NTSB Factual Report

HISTORY OF FLIGHT

On April 6, 1994, about 2258 central daylight time, a Piper PA- 32RT-300, N9710C, collided with the ground during an uncontrolled descent. The airplane was operated as flight DEE 55 by Tennessee Air Corporation, Inc.(TACAIR), under 14 CFR Part 135 with a valid instrument flight clearance. Visual weather conditions prevailed at the time of the accident. The airplane was destroyed, and the commercial rated pilot was fatally injured. The flight departed Knoxville, Tennessee, at 2205 hours and was enroute to Nashville, Tennessee.

According to TACAIR flight operations personnel, the pilot arrived at operations at the appropriate time and completed the preflight planning for his scheduled flight to Knoxville, Tennessee. No operational or aircraft problems were reported by the pilot to flight operations. Flight operations personnel reported that the pilot used the commercial weather service for his initial weather information.

At 1839:29, a man who identified himself as the pilot of TACAIR flight five five, telephoned Nashville Automated Flight Service Station (AFSS) and requested a weather update for Nashville. The pilot told the briefer that he had received an earlier weather briefing from a commercial weather service. As requested, the pilot was given a weather update for Nashville.

At 2000, DEE 55 departed Nashville. At 2014, 21 miles east of Nashville, the pilot radioed Nashville AFSS and reported that the cloud tops at his position were 6000 feet. The remainder of the flight to Knoxville was routine.

At 2205, DEE 55 departed Knoxville, and 45 minutes into the flight, the pilot reported a build up of airframe ice to Memphis Air Route Traffic Control Center (ARTCC). The pilot also requested a descent from 5000 feet to 4000 feet, but later requested a lower altitude to avoid icing conditions. Moments later, DEE 55's target disappeared from the radar scope. April 7, 1994, at 0110, the aircraft wreckage was located in a field near Smithville, after an extensive ground search by local law authorities.

PERSONNEL INFORMATION

Information on the pilot is contained in this report at the data field labeled "First Pilot Information". The pilot was hired by TACAIR on May 19, 1991 and upgraded to Pilot in command on the Beech 55/58 and the Piper PA-32RT-300 airplanes. He completed his last recurrent training on December 30, 1993. The review of the pilot's training record revealed that the pilot had received winter operation training on January 29, 1994. According to officials from another air taxi operator in Nashville, the pilot had given TACAIR management his two weeks notice of resignation, and was in the process of being hired as a pilot for their company. This was the pilot's last week with TACAIR.

AIRCRAFT INFORMATION

Information on the aircraft is contained in this report at the data field labeled "Aircraft Information".

METEOROLOGICAL INFORMATION

Visual weather conditions prevailed at the time of the accident. Weather information is contained in this report at the data field labeled "Weather Information". According to officials from Tennessee Air Corporation, the pilot received weather briefing information through a commercial weather service. Attempts to recover the content of the pilot's weather briefing failed. A review of weather data revealed that weather advisories were issued forecasting moderate ice in clouds and precipitation below 8000 feet. According to the weather study, weather data suggested that the cold air mass would be moving to the east throughout the night (see attached weather study). Forecast data was confirmed by a pilot's report of icing at 8000 feet 20 south Nashville. Air Traffic Control received a pilot report of icing between Knoxville and Nashville; it was not known if the pilot of the accident aircraft was aware of the reported icing. Two other TACAIR aircraft operated in the vicinity of DEE 55 at the time of the accident. Both aircraft were flying at higher altitudes and did not encounter icing conditions.

WRECKAGE AND IMPACT INFORMATION

The wreckage rested inverted with the nose section and engine assembly buried about three feet into the ground. Debris from the airplane we scattered over an area fifty feet square. Examination of the airplane and engine assemblies failed to disclose a mechanical failure or system malfunction. All aircraft flight control surfaces and airframe components were recovered from the accident site. Both wing assemblies received impact damage that crushed the top wing surface. The empennage and tail sections were substantially damaged, but, were attached to the airframe. The cockpit and cargo areas were compressed and deformed. An attitude gyro was also recovered from the wreckage. Examination of the attitude gyro revealed some rotational damage to the drum and the internal housing.

MEDICAL AND PATHOLOGICAL INFORMATION

The post mortem examination of the pilot was conducted by Dr. Charles Harlan at the Tennessee State Medical Examiners Office in Nashville, on April 7, 1994. The cause of death was multiple trauma secondary to the aircraft accident. Due to the traumatic damage, samples were not collected for the toxicological examination.

ADDITIONAL INFORMATION

During the review of TACAIR flight operations, it was discovered that the operations specifications did not require a dispatcher as part of the company. Operations specifications did provide for a flight coordinator; dispatch functions were pilot responsibilities. According to flight operations personnel, the pilot was responsible for the total preflight planning process and aircraft dispatch. During the on site visit with the Director of Operations and the Chief Pilot, they also stated that the pilot was the final authority for dispatching each flight.

Several telephone conversations with former pilots of TACAIR were conducted. It was discovered that the final authority for dispatching flights was not the pilot's, but flight operations. Each interviewed pilot reported how management reacted to pilot writeups on the airplanes. One pilot stated that he was suspended for grounding an airplane because of an interior light problem which had not been corrected after several oral requests. Pilots who refused to fly in questionable weather conditions were also pressured to fly under the threat of punitive action. According to the pilot's roommate, the accident pilot had been threatened by management several weeks before the accident. Other pilots reported the same treatment by management for refusing to fly airplanes that they believed were not safe. According to former pilots of TACAIR, within the last three years of the company, the operation was generally managed by coercion or intimidation.

On May 2, 1994, TACAIR voluntarily surrendered their Air Carrier Certificate, # FIVA745D, to the Nashville Flight Standards District Office of the FAA, and ceased all flight operations.

The wreckage was released to :

Mr. Jimmie Rickerson (insurance adjustor) 1450 Rivershyre Parkway NE Lawrenceville, Georgia 30243

NTSB Probable Cause

THE PILOT'S FAILURE TO OBTAIN RECENT WEATHER INFORMATION TO AVOID FLIGHT INTO ICING CONDITIONS. FACTORS IN THE ACCIDENT WERE: MANAGEMENT-INDUCED PRESSURE AND THE ICING CONDITIONS.