14 CFR Part 91: General Aviation
Accident occurred Friday, June 07, 2013 in Baker, LA
Probable Cause Approval Date: 09/15/2014
Aircraft: HAWKER BEECHCRAFT B200GT, registration: N510LD
Injuries: 1 Fatal.
NTSB investigators either traveled in support of this investigation or conducted a significant amount of investigative work without any travel, and used data obtained from various sources to prepare this aircraft accident report.
The accident pilot and two passengers had just completed a ferry flight on the recently purchased airplane. A review of the airplane’s cockpit voice recorder audio information revealed that, during the ferry flight, one of the passengers, who was also a pilot, was pointing out features of the new airplane, including the avionics suite, to the accident pilot. The pilot had previously flown another similar model airplane, but it was slightly older and had a different avionics package; the new airplane’s avionics and flight management system were new to the pilot.
After completing the ferry flight and dropping off the passengers, the pilot departed for a short cross-country flight in the airplane. According to air traffic control recordings, shortly after takeoff, an air traffic controller assigned the pilot a heading and altitude. The pilot acknowledged the transmission and indicated that he would turn to a 045 heading. The radio transmission sounded routine, and no concern was noted in the pilot’s voice. However, an audio tone consistent with the airplane’s stall warning horn was heard in the background of the pilot’s radio transmission. The pilot then made a radio transmission stating that he was going to crash. The audio tone was again heard in the background, and distress was noted in the pilot’s voice. The airplane impacted homes in a residential neighborhood; a postcrash fire ensued. A review of radar data revealed that the airplane made a climbing right turn after departure and then slowed and descended. The final radar return showed the airplane at a ground speed of 102 knots and an altitude of 400 feet. Examination of the engines and propellers indicated that the engines were rotating at the time of impact; however, the amount of power the engines were producing could not be determined. The examination of the airplane did not reveal any abnormalities that would have precluded normal operation. It is likely that the accident pilot failed to maintain adequate airspeed during departure, which resulted in an aerodynamic stall and subsequent impact with terrain, and that his lack of specific knowledge of the airplane’s avionics contributed to the accident.
The National Transportation Safety Board determines the probable cause(s) of this accident as follows:
The pilot’s failure to maintain adequate airspeed during departure, which resulted in an aerodynamic stall and subsequent impact with terrain. Contributing to the accident was the pilot’s lack of specific knowledge of the airplane’s avionics.
HISTORY OF FLIGHT
On June 7, 2013 about 1310, central daylight time, a Beechcraft, KingAir, B200GT, airplane, N510LD,impacted terrain shortly after departure in a residential neighborhood near Baker, Louisiana. The airline transport rated pilot received fatal injuries and the airplane was destroyed. The airplane was registered to and operated by Osage Air LLC, Wilmington, Delaware. Visual meteorological conditions prevailed and a flight plan was not filed for the 14 Code of Federal Regulations Part 91 personal cross-country flight. The flight originated from Baton Rouge Metropolitan Airport, Ryan Field (BTR), Baton Rouge, Louisiana, en route to (Pike County) John E Lewis Field Airport (KMCB), McComb, Mississippi.
The accident pilot and two passengers flew to Georgetown, Texas, in a B200 KingAir the day prior to the accident. The B200 airplane was being used as a trade-in, on N510LD. On the day of the accident and after the sale was finalized, the three people returned to BTR in N510LD, with the accident pilot as pilot in command. After dropping off the two passengers at BTR, the accident pilot planned to fly to McComb, with the recently purchased airplane.
Several witnesses reported that the airplane heading north and was low; the airplane then dropped and impacted the roof of a house. The airplane subsequently impacted a tree and two neighboring houses before erupting into flames.
PILOT INFORMATION
The pilot was employed as a corporate pilot, and held an airline transport pilot certificate with ratings for airplane single-engine and multiengine land, and instrument-airplane. The pilot also held several type ratings for jet airplanes. The pilot held a first class medical certificate that was issued on June 4, 2013, with the restriction, "must have available glasses for near vision". At the time of the exam the pilot reported 15,150 total flight hours and 75 hours in last six months. The pilot also reported to the insurance company that he had 5,075 in BE20 (KingAir 200) and had annual training at FSI, Simuflight, or SimCom depending on type of aircraft. The accident airplane was a B200GT and was equipped with Rockwell Collins Proline 21 avionics including an FMS-3000 (Flight Management System) suite. The amount of flight time the pilot had with the Proline 21 system was unknown; however, during delivery of the airplane another pilot noted that the B200GT's avionics were new to the accident pilot.
AIRCRAFT INFORMATION
The Beechcraft B200GT King Air is a twin-turboprop airplane powered by two Pratt & Whitney PT6A-52 engines. The airplane was maintained under the manufacturer's maintenance program. The airplane's maintenance records were located among the wreckage and were fire and water damaged. A review of the records revealed that the airframe's phase 1- 4 inspections were completed on March 18, 2013. At the time of the inspection, the airframe had a total time of 974.2 hours; the left and right engines had also accumulated 974.2 total hours.
METEOROLOGICAL INFORMATION
At 1353, the automated weather observation facility located at BTR, reported wind from 280 degrees at 8 knots, visibility 10 miles, scattered clouds at 3,300 and 7,500 feet, temperature 84 Fahrenheit (F), dew point 67 F, and a barometric pressure of 29.88 inches of mercury.
COMMUNICATIONS and RADAR INFORMATION
According to air traffic control communications, the airplane departed BTR runway 31. Just after takeoff, the controller assigned the pilot a heading and altitude to MCB. The pilot acknowledged the transmission and indicated he would turn to a 045 heading. The radio transmission appeared normal, with no concern in the pilot's voice. However, an audio tone was present in the background of the pilot's radio transmission. Shortly thereafter, the pilot made a radio transmission stating that he was going to crash. The same audio tone was heard in the background, along with distress noted in the pilot's voice. The tone was consistent with the airplane's stall warning horn. There was no further communications with the pilot.
Review of radar data revealed the airplane departed BTR, and tracked in a right arc away from the airport. After airborne, as the airplane started to turn right, radar data showed the ground speed as 124 knots and increased to about 128 knots; the first altitude started at 700 feet and increased to 1,200 feet, as the airplane started its turn. The radar track then depicted a northeasterly heading as the airplane appeared to proceed on course. Before the airplane disappeared from radar, the airspeed decreased to 102 knots and the altitude decreased to 400 feet.
WRECKAGE AND IMPACT INFORMATION
The accident site was located about 3.5 miles northeast of BTR, in a residential area. The first impact point was the roof of one home; the airplane then impacted a tree and shed in the backyard of neighboring homes. The airplane came to rest in an upright position, in the corner of a house. The impact with the tree, split the fuselage in two, with the empennage and about an 8-10 foot fuselage section coming to rest in the yard of the neighboring home. All major components were accounted for on site. A postcrash fire consumed most of the airplane; fire, smoke/water also damaged the two homes. The left propeller was separated from the engine and was just left of the main wreckage. The propeller blades were twisted and had cord wise marks near the tips. The right propeller remained attached to the engine; the two top, exposed blades were consumed by the fire, the two bottom blades were covered by the wreckage/debris.
MEDICAL AND PATHOLOGICAL INFORMATION
The Office of the Coroner, East Baton Rouge Parish, Paton Rouge, Louisiana, conducted an autopsy on the pilot. The cause of death on was determined to be, "blunt force, thermal, and inhalational injures".
The FAA Toxicology Accident Research Library, Oklahoma City, Oklahoma, conducted toxicological testing on pilot. The test was negative for ethanol and cyanide; however, the test was positive for carbon monoxide in the blood at 21%. Acetaminophen was detected in the urine (15 ug/ml, ug/g), diltiazem was detected in the blood and urine, and ibuprofen was detected in the urine.
Both acetaminophen and ibuprofen are non-prescription pain medicine and are commonly marketed under the trade name Tylenol and Motrin, respectively. Diltiazem is used to treat hypertension (high blood pressure), angina (chest pain), and certain heart rhythm disorders.
TEST AND RESEARCH
After initial documentation of the wreckage site, the wreckage was recovered for further examination. The airplane's cockpit voice recorder (CVR) was located and shipped to the vehicle recorder lab in Washington, DC for download.
A CVR group was convened. The recording was audited by the CVR group Laboratory and a summary report prepared. The CVR Specialist Factual Report is located in the official docket for this investigation.
The CVR captured part of the previous flight, in which the accident pilot received help from another pilot, in explaining the operation of the new airplane. The accident pilot also received instruction, prior to his departure on the accident flight.
The NTSB along with technical representatives from the airframe, engine, and propeller manufacturer conducted a follow up exam. The left hand, four bladed propeller and front section of the reduction gearbox had separated from the engine due to a fractured engine shaft. The 2nd stage planetary gears and bolt screws, displayed rotational scoring from contact with adjacent components during separation. Rotational scoring was noted on the compressor turbine and power turbine discs from contact with adjacent components. The 1st and 2nd stage power turbine blades exhibited rubs from localized contact regions of their respective shrouds.
The left engine propeller blades rotated freely in the hub, due to the blade knobs fracturing off during impact. All blades showed some rotational scoring and slight twisting at the tips. The propeller experienced severe thermal damage. Half of the spinner was missing due to melting away.
The right hand engine displayed light torsional bending aft of the exhaust duct. The compressor turbine disc exhibited rotational scoring from contact with the adjacent component. The 1st stage power turbine blades exhibited a 360 degree rub from contact with its respective shroud.
Two of the four propeller blades on the right engine were consumed by the post-crash fire, leaving about 10 inches of blades, from the hub assembly. The propeller was still attached to the engine. The blades rotated freely in the hub, due to the blade knobs fracturing off during impact. The spinner dome, bulkhead, three counterweights were missing.
Both engines and the left propeller displayed signatures consistent with some power being generated at impact; however, the amount of power could not be determined.
The fire damage to the right propeller and absence of signatures prevented any conclusion about power setting before impact.
The engines and propellers examination did not reveal any discrepancies that would have precluded normal operation.
John Cary Fowler had plenty of experience as a pilot, logging more than 15,000 hours in the air.
But on June 7, 2013, he was making his first flight in a Beechcraft B200GT King Air. A national safety agency says that lack of experience with the aircraft was likely the cause of the fiery crash in Baker that day, when the plane slammed into a subdivision, set fire to three houses and killed the 71-year-old pilot.
The National Transportation Safety Board’s causal report, dated Sept. 15, found that Fowler was unfamiliar with the aircraft’s equipment and that his inexperience led to the two-engine plane losing speed and stalling before crashing to the ground.
Fowler’s only other flight with that model came hours earlier, when he was flying to Baton Rouge with two other passengers. One could be heard on the plane’s cockpit audio recorder “pointing out” to Fowler some of the features of the plane, according to an earlier NTSB report released in August.
Fowler, of Brookhaven, Mississippi, then dropped off the pilots and was flying out of Baton Rouge toward McComb, Mississippi, when the plane stalled and crashed.
“Everyone knew that this was a tragedy, but … it strikes me that this easily could have been prevented,” said Logan Greenberg, an attorney with Ungelsby Law Firm, which is representing more than 30 Baker residents affected by the crash. “This did not come out of nowhere.”
The NTSB reports also provide new details about the crash itself. Minutes after Fowler took off alone from Baton Rouge Metropolitan Airport at about 1 p.m. on June 7, the two-engine plane — which is about 44 feet long and could have seated up to 11 people — began losing speed and was slowly descending. The plane’s audio captured a stall warning, and in Fowler’s last radio transmission, he said he was going to crash.
The plane crashed into the roof of a Rue Jennifer home, spilling fuel all over it, before striking a nearby tree and shed. The plane then caught fire while still sticking upright in the corner of a home. The blaze badly damaged three houses, but no one on the ground was injured. Most of the plane was destroyed by the fire, and the left propeller’s blades were found twisted and separated from the rest of the wreckage, while two other blades were burned away.
The plane’s last captured speed was 102 knots, the equivalent of 117 miles per hour.
The incident, Greenberg said, “was not some freak accident. … It was very clear cause and effect — somebody didn’t know how the plane worked, and that led to the plane crashing. It was terrible.”
Greenberg says the NTSB reports bolster lawsuits he filed in state district court against the pilot’s employer, Osage Air. The lawsuits, filed in late May, are in the early stages, but they allege the company should have taken more precautions before letting the pilot try to fly an unfamiliar plane on his own.
An attorney for the firm representing Osage Air, Bradley Schwab, denied the allegations in court documents filed in July. He declined to comment further on the lawsuit.
Greenberg said he isn’t yet sure how different the plane was from other planes Fowler had flown. On that question, the NTSB reports note that Fowler had flown “another similar model” that was “slightly older and had a different avionics package,” referring to its electronic equipment.
The monthslong aftermath of the crash has posed a host of problems for Baker neighbors. As late as January, one of the homes on Rue Jennifer still stood charred with its roof mostly caved in and looked as if the plane crashed into the roof only days earlier. Garbage bags with belongings from the home’s residents were still left in the backyard. At a Baker City Council meeting that month, neighbors also came away with no clear answers as to whether leaked jet fuel posed a health risk. Nine months after the crash, the soil was deemed safe.
The lawsuit also claims that residents are still suffering anxiety and depression nearly one year later.
“When they hear a plane now, they’re terrified,” Greenberg said.
Story and Photo Gallery: http://theadvocate.com
John Cary Fowler
To all of us who knew and loved John, he was a loving husband, father, grandfather and a friend. John was a corporate pilot, a resident of Brookhaven, MS, and a native of Oak Grove, Louisiana. He passed away June 7, 2013. - See more at: http://www.legacy.com
Sad story. Technology is fast out-pacing our mental capacity to handle it.
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