NTSB Factual Report

HISTORY OF FLIGHT

On March 6, 1997, at 0021 eastern standard time, a Beech E-18S, N54BT, owned and operated by Polaris Aviation, Sanford, North Carolina, was destroyed when it descended from cruise flight and impacted the ground near Mabie, West Virginia. The certificated airline transport pilot-in-command (PIC) and pilot rated passenger were fatality injured. Instrument meteorological conditions prevailed for the cargo flight that originated at the Sanford-Lee County Brick Field (W77), about 2217, destined for Detroit, Michigan. An instrument flight rules flight plan had been filed for the flight conducted under 14 CFR Part 135.

During an interview with the Sanford Airport Manager, also the Director of Maintenance for Polaris Aviation, he stated that the PIC was the Chief Pilot and Director of Operations for Polaris Aviation, and the passenger was the General Manager (GM) for Polaris. The flight was scheduled to depart Sanford, about 2100, with 550 pounds of automobile parts. During the day, the PIC had used a direct satellite link and a computer program at W77, to obtain weather information. About 2100, when the Airport Manager was about to leave, the passenger/GM approached him and stated that the weather was "really really bad," and that they would have to "do some deviating to get around it."

During the day, another pilot/witness not employed by Polaris, had spent the day at the airport with the PIC of the flight. The witness stated that the flight had been scheduled to depart about 2100, destined for Michigan, and was to return directly to Raleigh, North Carolina, for another cargo pick-up at 0600, the next morning. The witness stated that about 1900, he and the PIC had looked at a computer radar depiction of weather, which depicted a "squall line" just north of the Sanford area, with solid red areas. The witness stated that he had commented to the PIC, "you're not going to fly through that, are you?" The witness also commented to the PIC that the GM "wouldn't do that." The witness reported that the PIC responded that the GM would probably like the challenge.

Prior to the flight, severe weather had passed north of the Sanford area, and the GM had sent three FAX messages to the cargo receiving facility in Michigan. The first indicated a departure time of 2140 from W77. The second FAX indicated a departure time of 2215 from W77, and had a written message which stated, "Severe WX delay for all aircraft. No clearances issued until 2200 EST per Raleigh clearance delivery." A third FAX indicated a departure time of 2220 from W77, with a printed text of "Taxiing out Now."

According to Air Traffic Control (ATC) records, the PIC contacted the Raleigh Automated Flight Service Station (AFSS) by telephone at 2050, and filed an IFR flight plan from W77 to Detroit, Michigan, but did not request a preflight briefing. At 2112, the PIC contacted Raleigh AFSS by telephone and obtained a preflight pilot briefing for the flight, and at 2131, called back to Raleigh AFSS and requested the IFR clearance from W77 to Detroit, and was placed on hold. At 2142, the PIC was issued an expect departure clearance time of 15 minutes, and at 2159, was issued an IFR clearance by Fayetteville ATC, through Raleigh AFSS.

After departure from W77, N54BT was instructed to climb to 10,000 feet, and to contact the Washington Air Route Traffic Control Center (ARTCC). According to the ARTCC transcripts and a review of the voice tape, all communications were routine until 0007, when the ARTCC controller advised N54BT that radar contact was lost, and requested that the airplane report over the Elkins VOR. The PIC acknowledged the call, and stated that he would report over the VOR.

No other transmissions were received from N54BT, until 0020, when the controller received a radio transmission, "Mayday, Mayday, N54BT is going down, N54BT is going down." No further transmissions were received, and an emergency locator transmitter (ELT) was heard by other pilots about 55 seconds later. After several seconds, the ELT signal faded out. The last radar target of N54BT was recorded at 6,400 feet.

The airplane was located in a wooded area, about 1/2 mile from the last reported radar target. The accident occurred during the hours of darkness approximately 38 degrees, 52 minutes north latitude, and 80 degrees, 01 minutes west longitude.

PILOT INFORMATION

The pilot held an airline transport pilot certificate with a rating for airplane multiengine land, and a commercial pilot certificate with ratings for single engine land and instrument airplane. He also held a flight instructor certificate with ratings for airplane single and multiengine land and instrument airplane.

His most recent Federal Aviation Administration (FAA) second class medical certificate was issued on December 30, 1996.

Several pilot log books were located and reviewed. According to the log books and FAA records, the pilot obtained his commercial pilot certificate for airplane single engine land and instrument airplane, on January 7, 1994. He obtained his commercial pilot multiengine land rating on July 6, 1994, and he obtained his airline transport pilot certificate on April 1, 1996.

The pilot's log book (Book Two), that covered the period from February 1992, to April 1996, was reviewed. The log book ended on April 30, 1996, with 1667.6 hours of total flight experience logged, of which 244 hours were in multiengine airplanes. It also revealed that of the 244 hours, 170 hours were logged while flying with one of several flight instructors from which the pilot had obtained training.

The log book entries revealed that as of April 22, 1995, the pilot had logged 1,022.7 hours of total flight experience, of which 187.6 hours were in multiengine airplanes.

The most recent pilot log book (Book Three) began on April 22, 1995, and ended on July 21, 1996, which overlapped Book Two by 12 months. This log book began with 1,145.7 hours of total flight experience, 123 hours more than logged in Book Two. It also began with 292.6 hours of multiengine experience, verses the 187.6 hours that had been logged in Book Two. When Book Three reached the end date of the Book Two (April 30, 1996), all additional entries and changes increased the pilot's total flight experience by 162 hours, to 1,839.5 hours, and increased his multi engine experience by 161 hours, to 409 hours.

The pilot's log books, and his personal daily crew log which began July 1996, were used to determine the pilot's total flight experience. It was estimated that at the time of the accident, the pilot had accumulated about 2,000 hours of total flight experience, of which 450 hours were in multiengine airplanes, and 30 hours were in make and model.

The pilot rated passenger, also the General Manager of Polaris, held a commercial pilot certificate with a rating for airplane multiengine land, and a Private Pilot Certificate with a rating for airplane single engine land. He was not instrument rated, and his certificate limitations included the statement, "Carrying passengers in airplanes for hire is prohibited at night and on cross country flight of more than 50 nautical miles."

His most recent FAA second class medical certificate was issued on January 23, 1997.

A review of the pilot's log book revealed that he had obtained his airplane multiengine rating on January 26, 1997. He had accumulated about 328 hours of total flying experience. The log book also revealed that he had accumulated a total of 97 hours of multiengine experience, of which all 97 hours were logged as dual instruction. The log book did not contain any flight experience in Beech 18 airplanes.

AIRCRAFT INFORMATION.

Company documents and airplane records were reviewed, and Polaris personnel were interviewed concerning the airworthiness of N54BT. According to the documents and personnel statements, the airplane was purchased on January 5, 1997, from a company that had operated the airplane in accordance with 14 CFR Part 135. The airplane had received an annual inspection by the previous operator within the past 2 months and was within the last 100 hour inspection. The airplane was ferried to Sanford by the accident pilot, and was inspected for compliance with Airworthiness Directives and component overhaul requirements. During the inspection by the Director of Maintenance (DOM), the records were updated to reflect that some items listed in the airplane's records were not installed in the airplane. Examples of the items not installed included: the autopilot, weather radar, and storm scope.

In order to place the airplane on the Polaris Operations Specifications (OpSpecs), an initial inspection of the airplane was conducted on January 8, 1997, by the FAA Winston-Salem Flight Standards District Office (FSDO), which provided the oversight of the Polaris operation. On January 9, 1997, the FSDO sent a letter to the Polaris DOM, which listed 29 line items of "concerns and action items." The FSDO required a formal response that listed the actions taken, and on March 4, 1997, the DOM sent a letter to the FSDO with the actions taken in response to the discrepancies listed in the FSDO letter. The only discrepancies that remained were a compass check was overdue, and the legality of the cargo net installed could not be established, which would require a new net.

On March 5, 1997, the DOM overheard the Chief Pilot (PIC of the accident flight) and GM discuss a cargo flight to be conducted later that day in N54BT. The DOM reminded both of them that the airplane was not yet on the OpSpecs. The GM showed the DOM a page from the OpSpecs that included the E18S airplane and the signature of the FAA Principal Operations Inspector (POI), dated February 5, 1997. N54BT was the only E18S owned by Polaris. The DOM then discussed the issue of the cargo net, and was told by the GM that, "he wasn't going to let that stop them from making the trip." The Chief Pilot took the same position.

METEOROLOGICAL INFORMATION

The PIC contacted the Raleigh Automated Flight Service Station (AFSS) by telephone about 2050, and filed an instrument flight rules flight plan from Sanford, North Carolina, to Detroit, Michigan. A preflight weather briefing was not requested at the time. The proposed departure time was 2100.

At 2112, the PIC telephoned Raleigh AFSS again. A review of the certified voice tape of the briefing revealed that the PIC requested a standard IFR briefing for a flight from W77 to Detroit, and that the proposed takeoff was in 15 to 20 minutes. The AFSS briefer then provided the pilot a briefing which included an overview, general outlook, and several AIRMETS, SIGMETS, and Center weather advisories. These included severe thunderstorm watch number 97, for central North Carolina and Virginia, and SIGMET 3E which included the Sanford (W77) area.

SIGMET 3E: Line of severe thunderstorms 20 nautical miles wide, moving from 270 degree at 40 knots. Tops to flight level 350. Tornadoes, hail to 2 inches, wind gusts to 70 knots possible.

AIRMETS included: IFR conditions from W77 to Ohio, with moderate turbulence below 10,000 feet; moderate to isolated severe turbulence over Michigan; occasional moderate rime or mixed icing from 10,000 to 24,000 feet, over northern Virginia, West Virginia, and Ohio, lowering to 5,000 feet over northern Ohio.

A review of the winds aloft forecast for Elkins at 9,000 feet was performed. The forecast, valid until 0100, called for the winds to be from 250 degrees at 59 knots, with an air temperature of 4 degrees centigrade.

WRECKAGE INFORMATION

The airplane wreckage was examined at the accident site on March 6 and 7, 1997. The examination revealed that all major components of the airplane were accounted for at the scene. The airplane came to rest in a wooded area, on an approximate magnetic heading of 225 degrees, at a ground elevation of about 2,500 feet above mean sea level (MSL). The wreckage was contained within an area about 50 feet in diameter.

The nose section of the airplane was imbedded in the ground, on the northeast side of a 16-inch-diameter tree. Tree limbs that extended from the trees surrounding the accident site were intact, except for a few broken limbs directly overhead the nose section of the airplane. A significant amount of dirt was splattered to the southwest of the wreckage, parallel to the wing span. A lighter amount of dirt was splattered on the ground to the northeast of the wing span, toward the location of the airplane's tail section. The left and right engines were imbedded in dirt and rock, propeller hub side down. The engines remained attached to their respective sections of the airplane's wings. The wings extended outward from the wreckage, southeast (left side) to northwest (right side). The leading edges of the wings were crushed inward and compressed aft.

Control continuity was established from the pilot's yoke and rudder pedals to all airplane primary control surfaces. The elevator trim was measured at an approximate neutral setting. The rudder trim was measured to be 2 to 3 degrees tab right, and the aileron trim was measured at 6 degrees tab up. The landing gear and flaps were retracted.

An impact hole that began between the wings section, and extended northeast toward the tail section, measured about 6 feet across and about 3 feet deep at the center. The hole contained several hundred small rectangle shaped metal objects. A cargo strap tie down end was found attached to a floor tie down fitting. The left rear cargo door was examined and the door locking pins were found extended.

The cockpit area, the fuselage section between the wings, the back of the left and right engines, and the main fuselage section, were consumed by a post crash fire. The last 8 feet of the airplane's tail section remained intact and was northeast of the impact hole. The end of the tail section nearest the impact hole contained burned and melted metal along its edges. The tail-section contained the elevator and rudders. The elevator moved freely up and down, and the top of the elevator contained a layer of fire soot, while the underside of the elevator and fuselage contained no soot. The twin vertical rudders were intact and moved freely back and forth by hand. The inboard and outboard sides of both rudders, above the elevator, contained soot. The inboard and outboard sides of the rudders below the elevator were soot free. The lower sections of the rudders were wrinkled horizontal to the ground.

The emergency locator transmitter (ELT) that had been located in the tail section, was found in the northeast side of the impact hole. The ELT was fire damaged.

On the ground, about 3 to 4 feet north of the tail, were sections of 3/4 inch plywood with seat tracks. These sections were not fire damaged. Also northeast of the tail section were trees that were soot covered on their southwest side.

Examination of the cockpit area revealed two sets of lap seat belts which remained buckled. The pilot's airspeed indicator cover glass was broken, and the airspeed needle was stuck in a position indicating about 190 miles per hour, or 165 knots. The co-pilot's airspeed indicator was broken and fire damaged with dark soot; however, the instrument face plate contained a line of light gray soot that extended from the center of the instrument across an area between 180 and 200 miles per hour.

An electric gyro was found broken out of its case. Examination of the gyro revealed rotational scoring. A vacuum gyro was removed from its case, and rotational scoring was observed on the inside of the case and the gyro. The co-pilot's altimeter was observed to read 2,650 feet.

The engine and propellers were removed for further examination.

MEDICAL AND PATHOLOGICAL INFORMATION

Autopsies were performed on the pilot and pilot rated passenger on March 10 and 11, 1997, by Dr. Irvin Sopher, of the West Virginia Medical Examiner's Office, South Charleston, West Virginia. TESTS AND RESEARCH

On March 19 and 20, 1997, the engines and propellers were examined at Alphin Aircraft Inc., Hagerstown, Maryl

NTSB Probable Cause

The pilot's disregard of the preflight weather briefing for severe weather along his route of flight, and his departure into the known and forecasted severe weather. A factor in the accident was the inadequate FAA oversight of the operator, which fostered an attitude of rule bending.