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Cases › NYC08MA090 · Major investigation

RAYTHEON AIRCRAFT COMPANY C90ABLUE SKY AIRWAYS INC

Mount Airy, NC, USA · 2008-02-01·N57WR

6
fatal
0
serious
Fatal
highest injury
Substantial
damage

What happened

NTSB summary, verbatim

While flying a nonprecision approach, the pilot deliberately descended below the minimum descent altitude (MDA) and attempted to execute a circle to land below the published circling minimums instead of executing the published missed approach procedure. During the circle to land, visual contact with the airport environment was lost and engine power was never increased after the airplane had leveled off. The airplane decelerated and entered an aerodynamic stall, followed by an uncontrolled descent which continued until ground impact. Weather at the time consisted of rain, with ceilings ranging from 300 to 600 feet, and visibility remaining relatively constant at 2.5 miles in fog. Review of the cockpit voice recorder (CVR) audio revealed that the pilot had displayed some non professional behavior prior to initiating the approach. Also contained on the CVR were comments by the pilot indicating he planned to descend below the MDA prior to acquiring the airport visually, and would have to execute a circling approach. Moments after stating a circling approach would be needed, the pilot received a sink rate aural warning from the enhanced ground proximity warning system (EGPWS). After several seconds, a series of stall warnings was recorded prior to the airplane impacting terrain. EGPWS data revealed, the airplane had decelerated approximately 75 knots in the last 20 seconds of the flight. Examination of the wreckage did not reveal any preimpact failures or malfunctions with the airplane or any of its systems. Toxicology testing detected sertraline in the pilot’s kidney and liver. Sertraline is a prescription antidepressant medication used for anxiety, obsessive-compulsive disorder, panic disorder, posttraumatic stress disorder, and social phobia. The pilot’s personal medical records indicated that he had been treated previously with two other antidepressant medications for “anxiety and depression” and a history of “impatience” and “compulsiveness.” The records also documented a diagnosis of diabetes without any indication of medications for the condition, and further noted three episodes of kidney stones, most recently experiencing “severe and profound discomfort” from a kidney stone while flying in 2005. None of these conditions or medications had been noted by the pilot on prior applications for an airman medical certificate. It is not clear whether any of the pilot’s medical conditions could account for his behavior or may have contributed to the accident.

Photographs

3the aircraft, and what the investigators found
Wreckage and site documentation · 3 photographs from the docket

Photographs are NTSB docket attachments — works of the US government, in the public domain. Captions are the Board’s own.

Probable cause

the Board's determination
The pilot's failure to maintain control of the airplane in instrument meteorological conditions. Contributing to the accident were the pilot's improper decision to descend below the minimum descent altitude, and failure to follow the published missed approach procedure.

Occurrence sequence

5 stepsNTSB coding · CICTT taxonomy
  1. 1 · Approach-IFR final approach
    Altitude deviation
  2. 2 · Approach-IFR missed approach
    Terrain avoidance alert
  3. 3 · Approach-IFR missed approach
    Stall warn/stick-shaker/pusher
  4. 4 · Approach-IFR missed approach
    Aerodynamic stall/spin
    defining event
  5. 5 · Approach-IFR missed approach
    Collision with terr/obj (non-CFIT)

Findings

4 causal · 4 contributing
  • CAUSE
    Personnel issues › Task performance › Use of equip/info › Aircraft control — Pilot
  • CAUSE
    Personnel issues › Action/decision › Info processing/decision › Decision making/judgment — Pilot
  • CAUSE
    Aircraft › Aircraft oper/perf/capability › Performance/control parameters — Not attained/maintained
  • CAUSE
    Personnel issues › Task performance › Use of equip/info › Use of policy/procedure — Pilot
  • FACTOR
    Environmental issues › Conditions/weather/phenomena › Ceiling/visibility/precip › Low ceiling — Decision related to condition
  • FACTOR
    Environmental issues › Conditions/weather/phenomena › Ceiling/visibility/precip › Low visibility — Decision related to condition
  • FACTOR
    Environmental issues › Conditions/weather/phenomena › Ceiling/visibility/precip › Drizzle/mist — Decision related to condition
  • FACTOR
    Personnel issues › Physical › Health/Fitness › Use of medication/drugs — Pilot

NTSB analysis

from the final report

While flying a nonprecision approach, the pilot deliberately descended below the minimum descent altitude (MDA) and attempted to execute a circle to land below the published circling minimums instead of executing the published missed approach procedure. During the circle to land, visual contact with the airport environment was lost and engine power was never increased after the airplane had leveled off. The airplane decelerated and entered an aerodynamic stall, followed by an uncontrolled descent which continued until ground impact. Weather at the time consisted of rain, with ceilings ranging from 300 to 600 feet, and visibility remaining relatively constant at 2.5 miles in fog. Review of the cockpit voice recorder (CVR) audio revealed that the pilot had displayed some non professional behavior prior to initiating the approach. Also contained on the CVR were comments by the pilot indicating he planned to descend below the MDA prior to acquiring the airport visually, and would have to execute a circling approach. Moments after stating a circling approach would be needed, the pilot received a sink rate aural warning from the enhanced ground proximity warning system (EGPWS). After several seconds, a series of stall warnings was recorded prior to the airplane impacting terrain. EGPWS data revealed, the airplane had decelerated approximately 75 knots in the last 20 seconds of the flight. Examination of the wreckage did not reveal any preimpact failures or malfunctions with the airplane or any of its systems. Toxicology testing detected sertraline in the pilot’s kidney and liver. Sertraline is a prescription antidepressant medication used for anxiety, obsessive-compulsive disorder, panic disorder, posttraumatic stress disorder, and social phobia. The pilot’s personal medical records indicated that he had been treated previously with two other antidepressant medications for “anxiety and depression” and a history of “impatience” and “compulsiveness.” The records also documented a diagnosis of diabetes without any indication of medications for the condition, and further noted three episodes of kidney stones, most recently experiencing “severe and profound discomfort” from a kidney stone while flying in 2005. None of these conditions or medications had been noted by the pilot on prior applications for an airman medical certificate. It is not clear whether any of the pilot’s medical conditions could account for his behavior or may have contributed to the accident.