2003_美国_AAR0303.pdf

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Loss of Control and Impact With Terrain Aviation Charter, Inc.

Raytheon (Beechcraft) King Air A100, N41BE Eveleth, Minnesota October 25, 2002

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Aircraft Accident Report

NTSB/AAR-03/03

PB2003-910403

Notation 7602

National Transportation Safety Board Washington, D.C.

Aircraft Accident Report

Loss of Control and Impact With Terrain Aviation Charter, Inc.

Raytheon (Beechcraft) King Air A100, N41BE Eveleth, Minnesota

October 25, 2002

NTSB/AAR-03/03

PB2003-910403

Notation 7602

Adopted November 18, 2003

〔图〕O\n National Transportation Safety Board

490 L’Enfant Plaza. S. W.

Washington, D.C. 20594

References

Manufacturer ' s Guidance on Operation in Icing Conditions

Manufacturer ' s Guidance on Operation in Icing Conditions

Abstract

Company Guidance on Operation in Icing Conditions .

References

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Aircraft Accident Report

Abbreviations

AC

AFM

AFSS

agl

AIM

AIRMET

ARAC

ASOS

ATC

ATCT

ATP

ATSS

AWC

AWOS

BIS

C

CAMI

CDI

CFI

CFR

CG

CRM

CVR

DLH

DME

EVM

advisory circular

Aircraft Flight Manual

Automated Flight Service Station

above ground level

Aeronautical Information Manual

airmen's meteorological information

Aviation Rulemaking Advisory Committee

automated surface observing system

air traffic control

air traffic control tower

airline transport pilot

Airway Transportation System Specialist

Aviation Weather Center

automated weather observing system

Bismarck Municipal Airport

Celsius

Civil Aerospace Medical Institute

course deviation indicator

certified flight instructor

Code of Federal Regulations

center of gravity

crew resource management

cockpit voice recorder

Duluth International Airport

distance measuring equipment

Eveleth-Virginia Municipal Airport

Abbreviations

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Aircraft Accident Report

FA

FAA

FAF

FAR

FBO

FCM

FGS

fpm

FSDO

FSI

ft-lbs

GOM

HSI

IFR

ILS

IMC

JAR

KCAS

MAP

MDA

msl

NASA

NCAR

NOTAM

NWS

PIC

PIREP

POI

area forecast

Federal Aviation Administration

final approach fix

Federal Aviation Regulations

fixed-base operator

Flying Cloud Municipal Airport

flight guidance system

feet per minute

Flight Standards District Office

Flight Safety International

foot-pounds

General Operations Manual

horizontal situation indicator

instrument flight rules

instrument landing system

instrument meteorological conditions

Joint Aviation Requirements

knots calibrated airspeed

missed approach point

minimum descent altitude

mean sea level

National Aeronautics and Space Administration

National Center for Atmospheric Research

notice to airmen

National Weather Service

pilot-in-command

pilot report

principal operations inspector

Abbreviations

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Aircraft Accident Report

RASIP

Regional Aviation Safety Inspection Program

ROC

Rochester International Airport

RTCA

Radio Technical Commission of Aeronautics

SLD

supercooled large droplets

SOPs

Standard Operating Procedures

STP

St. Paul Downtown Airport

TAF

terminal aerodrome forecast

UTC

coordinated universal time

VOR

very high omnidirectional range

Factual Information

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Aircraft Accident Report

controller advised, “one zero miles from the vor turn left heading three zero zero maintain three thousand five hundred [un]til established on the final approach course cleared for the vor runway two seven approach eveleth.” The copilot acknowledged the instruction at 1018:31. Radar data indicate that shortly thereafter, the airplane began turning left while maintaining 3,500 feet and slowing through about 164 KCAS. Almost immediately after the airplane began its left turn, it overshot the approach course and traveled for almost 1 mile north of the course as it continued the turn toward the course until establishing a ground track of about 262°. See figures 1 and 2 for the ground track and profile view of the accident flight.

〔图〕SOTAAL-5236 (FAA)EVELETH,AVOR/DME EVM4215Rwy IdgVOR RWY 27APP CRSTDZE1369108.2276°EVELETH-VIRGINIA MUNI(EVM)1378Apt Elev

Figure 1. The published EVM VOR approach chart.

Factual Information

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Aircraft Accident Report

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Figure 2. Ground track of the accident flight.

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Figure 3. Profile view of the accident flight.

Factual Information

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Aircraft Accident Report

At 1019:12, the controller stated, “king air one bravo echo change to advisory frequency approved[;] advise cancellation of ifr with the princeton flight service when on the ground.” The copilot acknowledged the instruction at 1019:20. This was the last transmission received by ATC from the accident airplane. Radar data indicate that at this time, the airplane began its descent from 3,500 feet and that its airspeed stopped decreasing about 155 KCAS and began increasing.

The airplane's airspeed increased to about 170 KCAS and its vertical speed increased through 1,000 feet per minute (fpm) as it descended through 3,200 feet. The airspeed stabilized briefly at about 170 KCAS and the vertical speed peaked at about 1,400 fpm. At 1020:06, as the airplane passed through (south of) the approach course about 5 miles east of the runway 27 threshold, a slight right turn was initiated, and the airplane's airspeed and vertical speed began decreasing. The airplane established a ground track of about 269° and maintained this track until the end of the radar data at 1021:42. The last two radar returns indicate that the airplane had slowed to about 76 KCAS at 1,800 feet.$^{15}$

One witness indicated that he saw the airplane to the west of his location (approximately 4.5 miles east of the runway 27 threshold) “just beneath a low layer of clouds” and that “the top of the airplane may still have been in the clouds.” He stated that he noticed the landing gear was down, but that he could not remember if any lights were illuminated on the airplane.

The airplane impacted the ground about 1.8 miles southeast of the approach end of runway 27. The main wreckage was found at 47° 24.36' north latitude and 92° 27.05' west longitude at an elevation of 1,361 feet. The wreckage location was about 1/4 mile south-southwest of the last radar return.

1.2 Injuries to Persons

Table 1. Injury chart.

Factual Information

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Aircraft Accident Report

hours from the flight hour totals in the final entries of the two conflicting logbooks. Further, in August 1992, the pilot reported on an FAA medical certificate application form that he had a total of 3,250 flight hours, which is 1,268 fewer hours than he claimed in the notarized statement to have acquired as of December 1994.$^{24}$ Safety Board investigators did not find any records that could verify the hours reported by the pilot in his private logbooks. See figure 4 for a reconstruction of the pilot's reported flight hours.

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Figure 4. Reconstruction of pilot's reported flight hours.

1.5.2 The Copilot

The copilot, age 30, was hired by Aviation Charter on February 7, 2001. The copilot held a single- and multi-engine land, instrument airplane commercial pilot certificate, which was issued in May 1997. The copilot's most recent FAA first-class medical certificate was issued on August 2, 2002, with no restrictions.

Analysis

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Aircraft Accident Report

was not able to determine when or whether the stall warning horn activated on the accident flight or if buffeting or loss of flight control effectiveness occurred. Nevertheless, it is clear that the flight crew failed to monitor the airplane's airspeed and allowed it to decrease to a dangerously low level (as low as about 50 knots below the company's recommended approach airspeed) and to remain below the recommended approach airspeed for about 50 seconds. Further, the flight crew failed to recognize that a stall was imminent.

According to the stabilized approach criteria contained in Aviation Charter's Turbopropellers Maneuvers Guide, while on the final approach segment of a nonprecision approach, pilots should allow no more than a three-quarter-scale deflection of the CDI needle and maintain airspeed within 10 knots of the approach airspeed. Further, according to the Abandoned Approach procedure contained in Aviation Charter's SOPs, when the flight is within 500 feet agl, the airspeed must be within ± 10 knots of the recommended approach speed. If the airplane does not meet these acceptable margins, the flight crew is expected to execute a go-around. Computations showed that the airplane's position relative to the VOR course would result in the CDI needle likely at full deflection approximately 2.6 miles from the VOR station. Further, at this point in the approach, the airspeed had fallen to about 110 knots and was still decreasing, ultimately reaching a low of about 76 knots. Therefore, the inadequate airspeed or the full CDI needle deflection should have prompted the flight crew to execute a go-around.

2.3.3 Summary of Flight Crew's Performance During the Approach

In sum, the Safety Board concludes that the flight crew failed to maintain an appropriate course and speed for the approach and did not properly configure the airplane at the start of the approach, making the later stages of the approach more difficult. Further, the Safety Board concludes that, during the later stages of the approach, the flight crew failed to monitor the airplane's airspeed and allowed it to decrease to a dangerously low level (as low as about 50 knots below the company's recommended approach airspeed) and to remain below the recommended approach airspeed for about 50 seconds. The Board further concludes that the flight crew failed to recognize that a stall was imminent and allowed the airplane to enter a stall from which they did not recover. The Board also concludes that the inadequate airspeed or the full CDI needle deflection should have prompted the flight crew to execute a go-around; however, they failed to do so.

Lastly, the Safety Board notes that if the flight crew had been adhering to Aviation Charter's approach procedures and effectively applying CRM techniques in the cockpit, at least one of the flight crewmembers should have been monitoring the instruments. The evidence clearly indicates that neither flight crewmember was monitoring the airspeed indicator or CDI during the approach. Therefore, the Safety Board concludes that the flight crew was not adhering to Aviation Charter's approach procedures and was not effectively applying CRM techniques during the approach segment of the flight.