileExtension=.PDF&FileName=Photo%2020.%20%20View%20of%20upper%20skin,%20left%20wing.-Master.PDF - Photo 21. View of lower skin right wing with pitot tube. (item 32, .PDF, 32 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40110395&FileExtension=.PDF&FileName=Photo%2021.%20%20View%20of%20lower%20skin%20right%20wing%20with%20pitot%20tube.-Master.PDF - Photo 22. View of damaged flap hinge. (item 33, .PDF, 27 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40110396&FileExtension=.PDF&FileName=Photo%2022.%20%20View%20of%20damaged%20flap%20hinge.-Master.PDF - Photo 23. View of damaged flap hinge. (item 34, .PDF, 29 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40110397&FileExtension=.PDF&FileName=Photo%2023.%20View%20of%20damaged%20flap%20hinge.-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.