A friend of a friend knew the pilot of a King Air that crashed, killing six of the seven people on board, so I was asked to be on the lookout for the NTSB’s final report on the accident. The thinking among those who knew the pilot was that there had to be some sort of catastrophic mechanical failure or a series of problems with the plane and avionics, far beyond the coping capabilities of any mere mortal. You probably can guess what’s coming: The NTSB found that the probable cause of the accident involved something pretty basic, which all student pilots learn about early in their training. The Safety Board said the pilot maneuvered using an excessive bank angle and failed to maintain adequate airspeed to avoid a stall.
Stall speed increases dramatically as the bank angle becomes more dramatic. When you add flaps, you indeed lower the stall speeds, but the percentage rate of increase in the stall speed as the bank angle increases remains the same.
On April 4, 2003, at 9:35 a.m., the Beechcraft B200 crashed into a building in Leominster, Mass., while on approach to Fitchburg Municipal Airport (FIT), Fitchburg, Mass. The certificated airline transport pilot, the pilot-rated passenger and four additional passengers were fatally injured. One passenger was seriously injured and one person inside the building received minor injuries. IMC prevailed and an IFR flight plan had been filed for the flight that departed LaGuardia International Airport (LGA) in Flushing, N.Y., at 8:31. The personal flight was conducted under Part 91.
According to the FAA, the pilot contacted the Bridgeport Automated Flight Service Station (AFSS) at about 6:50 on the evening prior to the accident. The pilot stated that he’d be departing Bedford the following morning at 7:00 and requested specific weather for Bedford, Martha’s Vineyard and LaGuardia. The pilot again called the Bridgeport AFSS on the morning of the accident at 6:16 and requested specific weather for Fitchburg and LaGuardia. At the same time, the pilot-rated passenger called the Burlington AFSS and obtained a preflight weather briefing for an IFR flight from Bedford to Nantucket, Mass., then to LaGuardia.
A review of ATC communications revealed that the pilot contacted Boston TRACON at 9:18 and requested the GPS RWY 14 approach at Fitchburg. At 9:21, the airplane was cleared for the approach. At 9:23, the controller radioed, “You just gonna go to the V-O-R and turn inbound on the approach?”
The pilot responded, “Actually, I suppose direct with that adice [initial approach fix] would be okay.” The pilot was asked to repeat his transmission, and he stated, “Direct adice or whatever you call it would be fine, too.” At 9:27, the pilot stated, “And King Air Two-Five-Seven-Charlie-Golf on the way to whatever it’s called.” The pilot was again instructed to repeat his transmission, and at 9:28, he stated, “Direct canat [final approach fix] for Seven-Charlie-Golf.”
At 9:28, the pilot was advised to “change to advisory and report cancellation in the air or promptly on the ground with Bridgeport FSS.” The pilot responded, “It’ll probably be on the ground.” ATC didn’t receive anymore transmissions from the airplane.
A review of radar data revealed that the accident airplane descended along the GPS RWY 14 final approach course at an average groundspeed of 120 knots. The target descended from 2,800 feet at the final approach fix to 1,600 feet at the missed approach point (MAP). After crossing the MAP at 9:32, the target maintained approximately the same course and continued to descend, passing over the approach end of runway 02 at an altitude of about 1,300 feet. It continued along the same course, until the last radar return was recorded at an altitude of 800 feet at 9:34. The last radar return was positioned to the left of course, on a magnetic heading of 165 degrees, approximately 1 nm from the threshold of runway 32.
According to the surviving passenger, the pilot’s daughter, “everything seemed fine” during the flight until her father reported they were circling the airport and were “close to landing.” The passenger subsequently felt the airplane enter a left turn, in which the airplane became “almost completely upside down.” The airplane briefly straightened out, then entered another left turn with a bank angle of the same severity. The airplane then seemed to roll level “just for a second,” then entered a dive “straight down” until it impacted the building. The passenger also noted that the engines were running “normally” throughout the entire flight and she didn’t recall any unusual sounds. In addition, the steep turns didn’t concern her, as she had flown with the accident pilot before and knew he “liked to make sharp turns.” The passenger further noted that she was unable to see the ground during the sequence of turns, but saw it briefly “just a split second before the impact.”
In a written statement, a witness who was working at the airport at the time of the accident reported hearing the flight crew of the accident airplane call in on the Unicom frequency and ask about runway conditions. Airport personnel responded that the braking action was “fair.” The flight crew then asked if there was any additional traffic in the pattern or vehicles on the runway, to which the airport personnel replied, “Negative.” The flight crew then stated, “If there is anyone on the runway, tell them to get off because we’re coming in!” The witness further recalled hearing the flight being vectored by air traffic control over the radio.
After hearing the radio transmissions from the flight, the witness walked outside and observed the airplane approaching the airport directly over runway 14 “going in and out of low scattered clouds.” The airplane turned slightly to the right to join a left downwind for runway 32, “in close, and slow and low.” The airplane continued on a close tight downwind, making a slight left turn, then a steep left base-to-final turn, “90 degrees, wings up.” The witness then observed the airplane disappear behind the tree line in a left wing-down attitude.
Another witness observed the airplane flying east, “just above the tree line and just below the cloud deck.” The airplane’s landing gears were down, and both propellers were turning. The airspeed was “extremely slow,” and the airplane appeared to be flying without enough lift. In addition, the weather conditions were “extremely poor,” with a low cloud deck and freezing rain. A special weather observation recorded at FIT at 9:31 included wind from 70 degrees at nine knots; visibility three miles in mist; ceiling broken at 1,100 feet AGL and overcast clouds at 1,700 feet; temperature at 29 degrees F; dew point at 27 degrees F; and altimeter setting at 30.15.
The pilot held an airline transport pilot certificate and was a certified flight instructor and ground instructor. His second-class FAA medical certificate was current. On an insurance renewal form, the pilot reported 6,100 hours of total flight experience. The pilot’s family provided investigators with computer spreadsheets that showed that the pilot had accumulated 1,334 hours in the accident airplane.
The FAA’s Toxicology and Accident Research Laboratory in Oklahoma City conducted toxicological testing on the pilot, which detected imipramine, carbamazepine, morphine and salicylate (aspirin). The NTSB noted that imipramine is an antidepressant that has detrimental effects on driving skills and other cognitive functions. Carbamazepine, typically prescribed to control seizures or treat chronic pain, can impair psychomotor performance. Morphine, a prescription opiate painkiller, is also a metabolite of heroin and many prescription medications, such as codeine, which is used to control moderate pain.
Hospital and pharmacy records maintained on the pilot were obtained and reviewed by the NTSB’s medical officer. Records showed that the pilot had an extensive medical history, both before and after his most recent FAA medical examination. The pilot suffered from “head-to-toe body aches, explosive headaches, episodes of not knowing where he is, medical history, seizure and migraines.” In addition, he had been diagnosed with viral meningitis. He also had an episode of multiple abscesses on his right upper extremity, including a drug-resistant staph infection.
On his most recent FAA medical application, dated about a year before the accident, the pilot answered no for item 17.a, which asked, “Do you currently use any medication?” The application also indicated a no for item 18.l. which stated, “Neurological disorders: epilepsy, seizures, stroke, paralysis,” and another no for item 19, which stated, “Visits to health professional within the last three years.” A review of the “Stall Speeds—Power Idle” chart from the Beech King Air Pilot’s Operating Handbook revealed that with approach flaps selected, the airplane would stall at the following speeds: 1) At a weight of 11,000 pounds and a bank angle of 45 degrees, the stall speed would be about 104 knots; 2) At a weight of 11,000 pounds and a bank angle of 60 degrees, the stall speed would be about 123 knots.
The NTSB determined that the probable cause of this accident was the pilot’s low-altitude maneuver by using an excessive bank angle as well as his failure to maintain airspeed, which resulted in an inadvertent stall and the subsequent collision with a building. A factor causing the accident was the pilot’s impairment from prescription medications.
Peter Katz is editor and publisher of NTSB Reporter, an independent monthly update on aircraft accident investigations and other news concerning the National Transportation Safety Board. To subscribe, write to: NTSB Reporter, Subscription Dept., P.O. Box 831, White Plains, NY 10602-0831.