Tuesday, April 05, 2022

Clear Air Turbulence Encounter: Beech B200 Super King Air, N469SL; accident occurred March 29, 2022 in Odessa, Texas









Aviation Accident Final Report - National Transportation Safety Board

The National Transportation Safety Board did not travel to the scene of this accident. 

Additional Participating Entity:
Federal Aviation Administration / Flight Standards District Office; Lubbock, Texas

Investigation Docket - National Transportation Safety Board:

Vole Enterprises LLC

Does Business As: Integrated Pain Associates PLLC


Location: Odessa, Texas 
Accident Number: CEN22LA166
Date and Time: March 29, 2022, 18:45 Local
Registration: N469SL
Aircraft: Beech B200
Aircraft Damage: None
Defining Event: Clear air turbulence encounter 
Injuries: 1 Serious, 5 None
Flight Conducted Under: Part 91: General aviation - Business

Analysis

The pilot reported that while descending at about 160 kts during an instrument approach in visual meteorological conditions with the autopilot engaged, and passing through 5,000 ft msl, the airplane encountered “a sudden pocket” of severe clear air turbulence for one second, resulting in the loss of about 300 ft of altitude. A passenger in the cabin, who was in the process of restraining himself when the turbulence encounter occurred, hit his head on the cabin ceiling and sustained a serious injury. The autopilot was turned off, the pilot continued with the approach, and the airplane landed at the destination airport without further incident.

The airplane did not sustain any damage from the turbulence encounter. The pilot reported there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation. The pilot reported that at the time of the accident, an AIRMET for moderate turbulence below 12,000 ft msl and high surface winds was active for the area.

The passengers were verbally instructed by the pilot to make sure their restraint systems were fastened. The pilot activated the cabin seatbelt sign as an aural and visual warning as reinforcement.

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The airplane’s encounter with severe clear air turbulence that was not forecasted, which resulted in a serious injury to an unrestrained passenger. 

Findings

Environmental issues Clear air turbulence - Effect on personnel
Environmental issues Clear air turbulence - Awareness of condition
Environmental issues Clear air turbulence - Contributed to outcome
Environmental issues Clear air turbulence - Compliance w/ procedure
Personnel issues Use of equip/system - Passenger
Aircraft Passenger compartment equip - Not used/operated

Factual Information

History of Flight

Approach Clear air turbulence encounter (Defining event)

Pilot Information

Certificate: Commercial; Flight instructor
Age: 31,Male
Airplane Rating(s): Single-engine land; Multi-engine land
Seat Occupied: Left
Other Aircraft Rating(s): None
Restraint Used: 4-point
Instrument Rating(s): Airplane
Second Pilot Present: No
Instructor Rating(s): Airplane multi-engine; Airplane single-engine; Instrument airplane
Toxicology Performed:
Medical Certification: Class 1 Without waivers/limitations
Last FAA Medical Exam: August 2, 2021
Occupational Pilot: Yes
Last Flight Review or Equivalent: May 20, 2021
Flight Time: (Estimated) 4000 hours (Total, all aircraft), 1300 hours (Total, this make and model), 3800 hours (Pilot In Command, all aircraft), 100 hours (Last 90 days, all aircraft), 50 hours (Last 30 days, all aircraft), 4 hours (Last 24 hours, all aircraft)

Aircraft and Owner/Operator Information

Aircraft Make: Beech 
Registration: N469SL
Model/Series: B200 None 
Aircraft Category: Airplane
Year of Manufacture: 1982
Amateur Built:
Airworthiness Certificate: Normal 
Serial Number: BB-1036
Landing Gear Type: Retractable - Tricycle 
Seats: 10
Date/Type of Last Inspection: September 14, 2021 AAIP Certified
Max Gross Wt.: 12500 lbs
Time Since Last Inspection:
Engines: 2 Turbo prop
Airframe Total Time: 9044 Hrs as of last inspection 
Engine Manufacturer: Pratt & Whitney Canada
ELT: C126 installed, not activated 
Engine Model/Series: PT6A-52
Registered Owner: 
Rated Power: 850 Horsepower
Operator:
Operating Certificate(s) Held: None
Operator Does Business As: Integrated Pain Associates PLLC
Operator Designator Code: None

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual (VMC) 
Condition of Light: Day
Observation Facility, Elevation: KODO, 2983 ft msl 
Distance from Accident Site: 1 Nautical Miles
Observation Time: 18:53 Local
Direction from Accident Site: 310°
Lowest Cloud Condition: Clear
Visibility 6 miles
Lowest Ceiling: None
Visibility (RVR):
Wind Speed/Gusts: 26 knots / 33 knots
Turbulence Type Forecast/Actual: Clear air / Clear air
Wind Direction: 300° 
Turbulence Severity Forecast/Actual: Moderate / Severe
Altimeter Setting: 29.47 inches Hg
Temperature/Dew Point: 29°C / -8°C
Precipitation and Obscuration: Moderate - None - Haze
Departure Point: Temple, TX (TPL)
Type of Flight Plan Filed: IFR
Destination: Odessa, TX 
Type of Clearance: IFR
Departure Time: 17:41 Local
Type of Airspace: Class C

Airport Information

Airport: Odessa Airport-Schlemeyer Field ODO
Runway Surface Type: Asphalt
Airport Elevation: 3004 ft msl 
Runway Surface Condition: Dry
Runway Used: 29 
IFR Approach: Global positioning system; RNAV
Runway Length/Width: 6200 ft / 100 ft 
VFR Approach/Landing: None

Wreckage and Impact Information

Crew Injuries: 1 None 
Aircraft Damage: None
Passenger Injuries: 1 Serious, 4 None 
Aircraft Fire: None
Ground Injuries: N/A 
Aircraft Explosion: None
Total Injuries: 1 Serious, 5 None
Latitude, Longitude: 31.917969,-102.37715(est)


Location: Odessa, Texas
Accident Number: CEN22LA166
Date and Time: March 29, 2022, 18:45 Local
Registration: N469SL
Aircraft: Beech B200 
Injuries: 1 Serious
Flight Conducted Under: Part 91: General aviation - Business

Aircraft and Owner/Operator Information

Aircraft Make: Beech 
Registration: N469SL
Model/Series: B200 
Aircraft Category: Airplane
Amateur Built:
Operator: 
Operating Certificate(s) Held: None
Operator Designator Code:

Meteorological Information and Flight Plan

Conditions at Accident Site: VMC
Condition of Light: Day
Observation Facility, Elevation: KODO,2983 ft msl
Observation Time: 18:53 Local
Distance from Accident Site: 0 Nautical Miles 
Temperature/Dew Point: 29°C /-8°C
Lowest Cloud Condition: Clear 
Wind Speed/Gusts, Direction: 26 knots / 33 knots, 300°
Lowest Ceiling: None 
Visibility: 6 miles
Altimeter Setting: 29.47 inches Hg 
Type of Flight Plan Filed: IFR
Departure Point: 
Destination: Odessa, TX

Wreckage and Impact Information

Crew Injuries: N/A
Aircraft Damage: None
Passenger Injuries: 1 Serious
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 1 Serious
Latitude, Longitude: 31.922881,-102.38682 (est)

Aircraft encountered severe turbulence injuring a passenger. 

Date: 29-MAR-22
Time: 23:45:00Z
Regis#: N469SL
Aircraft Make: BEECH
Aircraft Model: B200
Event Type: ACCIDENT
Highest Injury: SERIOUS
Aircraft Missing: No
Damage: UNKNOWN
Activity: CORPORATE
Flight Phase: APPROACH (APR)
Operation: 91
City: MIDLAND
State: TEXAS

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