NTSB Factual Report

HISTORY OF FLIGHT

On January 26, 1994, at 2202 hours eastern standard time, N555AC, a Beech BE-58, operating as Flight 203 by Cape Central Airways, Inc., collided with terrain in Newtown, Ohio, following an uncontrolled descent immediately after climbout. The airplane was destroyed. The certificated commercial pilot, the sole occupant, was fatally injured. Instrument meteorological conditions prevailed and an instrument flight rules (IFR) flight plan was filed. The airplane had departed Lunken Field, Cincinnati, about 2158 hours, and was en route to Cleveland, Ohio. The cargo flight was conducted under 14 CFR 135.

The purpose of the flight was to deliver cancelled bank checks from Cincinnati to Cleveland, Ohio. The accident occurred during the first leg of a scheduled night cargo run to Cleveland and return.

According to witnesses, the pilot had slept on the day accident and awoke about 2000 hours. About 2100 hours, the pilot arrived at the Lunken Field to pre-flight the airplane. A line service technician stated that the pilot spent about 15 minutes pre-flighting the airplane. The pilot appeared to be "feeling fine" and was "behaving normally." The pilot did not indicate that he was having problems with the airplane, and he did not request any services from the technician.

At 2107 hours, the pilot contacted the Dayton Automated Flight Service Station by telephone and received a weather briefing. The briefing was concluded at 2120 hours. About 2150 hours, a courier who delivered cancelled bank checks arrived to load the airplane. The courier's observations of the pilot and the airplane were consistent with the line service technician's observations.

According to the FAA air traffic control (ATC) voice recordings and recorded radar data (attached), the pilot received taxi instructions to runway 6 and an IFR clearance to Burke Lakefront Airport in Cleveland, Ohio, at 2154 hours. At 2158 hours, the pilot was cleared for takeoff. At 2159:30 the pilot contacted Cincinnati Departure control and reported he was flying "...runway heading climbing to [2,500 feet]." Departure controller stated "radar contact climb and maintain [4,000 feet]." The pilot acknowledged.

At 2200:00 hours, the airplane was at an altitude of 2,100 feet mean sea level (msl), and was turning right from a heading of 049 degrees magnetic at a ground speed of 101 knots. The pilot was asked to "say on course heading" and the pilot responded "about [040 degrees] or so." At 2200:08 hours, the pilot was told "to resume own navigation climb and maintain nine thousand." The pilot acknowledged. At the time the pilot acknowledged, the airplane was climbing from an altitude of 2,300 feet msl, heading 044 degrees magnetic.

During the next 28 seconds, the airplane climbed at a rate of 600 feet per second to an altitude of 2,600 feet msl and began to turn to the right from a heading of 044 degrees to 058 degrees, opposite the direction of the pilot's intended course. During the next 14 seconds, from 2200:40 hours to 2200:54 hours, the airplane descended to 1,700 feet msl at a rate of 3,857 feet per minute. The airplane's heading deviated 52 degrees to the right and the ground speed increased 10 knots.

At 2200:59 hours, radar contact was lost. At 2203:00 hours the controller attempted to contact the pilot; the pilot never responded. About 2203 hours, a phone call was received by the FAA reporting that an airplane had crashed near Newtown.

No distress calls from the pilot were recorded during the entire flight.

A resident was in her home, located about 1/8 mile from the accident site, when the accident occurred. She stated that she heard the airplane flying "low" over her house. She also stated:

It did not sound like it was having engine problems. The engines sounded smooth at first for about 15-20 seconds. Then, the engine noise sounded like it decreased in power, but smoothly and quickly, not like it suddenly died. This lasted about 2 seconds. Then the engines revved up to full throttle. This lasted about 2 to 3 seconds. Then I heard a loud thud - engine noise went silent. I did not hear any popping and sputtering.

The airplane wreckage was found about three miles from the departure airport on the extended centerline of runway 6.

The accident occurred during the hours of darkness about 39 degrees 06.20 minutes North, and 84 degrees 25.12 minutes West.

PERSONNEL INFORMATION

The pilot, age 40, possessed an FAA Commercial Pilot certificate and Instrument rating issued July 19, 1990. The certificate contained ratings and limitations of airplane single and multiengine land. The pilot also possessed an FAA Certified Flight Instructor certificate with ratings for airplane single engine and instrument airplane. His first class medical certificate, dated August 9, 1993, contained the limitation that he "must wear corrective lenses for distant and near vision."

Company training records (attached) indicate that the pilot began initial ground and flight training with Cape Central Airways in December 1993. According to the records, the pilot satisfactorily completed 7.7 hours of company instuction from the chief pilot during six flights.

The pilot successfully completed an airmen competency /proficiency check flight on January 19, 1994. The check flight was administered by the chief pilot. The chief pilot stated that the flight was conducted at night in instrument conditions. He stated the flight included a localizer backcourse approach, an instrument landing system approach, a VOR approach, and an NDB approach. The duration listed on the check ride form was 1.2 hours with all items, including air work, satisfactorily completed.

The chief pilot stated that he was a "good friend" of the pilot. The pilot worked for him as a single-engine flight instructor at Acme Aviation, Harrison Field, Ohio. The accident pilot was also employed by BlesAir, Miami University Airport, Oxford, Ohio, for about 2 to 2 1/2 years prior to his employment with Cape Central Airways.

According to the chief pilot, the accident pilot acted as pilot-in-command on the "Part 91 legs" during Cape Central flights. These flights were conducted in a Piper Aztec, Beech Baron, and Beech 18. He flew with the chief pilot and received dual instruction. When asked how many flights the accident pilot flew during this time, the chief pilot stated that he flew "about half" of the 16 flights the company would schedule a month for the cargo run. The chief pilot could not provide documentation to verify the instruction.

The chief pilot provided copies of the accident pilot's personal logbook to the NTSB; however, he stated that he did not know where copies of the last three months of entries from the logbook were located. The chief pilot also stated that recent fight manifest information leading up to the time of the accident was found in a metal binder at the accident site, and that he gave the information to FAA inspector. The FAA inspector stated that she did not receive the information.

The following pilot flight experience (in hours) was extracted from the pilot's personal logbook, airline resume, and NTSB pilot/operator report:

PILOT LOGBOOK AIRLINE RESUME NTSB Form 6120.1/2

Date: 10/5/93 1/19/94 1/28/94

Total Time: 1517.4 1700 1750 SEL: 1480 1400 1550 MEL: 31.5 200 200 X-Country: 267.5 575 --- Total Night: 100.5 400 200 Night X-C: 23.7 300 --- Instrument: 65.7 (total) BLANK 155

The resume and NTSB form 6120.1/2 were both completed and verified by the chief pilot. The chief pilot was authorized by the FAA to conduct line checks for Cape Central Airways on December 21, 1993.

When asked how the information was verified on the accident pilot's company resume, the chief pilot stated that he "went through the pilot logbook" to make sure that it "jibed" with the information of the resume, and he "got out the regulations to make sure the times met part 135 requirements." He also stated that the hours on the resume were "rounded off to the nearest ten hours."

When asked to explain the discrepancies with the flight times listed on each of the three documents, the Director of Operations stated that the discrepancies could be explained "simply by the fact the log books only go up to 9/21/93, while his employment record extends three months further by doing quite of bit of flying . . . . Any other discrepancies cannot be explained without having a current copy of [the accident pilot's] logs."

Attempts to locate the accident pilot's personal flight log for dates subsequent to October 5, 1993, were not successful.

The Director of Operations also stated that the company's minimum flight time requirements were the same as those outlined in the Federal Aviation regulations.

On the evening of January 20, 1994, six days prior to the accident, a passenger was on board N555AC on a flight from Lunken Airport, Cincinnati, Ohio, to Cleveland, Ohio. The passenger was employed as the Chief Pilot at Executive Jet Management, Inc., and routinely flew with other carriers for transportation. The accident pilot was piloting the airplane. The passenger stated that the pilot's flying made him feel "uncomfortable" and "quite nervous." He stated that the pilot appeared to be "thoroughly saturated with the Baron." He recalled the weather was good during the flight.

The passenger stated that during the flight, the pilot discussed how the flight was only his second with Cape Central Airways; his first flight was on the previous evening. The pilot also told the passenger that he was fortunate to have the job because he had only "about 30 to 35 hours of multi-engine time." The passenger stated that the pilot's lack of experience struck him as odd, considering he was flying for a Part 135 operator. When the passenger asked him how he got the job, the pilot stated that "he got to know" the chief pilot of Cape Central Airways.

Five days later, on January 25, 1994, one day prior to the accident, the passenger was in the lounge of a fixed based operator in Cleveland during the evening hours when he saw the accident pilot again. He stated that the pilot had just flown in and was "soaked in sweat." The weather was "very cold" and included instrument meteorological conditions.

According to the company, the accident flight was the pilot's fourth or fifth single-pilot Part 135 flight.

AIRCRAFT INFORMATION

The accident airplane, N555AC, a Beech BE-58 Baron, serial number TH-12, was registered to River City Aviation, Inc., Cape Girardeau, and operated by Cape Central Airways, Inc. The airplane was based at Lunken Field and used for the cancelled check runs.

Examination of the airplane's log books indicated no open or deferred maintenance items at the time of the accident. Records showed that the airplane was in compliance with applicable airworthiness directives. The mechanic who maintained the airplane was also the chief pilot.

N555AC was equipped with basic flight instruments, as well as vacuum-driven gyroscopic instruments and radio navigation equipment required for instrument flight. Heading information was provided by a magnetic compass and an electrically-driven slaved horizontal situation indicator gyro. There was an attitude indicator and a turn and slip coordinator. VOR signals were displayed on a course deviation indicator. Two navigation/communication transceivers were available. The airplane was also equipped with a King KR 85 ADF, a King KFC 200 auto pilot with flight director, a Foster 501 LORAN, and a King KWX 58 color weather radar.

A copy of the cargo shipping manifest for the flight was found in the wreckage. The manifest indicated a cargo load of 23 bags of cancelled checks weighing a total of 155 pounds. The estimated weight of the cargo found at the accident site is consistent with the listed weight on the manifest.

According to the operator, the airplane had been refueled in Cleveland on the previous flight, one day prior to the accident flight.

METEOROLOGICAL CONDITIONS

A surface weather observation was recorded at the departure airport at 2212 hours, 10 minutes after the accident. The observation read: "cloud ceiling 1,700 feet overcast, visibility 8 statute miles, temperature 31 degrees F, dewpoint 25 degrees F, wind from 030 degrees at 11 knots, altimeter 30.27 inches Hg." There was no record of precipitation at the time of this observation.

Cloud ceilings are measured in feet above the ground elevation of the airport. The elevation of the airport is 483 feet msl; therefore, the cloud ceiling above the departure airport was 2,183 feet msl.

Witnesses who spoke with the pilot just prior to the airplane's departure stated that the ramps of the airport were dry and there was no evidence of precipitation or ice on the ramps or any of the parked airplanes.

WRECKAGE AND IMPACT INFORMATION

The airplane wreckage was examined at the accident site on January 27 and January 28, 1994. The examination revealed that the airplane impacted the tops of trees and a soft, muddy sod field about three miles from the departure airport along the extended centerline of the departure runway. The entire wreckage path was about 730 feet in length, and was oriented along a magnetic bearing of 290 degrees. There was no evidence of fire.

Tree strikes marked the initial location of the wreckage path. The tops of branches located about 70 feet above the ground were cleanly cut. The cut was measured to be about 47 degrees right wing down from the horizon. Two craters and ground scars consistent with the dimensions of the airplanes engines and right wing were found 155 feet from the initial tree strikes. One of the craters was four feet in depth and contained the propeller blades and hub from the left engine. The second crater was three feet in depth and contained the propeller blades and hub from the right engine. The angle of impact was measured to be about 30 degrees nose down.

Pieces of the right wing littered the wreckage path beyond the initial ground scars. About 395 feet from the initial tree strikes, the inboard portion of the left wing, left landing gear, and empennage were found; this was the largest piece of wreckage found at the accident site. The wing and floor center section, outboard section of the left wing, right engine, and instrument panel were separated from the airplane and were strewn beyond the empennage section.

All primary and secondary flight control surfaces were accounted for in the wreckage. All associated flight control cables were stretched and separated. According to Beech Aircraft Company engineering data, the landing gear and flaps were found in the retracted position.

The instrument panel was separated from the cabin area and was partially destroyed. The tachometer read 3,000 revolutions per minute on the left engine, and 3,400 rpm for the right engine. Both sets of magneto switches were found in the ON position. The gyros from the vacuum-driven attitude indicator and the electrically-driven directional gyro were disassembled, and inspected. Evidence of rotational scoring was found.

The propellers from both engines were examined. One of the blades from the left engine remained in the hub and was twisted opposite the direction of rotation. It exhibited evidence of S- bending, chordwise scratching, and leading edge gouging. The other blade had fractured at the shank and exhibited evidence of S-bending and leading edge gouging. Both blades from the right engine had separated from the hub. One of the blades exhibited evidence of twisting opposite the direction of rotation, S- bending, chordwise scratching, and leading edge gouging.

Both engines were removed fr

NTSB Probable Cause

FAILURE OF THE PILOT TO MAINTAIN CONTROL OF THE AIRCRAFT AFTER BECOMING SPATIALLY DISORIENTATED IN NIGHT INSTRUMENT METEOROLOGICAL CONDITIONS (IMC). FACTORS RELATED TO THE ACCIDENT WERE: THE PILOT'S LACK OF EXPERIENCE IN THE TYPE OF OPERATION, HIS LACK OF RECENT INSTRUMENT EXPERIENCE, AND INADEQUATE SURVEILLANCE OF THE OPERATION BY THE CHIEF PILOT/COMPANY MANAGEMENT.