NTSB Factual Report

HISTORY OF FLIGHT

On August 5, 1997, at 1058 mountain daylight time, a Beech 58P, N258W, was destroyed when it collided with terrain during a missed approach at Colorado Springs, Colorado. The private pilot and passenger were fatally injured. Instrument meteorological conditions prevailed, and an IFR flight plan had been filed for the business flight being conducted under Title 14 CFR Part 91. The flight originated at Broomfield, Colorado, at 1027.

At 0836, the pilot contacted the Denver Automated Flight Service Station (AFSS) and requested "an IFR briefing, BJC (Broomfield-Jefferson County Airport) to Colorado Springs." The pilot was provided a standard briefing. He then filed an IFR flight plan, indicating his airplane was equipped with RNAV (area navigation) and a transponder with altitude encoding capability. His proposed takeoff time was 1000, and he indicated that he planned to fly at 200 KTAS (knots true airspeed) at 10,000 feet to Colorado Springs via V-81. He estimated his time en route to be 30 minutes, and that he had 5 hours of fuel on board. The pilot also filed an IFR flight plan for his return trip to Broomfield. The conversation terminated at 0844.

At 1017, the pilot contacted BJC ground control and was issued his IFR clearance to Colorado Springs (COS). The pilot failed to obtain a taxi clearance and ground control advised him of the mistake when they observed him taxiing on taxiway A. He was subsequently cleared to continue taxiing to runway 29R. At 1027, the pilot was cleared for takeoff. At 1030, the pilot contacted Denver departure control and was given radar vectors to join V-81. At 1047, the pilot contacted COS approach control and was vectored to join the runway 17L localizer and was advised to expect the ILS DME (instrument landing system/distance measuring equipment) approach to runway 17L. He was also advised that the runway visual range (RVR) was 4,000 feet (about 3/4-mile visibility). In his written statement, the controller said the airplane "flew what appeared to be a normal ILS."

At 1054, the pilot contacted COS tower. At 1056:27, after observing the target moving away from the localizer in a southeast direction, the local controller asked the pilot, "Are you showing yourself on the localizer? I show you east of it, proceeding away." The pilot concurred and when asked what his intentions were, he replied: "Do a missed approach." The pilot was instructed to turn left to a heading of 090 degrees and climb and maintain 9,000 feet. At 1056:43, after noting the airplane was at an encoded altitude of 8,000, the local controller instructed the pilot to "start your climb to niner thousand (feet). You're well below the minimum vectoring altitude in that area." The pilot acknowledged.

At 1057:08, the local controller instructed the pilot of N58LC, a Cessna 501 Citation jet that was following N258W, to "climb and maintain one zero thousand. Start the climb now. Traffic twelve o'clock, two miles. I can't tell what he's going to do...That Baron's at seven thousand, eight hundred, needs to be climbing...Just fly the localizer for right now. I can't exactly tell where that Baron's going." The pilot of N58LC replied, "Yeah, we have him off and on the TCAS (terminal collision avoidance system). He looks like he's going to pass underneath us here." The local controller then advised the approach controller, "I'm climbing Lima Charlie to ten. That Baron's making a reverse course. I don't know what he's doing...He's supposed to be going on a ninety heading, but I don't know...I'm trying to do something with him."

At 1057:46, the local controller asked the pilot of N258W for his heading and he replied, "...one nine zero heading to zero nine zero." The controller then told the pilot, "Start a left turn now. You're headed towards the mountains." The pilot acknowledged. This was the last known contact with N258W. At 1058:50, after noting that the data block for N258W had disappeared from the radarscope, the local controller told the approach controller: "I think that Baron just augured in up there. I can't talk to him." Search and rescue procedures were then initiated (see transcripts of radio communications, attached).

The captain of N58LC was asked to submit a written statement as to his observations. The captain wrote, "Just prior to glideslope interception, I noticed on our TCAS (Terminal Collision and Avoidance System) that the Baron was west of the localizer, as was pointed out by the controller. The pilot of the Baron responded and, as I recall, indicated that he would correct. The controller has stated as a reminder that 'there are mountains to the west.'

"Our TCAS indicated that the Baron was correcting, but to such an extent that he was proceeding more east than south. Further, I observed on the TCAS that he was climbing and separation from him was becoming an issue. I elected to maintain altitude rather than continue with the descent on the glideslope just as the controller instructed me to maintain an altitude that I think was 10,000 feet. On the TCAS we observed the Baron pass under and behind to the east. I abandoned the approach and went around for a successful ILS and landing."

The captain said that during this entire time, he was in instrument meteorological conditions and never had a visual sighting of N258W. He believed there was "stress" in the voice of the pilot of N258W that sounded like "controlled panic."

A City of Colorado Springs employee told investigators he was sitting in his truck about 3 to 4 miles north of the accident site when he heard a low flying twin engine airplane. Although he did not see the airplane or hear the sounds of impact, he did hear the engines being "powered up and down." He described the weather conditions as being "foggy."

The accident occurred during the hours of daylight at a location of 30 degrees, 54 minutes north latitude and 104 degrees, 41 minutes west longitude.

PERSONNEL INFORMATION

The pilot's logbook was made available for examination. He began taking flying lessons on April 21, 1994, and soloed on May 22, 1994, in a Cessna 172. He received his private pilot license on August 17, 1994, flying a Cessna T206.

On December 17, 1994, the pilot began taking instrument flight instruction. He took the instrument rating practical test on March 30, 1995, and failed. The Notice of Disapproval cited deficient instrument approach procedures. He passed the instrument practical test on April 15, 1996, flying a Cessna T206.

The pilot first flew the Beech 58P on July 10, 1996. He purchased N258W and began taking multiengine flight instruction on August 22, 1996. On October 15, the pilot inadvertently landed wheels up at Colorado Springs. While the airplane was being repaired, the pilot flew single engine airplanes.

The pilot's insurance company required that he attend an approved Beech 58 training facility of his choice. Between January 20 and 24, 1997, the pilot attended a Beech 58 initial training course at SIMCOM in Prescott, Arizona. He received 15.5 hours of ground school, 12.8 hours of simulator training, and 10.0 hours of briefings/debriefings. According to SIMCOM's training records, simulator sessions 1, 2, 3, 7, and 8 were satisfactory. Sessions 4, 5, 6, 9, and 10 contained unsatisfactory grades. The pilot was marked deficient in the following areas: balked landing; departure, en route, and arrival procedures; ILS approach; VOR approach; NDB approach; circling approach; engine failure in flight; engine inoperative go-around. The instructor wrote, "VFR only. Could not do IFR very well --- in fact, terrible!" His graduation certificate was marked, "VFR only."

On February 14, 1997, the pilot began an accelerated multiengine flight course in the Beech 95 at Red Bird Airport, Dallas, Texas. He failed the practical test on February 17, then passed it on February 28. He began flying N258W on March 6 after it had been repaired, and flew it exclusively until the day of the accident.

The last entry in the pilot's logbook was dated July 23, 1997. As of that date, he had recorded the following flight times: Total time, 609.2 hours; pilot in command, 419.5 hours; dual instruction received, 166.4 hours; cross country, 451.2 hours; night, 46.9 hours; single engine airplanes, 469.1 hours; multiengine airplanes, 136.2 hours; Beech 58P, 104.5 hours; instruments (hood), 74.3 hours; instruments (simulator), 31.4 hours; instruments (actual), 21.5 hours.

Of the 104.5 hours the pilot had logged in the Beech 58P, 21.3 hours were with a certified flight instructor during which the pilot logged 12.5 hours of simulated (hood) instruments and 0.8 hours in actual instrument conditions. Thereafter, and in the six months preceding the accident, the pilot had logged 13.8 hours under simulated (hood) instrument conditions, 7.1 hours in actual instrument conditions and 21 instrument approaches as pilot-in-command.

AIRCRAFT INFORMATION

Examination of the aircraft maintenance records disclosed the airframe received an annual inspection and the engines received 100-hour inspections on July 21, 1997. The tachometer read 1,364.6 hours and total airframe time was 2,096.0 hours. Both engines received major overhauls on February 14, 1997. At the time of the 100-hour inspection, each engine had accrued 2,106.1 hours total time, and 54.9 hours since major overhaul. New propellers were installed on both engines on February 21, 1997.

The airplane's static system, transponder, and encoding altimeter were tested and IFR-certified on July 29, 1997.

METEOROLOGICAL INFORMATION

When N258W departed BJC, the following weather observation, identical to ATIS (automatic terminal information service) information "X-Ray", was current (see weather documents, attached):

1555Z: Wind, 350 degrees at 3 knots, visibility 25 statute miles. Scattered clouds at 500 feet, ceiling 1,100 feet broken, 24,000 feet broken. Temperature, 22 degrees C., dew point 17 degrees. Altimeter 30.37.

When the pilot initiated the instrument approach to COS, ATIS information "Echo" was current:

1654Z: Wind, 150 degrees at 13 knots, visibility 1/2 statute mile, light rain, mist. Ceiling 100 feet overcast. Temperature 15 degrees C., dew point 15 degrees C. Altimeter 30.42. REMARKS: Surface visibility 1 statute mile.

In addition, the following PIREP (pilot report) was current for the Colorado Springs area:

Cloud tops 9,500 feet msl over the Colorado Springs VORTAC, cloud bases 200 feet on final to runway 17L.

AERODROME INFORMATION

The City of Colorado Springs Municipal Airport (COS) is collocated with Peterson Air Force Base and is situated at an elevation of 6,184 feet msl (above mean sea level). At the time of the accident, the PAPI-L (precision approach path indicator the MALSR (medium intensity approach lighting system with runway alignment indicator lights) was set at an intensity level of 3, the HIRL (high intensity runway lights) was set at an intensity level of 5, and the taxiway lights were set at an intensity level of 2.

Runway 17L is 13,500 feet x 150 feet, concrete, grooved, and is served by an ILS DME instrument approach (see instrument approach procedure chart, attached).

WRECKAGE AND IMPACT INFORMATION

The on-scene examination (see Wreckage Diagram and Legend attached to this report) disclosed a ground disruption at the beginning of the wreckage path. This disruption was aligned on a magnetic heading of 080 degrees and extended up a 7 degree slope of a small hill. Within this disruption were an elevator balance weight and fragments of a strobe and red position lights. Beyond this disruption, the wreckage path curved and became aligned on a magnetic heading of 060 degrees. The distance between the initial ground disruption and the main body of wreckage was approximately 1,000 feet. The grass in this area, extending about 300 feet beyond, was burnt.

Within this burnt area were three propeller blades and pieces of a propeller hub. Serial numbers confirmed that these were from the left propeller assembly. Blade L-1 (arbitrarily numbered) exhibited a forward twist at the leading edge, about 8 inches from the tip. Blade L-2 exhibited a more pronounced leading edge forward twist and was bent 80 degrees aft about 8 inches from the hub. Blade L-3 exhibited a forward leading edge twist of almost 180 degrees at about midspan (see photos). Next to this blade was the tailcone and tail position light. Examination of the bulb under a magnifying glass disclosed a stretched filament. Just beyond the remnants of the left propeller was the intact right propeller assembly. Damage to the propeller blades was similar to that observed of the left propeller blades. All six blades bore chordwise scratches on the cambered surfaces, leading edge gouges, and were bent back in the opposite direction of rotation.

Both turbochargers were located about halfway up the hill and outside the fire area, and their positions were identified by serial numbers. There was component separation of the left engine turbocharger. The compressor housing bore rotational scoring marks. The compressor was jammed against the housing and could not be turned by hand. The turbine housing bore rotational scoring marks and deep gouges. A portion of the housing lip was missing. All of the turbine blade leading edges were broken. The right engine turbocharger compressor and turbine housing bore rotational scoring. Both could be turned by hand.

The other side of the hill had a downslope of approximately 6 degrees. The fuselage was on its left side. A portion of the right wing and the right engine rested against the rear of the fuselage. The separated left engine was about 50 feet behind the fuselage. The nose section was destroyed, exposing the cockpit and cabin areas. Examination of the landing gear turnbuckle and flap jackscrew indicated the landing gear was extended and the flaps were 15 degrees down. According to the Beech Aircraft representative, this setting equates to approach flaps. Measurement of the aileron trim tab actuator was not possible, but measurements of the rudder and both elevator trim tab actuators were 8 degrees left, 10 degrees up, and 10 degrees down, respectively. According to the Beech Aircraft representative, these readings are suspect because impact stretched the cables.

The lubber line of the horizontal situation indicator was over 040 degrees. The heading bug was position at 126 degrees. The course bug was destroyed, but the tail was at 305 degrees. The course needle was at the bottom of the instrument (tail of the aircraft). The attitude indicator was destroyed. The altimeter read 6,720 feet, and was set to 30.37 inches of mercury. The airspeed indicator read 56 KIAS.

MEDICAL AND PATHOLOGICAL INFORMATION

An autopsy (report #97A-266) was performed on the pilot the following morning by Dr. David L. Bowerman for the El Paso County Coroner's Office. A toxicological screen revealed the presence of caffeine in the pilot's urine, but there was no evidence of drugs or alcohol. The passenger tested positive for cocaine.

Pilot specimens were also tested by FAA's Civil Aeromedical Institute (CAMI) in Oklahoma City, Oklahoma. According to CAMI's report (#9700185001), no ethanol or drugs were detected in the urine sample. Tests for carbon monoxide and cyanide could not be performed due to a lack of suitable specimen.

ADDITIONAL INFORMATION

An air traffic control specialist, assisted by representatives of the Federal Aviation Administration and the National Air Traffic Controllers Association, was dispatched from NTSB headquarters to conduct the ATC portion of this investigation. According to the Air Traffic Control Group Chairman's Factual Report, the arrival controller failed to ensure that the pilot of N258W had the current weather and airport information (contained in the ATIS broadcasts), and he failed to issue the pilot an approach clearance.

In addition to the Federal Aviation Administration, parties to the investigation included the Beech Aircraft Corporation and the National Air Traffic Controllers Association.

The wreckage was released to a representativ

NTSB Probable Cause

failure of the pilot to follow IFR procedures; and his failure to maintain proper altitude, while executing a missed approach from an attempted ILS approach. Related factors included: low ceiling, rain, fog, the pilot's overconfidence in his personal ability, and inadequate service provided by the approach controller by not providing current weather and airport information.