The National Transportation Safety Board did not travel to the scene of this accident.
Additional Participating Entities:
Federal Aviation Administration / Flight Standards District Office; Indianapolis, Indiana
Cessna Aircraft Company; Wichita, Kansas
Teledyne Continental Motors; Mobile, Alabama
Location: Bloomington, IN
Accident Number: CHI06FA117
Date & Time: 04/20/2006, 2345 EDT
Registration: N120HS
Aircraft: Cessna U206G
Aircraft Damage: Destroyed
Defining Event:
Injuries: 5 Fatal
Flight Conducted Under: Part 91: General Aviation - Personal
Analysis
The airplane crashed into trees about 1/2-mile from the approach end of runway 35 while the aircraft was conducting a precision instrument approach in night instrument weather. The flight's plotted radar data was consistent with an airplane that was being vectored for an instrument landing system (ILS) approach. The radar track depicted the aircraft flying above glide path and to the right of course until radar contact was lost at 2,000 feet at 2338:34 about two and a half miles from the approach end of the runway. About 2345, the Sheriff responded to telephone calls of a possible airplane crash. A witness described the airplane sounds as an engine acceleration, followed by a thud, and then no more engine sounds were heard. The airport's weather about the time of the accident was: Wind 230 degrees at 5 knots; visibility 1 statute mile; present weather mist; sky condition overcast 100 feet. The published decision height for the approach was 200 feet agl and one-half mile visibility. A post accident inspection of the ILS determined the ILS was operating normally. The tower did not record after hour radio transmissions. An on-scene examination of the aircraft wreckage did not reveal any pre-impact anomalies. A review of data from an engine monitor showed a reduction in fuel flow consistent with a descent followed by an increase in fuel flow consistent with a full power setting.
Probable Cause and Findings
The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The pilot's continued descent below decision height and not maintaining adequate altitude/clearance from the trees while on approach. Factors were the the night lighting conditions, and the mist.
Findings
Occurrence #1:
IN FLIGHT COLLISION WITH OBJECT
Phase of Operation: APPROACH - FAF/OUTER MARKER TO THRESHOLD (IFR)
Findings
1. OBJECT - TREE(S)
2. (C) DECISION HEIGHT - CONTINUED BELOW - PILOT IN COMMAND
3. (F) LIGHT CONDITION - NIGHT
4. (C) ALTITUDE/CLEARANCE - NOT MAINTAINED - PILOT IN COMMAND
5. (F) WEATHER CONDITION - DRIZZLE/MIST
Occurrence #2:
IN FLIGHT COLLISION WITH TERRAIN/WATER
Phase of Operation: DESCENT - UNCONTROLLED
Findings
6. TERRAIN CONDITION - GROUND
Factual Information
HISTORY OF FLIGHT
On April 20, 2006, about 2345 eastern daylight time, a Cessna U206G, N120HS, piloted by an instrument rated private pilot, was destroyed on impact with trees and terrain while on approach to runway 35 at the Monroe County Airport (BMG), near Bloomington, Indiana. The personal flight was operating under the provisions of 14 Code of Federal Regulations Part 91. Night instrument meteorological conditions prevailed at the time of the accident. An instrument flight rules (IFR) flight plan was on file and was activated. The pilot and four passengers sustained fatal injuries. The flight originated from the Purdue University Airport (LAF), near Lafayette, Indiana, about 2245.
The person representing N120HS contacted the Terre Haute, Indiana, federal contract facility automated flight service station (AFSS) to get a weather briefing about 2213.
The AFSS briefer at position "PF-3" gave the following brief, in part, to the pilot:
2213:25 PF-3 terre haute flight service
2213:27 N120HS hi i'd like to get a weather briefing
2213:29 PF-3 yes ma'am
2213:30 N120HS um lafayette lima alpha foxtrot and bloomington bravo mike golf and any interesting weather that might be between them
2213:39 PF-3 okay uh what's the aircraft call sign you're using
2213:42 N120HS november one two zero hotel sierra
2213:45 PF-3 and what time are you leaving lafayette
2213:47 N120HS we will probably be leaving in about twenty minutes to half an hour
2213:58 PF-3 okay and is this a v f r flight or IFR
2214:02 N120HS for VFR
2214:03 PF-3 VFR only
2214:05 N120HS *(ho ho) wait i'm sorry go ahead
2214:08 PF-3 is that VFR only
2214:10 N120HS yes yes sir well depending on what the weather's like
2214:19 PF-3 and they're saying that that may continue the rest of the evening into early tomorrow morning and
2214:23 N120HS okay
2214:23 PF-3 looking at the bloomington weather they do have IFR ceilings eight hundred broken right now with visibility eight miles
2214:30 N120HS *(okay)
2214:30 PF-3 so i wouldn't recommend VFR
2214:32 N120HS okay well
2214:33 PF-3 uh
2214:33 N120HS definitely not I'm sorry I got I looked at the *(tafs they) didn't predict that okay can I file an IFR flight plan with you
2214:39 PF-3 sure would you like me to continue with the rest of the weather and and all that
2214:42 N120HS yeah that would that would be great
2214:44 PF-3 okay uh that's the only airmet uh going down that way for you uh looks like a low pressure system we've got uh one in western Kentucky Tennessee another one's up around the chicago area *(it's a) stationary front running from that one across northern Indiana and Ohio and then uh high pressure over to our east precip uh nothing really along that route there is some in southeastern Indiana but it shouldn't affect your flight at all
2215:08 N120HS *(okay)
2215:08 PF-3 at Lafayette uh the winds are two eighty at four ten miles skies clear below twelve thousand sixteen and seven and two nine nine one that's an automated report en route looking at a few clouds at thirteen thousand with niner miles and then again in the Bloomington area winds two forty at three eight miles ceiling eight hundred broken seventeen and sixteen and two nine nine four that's also an automated report at Bloomington and I don't see any uh pilot reports right now along that route for you the forecast Lafayette was saying the rest of the evening a few clouds at six thousand winds three ten at five en route uh calling for *(uh) it looks like three thousand scattered six to ten thousand broken to overcast they were saying occasional showers in central indiana til zero three hundred though there's nothing really showing except for a little northeast of indy and then uh for the Bloomington area uh six hundred broken five thousand overcast visibility better than six winds one sixty at four now they were saying within an hour you might see six hundred scattered five in mist around Bloomington four hun four thousand broken and winds one fifty at four but the airmet was calling for IFR to continue the rest of the night into early tomorrow
2216:26 N120HS boy am I glad I called you wow
2216:27 PF-3 and
2216:28 N120HS okay
2216:28 PF-3 and then winds aloft uh would you like three and six for those
2216:32 N120HS um just three please
2216:33 PF-3 three thousand you're looking at light and variable winds at three thousand
2216:37 N120HS okay great
2216:38 PF-3 and notams uh Lafayette RCO one two two three five is out of service
2216:44 PF-3 and uh it says the class D surface area and uh tower only available through zero one hundred daily down at Bloomington uh showing tower and class d surface area available through zero one thirty daily and three five pilot controlled lighting is out of service at Bloomington Indiana and otherwise en route I don't see anything else enroute for you notam D wise as far as TFRs no unpublished TFRs along that route at this time 2217:15 N120HS *(great)
2217:15 PF-3 *(we'd) appreciate uh pilot reports flight watch is shut down for the evening but any any flight service frequencies along the route for you would you like to go ahead and file then
2217:24 N120HS yes sir
2217:25 PF-3 okay i'm ready to copy
2217:26 N120HS (unintelligible) november one two zero hotel sierra it's a Cessna two oh six slash alpha airspeed a hundred and a hundred and thirty knots flying at three thousand feet departing lafayette lima alpha foxtrot Lafayette direct Bloomington Indiana bravo mike golf five on board three hours of fuel the aircraft is based in South Bend pilots name ... and aircraft is red white and blue
2218:12 PF-3 (unintelligible) uh what's your time enroute from Lafayette to Bloomington
2218:15 N120HS time on route forty minutes
2218:19 PF-3 and you say you're leaving in just a few minutes I put that out for zero two thirty that's on the half hour
2218:23 N120HS *(perfect)
The transcript of the weather briefing showed that the pilot did not give an alternate airport to the briefer when the flight plan was filed. The briefer did not ask for an alternate airport and was not required to ask for one.
About 2319, the pilot checked on with the Air Route Traffic Control Center controller working the Shelbyville, Indiana, sector (SHB R). The transcript of their transmissions, in part, stated:
2319:57 N120HS indy center november one two zero hotel sierra is with you at five thousand
2320:01 SHB R november one two zero hotel sierra Indianapolis center roger how do you hear center
2320:04 N120HS ah loud and clear
2320:05 SHB R okay and ah what type of approach are you going to shoot into Bloomington this morning or this evening
2320:11 N120HS we'd like to go for a runway three five six ah i l s
2320:14 SHB R i l s three five okay you can expect that ah one two zero hotel sierra do you have the ah asos weather
2320:19 N120HS yes sir
2320:20 SHB R all right
2323:11 SHB R Cessna one two zero hotel sierra you're one two miles north of Bloomington cross Bloomington at or above two thousand six hundred cleared for the i l s runway three five approach report procedure turn inbound
2323:23 N120HS oh any way we can have vectors to the---ah final course
2323:26 SHB R not a problem at all ma'am what's your heading
2323:30 N120HS one seven zero
2323:32 SHB R okay turn ah right heading of ah one nine zero it'll be a vector for a left down wind entry for i l s three five straight in
2323:39 N120HS one niner zero for a---right down wind entry ah for three five zero hotel sierra
2323:43 SHB R yes ma'am and maintain five thousand
2323:46 N120HS maintain five thousand
2328:35 SHB R cessna one two zero hotel turn left heading one eight zero
2328:39 N120HS left heading one eight zero
2333:03 SHB R Cessna one two zero hotel sierra descend at pilot's discretion maintain four thousand
2333:08 N120HS descend and maintain four thousand for zero hotel sierra
2333:13 SHB R I am going to take you about two miles outside of claye if that's okay with you ma'am
2333: 18 N120HS that's great
2333:50 SHB R Cessna one two zero hotel sierra turn left heading zero eight zero
2333:53 N120HS left heading zero eight zero
2334:36 SHB R cessna one two zero hotel sierra three and a half miles south of claye turn left heading zero two zero maintain two thousand six hundred until established on the localizer you're cleared straight in i l s runway three five approach
2334:48 N120HS turn left heading zero two zero---cleared for the approach maintain twenty six hundred til ah established zero hotel sierra
2336:15 SHB R Cessna one two zero hotel sierra see you joining up on the localizer now radar service is terminated change to advisory
tower frequency of one two eight point zero two is approved---and i'll need you to cancel---with ah terre haute tower on that frequency one two eight point zero two they monitor that frequency and they'll relay for ya
2336:35 N120HS radar service terminated and cancel with terre haute on one two eight point zero two thanks (unintelligible) zero hotel sierra
2336:40 SHB R and you can change to that frequency now you have a good night
2336:43 N120HS thanks
A Continuous Data Recording (CDR) airplane radar track data file was obtained from the Federal Aviation Administration (FAA) in reference to the accident flight. The airplane's radar returns along with their respective altitudes and times were plotted. The plotted data was consistent with an airplane that was being vectored for an instrument landing system (ILS) approach to runway (rwy) 35. The plot showed the airplane at about 5,000 feet on a downwind. At 2334:30, the return showed the airplane was about 4,500 feet on base about ten miles from the approach end of runway 35. The airplane's return at 2337 was right of and approaching the outer marker CLAYE at an altitude of 3,300 feet. About 2337, the pilot made an advisory radio call on the Hulman Approach control frequency for BMG (128.025) that the flight was six miles south of BMG and inbound for runway 35. The last plotted return showed the airplane at 2,000 feet at 2338:34 about two and a half miles from the approach end of runway 35. About 2343, the controller from the Terre Haute International Airport-Hulman Field air traffic control tower, near Terre Haute, Indiana, who was working the approach frequency, advised the flight that the BMG common traffic advisory frequency (CTAF) was 120.77 and the flight responded with "Thank you sir." No further communication was recorded with the accident flight. That plotted chart is appended to the docket material associated with this case.
About 2345, the Monroe County Sheriff responded to telephone calls of a possible airplane crash. About 0400, the wreckage was located in a wooded area about one-half mile from the approach end of runway 35.
Witnesses in the area stated that they were awakened by a low flying aircraft. A witness said that the airplane noise was like a roar. Another described it as an engine acceleration. A thud was heard and no more engine sounds were heard.
PERSONNEL INFORMATION
The pilot held a private pilot certificate with single-engine land, multiengine land, and instrument airplane ratings. The airplane operator reported that the pilot had completed a flight review or equivalent on July 3, 2005. It was further reported that the pilot had accumulated 379.1 hours of total flight time, 24.5 hours of actual instrument time, 51.1 hours of simulated instrument time, 30.4 hours of total flight time in the previous 90 days, 18.0 hours of total flight time in the previous 30 days, and 1.8 hours of total flight time in the previous 24 hours.
She held a FAA third-class medical certificate issued on August 19, 2003, with a limitation for corrective lenses.
AIRCRAFT INFORMATION
N120HS, a Cessna U206G, Stationair 6, serial number U20604728, was a six-place, single engine, high-wing, all-metal airplane of semi-monocoque construction. The wings were externally braced and each wing contained a standard integral 46-gallon fuel tank. The airplane was powered by a six-cylinder, horizontally opposed, air cooled, fuel injected, marked as a Continental IO-520-F (17) engine, with serial number 812264-R. The engine was rated at 300 horsepower for five minutes and 285 horsepower continuously. Maintenance records showed that the airplane's propeller was a three-bladed McCauley D3A34C404B model, hub serial number 785309. The airplane was issued a standard airworthiness certificate and was certified for normal category operations.
Maintenance records show that the last annual inspection was performed on June 7, 2005, and that the airplane had accumulated 2,125.7 hours at the time of that inspection. An entry in the records showed that the static system was inspected in accordance with Part 91.411 and 91.413 requirements on May 19, 2005.
The airplane was equipped with a J.P. Instruments Engine Data Management (EDM) 700 system. According to manufacturer's data, the EDM will monitor up to twenty-four critical parameters in your engine, four times a second, with a linearized thermocouple accuracy of better than 0.1 percent or 2 degrees F, has a user selectable index rate, fast response probes, non-volatile long term memory, records and stores data up to 30 hours, and has post-flight data retrieval capabilities.
METEOROLOGICAL INFORMATION
At 2340, the recorded weather at BMG was: Wind 230 degrees at 5 knots; visibility 1 statute mile; present weather mist; sky condition overcast 100 feet; temperature 17 degrees C; dew point 16 degrees C; altimeter 29.94 inches of mercury.
AIDS TO NAVIGATION
There were eight non-precision instrument approaches and one precision approach available at the airport.
The published inbound course for BMG's ILS RWY 35 approach was 354 degrees magnetic, with the published decision height (DH) of 1,045 feet msl. The crossing altitude for the final approach fix (CLAYE) was 2,533 feet msl. The distance between CLAYE and the missed approach point was 5.1 nautical miles (nm). The airport elevation was 846 feet msl.
The published weather minimums for the ILS RWY 35 approach were a 200-foot ceiling and one-half mile visibility for category A, B, C, and D aircraft.
On April 21, 2006 the FAA conducted a post aircraft accident technical inspection and found the ILS system was operating normally.
AIRPORT INFORMATION
BMG had two asphalt-surfaced runways, 17/35 and 6/24. Runway 17/35 was 6,500 feet long and 150 feet wide. Runway 35 was equipped with a medium intensity approach lighting system with runway alignment indicator lights (MALSR) and high intensity runway lights (HIRL). Runways 6,17, and 24 were equipped with visual approach slope indicators (VASI) located on the left side of their respective runways.
The airport was serviced by an Air Traffic Control tower. The tower was attended from 0630 - 2130 local. After hour local traffic communications were accomplished via the published airport CTAF 120.775 megahertz (MHz). The tower did not record the CTAF transmissions made after hours. Indianapolis Approach provided approach/departure control services for the airport.
The pilot controlled lighting function of the approach lights was not operative. The approach lights were turned on before the tower was closed.
WRECKAGE AND IMPACT INFORMATION
The airplane came to rest inverted on an approximate 180 degree magnetic heading. Broken and linearly separated tree branches were observed. A tree on a 230 degree magnetic heading from the wreckage and about 6 feet from the wreckage contained embedded aluminum colored metal consistent with the nose wheel rim. The engine was found about three feet below the surface. The propeller hub remained attached to the engine crankshaft propeller flange. The propeller blades separated from their hub. One blade exhibited forward bending and leading edge deformation. All of the blades exhibited chordwise abrasion. The wings were detached from the fuselage. The outboard section of the left wing had separated from the inboard section. The rudder was detached from the empennage and its control cables remained attached.
An on-scene examination of the wreckage was conducted. Flight control cables were traced. All breaks in cables were consistent with overload. Flight control continuity was established from the cabin area to all flight control surfaces. The engine's control cables were traced from the cabin to the engine and engine control continuity was established. A blue liquid consistent with 100 low lead aviation gasoline was observed in the left tank.
The wreckage was relocated for a detailed examination and wreckage layout. The right engine driven vacuum pump was separated from the accessory case. The pump's drive coupler was not recovered. The right vacuum pump was rotated by hand and an inspection revealed that its rotor and vanes were intact. The left pump was attached to the accessory case. The pump was crushed and an inspection revealed its rotor was fragmented. The sparkplugs were removed and no anomalies were detected. The engine was rotated by hand and a thumb compression was observed at all cylinders. The right magneto was crushed, deformed, and did not produce any spark when rotated by hand. The left magneto produced spark at all leads when rotated by hand. The engine driven fuel pump's coupler was intact. A blue liquid consistent with 100 low lead aviation gasoline was found in the fuel line from the engine driven fuel pump to the manifold valve. The attitude indicator and horizontal situation indicator rotors exhibited rotational scoring. The rotor housings exhibited witness marks consistent with contact with their rotors. The altimeter's Kollsman window indicated 29.91. The airplane's engine monitor was crushed. The on-scene investigation did not reveal any pre-impact anomalies.
MEDICAL AND PATHOLOGICAL INFORMATION
An autopsy was performed on the pilot by the Monroe County Coroner's Office on April 22, 2006.
The FAA Civil Aeromedical Institute prepared a Final Forensic Toxicology Accident Report. The report was negative for the tests performed.
TESTS AND RESEARCH
The engine monitor was examined at its manufacturer. The unit and its circuit board were crushed. The data memory chip was removed from its circuit board and installed on a serviceable circuit board. The accident flight's data was downloaded. The downloaded data was graphed. The end of the graph showed a reduction in fuel flow consistent with a descent followed by an increase in fuel flow consistent with a full power setting and the data stopped at that point. The graph of the engine monitor's data is appended to the docket material associated with this investigation.
ADDITIONAL DATA/INFORMATION
Federal Aviation Regulation Part 91.169 IFR flight plan: information required, in part, stated:
(a) Information required. Unless otherwise authorized by ATC, each person filing an IFR flight plan shall include in it the following information:
(1) Information required under Sec. 91.153(a).
(2) An alternate airport, except as provided in paragraph (b) of this section.
(b) Exceptions to applicability of paragraph (a)(2) of this section.
Paragraph (a)(2) of this section does not apply if part 97 of this chapter prescribes a standard instrument approach procedure for the first airport of intended landing and, for at least 1 hour before and 1 hour after the estimated time of arrival, the weather reports or forecasts, or any combination of them indicate--
(1) The ceiling will be at least 2,000 feet above the airport elevation; and
(2) The visibility will be at least 3 statute miles.
(c) IFR alternate airport weather minimums. Unless otherwise authorized by the Administrator, no person may include an alternate airport in an IFR flight plan unless current weather forecasts indicate that, at the estimated time of arrival at the alternate airport, the ceiling and visibility at that airport will be at or above the following alternate airport weather minimums:
(1) If an instrument approach procedure has been published in part 97 of this chapter for that airport, the alternate airport minimums specified in that procedure or, if none are so specified, the following minimums:
(i) Precision approach procedure: Ceiling 600 feet and visibility 2 statute miles.
(ii) Non-precision approach procedure: Ceiling 800 feet and visibility 2 statute miles.
(2) If no instrument approach procedure has been published in part 97 of this chapter for that airport, the ceiling and visibility minimums are those allowing descent from the MEA, approach, and landing under basic VFR.
The operator's safety recommendation, in part stated:
Even if a tower is closed, as it was in this case, there should be an automatic recording of all pilot transmissions on the common frequency. Such a recording would make available vital information in the case of a fatal accident [for example] did the pilot make a distress call? Does the pilot's voice indicate that they are under duress? Was it the pilot's intention to do a missed approach? Was there anything that may have interfered with the pilot's conduct of the flight? Did the pilot make any announcement indicating what problem they were facing? Was there any other aircraft in the immediate vicinity?
The parties to the investigation included the FAA, Cessna Aircraft Company, and Teledyne Continental Motors.
The aircraft wreckage was released to a representative of the insurance company.
Pilot Information
Certificate: Private
Age: 24, Female
Airplane Rating(s): Multi-engine Land; Single-engine Land
Seat Occupied: Left
Other Aircraft Rating(s): None
Restraint Used: Seatbelt, Shoulder harness
Instrument Rating(s): Airplane
Second Pilot Present: No
Instructor Rating(s): None
Toxicology Performed: Yes
Medical Certification: Class 3 With Waivers/Limitations
Last FAA Medical Exam: 08/01/2003
Occupational Pilot:
Last Flight Review or Equivalent: 07/01/2005
Flight Time: 379 hours (Total, all aircraft), 144 hours (Total, this make and model), 312 hours (Pilot In Command, all aircraft), 30 hours (Last 90 days, all aircraft), 18 hours (Last 30 days, all aircraft), 2 hours (Last 24 hours, all aircraft)
Aircraft and Owner/Operator Information
Aircraft Make: Cessna
Registration: N120HS
Model/Series: U206G
Aircraft Category: Airplane
Year of Manufacture:
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: U20604728
Landing Gear Type: Tricycle
Seats: 6
Date/Type of Last Inspection: 06/01/2005, Annual
Certified Max Gross Wt.: 3600 lbs
Time Since Last Inspection:
Engines: 1 Reciprocating
Airframe Total Time: 2125.7 Hours as of last inspection
Engine Manufacturer: Teledyne Continental
ELT: Installed, activated, aided in locating accident
Engine Model/Series: IO-520-F
Registered Owner: Yatish Air LLC
Rated Power: 285 hp
Operator: Yatish Air LLC
Operating Certificate(s) Held: None
Meteorological Information and Flight Plan
Conditions at Accident Site: Instrument Conditions
Condition of Light: Night
Observation Facility, Elevation: BMG, 846 ft msl
Distance from Accident Site: 1 Nautical Miles
Observation Time: 2340 EDT
Direction from Accident Site: 355°
Lowest Cloud Condition:
Visibility: 1 Miles
Lowest Ceiling: Overcast / 100 ft agl
Visibility (RVR):
Wind Speed/Gusts: 5 knots /
Turbulence Type Forecast/Actual: /
Wind Direction: 230°
Turbulence Severity Forecast/Actual: /
Altimeter Setting: 29.94 inches Hg
Temperature/Dew Point: 17°C / 16°C
Precipitation and Obscuration: In the Vicinity - Mist
Departure Point: LAFAYETTE, IN (LAF)
Type of Flight Plan Filed: IFR
Destination: Bloomington, IN (BMG)
Type of Clearance: IFR
Departure Time: 2245 EDT
Type of Airspace:
Airport Information
Airport: MONROE COUNTY (BMG)
Runway Surface Type:
Airport Elevation: 846 ft
Runway Surface Condition: Dry
Runway Used: 35
IFR Approach: ILS
Runway Length/Width: 6500 ft / 150 ft
VFR Approach/Landing: Full Stop
Wreckage and Impact Information
Crew Injuries: 1 Fatal
Aircraft Damage: Destroyed
Passenger Injuries: 4 Fatal
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 5 Fatal
Latitude, Longitude: 39.154722, -86.616667
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