NTSB Factual Report

HISTORY OF THE FLIGHT

On February 24, 1994, about 0949 central standard time (CST), a Cessna 401A airplane, N4071Q, registered to B & L Aviation, Rapid City, South Dakota, and operated by the U.S. Department of Health and Human Services,Indian Health Service, a federal agency, sustained substantial damage when it crashed in instrument meteorological conditions during an instrument approach (ILS) to runway 31 at Minot International Airport, Minot, North Dakota. The airline transport certificated pilot and the three physician passengers aboard were fatally injured.

The flight was a section of a routine quarterly visit by Indian Health Service (IHS) doctors to sites in North Dakota. The airplane and pilot were chartered by IHS from B & L Aviation, Rapid City, South Dakota. The flight departed Devil's Lake, North Dakota about 0800 with an initial destination of Rolla. Weather conditions at Rolla were unsuitable for a VFR approach, and the flight diverted to Minot for an instrument approach.

The pilot received an outlook weather brief from the Grand Forks Automated Flight Service Station (AFSS) at 2103 CST on February 23, 1994. He requested the weather for a flight from Devil's Lake to Rolla, and from Rolla to Minot. The customer service agent for Great Lakes Airways at Devil's Lake reported the pilot came in at 0730. He stated the pilot didn't get a weather brief, and went out to the airplane at 0745. There was no record of the pilot receiving a weather brief the morning of the accident from the Grand Forks AFSS, the State of North Dakota contract weather service, or either FAA DUATS contractors.

The airport manager at Rolla said he talked to the pilot on the radio about 0900. The manager reported it was snowing heavily at the time. He stated the pilot made one attempt to land but terminated the visual approach and went around for a second attempt. The pilot also terminated the second approach and communicated to the airport manager that he encountered "white- out" conditions at 400 feet, and was going to Minot.

The pilot contacted Minot Air Force Base Approach Control at 0903 and requested an IFR clearance to Minot International Airport. Approach control provided vectors to Minot. At 0927, the pilot was cleared for the ILS approach to runway 31 at Minot. At 0933, the pilot reported a missed approach, and was given vectors for a second ILS approach. After executing the missed approach, the pilot remarked to the approach controller, "...that was my mistake...I've got to get this thing a little slower on final." The pilot was cleared for the second approach at 0942. At 0948:23, the pilot reported a missed approach. This was the last radio transmission from the pilot.

The wreckage of the airplane was found on the airport at 1040, by an airport employee plowing snow.

The pilot of the airplane which landed ahead of the mishap airplane reported snow was very heavy, and the visibility was about one-half mile. He also said there was no icing, and no turbulence. The pilot of the airplane (N7786Q) behind the mishap pilot also reported very heavy snow. He described the conditions as almost at white-out. This pilot had to execute a missed approach on his first attempt. The time of the missed approach was 0952:49. On the second approach he stated he had visual contact with the ground at 300 feet agl. He reported the horizontal visibility was very poor. The pilot stated he saw the sequential approach lights about the time he was starting to execute his second missed approach, and he continued the approach and landed.

The air traffic control facility operating records did not indicate any abnormal conditions with the navigation or approach equipment at the time of the mishap.

PERSONNEL INFORMATION

The pilot held an airline transport pilot certificate with airplane single engine and multiengine land, and instrument ratings. He held a class 2 medical certificate with the limitation that he wear glasses when flying. The pilot's log book indicated he had accrued 5380 hours total flying time, and 1500 hours in this model airplane. He had also accrued 231 hours actual instrument time. In the last 90 day, 30 day, and 24 hour periods respectively, he had flown 75 hours, 28 hours, and 3 hours total time, and 68 hours, 25 hours, and 3 hours in this model airplane. The log book also indicated the pilot had flown 24 hours actual instrument conditions in the last 90 days, and 12 hours actual instrument conditions in the last 30 days. The pilot successfully completed a FAR Part 135.293, 135.297, 135.299 Airman Competency/Proficiency Check on December 4, 1993.

AIRCRAFT INFORMATION

The airplane was a Cessna 401A, manufactured in 1969. The serial number was 401A-0115. The airplane was listed on the owner's FAR Part 135 Air Taxi and Commercial Operator's certificate for IFR or VFR flight, day or night. The owner's Part 135 certificate also authorized use of an autopilot in lieu of a second pilot for IFR operations in the airplane. The last inspection conducted on the airplane was a 100 hour inspection completed on November 11, 1993. The airplane had been flown 33 hours since the last inspection. The total airframe time was 4220 hours. Inspection of the airplane log books revealed no outstanding or deferred maintenance actions.

METEOROLOGICAL INFORMATION

The weather observation taken at Minot at 0959 was: indefinite ceiling 600 feet, sky obscured; visibility one-half mile variable in snow; temperature 6 degrees F, dew point 3 degrees F; wind 110 degrees magnetic at 11 knots; altimeter setting 29.67; remarks, visibility variable from one-quarter to three-quarters of a mile.

There were pilot reports of instrument meteorological conditions and heavy snow at the time of the mishap.

COMMUNICATIONS

The pilot had been in radio communication with air traffic control just prior to the mishap. A transcript of all known radio communications is a part of this report.

WRECKAGE

The on-scene investigation commenced at 0800, February 25, 1994. The airplane crashed on the Minot International Airport. The crash site was 750 feet east, and 600 feet north of the intersection of runways 13/31, and 8/26. This is about one- quarter mile north of the approach end of runway 31. From the initial ground impact point to the main wreckage was 460 feet. The debris trail from the initial impact point to the main wreckage was oriented 288 degrees magnetic. Both of the wings separated from the airplane outboard of the engine nacelles. The heading of the main wreckage was 040 degrees magnetic. The debris trail contains pieces of both wings, both tip tanks and both propellers.

The landing gear was in the UP position. The flaps were extended 15 degrees, as determined by measuring the drive motor chain. Control continuity was established from the cockpit pedestal to the elevator and rudder, and to the point of wing separation on both wings.

The cockpit throttle control was at midrange, the cockpit propeller and mixture controls were aft in the throttle quadrant.

All three sets of cockpit engine controls were bent to the right.

The attitude gyro was jammed at 10 degrees nose down, and 15 degrees right wing down. The vacuum pumps on both engines turned freely and produced suction.

Both propellers were stripped from the propeller mounting flange. Both propellers exhibited multiple twists and bends. Both engines turned freely. There was continuity through the accessory drive train and valve action on both engines. The magnetos on both engines produced spark. Fuel was found in the induction manifold and fuel pump on both engines. No preimpact discrepancies were discovered on the airframe or engines during the on-scene investigation.

The Morrow Model 820 GPS receiver installed in the airplane was removed for further examination.

MEDICAL AND PATHOLOGICAL INFORMATION

An autopsy and toxicological examination was conducted on the pilot. The autopsy was performed by Richard V. Crisera, M.D., at St. Joseph's Hospital, Minot, North Dakota. The toxicological examination was negative.

TESTS AND RESEARCH

The Morrow Model 820 GPS, serial number 01023754, which was installed in the airplane was examined at an FAA certified repair station. When power was applied to the unit, the self test feature indicated a fault in the data base card. No route information could be extracted from the unit. The operating parameters were set for operation in the manual mode, and the CDI sensitivity was set to 0.10 nm, the most sensitive setting possible. The last position in the unit's memory was 48 degrees, 15.65 minutes north; and 101 degrees, 16.13 minutes west. This point is on the Minot International Airport.

ADDITIONAL DATA

A review of the information provided by the United States Forest Service regarding B & L Aviation, Inc.'s prior operating practices and quality of maintenance, disclosed no evidence of a deficiency, or deficiencies, associated with this particular accident flight.

The wreckage was released to Mr. James E. McClure, agent for the owner, on February 27, 1994.

NTSB Probable Cause

FAILURE OF THE PILOT TO MAINTAIN PROPER ALTITUDE DURING A MISSED APPROACH. FACTORS RELATED TO THE ACCIDENT WERE: THE UNFAVORABLE WEATHER AND SNOW COVERED TERRAIN.