NTSB Factual Report

HISTORY OF FLIGHT

On October 23, 2001, at 0522 central daylight time, a Beech 58, N7235R, operated by Multi-Aero, Inc., was destroyed when it impacted trees and the embankment of a county road about 1.25 miles southeast of the Dubuque Regional Airport (DBQ), Dubuque, Iowa. The airline transport pilot received fatal injuries. The 14 CFR Part 91 positioning flight departed DuPage Airport (DPA), West Chicago, Illinois, at 0435 and was en route to DBQ. The flight had been cleared for and was flying the DBQ LOC RWY 31 instrument approach. Instrument meteorological conditions prevailed at the time of the accident and an instrument flight rules (IFR) flight plan had been filed.

At 0506:29, the pilot contacted the air traffic controller at the Federal Aviation Administration (FAA) Chicago Air Route Traffic Control Center (ARTCC). The pilot reported that N7235R was at 4,000 feet mean sea level (msl).

At 0506:49, the pilot reported, "We got the weather and we'd like to do the three one ILS, negative glide slope, localizer approach to Dubuque."

At 0512:23, the controller stated, "Three Five Romeo is radar contact, ah, show you at four. Fly heading of, ah, two six zero. Vectors for the, ah, localizer three one approach."

At 0516:40, the controller stated, "Three Five Romeo, ah, position seven miles southeast of the outer marker. Fly heading two eight zero. Maintain three thousand, three hundred until established and, ah, cleared for the straight in ILS runway 31 approach with the glide slope out of service."

At 0517:01, the pilot responded, "Ok. Three point three, two eighty to join, ah, cleared for the localizer three one, Five Romeo.

At 0518:11, the controller stated, "Three Five Romeo, radar service is terminated. You can cancel IFR on this frequency. I should be able to read you on the ground. Change to advisory at this time."

The control tower tape at DBQ indicated that at 0519:20, the pilot transmitted on the local radio frequency that N7235R was 7.5 miles from the airport and was in-bound on the runway 31 localizer approach. No further radio transmissions were received from N7235R.

A search was conducted for N7235R and it was located at approximately 0700. The first responders reported ground fog with low visibilities hindered the search effort. The wreckage coordinates were North 42 degrees 22.92 minutes and West 090 degrees 40.73 minutes.

PERSONNEL INFORMATION

The pilot was an airline transport rated pilot with single and multi-engine land ratings. He held a First Class Medical Certificate that was issued on June 11, 2001. The operator reported the pilot had a total of about 15,000 hours of flight time. 2,000 hours were in the make and model of the accident airplane, and he had flown 88 hours in make and model in the last 90 days. The pilot had logged about 2,400 hours at night, and had logged about 800 hours of flight in actual instrument conditions.

AIRCRAFT INFORMATION

The airplane was a twin-engine Beech 58, Baron, serial number TH-559. The airplane was configured for cargo operations. It seated the pilot and copilot, and had a maximum gross weight of 5,500 pounds. The engines were 285 horsepower Continental IO-520-C7B engines. The last annual inspection was conducted on October 18, 2001. The airplane had flown 31 hours since the last inspection and had a total time of 3,826 hours. A review of the aircraft logbooks showed the airplane had a current Airworthiness Directives (AD) list and the inspections of the transponder, altimeter, and emergency locator transmitter (ELT) were current.

METEOROLOGICAL CONDITIONS

At 0407, the observed weather at DBQ was: winds 330 degrees at 5 knots; visibility 1/4 mile; fog; clouds broken 100 feet above ground level (agl); overcast 500 feet agl; temperature 52 degrees F; dew point 52 degrees F; altimeter 29.49.

At 0455, the observed weather at DBQ was: winds 310 degrees at 3 knots; visibility 1/4 mile; fog; clouds few 100 feet agl; overcast 500 feet agl; temperature 52 degrees F; dew point 52 degrees F; altimeter 29.49.

At 0513, the observed weather at DBQ was: winds 300 degrees at 4 knots; visibility 1/4 mile; fog; clouds broken 100 feet agl; overcast 500 feet agl; temperature 52 degrees F; dew point 52 degrees F; altimeter 29.50.

AIDS TO NAVIGATION

The DBQ LOC RWY 31 approach plate indicated the airport elevation at DBQ is 1,076 feet. The in-bound heading is 312 degrees at an altitude of 3,100 feet msl, and the Final Approach Fix (FAF) is located 6.3 nautical miles from the runway. The Minimum Descent Altitude for the Missed Approach is listed as 1,540 feet msl, and the visibility minimum is 1/2 mile. The Height Above Touchdown is listed as 478 feet agl.

A Notice to Airmen (NOTAM) listed as DBQ 08/006 stated, "DBQ 31 ILS GP DCMSND WEF 0108131230." The NOTAM indicated that the runway 31 ILS glide slope was decommissioned effective August 13, 2001, at 1230.

WRECKAGE AND IMPACT INFORMATION

The airplane was found on the south side of Feeney Road located about 1.25 miles from the approach end of the runway. The elevation at the accident site was about 1,100 feet. The nose of the airplane was heading about 090 degrees. The wreckage path indicated the airplane impacted a stand of trees on a heading of about 320 degrees. The height of the initial tree impact was about 25 feet agl. The airplane impacted the embankment of Feeney Road that was located about 166 feet from the initial tree impact on a heading of about 320 degrees. The left and right propellers separated from the engines and were found partially buried in the road embankment in their respective left/right positions. The furthest piece of wreckage was a main landing gear, and it was found about 287 feet from the initial impact.

The left wing remained attached to the fuselage. The left flap remained attached to the wing and the left aileron remained partially attached to the wing. The left wingtip and left outboard leading edge had separated from the wing. The leading edge outboard of the left nacelle was crushed and buckled. The left engine was partially separated from the left wing.

The right wing remained attached to the fuselage. The right flap remained attached to the wing and the right aileron remained partially attached to the wing. The right wingtip and right outboard leading edge had separated from the wing. The leading edge outboard of the right nacelle was crushed and buckled. The right engine was separated from the right wing and was found under the right wing in the ditch.

The vertical stabilizer, rudder, right horizontal stabilizer, and right elevator remained attached to the fuselage. The left horizontal stabilizer was separated from the empennage. The left control tube was separated from the elevator control horn.

Flight control continuity was confirmed from the flight controls to the control surfaces.

The inspection of the left engine revealed the engine rotated. Valve train continuity was confirmed to all cylinders and to the rear of the engine. All cylinders exhibited compression and suction. The left and right magnetos would not spark. They were opened and their interiors were wet, but no damage was noted. The vacuum pump drive coupling was intact and the unit was free to rotate. The fuel pump drive coupling was intact and it was free to rotate. It pumped fuel when the drive was rotated.

The inspection of the right engine revealed the engine rotated. Valve train continuity was confirmed to all cylinders and to the rear of the engine. All cylinders exhibited compression and suction. The left magneto sparked on all terminals. The right magneto would not spark. It was opened and its interior was wet, but no damage was noted. The vacuum pump drive coupling was separated and the unit could not rotate. The unit was opened and the interior element was found shattered. The fuel pump drive coupling was intact and it was free to rotate.

The left propeller was separated from the engine at the attachment flange on the crankshaft. The first blade was curled toward the direction of rotation and had chordwise scaring on the cambered side. The second blade was twisted toward the direction of rotation. The third blade had leading edge gouges.

The right propeller was separated from the engine at the crankshaft attach flange. The first blade was curled toward the direction of rotation and had scaring on the cambered side. The second blade was bent about 80 degrees toward the non-cambered side, and chordwise scaring was found on the cambered side. The third blade had damage near the blade tip.

A visual inspection of the attitude indicator's gyro found no rotational damage on the gyro's surface. The gyro housing end plate exhibited rotational scoring. The gyro housing did not exhibit rotational scoring.

A visual inspection of the horizontal situation indicator's (HSI) found no rotational damage on the gyro or gyro housing. The gyro housing end plate exhibited rotational scoring.

The turn coordinator gyro exhibited about a 150-degree arc of scoring in the middle of the gyro cylinder.

MEDICAL AND PATHOLOGICAL INFORMATION

An autopsy was performed on the pilot at the Broadlawns Hospital Morgue, Dubuque, Iowa, on October 24, 2001.

A Forensic Toxicology Fatal Accident Report was prepared on the pilot by the FAA Civil Aeromedical Institute. The results were negative.

TESTS AND RESEARCH

The pilot's altimeter was inspected. The altimeter read 850 feet below actual elevation. The Mode C matched the altimeter setting.

ADDITIONAL INFORMATION

The pilot's flight duty log was found at the accident site. It indicated the pilot had been off duty on October 19, 2001. On October 20, 2001, he logged 16.1 hours for his duty day that included 4.3 hours of flight time. He was off duty on October 21, 2001.

The pilot reported for flight duty at 1400 on October 22, 2001. The flight duty consisted of flying seven separate flight legs conducted under 14 CFR Part 135 regulations, and the eighth leg was a Part 91 positioning flight from DPA to DBQ. The route of flight indicated by the aircraft flight log that the pilot completed during the flight, and pilot's "kneeboard" scratchpad (both found in the airplane at the accident site) indicated the following flight legs were flown:

1. Festus, MO (FES) to DBQ; takeoff 1430; landed 1604.

2. DBQ to Davenport, IA (DVN); takeoff 1614; landed 1637.

3. DVN to Cedar Rapids, IA (CID); takeoff 1644; landed 1710.

4. CID to Midway Airport (MDW), Chicago, IL; takeoff 1817; landed 1923.

5. MDW to Indianapolis, IN (IND); takeoff 1947; landed 2058.

6. IND to St. Louis, MO (STL); takeoff 2145; landed 2304.

7. STL to DPA; takeoff 0255; landed 0405.

8. DPA to DBQ; takeoff 0435.

The airplane was fueled with 128 gallons of fuel at STL at 2356 on October 22, 2001.

The pilot's kneeboard scratchpad indicated the following weather conditions written in the block of flight labeled DPA - DBQ: 0956; 29.49; 310 - 3; vis 1/4; Few; 500 (with overcast symbol); and 11:11.

The operator completed the National Transportation Safety Board Form 6120.1/2. In the section titled "Recommendation (How Could This Accident Have Been Prevented)," the operator stated the following:

"Pilot in command should not have departed from last departure point due to the destination weather being below and available straight CAT 1 approach for the airport of intended landing. Pilot in command needed to have a better judgement call for that flight to take place. Should have waited for weather to improve for landing minimums."

Parties to the investigation included the FAA, Raytheon Aircraft Company, and Continental Motors.

The airplane wreckage was released to Kern and Wooly, Los Angeles, California.

NTSB Probable Cause

The pilot continued flight into known adverse weather and disregarded the minimum descent altitude. Additional factors were the conditions conducive to pilot fatigue, fog, and night.