NTSB Factual Report

HISTORY OF FLIGHT

On January 8, 1996, at 1907 Pacific standard time, N117AC, a Cessna 401, operated by Pacific States Charter Services, Inc., as Aeromed Lifeguard 117AC, collided with a pole and a building during an instrument approach to runway 3 at the Spokane International Airport, Spokane, Washington. The airplane was destroyed and there was a ground fire. The commercial pilot and two passengers were fatally injured. A third passenger received serious injuries. Instrument meteorological conditions prevailed and an instrument flight rules (IFR) flight plan had been filed. The air medical transport flight departed from Pasco, Washington, at 1829 and was destined for Spokane. The flight was conducted under 14 CFR 135.

In an interview (record attached) with the Safety Board, the sole survivor of the accident stated that he was at home near Kennewick, Washington, and "on call" as Aeromed's flight paramedic on the day of the accident. He stated he received a telephone call from the accident pilot who told him that a patient needed to be flown from Pasco to Spokane for urgent medical treatment. The paramedic later arrived at Our Lady of Lourdes Hospital in Pasco to review the patient's charts. He was met by the pilot and a flight nurse. The paramedic stated that the patient's condition was "critical" and that he "didn't think she would make it" to Spokane. Nevertheless, the three Aeromed employees "wasted no time" to get to the Tri-Cities Airport in Pasco in order to fly the patient to the Spokane International Airport for emergency surgery at the Deaconess Hospital in Spokane.

After arriving at the Tri-Cities Airport via ground ambulance, the paramedic helped load the patient into the accident airplane. He stated that the pilot "prepped the plane" and helped transfer medical equipment into the aircraft. The paramedic also stated that it was a "clear night" at the airport, and that the pilot appeared "typical" and "serious." According to the paramedic, the pilot did not indicate that he was having any problems with himself or the airplane, and the pilot wanted to take off as soon as possible. The paramedic said the pilot made statements such as "hurry up...let's go."

The paramedic also stated that about 15 minutes passed from the time they had arrived at the Tri-Cities Airport to the time the aircraft was airborne. He stated that he did not perceive any problems with the airplane during start-up, taxi, or takeoff. He and the flight nurse were seated at the rear of the aircraft, at the feet of the patient's gurney, and were not wearing headsets. The paramedic stated that he was seated on the left side of the aircraft in "front of the back seat."

According to transcripts and records (attached) provided by the Federal Aviation Administration (FAA), a person identifying himself as the pilot of N117AC telephoned the Seattle Automated Flight Service Station (AFSS) at 1719 to receive an abbreviated weather briefing. The pilot requested the current weather conditions at the Spokane International Airport, and was told by the AFSS briefer: "measured ceiling three hundred overcast, visibility one zero...." The pilot also asked: "has the visibility dropped below two miles, is there a fog bank coming in?" The briefer stated: "nah it just the temperature dew point is close together there and they're forecast until [2000 hours] is ceiling of four hundred overcast, visibility three in fog." The pilot responded with "okay, as long as we stay above that three we're in good shape. Thank you sir."

Thirty-seven minutes later, at 1757, the pilot again telephoned the AFSS to file an IFR flight plan from Pasco to Spokane. The pilot told the briefer that he did not "have my flight plan right in front of me. It's kind of expeditious filing here ...." The pilot did not file for an alternate destination, as required by 14 CFR 135.223. The briefer accepted the flight plan and the call was completed at 1758.

Thirty-one minutes after the pilot filed the flight plan, at 1829, the flight departed from Pasco and the pilot initiated communications with air traffic control (ATC).

The paramedic stated that during the flight, he was busy caring for the critical patient. He stated that it was a "hectic flight" as he was out of his seat the majority of the flight and "constantly pushing drugs" into the patient. He stated that he did not perceive any problems with the airplane during the cruise portion of the flight. He recalled that the flight nurse initiated two calls from a cellular telephone on board the aircraft. One of the calls was made just prior to the accident, and he stated that the flight nurse may have been using the cellular telephone at the time of the accident.

The Safety Board interviewed (record attached) a nurse employed by the Deaconess Hospital in Spokane who was the recipient of two telephone calls from the flight nurse. The Spokane nurse stated that she was working at the hospital on the evening of the accident. At 1845, as verified by a log entry, she received a telephone call from the flight nurse aboard the accident flight. The Spokane nurse took down a report regarding the patient's status. She stated that the flight nurse provided a "thorough" report of the patient, and that the flight would be on the ground about 1915. The Spokane nurse also stated that the reception of the telephone transmission was "clear...but some breaking up," and that it was "hard to hear." The Spokane nurse recalled that the flight nurse said the on-board patient was "alert but confused," "on breathing oxygen" and was experiencing "significant pain."

Later, sometime between 1905 and 1912, the flight nurse again called the Spokane nurse. She recalled that the flight nurse said: "This is Aeromed. We are ...." The Spokane nurse stated that this is all that was said, and then the connection ended. The Spokane nurse also recalled hearing a "man's voice in the background" and "no alarms or beeping" during the short transmission. The Spokane nurse stated that the call ended with abrupt "silence.... as if the line was cut off, as if you were to hang up."

The Safety Board obtained telephone records from a representative of Aeromed. A review of the records (attached) revealed that a telephone call was placed from the airplane to the Deaconess Hospital at 1843 for a duration of 2 minutes, and another call was made at 1906 for a duration of one minute.

According to ATC recorded voice communications and radar data (attached), the pilot was cleared for the instrument landing system (ILS) approach to runway 3 at 1902:17 by Spokane Approach Control. The pilot acknowledged the clearance and the airplane was established on the localizer course to the runway. At 1904:07, the pilot was instructed to contact the Spokane Tower, which he performed. At 1904:50, the pilot was cleared to land on runway 3 by the tower controller, and he was given wind and runway visual range information. The pilot acknowledged the clearance; this was his last recorded transmission. No distress calls from the airplane were recorded, and all previous communications had been routine and professional.

According to a Recorded Radar Study (report attached) performed by the Safety Board's Office of Research and Engineering, the airplane was established on the center of the ILS runway 3 localizer course while descending through 4,400 feet msl at the time the pilot was given clearance to land. The airplane was also about 500 feet above the center of the ILS runway 3 glide slope course, and was traveling at 153 knots true air speed. During the subsequent 90 seconds of flight, as the airplane continued its approach, its true airspeed decreased from 153 knots to 100 knots, while its vertical speed increased from a 711-feet-per- minute descent to about a 1,250-feet-per-minute descent. The airplane continued to track within the localizer course width during this time, but it remained high on the glide slope course without ever descending to the center of it.

At 1906:13, while the airplane was about 1 mile from the runway 3 threshold and about 500 feet above the ground, the airplane initiated an abrupt turn to the left with about 15 degrees angle of bank; it changed course from 038 degrees magnetic to 303 degrees magnetic. During this 95-degree course change, the airplane's true airspeed increased from 100 knots to 129 knots, its rate of descent gradually decreased to zero, and it flew less than 200 feet above the ground as it exited out of and away from the localizer course. After the abrupt course change, the airplane continued to fly away from the localizer in a northerly direction for about 40 seconds, with no radio communications from the pilot. An emergency locator transmitter (ELT) beacon was received by ATC at 1907:03; the closest radar data point to this time indicates that the airplane was in the vicinity of a power pole. The final radar data point was recorded 10 seconds after the beginning of the ELT signal (1907:13), and the point corresponds to the coordinates of the crash site.

A Cessna 172 pilot (statement attached) who was following the accident airplane on the approach stated that he remembered that the accident airplane descended into the fog when it was about 4 miles outside of the outer marker OLAKE, and he stated that the airplane may have been "still on an intercept" for the localizer at the time he last saw it. He stated that he saw the accident airplane disappear into the fog when it was "pretty much wings level," and he stated that he was about 1 mile behind the accident airplane at that time.

The paramedic stated that he recalled a "thump" that shook the airplane. The "thump" felt "...like a jarring motion... like a low speed impact." He remembered that he looked out the window and "saw sparks shooting out of the left engine," but no fire. He said that he yelled at the flight nurse to "assume the crash position." He further stated that he looked up at the pilot and the pilot looked back at him "for a brief second" with an expression of "fear" on the pilot's face. The paramedic stated that the pilot did not say anything to the paramedic during this interaction. The paramedic then perceived a sharp left turn after the "thump" and "had enough time to curl up in a ball," just prior to the impact.

A ground eyewitness reported (report attached) that the airplane was flying "low and fast and loud," just before it impacted a building located 1.4 nautical miles northwest of the center of the airport.

The accident occurred during dark night conditions at the following coordinates: North 47 degrees, 37.81 minutes; West 117 degrees, 33.91 minutes.

OTHER DAMAGE

The airplane impacted a commercial building used for manufacturing large tanks and equipment. The roof structure and south wall were partially destroyed by impact forces and post-crash fire. Equipment stored inside the building, including a motor vehicle, trailer, tool and dye fixtures, and newly-completed tanks, were also damaged. The total amount of the structural and equipment damage was estimated to be about $428,000.

AIRCRAFT INFORMATION

The accident airplane, a Cessna model 401A, was manufactured in 1969. It was powered by two 300-horsepower Continental turbocharged, propeller-driven engines, had a maximum gross landing weight of 6,200 pounds, and was configured as a flying medical ambulance. The airplane was registered to RMA Inc., doing business as Spokane Airways, leased back to the Pacific States Charter Service, Inc., and operated as Aeromed, Inc. It was the only aircraft in Aeromed's livery; and the operator was decertified by the FAA shortly after the accident.

The aircraft maintenance records were not recovered and were presumed to have been destroyed in the accident. The Safety Board collected and examined copies of maintenance work orders for the aircraft that were obtained from Spokane Airways. The examination revealed that the airplane had received a 50-hour inspection and oil change on December 15, 1995, with no unresolved discrepancies noted. The airplane had logged a total of 5,845 hours at the time of the inspection. The records also indicated that the airplane received a 100-hour/annual inspection on October 6, 1995, with no unresolved discrepancies noted.

One work order, dated September 19, 1995, indicated that the "autopilot requires more work." This record was attached to another work order, dated October 5, 1995, which indicated that an "avionics repair" had been performed, with no other details of the repair provided. Another work order indicated that both propellers were removed on June 22, 1995, for overhaul. Also, the airplane passed an "IFR certification" during an inspection that was documented on a work order dated March 27, 1995.

The Safety Board could not conclusively determine what avionics had been installed and were operating on the airplane immediately prior to the accident, due to the destruction of the avionics and maintenance records in the accident. According to a review of the work orders obtained by Spokane Airways, the following avionics equipment had been installed in the airplane prior to the accident:

Two Bendix/King KX-155 navigation/communication digital transceivers Bendix/King KI-208 navigational head(s) Bendix/King KMA-24 Audio Panel Cessna 400A Navamatic Autopilot Cessna/EDO Air Horizontal Situational Indicator Bendix/King KN-64 Distance Measuring Equipment Bendix/King KT-76A Transponder Collins ADF-650 Automatic Direction Finder Bendix/King Radar ARNAV 20 LORAN According to receipts obtained from Bergstrom Aircraft, Inc., a fixed based operator at the Tri-Cities Airport in Pasco, the accident airplane received 23.4 gallons of 100 low lead aviation fuel on the day of the accident.

PERSONNEL INFORMATION

The pilot, age 36, held an FAA commercial pilot certificate with ratings for airplane single-engine land, airplane multiengine land, rotorcraft-helicopter, and instrument airplane/helicopter. The pilot's personal flight log books were not recovered. According to an insurance application (attached) that was completed by the pilot two months prior to the accident, that pilot had logged a total of 369.7 hours of civilian pilot-in-command (PIC) flight time in fixed-wing airplanes, including 149.8 hours in multiengine airplanes and 62.2 hours in the Cessna 401A. The pilot also reported that he had logged 22.3 hours of PIC time under either simulated or actual instrument conditions during the previous six months from the date of the application.

The pilot further reported in the application that he had been previously employed as a helicopter pilot while serving as an officer of the United States Marine Corps. He graduated from the U.S. Navy Flight School in 1982 where he received his initial flight training in fixed-wing airplanes. He was then trained as a helicopter pilot and logged 2,543 hours in the Sikorsky CH-53E military helicopter. He was discharged from the military in early 1995; he became the chief executive officer and sole pilot of Aeromed on May 1, 1995.

According to FAA records, the pilot was issued an FAA Second Class Medical Certificate on June 6, 1995, with no limitations. The pilot indicated that he had logged a total of 3,500 flight hours at the time of the medical application.

According to records (excerpts attached) obtained from FlightSafety International of Long Beach, California, the pilot successfully completed a 5-day course entitled "Cessna 402B Tip Tank Pilot Initial Course" on July 5, 1995. According to the records, the pilot logged 7.5 hours in a Cessna 402B procedures ground trainer and 7.5 hours in a Cessna 402B flight simulator. The records also indicated that the pilot experienced some difficulty during training sessions involving ILS approaches, instrument navigation, use of the horizontal situation indicator, and aircraft control.

The Safety Board also reviewed the FAA Part 135 Airmen Competency/Proficiency Checks (FAA Forms 8410-3 are attached) that were performed on the pilot for certification as Aeromed's pilot. The pilot failed his first check on August 9, 19

NTSB Probable Cause

failure of the pilot to follow proper IFR procedures, by failing to maintain proper alignment with the localizer course during the ILS approach and/or by failing to follow the proper missed approach procedure. Factors relating to the accident were: darkness; adverse weather conditions; and pressure on the pilot to complete the EMS flight, due to the circumstances and conditions that prevailed.