National Transportation Safety Board
Aviation Accident Final Report

 

 

Location:

ANNISTON, AL

Accident Number:

ATL92MA118

Date & Time:

06/08/1992, 0853 CDT

Registration:

N118GP

Aircraft:

BEECH C99

Aircraft Damage:

Destroyed

Defining Event:

 

Injuries:

3 Fatal, 3 Serious

Flight Conducted Under:

Part 135: Air Taxi & Commuter - Scheduled

Analysis

THIS WAS THE FIRST DAY ON DUTY IN THE SOUTHERN REGION OPERATION FOR BOTH PILOTS. IN ADDITION, THEY HAD NEVER FLOWN TOGETHER. DURING THE FLIGHT, THE FLIGHTCREW LOST AWARENESS OF THEIR AIRPLANE'S POSITION, ERRONEOUSLY BELIEVED THAT THE FLIGHT WAS RECEIVING RADAR SERVICES FROM ATC, AND COMMENCED THE APPROACH FROM AN EXCESSIVE ALTITUDE AND AT A CRUISE AIRSPEED WITHOUT ACCOMPLISHING THE PUBLISHED PROCEDURE SPECIFIED ON THE APPROCH CHART. THE CREW BELIEVED THAT THE AIRPLANE WAS SOUTH OF THE AIRPORT, AND TURNED TOWARD THE NORTH TO EXECUTE THE ILS RWY 5 APPROACH. IN ACTUALITY, THE AIRPLANE HAD INTERCEPTED THE BACK COURSE LOCALIZER SIGNAL, AND THE AIRPLANE CONTINUED A CONTROLLED DESCENT UNTIL IT IMPACTED TERRAIN.

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this accident to be:
THE FAILURE OF SENIOR MANAGEMENT OF GP EXPRESS TO PROVIDE ADEQUATE TRAINING AND OPERATIONAL SUPPORT FOR THE STARTUP OF THE SOUTHERN OPERATION, WHICH RESULTED IN THE ASSIGNMENT OF AN INADEQUATELY PREPARED CAPTAIN WITH A RELATIVELY INEXPERIENCED FIRST OFFICER IN REVENUE PASSENGER SERVICE, AND THE FAILURE OF THE FLIGHTCREW TO USE APPROVED INSTRUMENT FLIGHT PROCEDURES, WHICH RESULTED IN A LOSS OF SITUATIONAL AWARENESS AND TERRAIN CLEARANCE. CONTRIBUTING TO THE CAUSES OF THE ACCIDENT WAS GP EXPRESS' FAILURE TO PROVIDE APPROACH CHARTS TO EACH PILOT AND TO ESTABLISH STABILIZED APPROACH CRITERIA. ALSO CONTRIBUTING WERE THE INADEQUATE CREW COORDINATION AND A ROLE REVERSAL ON THE PART OF THE CAPTAIN AND FIRST OFFICER. (NTSB REPORT AAR-93/03)

Findings

 

Occurrence #1: IN FLIGHT COLLISION WITH TERRAIN/WATER
Phase of Operation: APPROACH - FAF/OUTER MARKER TO THRESHOLD (IFR)

Findings
1. (C) IFR PROCEDURE - IMPROPER - PILOT IN COMMAND
2. (C) INADEQUATE TRAINING - COMPANY/OPERATOR MANAGEMENT
3. (F) INFORMATION INSUFFICIENT - COMPANY/OPERATOR MANAGEMENT
4. (F) CREW/GROUP COORDINATION - INADEQUATE

 

Factual Information

 

 

 

 

Pilot Information

Certificate:

Airline Transport; Flight Instructor; Commercial

Age:

29, Male

Airplane Rating(s):

Multi-engine Land; Single-engine Land

Seat Occupied:

Left

Other Aircraft Rating(s):

Helicopter

Restraint Used:

Seatbelt, Shoulder harness

Instrument Rating(s):

Airplane; Helicopter

Second Pilot Present:

Yes

Instructor Rating(s):

Airplane Multi-engine; Airplane Single-engine

Toxicology Performed:

Yes

Medical Certification:

Class 1 Valid Medical--no waivers/lim.

Last FAA Medical Exam:

10/30/1991

Occupational Pilot:

 

Last Flight Review or Equivalent:

 

Flight Time:

1700 hours (Total, all aircraft), 24 hours (Total, this make and model)

 

 

Aircraft and Owner/Operator Information

Aircraft Make:

BEECH

Registration:

N118GP

Model/Series:

C99 C99

Aircraft Category:

Airplane

Year of Manufacture:

 

Amateur Built:

No

Airworthiness Certificate:

Normal

Serial Number:

U-185

Landing Gear Type:

Retractable - Tricycle

Seats:

17

Date/Type of Last Inspection:

03/16/1992, Continuous Airworthiness

Certified Max Gross Wt.:

11380 lbs

Time Since Last Inspection:

60 Hours

Engines:

2 Turbo Prop

Airframe Total Time:

9725 Hours

Engine Manufacturer:

P&W

ELT:

Installed, not activated

Engine Model/Series:

PT6A-36

Registered Owner:

GP EXPRESS AIRLINES, INC.

Rated Power:

750 hp

Operator:

GP EXPRESS AIRLINES, INC.

Operating Certificate(s) Held:

Commuter Air Carrier (135)

Operator Does Business As:

 

Operator Designator Code:

GPPA

 

Meteorological Information and Flight Plan

Conditions at Accident Site:

Visual Conditions

Condition of Light:

Day

Observation Facility, Elevation:

ANB, 611 ft msl

Distance from Accident Site:

8 Nautical Miles

Observation Time:

0846 CDT

Direction from Accident Site:

229°

Lowest Cloud Condition:

Scattered / 700 ft agl

Visibility

3 Miles

Lowest Ceiling:

Broken / 1500 ft agl

Visibility (RVR):

0 ft

Wind Speed/Gusts:

6 knots /

Turbulence Type Forecast/Actual:

/

Wind Direction:

60°

Turbulence Severity Forecast/Actual:

/

Altimeter Setting:

30 inches Hg

Temperature/Dew Point:

23°C / 22°C

Precipitation and Obscuration:

 

Departure Point:

ATLANTA, GA (ATL)

Type of Flight Plan Filed:

IFR

Destination:

 

Type of Clearance:

IFR

Departure Time:

0920 EDT

Type of Airspace:

Class E

 

Airport Information

Airport:

ANNISTON METROPOLITAN (ANB)

Runway Surface Type:

Asphalt

Airport Elevation:

611 ft

Runway Surface Condition:

 

Runway Used:

5

IFR Approach:

None

Runway Length/Width:

7001 ft / 150 ft

VFR Approach/Landing:

None

 

Wreckage and Impact Information

Crew Injuries:

1 Fatal, 1 Serious

Aircraft Damage:

Destroyed

Passenger Injuries:

2 Fatal, 2 Serious

Aircraft Fire:

On-Ground

Ground Injuries:

N/A

Aircraft Explosion:

None

Total Injuries:

3 Fatal, 3 Serious

Latitude, Longitude:

 

 


 


Administrative Information

Investigator In Charge (IIC):

PHILLIP      POWELL

Report Date:

10/08/1993

Additional Participating Persons:

PAUL   BAKER; WASHINGTON, DC

TIM   BORSON; WASHINGTON, DC

FRANK   HILLDRUP; WASHINGTON, DC

FRED   HYMAN; WASHINGTON, DC

Publish Date:

 

Investigation Docket:

NTSB accident and incident dockets serve as permanent archival information for the NTSB’s investigations. Dockets released prior to June 1, 2009 are publicly available from the NTSB’s Record Management Division at pubinq@ntsb.gov, or at 800-877-6799. Dockets released after this date are available at http://dms.ntsb.gov/pubdms/.