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**Safety Benefits of the**

**Local Area Augmentation System**

**FINAL DRAFT**

August 30, 2004

***[For Official Use Only]{.underline}***

**Safety Benefits of the**

**Local Area Augmentation System**

**Robert Dodd, Sc.D., M.S.**

**J.M. Jobanek M.C.E.**

**Richard Tarrel, S.B.**

**August 30, 2004**

Executive Summary

The key benefit of the local area augmentation system (LAAS) is that it
provides accurate and reliable navigation information in three
dimensions. This means that pilots can receive accurate information
about their relative position in the traditional two-dimensional
horizontal plane (i.e., latitude and longitude), as well as accurate
information about their position in the vertical plane (i.e., altitude).

The general purpose of this study is to measure the degree of risk
reduction that can be expected with the implementation of LAAS within
the U.S. National Airspace System (NAS). Specifically, this study
estimates the reduction in accidents and loss of life through the
introduction of precision approach capability provided by LAAS to
airports that currently have runways with non-precision approaches as
well as benefits associated with the unique navigational capabilities of
LAAS. The study was limited to this very specific focus because it was a
benefit that could be quantified and described.

The results indicate that 49 accidents could be prevented over a 20-year
period and that more than 21 lives could be saved through the
introduction of LAAS. This is a conservative estimate. These reductions
in loss would result in an anticipated benefit of approximately \$78
million with LAAS alone.

If WAAS is considered, LAAS benefits are decreased, if it is assumed
that all the credit for risk reduction due to the addition of precision
approaches is credited to WAAS. In that situation, where LAAS and WAAS
co-exist with their respective implementation schedules starting in 2009
and 2015 respectively, LAAS will provide \$55.225 million in benefits
due to reduced accidents and injuries for the time period of 2009-2028.

Table of Contents

# **I) Introduction Page 1**

**A) Project Background**

> **1) LAAS and WAAS**
>
> **2) Goals and Scope of the Project:**
>
> **3) Objectives:**

**II) Approach and Methods Page 4**

**A) General Approach and Assumptions Central to the Study**

> **1) Basic approach:**
>
> **2) Data sources:**
>
> **3) Airport Selection and Activity Projections**

**B) Methodology and Assumptions for the Quantitative Analyses:**

> **1) Safety Benefits:**
>
> **2) Study Population:**
>
> **3) Airport Selection and Activity Projections:**
>
> **4) Case Selection**
>
> **5) Schedules for Benefits:**
>
> **a) LAAS Implementation Schedule:**
>
> **b) WAAS Implementation Schedule**:
>
> **6) Cost of Human Life and Injuries:**
>
> **7) Cost of Aircraft:**
>
> **8) Adjustment of Dollar Value**
>
> **9) Benefit Calculation Process**
>
> **a) Accident Rate Determination**
>
> **b) Future Project**
>
> **c) Benefit Value Assignment**

**C.) Limitations of Quantitative Analyses:**

> **1) Corporate Aircraft Activity Assumptions**:
>
> **2) Activity Forecasts:**
>
> **3) Problem of Small Numbers:**
>
> **4) NTSB Screening Methods:**

**D) Qualitative Analyses:**

> **1) Positive Airport Surface Guidance: Background**
>
> **2) Positive Airport Surface Guidance: Methods**
>
> **3) Obstacle and Terrain Avoidance: Background**

**III) Findings Page 18**

## **A) Findings from Quantitative Analyses**

> **1) Analysis of Accidents that Would Have Benefited from LAAS
> Approach Capability:**
>
> **2) Analysis of Accidents that Would Have Benefited from LAAS
> Capabilities Other Than the Precision Approach Capability**
>
> **3) Benefits of LAAS for Both Precision Approach and Non-Approach
> Related Accident Reduction:**

## **B) Findings from Qualitative Analyses**

> **1) Runway Incursions:**

**IV) Discussion Page 32**

# **I) Introduction**

**A) Project Background**

The Federal Aviation Administration (FAA) has embarked upon a program to
revise and improve the navigation systems used for aircraft guidance in
airport terminal areas in the United States. The goal of this
modernization program is to take advantage of the satellite-based global
positioning system (GPS) that has been developed and deployed by the
United States military over the last two decades. In 1991, the United
States formally offered the GPS system as an element for future civil
navigation systems for the foreseeable future with no direct user
charges.[^1] This resource paved the way for a dramatic improvement in
aviation navigation capability.

The underlying rationale for transitioning to a GPS-based system is a
strong one and is predicated on improved safety and efficiency.
Currently, there are many different types of navigation aids that are
used in the airport terminal area. The majority of these systems require
ground-based transmitters and provide various levels of precision or
non-precision guidance to the pilots. These navigation systems are
expensive to install and maintain. In contrast, GPS-based navigation
systems are expected to provide significant economic benefits due to the
reduced number of ground transmitters needed to provide the same or
better level of service.

Currently, there are approximately 18 different kinds of
navigation-based approaches to runways (usually called instrument
approaches since they are required during reduced visibility when the
pilot must rely on aircraft navigation instruments to locate the runway)
at the more than 4,000 public use airports with paved runways.[^2] These
airports have well over 10,000 runways. Of these, approximately 1,160 of
the runways have instrument landing system (ILS) precision instrument
approaches[^3]. The balance of these runways have no instrument
approaches or use a variety of less precise non-precision instrument
approaches.

A precision approach provides the pilot with both vertical and
horizontal guidance to the end of the runway. The ability to maintain a
constant reference to the vertical and horizontal path to the runway
enhances the ability of a pilot to fly a stable approach. (According to
the Flight Safety Foundation[^4], a stable approach is one where the
aircraft is on the correct flight path, only small changes in heading
and pitch are required to maintain that path, airspeed is at the correct
approach speed, the aircraft is in the proper landing configuration
(flaps and landing gear in landing positions), and the descent rate is a
maximum of 1,000 feet per minute). In contrast, a non-precision approach
provides the pilot with only horizontal guidance to the runway. The
pilot is responsible for maintaining vertical separation from terrain
using the aircraft's altimeter and other onboard instruments. It is
generally acknowledged that a precision approach is safer than a
non-precision approach. This is supported by research conducted by the
Flight Safety Foundation which indicated that the risk of an accident
among air carrier airplanes is five times greater during a non-precision
approach than a precision approach.[^5]

The GPS-based navigation system used for instrument approaches will
ultimately provide some degree of precision instrument approach
capability at many of the runways at the nation's 4,000 public use
airports. This is expected to have a profound and positive impact on
safety.[^6] The satellite-based navigation system has three main
components: the GPS satellite constellation, and two augmentations
systems, the Wide Area Augmentation System (WAAS) and the Local Area
Augmentation System (LAAS). This paper addresses the anticipated safety
benefits associated with LAAS.

**1) LAAS and WAAS**

There are many potential benefits associated with the GPS augmentation
systems. Some of the main benefits are listed below:

-   Precision approach capability at many of the nation's runways

-   Three-dimensional navigation guidance (horizontal and vertical) in
    the terminal area

-   Complex approach and departure path guidance

-   Precise surface guidance navigation

New receivers will be required in the aircraft to take advantage of the
increased utility, but it is anticipated that the requirements for
aircraft systems, crew qualifications and other operational aspects will
be similar to the requirements associated with current operational
procedures.[^7]

WAAS is anticipated to provide multiple levels of navigation service
across the National Airspace System (NAS). This will include en-route,
terminal, and approach guidance. WAAS is expected to provide LNAV/VNAV
and LPV capabilities, although this capability will not reach Cat I
approach standards (generally 200 feet ceiling and ½ mile visibility)
until 2015. WAAS testing in September 2002 confirmed accuracy
performance of 1 -- 2 meters horizontally and 2 --3 meters vertically
throughout most of the continental U.S. and portions of Alaska.[^8]

LAAS provides greater accuracy than WAAS and requires supplemental
ground transmitters. The FAA describes LAAS as follows:

> "The Local Area Augmentation System (LAAS) is an augmentation to GPS
> that focuses its service on the airport area (approximately a 20-30
> mile radius). It broadcasts its correction message via a very high
> frequency (VHF) radio data link from a ground-based transmitter. LAAS
> will yield the extremely high accuracy, availability, and integrity
> necessary for Cat I, II, and III precision approaches, and will
> provide the ability for more flexible, curved approach paths. LAAS
> demonstrated accuracy is less than 1 meter in both the horizontal and
> vertical axis." [^9]

LAAS will also provide the guidance necessary for precise surface
navigation. This will be a central capability to reduce the risk of
runway incursions caused by pilots being lost on the airport surface.

**2) Goals and Scope of the Project:**

The primary goal associated with this study is to quantify the safety
improvement that can reasonably be expected with the implementation of
LAAS. The analyses focus on the additional benefit that LAAS can provide
over that provided by existing and planned non-LAAS landing and area
navigation systems. The evaluation is limited to the NAS and relies on
historical safety information, primarily accidents, from the last 10
years.

The analyses address two primary scenarios. The first analysis scenario
entails the measurement of LAAS benefits without consideration of any
additional safety benefit from WAAS (comparable to the "0% WAAS"
scenario in the LAAS Efficiency Benefits analyses). The second scenario
includes the consideration of WAAS Cat I capability being available to
all aircraft operators beginning in 2015 (comparable to the "100% WAAS"
scenario in the LAAS Efficiency Benefits analyses).

Safety benefits that were not easily quantified are also discussed in
this paper. These benefits are associated with an anticipated increase
in the precision provided by LAAS for enhanced pilot situational
awareness in the airport terminal area. These benefits will be most
apparent with the introduction of enabling technologies or techniques
such as three-dimensional departure path guidance and aircraft-based
precision surface guidance and control.

**3) Objectives:**

There are three main objectives associated with this project. They are:

a)  Quantify the safety benefit increment associated with implementation
    of LAAS in the NAS during the 20-year period from 2009 to 2028
    inclusive. The quantification is presented in terms of accidents
    prevented, lives saved, and the associated benefit in dollars.

b)  Develop graphical depictions of the incremental benefit associated
    with LAAS (as measured by lives saved and accidents prevented)
    compared to the situation without the implementation of LAAS (this
    assumes the existing and planned navigation and landing systems as a
    baseline). LAAS safety benefits are also considered within the
    context of WAAS implementation.

c)  Identify and discuss non-quantifiable safety benefits that may
    result from the introduction of LAAS. These potential benefits are
    not quantifiable since they involve the addition of enabling
    technologies or procedures such as curved approaches and other
    complex procedures.

# **II) Approach and Methods:**

The methods associated with benefit analysis depend heavily on
assumptions made during the data analysis process. For example,
assumptions were made concerning the rate of LAAS implementation (both
installation of the ground transmitters and the installation of the
receivers in airplanes). Assumptions also had to be made concerning the
anticipated growth of air traffic for the benefit time period of 2009
through 2028, the conditions under which LAAS would be beneficial, and
how new technologies might enhance LAAS safety benefits in the future.

This section describes the underlying assumptions and methods used to
evaluate the anticipated benefits of LAAS. There are three components to
this section describing the methods of the study. First, a general
discussion is provided outlining the assumptions associated with the
study. Next, the procedures for evaluating relevant accidents are
discussed and a summary provided of the accidents. Finally, limitations
associated with the analyses are described and discussed.

**A) General Approach and Assumptions Central to the Study**

The primary benefits associated with LAAS for this study include the
following:

-   LAAS will provide Cat I approach capability at those locations where
    WAAS service is not anticipated or Cat I ILS guidance is not
    provided or anticipated

-   LAAS will provide positive surface guidance in reduced visibility,
    and/or in dark conditions, to aircraft equipped with heads-up
    displays (HUD), LAAS, and the appropriate equipment to integrate the
    information.

-   LAAS will provide positive three-dimensional navigational guidance
    in the cockpit that will reduce the risk of controlled flight into
    terrain (CFIT) accidents for approach and departure in the terminal
    area

-   LAAS will provide Cat II and Cat III approach capability at
    facilities that do not currently have that capability

-   LAAS will help reduce pilot and controller workload for complex
    approach and departure routings

-   LAAS will provide positive lead-in guidance to parallel approach
    situations.

To evaluate these potential benefits, the study relied heavily on a
retrospective evaluation of past accidents and incidents to estimate the
safety benefits of LAAS implementation. The underlying rates of these
accidents were used to project anticipated losses if LAAS were not
implemented. Past studies and related literature were reviewed to ensure
that all relevant references were considered as the data analysis
proceeded. Once the benefits of LAAS implementation were determined,
they were used to develop a cost assessment of the benefits of reduced
crashes.

**1) Basic approach:**

The basic approach used for the analysis focused on the following steps:

-   First, the actual crash and incident experience for the time period
    of 1993-2002 was reviewed and events selected that might have been
    prevented if LAAS had been operational.

-   Using this information, a baseline incident rate per 1,000,000
    departures based on the 10 year period of 1993-2002 was developed.

-   Next, the anticipated incident risk at airports likely to be
    equipped with LAAS was estimated for the time period of 2009-2028.
    This estimate was adjusted for an anticipated LAAS implementation
    schedule (described in more detail in Section II.B.5, Schedule for
    LAAS Benefits) that accounted for a gradual implementation of LAAS
    in the NAS.

Using this approach, an estimate of crash risk during the implementation
cycle of LAAS was developed. The anticipated number of lives saved and
crashes prevented due to the future implementation of LAAS was also
estimated (benefit). Using the resulting values, the estimated benefit
of the anticipated reduction of losses in future dollars was developed.

It is anticipated that LAAS implementation will differ significantly in
the continental United States (often called the CONUS) and Alaska. As a
result, the analyses and results of this study are stratified into two
sections, one addressing the CONUS and the other addressing Alaska.

**2) Data sources:**

There are a number of data sources that were used for this analysis. The
National Transportation Safety Board (NTSB) accident and incident
investigation database was used to identify accidents and serious
incidents. The FAA's [National Airspace Incidents Monitoring System
(NAIMS)](https://extranet.nasdac.faa.gov/servlet/page?_pageid=65,71&_dad=nasdac&_schema=NASDAC&104_FOLDER_689267.p_subid=4598&104_FOLDER_689267.p_sub_siteid=33&104_FOLDER_689267.p_edit=0) was
used to identify surface-related incidents that did not result in an
accident. This included events such as runway incursions and surface
near-collisions. Airport activity data, both historical and forecast,
were obtained from the FAA's Office of Aviation Policy and Plans (APO).
On-line databases were queried and forecast reports were referenced.
Information was also obtained from the National Aeronautical and Space
Administration's (NASA) Aviation Safety Reporting System (ASRS). This
data system was queried to learn more about factors associated with
pilot-reported runway incursions and approach incidents.

**B) Methodology and Assumptions for the Quantitative Analyses:**

As mentioned earlier, numerous assumptions were made to support the
quantitative analyses in this study. These assumptions, and the
associated procedures, are described in more detail below.

**1) Safety Benefits:** For the quantitative analysis, the primary
safety benefit assigned to LAAS was the capability to fly precision
approaches to Cat I minimums. An additional benefit was an enhanced
ability for precise and positive cockpit-based surface guidance as well
as three-dimensional guidance in the airport traffic area.

**2) Study Population:** The study focused on two different populations.
These were the operational environment of Alaska and that of the
continental United States, or CONUS. The analysis for each study
population was conducted in exactly the same way although some
underlying assumptions were different.

For Alaska, all aircraft types were considered in the analyses. This
included air carrier aircraft, commuter aircraft, and general aviation
aircraft. The underlying assumption was based on the fact that the Wide
Area Augmentation System (WAAS) will have limited precision approach
functionality in the Alaska region for the foreseeable future due to
poor signal coverage in this area of the world. Consequently, LAAS
receivers will likely be used by all classes of aircraft that typically
fly IFR flights for the benefits of precision approach capability.

For the CONUS, it was assumed that the WAAS system would provide better
precision approach capability than in Alaska. Consequently, it was
determined that WAAS could provide Cat I approach capability for all of
the CONUS once it was fully operational. However, it was assumed that
for air carrier operators and operators of turbine powered and heavy
piston corporate aircraft LAAS would be a preferred alternative to WAAS
due to the additional benefits provided by the LAAS signal.
Consequently, the evaluation of safety benefits associated with LAAS in
the CONUS was limited to air carrier and "heavy" non-air carrier
aircraft typically operated by business and corporate operators. Smaller
general aviation aircraft were not included in the CONUS analysis.
Examples of aircraft included in the corporate category were turbine
powered passenger aircraft and heavy piston-powered twins such as Piper
PA-31 Navaho or the Cessna 400 series aircraft (Cessna 404, 414, 421).
However, the analyses for these types of aircraft also considered the
anticipated benefit of LAAS with and without WAAS equipage on the
aircraft.

**3) Airport Selection and Activity Projections:** The study was limited
to those airports used in the LAAS Efficiency Benefits analysis. For the
CONUS, 117 airports were selected. In Alaska, three major air carrier
airports were included.

Historical activity data (departures) for airports selected for the
analyses was obtained for the time period of 1990 to present from the
FAA's Office of Aviation Policy and Plans (APO). Forecast data was
obtained from APO's website[^10] and from the Long-Range Forecast for
Fiscal Years 2015, 2020 and 2025.[^11]

For airports in the Alaska region, no adjustment was required for type
of aircraft (air carrier, turbine-powered general aviation or
piston-power general aviation) since all aircraft were considered in
this analysis to be potential beneficiaries of LAAS safety benefits. The
APO departure reported values and estimates were used. For the CONUS
however, a method was needed to adjust for the fact that only air
carrier and corporate type aircraft were being included in the analyses
(See Item II.B.2, Study Population for more information). This was
accomplished by obtaining estimated activity information from the
National Business Aviation Association (NBAA) for corporate aircraft
included in this study. The NBAA provides estimates of hours flown by
aircraft type (turbo-jet, turbo-prop, etc) in a document titled "NBAA
Business Aviation Fact Book, 2002.[^12] This resource was used to
determine that on average, corporate aviation (as defined here) flew
16.5% of all reported general aviation hours for the time period of 1997
through 2004. Consequently, estimates for corporate aviation departures
for the period of this study were determined to be 16.5% of that
forecast for all of general aviation by the APO. For additional
discussion on this approach see Section II.C titled Limitations.

For both Alaska and CONUS airports, some interpolation was required to
fill in airport departure estimates for the time frame of 2020-2028.
These estimates were not provided by APO although estimates were given
for 2025. The approach used to interpolate was based on the percentage
change for the estimated departures provided by APO for the years
2005-2020. Within the CONUS, air carrier departures are, on average,
forecast to increase 1.7% per year and general aviation activity is
forecast to increase 1% per year. These values were applied to the
departure estimates for each of these groups for the 2020-2028
timeframe. The same approach was used to estimate Alaska departures, but
the anticipated traffic increase value for all aircraft combined at the
study airports was 0.9% per year. This was the value used for the
2020-2028 timeframe for the Alaska airports. More information on the
underlying process for this interpolation can be found in Appendix 3.

**4) Case Selection:** Past accidents and serious incidents were used to
provide insight on the potential benefits of LAAS. NTSB accident records
were reviewed to determine what accidents, if any, might have been
prevented if LAAS had been present. The methodology followed is
described below:

> **a) Initial Record Filter:** All NTSB accident records for the time
> period of 1993-2002 were selected and compiled in a database using
> SPSS software.[^13] Records were then selected based on the following
> criteria:

-   The accident must have occurred within 10 miles of an airport. This
    required that airport identification be provided.

-   The accident occurred while on approach, in IFR conditions, on the
    airport surface or during departure.

> **b) Airport Filter:** Once the above filtering was completed, only
> those events that occurred at the study airports (See Section II.B.3,
> Airport Selection and Activity Projections) were selected. This was
> accomplished by selecting only those accident records that had an
> airport ID that matched an airport ID in either the Alaska or CONUS
> airport lists (Appendices 1 and 2).
>
> **c) Manual Review:** The resulting records were then used to obtain
> NTSB "briefs" which provided summaries of pertinent information
> associated with the accident and the resulting investigation.[^14]
> These briefs were reviewed independently by two different aviation
> subject matter experts to determine each case's suitability for
> inclusion in the study. The manual review focused on determining the
> safety benefits if LAAS had been present. The potential benefits that
> might be attributed to WAAS were not considered during this part of
> the analyses but were accounted for later in the evaluation.
> Additionally, among CONUS events, the brief was reviewed to determine
> whether the accident involved an air carrier or corporate type of
> aircraft using make and model as the initial indicator. This was
> further confirmed by reviewing the narrative associated with the
> accident or incident as well as reviewing the regulation that the
> aircraft was operated under (FAR parts 121, or 135 or 91 for example).
> The results of these analyses were used in the benefit calculations.
> Summaries of all the accidents used in the final calculations are
> provided in Appendix 4.

**5) Schedules for Benefits:**

**a) LAAS Implementation Schedule:** The installation of LAAS at various
airports will not occur all at once but will gradually increase over
time until all the selected airports have been equipped. To account for
this, an "implementation schedule" was developed that is predicated on
an anticipated LAAS install rate of 24 per year[^15]. However, during
the first year of LAAS Cat I installations in 2009, credit for
installation was limited to 21 in the CONUS with the remaining three of
the 24 scheduled for installation that year being installed in Alaska.
Using this install rate as a baseline, it was determined that 17% of the
studied CONUS airports would be equipped with LAAS during the first year
and the rate would increase to 21% per year starting the second year.
This rate is maintained until all of the 120 study airports in both the
CONUS and Alaska are equipped in late 2013.

**b) WAAS Implementation Schedule**: A mentioned earlier, one of the
analysis scenarios incorporates the use of WAAS for Cat I approach
capability for all aircraft flying into the 117 CONUS airports. The
benefits from the use of WAAS are considered in context with the
benefits of LAAS. Cat I WAAS guidance is scheduled to be implemented
starting in 2015. For the following analyses, WAAS avionics equipage was
assumed to increase 16.6% per year starting in 2015 and to be completed
in 2021.

**6) Cost of Human Life and Injuries:** For this study, a cost of a
human life was deemed to be 3 million dollars in 2001 dollars. Injuries
deemed as serious by the NTSB do not match the injury categorization
used by the Department of Transportation (DOT). The DOT states that a
serious injury (Abbreviated Injury Scale or AIS code of 3) would cost
\$172,000. A severe injury (AIS 4) would cost \$562,000 and a critical
injury (AIS 5) would cost \$2.287 million.[^16] Since the severity of
the NTSB injuries was unknown, a conservative approach was used. Each
injury prevented by LAAS was shown to have a benefit of \$172,000.

**7) Cost of Aircraft:** Aircraft destroyed or damaged in accidents that
were deemed to be preventable with LAAS were estimated to have the
following values. These values represent used market values for the
categories of airplanes described below in Table 1.

**Table 1**: Aircraft Value and Repair Costs

  ----------------------------------------- -------------- --------------
  **Aircraft Category**                     **Repair       **Used
                                            Cost**         Value**[^17]

  Small GA Aircraft                         \$30,000       \$100,000

  Heavy Twin-Engine Piston Corporate        \$60,000       \$200,000
  Aircraft                                                 

  Corporate Turboprop                       \$300,000      \$1 million

  Corporate Jet                             \$900,000      \$3 million

  Air Carrier-Turboprop                     \$1.5 million  \$5 million

  Air Carrier-Jet                           \$3 million    \$10 million
  ----------------------------------------- -------------- --------------

**8) Adjustment of Dollar Value:** Benefits and costs estimated in these
analyses were adjusted to take into account the impact of inflation and
the decreasing value of money over time. This adjustment is the real
*discount rate*, and was set at 7 percent per OMB Circular A-94
§8(b)(1). For typical investments, with costs concentrated in early
periods and benefits following in later periods, raising the discount
rate tends to reduce the net present value. To account for this in a
base-case analysis (such as this involving LAAS), OMB Circular A-94
states: "Constant-dollar benefit-cost analyses of proposed investments
and regulations should report net present value and other outcomes
determined using a real discount rate of 7 percent. This rate
approximates the marginal pretax rate of return on an average investment
in the private sector in recent years."

**9) Benefit Calculation Process:** The calculations of the benefits
associated with LAAS involved the following steps.

> **a) Accident Rate Determination:** An average accident rate for
> accidents that could have been prevented if LAAS was operational was
> calculated for the time period of 1993-2002. Rates were calculated per
> 1 million departures for accidents, fatal accidents, serious injuries
> and fatal injuries. These rates were used as a baseline measure for
> future accident risk with and without LAAS or WAAS.
>
> **b) Future Projections:** Using the baseline average rate, the number
> of future accidents, fatal accidents, serious injuries, and fatal
> injuries were calculated for the time period of 2009 through 2028.
> These calculations used the forecast number of departures at the
> airports contained in this study as the multiplier for these
> calculations. The resulting values provided an estimate of the number
> of these events that could be expected if LAAS or WAAS are not
> implemented.
>
> Once this was accomplished, these values were adjusted by year for the
> LAAS and WAAS implementation schedules (See Section II.B.5,
> Implementation Schedule for LAAS Benefits for more information on this
> process).
>
> **c) Benefit Value Assignment**: Once the incidence of the future
> accidents and injuries were estimated, the associated costs of the
> injuries, fatalities and aircraft damage were calculated.

**C.) Limitations of Quantitative Analyses:**

There are a number of limitations associated with this benefits
evaluation. The applicability of a study such as this is directly
related to the underlying assumptions. The discussion of the following
limitations is designed to make sure that the reader is aware of some of
the more notable limitations that could affect the applicability of the
results.

**1) Corporate Aircraft Activity Assumptions**: The FAA does not provide
estimated level of activity for corporate aviation like it does for air
carrier activity. This was potentially problematic for this evaluation
since the activity estimates were limited to specific airports (those
likely to receive LAAS) and not the NAS as a whole. The FAA does,
however, provide activity estimates for general aviation which includes
corporate aviation.

For the analyses in this study, estimates for corporate aviation were
derived by reported and forecast activity statistics, reported by the
NBAA in hours. These values were reported for the time period of
1997-2004 and indicated that 16.5% of all general aviation activity is
conducted by corporate aircraft. The assumption that cannot be validated
is that the ratio of corporate hours to all GA hours (16.5%) is the same
for departures. If there is a bias, it will be consistent for both the
reference period calculations as well as the forecast calculations,
thereby minimizing the biasing effect of the error.

**2) Activity Forecasts:** Activity forecasts are just estimated levels
of activity for the future. For this study, forecast data are used that
project airport activity measures 24 years into the future. There are
many factors that cannot be accounted for in generating such forecasts.
Political events, economic dynamics, introduction of new technologies,
and many other issues may result in actual activity levels that are
smaller or greater than forecast. Since the activity estimates are used
to derive event rates that are in turn used to generate estimates of
actual events in the future, any errors in the activity measure may
result in significant differences in the actual number of events that
occur.

**3) Problem of Small Numbers:** The type of events that were used in
this analysis are relatively rare events. For example, for the time
period of 1993-2002 there were an estimated 106.5 million departures
that involved air carrier and corporate aircraft at the study airports
in the CONUS. There were only 11 accidents, however, at these same
airports for the same time period that might have benefited from LAAS.
Consequently, one additional event in which an air carrier crashed and
killed all on board (or didn't) could have a profound effect on the
resulting accident rates and future benefit projections. This problem
does not invalidate the results, but needs to be considered since these
events, and all crashes of air carrier and corporate aircraft, are rare
events.

**4) NTSB Screening Methods:** The methods chosen to conduct the initial
computer screening of the NTSB accident records were somewhat
conservative and may have missed relevant cases. The screening approach
chosen required that an accident meet specific criteria before it could
be selected as a possible candidate for further evaluation. These
factors included the following:

-   Accident or event had to be within 10 miles of the airport

-   Accident record must have had a valid airport identification

-   Accident must have occurred on approach, in IFR conditions, on the
    airport surface or during departure

-   Aircraft make and model had to be listed

The difficulty with this approach is that some NTSB records were
probably suitable for inclusion in the study, but were not selected by
the initial computer selection because of missing data in one or more
relevant computer fields. The effect of not including all cases, if it
exists, is to make the associated benefit assumptions more conservative,
understating the potential benefit of LAAS.

**D) Qualitative Analyses:**

In addition to the quantitative analyses, additional evaluation was
undertaken to understand other potential safety benefits of LAAS that
are more difficult to quantify. Two specific benefits are explored. One
is the addition of precise surface guidance through the combination of
digital airport maps and real time airport location provided by LAAS.
This capability will improve a pilot's situational awareness on the
airport surface, thereby reducing or eliminating runway incursions. The
second issue is the possibility of using LAAS to precisely locate
obstacles and high terrain within the airport terminal area. With
appropriate modification, the LAAS signal can be integrated with an
aircraft's navigation computer to provide guidance to avoid high terrain
and obstacles. This capability can be useful during approach and
departures phases of flight. It should be pointed out that these
capabilities may be available with WAAS alone but in discussions with
manufacturers of avionics and major airframe manufactures, it is
anticipated that the preferred guidance signal for these capabilities
will be LAAS.[^18]

**1) Positive Airport Surface Guidance: Background**

The integration through an aircraft's navigation computer of LAAS
signals and a digital airport map is all that is required to provide a
pilot with a real time assessment of the aircraft's position on the
airport surface. The information can be displayed on a display screen
that the pilot can reference during taxi. But to be most useful, such
guidance could be displayed through a Head--Up Display (HUD).

HUDs are designed to present important operational information on a
transparent screen that the pilot looks through as he/she views the
outside world through the airplane's front windscreens. The safety
benefit of HUDs is that a pilot does not have to look down at the
aircraft instruments to acquire and assimilate important operational
information, but can assimilate that information while maintaining
his/her visual perspective of the outside world. With the advent of
precise navigational signals such as that provided by LAAS, the HUD can
be modified to be very useful for various types of guidance including
positive and precise guidance for the pilot on the airport surface. A
major airframe manufacturer has expressed interest in equipping all of
its newly manufactured airplanes with integrated HUD systems that are
modified to provide precise surface guidance as described above.[^19]

The surface guidance component of HUD includes two main components that
enable this capability. The first is a precise digital map of an
airport's runway, taxiway and ramp configuration. The second capability
is a a method to accurately determine an aircraft's position on an
airport's surface, ideally with 1 meter accuracy or better, in real
time. LAAS is expected to provide this capability. Combining these two
capabilities, and a way to interface the information (a flight
management computer can easily be modified to undertake this task), a
pilot could know at all times the aircraft's location on an airport's
surface. Using this proposed technology, runway incursions could be
greatly reduced or eliminated.

Improved surface guidance for pilots using advanced aircraft systems has
recently been highlighted by the Department of Transportation's (DOT)
Office of the Inspector General (OIG) study which resulted in a number
of recommendations to the FAA concerning efforts to reduce runway
incursions. In part, the OIG recommends that the FAA "Expedite the use
of in-cockpit moving map displays and ADS-B for use by pilots in
reducing runway incursions...."[^20] One HUD manufacturer, and perhaps
others, have already developed this capability.[^21] This information
can be displayed irrespective of the outside visibility or light
conditions. Figure 1 provides an example of this display and the
associated HUD symbology. As can be seen, the edges of the runway as
well as the path to follow for the taxiway turnoff are clearly
displayed. Further, information on aircraft ground speed, desired speed,
hold lines and much more is provided to the pilot.

![](media/image2.wmf){width="6.489583333333333in" height="5.00625in"}

**Figure 1: HUD-Based Surface Guidance System**[^22]

This technology will clearly offer a safety benefit, but it is difficult
to determine how it will really be used in the future. Without an
accurate operational concept, projecting future benefits is difficult.
For that reason, the analyses associated with this potential safety
benefit of LAAS are described qualitatively rather than quantitatively.

**2) Positive Airport Surface Guidance: Methods**

In an effort to determine the benefit of LAAS with respect to past
runway incursions, the FAA's NAIMS data system was queried for runway
incursions that occurred between January 16, 1987 and January 16, 2003.
The initial query listed 30,683 pilot deviations of which 95 were runway
incursion related. These 95 reports were manually reviewed to determine
the potential benefit that LAAS-enabled surface guidance might have had.
Relevant literature and past FAA studies were also reviewed. Findings
from this analysis highlight events that might have been prevented if
LAAS-based positive surface guidance systems had been operational.

**3) Obstacle and Terrain Avoidance: Background**

One of the greatest risks associated with commercial aviation
world-wide, including the United States, is the unintentional controlled
flight into terrain (CFIT).[^23] CFIT occurs most often close to
airports as aircraft are maneuvering after takeoff or as they prepare
for landing. CFIT almost always results in the destruction of the
airplane and death to all the occupants. These are always very serious
events. The most common causative feature of all CFIT accidents is the
pilot's lack of situation awareness as it pertains to the terrain and
associated obstacles.

The danger of CFIT has been closely studied by organizations like the
Flight Safety Foundation and FAA and multiple interventions have been
identified.[^24] Some of these interventions are predicated on improved
crew training and performance while others on improved technology to
enhance a pilot's awareness of high terrain. The most notable technology
improvement is an enhancement to the ground proximity warning system
(GPWS). This improved system is known either as TAWS (terrain avoidance
warning system) or by EGPWS (enhanced ground proximity warning system).

The most basic task of a GPWS system is to provide a pilot with a
warning if the aircraft is getting too close to the ground. The
limitation with GPWS is that it often does not give a pilot a warning
soon enough so that he/she can conduct a corrective action or escape
maneuver. The current enhancements to GPWS are designed to correct this
problem by integrating information from digital terrain maps (height and
location of terrain) with the GPWS. This information is used to
calculate the possibility that the aircraft will strike this terrain if
it continues following its current flight path. If a certain
predetermined risk threshold is passed, the system provides the pilot
with a warning and a visual display of the upcoming terrain. This allows
a pilot to receive warnings and a visual depiction far in advance of a
possible conflict with high terrain thereby providing greater time for
corrective action. The aircraft's location relative to the terrain is
determined by integrating information from onboard navigation systems.

Enhanced GPWS (EGPWS) systems do not provide precision guidance, but
serve to warn pilots of high terrain danger. This is a very important
consideration since the terrain map database used by the airplane
computer is not precise enough to be used for navigation. The guidance
is more than adequate to provide a warning that a terrain collision may
occur if an airplane's current flight path is maintained. When in the
terminal area, approach guidance systems provide terrain and obstacle
clearance during the approach and during missed approach if followed
correctly. However, these systems give no guidance if the pilot deviates
from the approach or missed approach paths.

LAAS, integrated with digital maps of high terrain and obstacles,
however, could provide far more precise awareness and warnings of
obstacles within 23 miles of a LAAS-equipped airport. A pilot could fly
in these areas with precise guidance to avoid the terrain or obstacles.
One aircraft operator has used other sources of information to achieve
much of the same capability for one particular airport.

Alaska Airlines has developed an FAA-approved approach that requires a
turn while descending through the rocky Gastineau channel to Runway 26
in Juneau, Alaska. The approach was constructed by using Required
Navigation Performance (RNP) and area navigation (RNAV). Using GPS
linked with an onboard navigation database, an approach that avoids the
high terrain and provides a glide path to a 337 foot high missed
approach point (MAP). This approach is depicted schematically in
![](media/image3.jpeg){width="4.131944444444445in"
height="6.977083333333334in"}Figure 2.

As can be seen, the approach allows the flight crew to maneuver safely
to line up with the runway while avoiding the surrounding terrain. This
would not be possible with a "straight-in" approach. If LAAS were
available at this airport, the minimums for this approach

could possibly be even lower than the 600 feet above ground level
depicted in Figure 2. According to Alaska Airlines, use of this approach
has resulted in 65 completed flights during the first 9 months of 2001
that would not have been possible otherwise.[^25]

# **III) Findings**

## **A) Findings from Quantitative Analyses**

The following tables and charts present the findings from the benefit
analysis of LAAS for the time period of 2009 -- 2028. These analyses are
presented in two parts. The first part addresses the benefits likely to
occur from the precision approach capability provided by LAAS starting
in 2009. The second part of the analysis addresses the likely benefits
of LAAS not associated with precision approach capability.

**1) Analysis of Accidents that Would Have Benefited from LAAS Approach
Capability:** Table 2 provides the distribution of approach accidents in
the CONUS stratified by aircraft category that would have been unlikely
to occur if LAAS had been operational and the accident aircraft had been
equipped with appropriate LAAS receivers. These accidents were selected
as described in Section II.B., (Methodology and Assumptions for the
Quantitative Analyses) and were limited to events that occurred at the
117 CONUS airports selected for analysis (Appendix 2).

As can be seen, 5 turbo-jet aircraft and 2 corporate turbo-prop aircraft
were involved in accidents that would have benefited from Cat I
precision approach capability during the study period. No crashes
reviewed would have benefited from Cat II capability. The distribution
of these aircraft is listed in Table 2. The actual make and model of the
aircraft are listed in Appendix 5.

**Table 2: Distribution of Accidents in the CONUS That Would Have
Benefited From LAAS, 1993-2002**

  --------------- --------- -------------- ------------- ------------- ------------- -----------
  **Year**        **Air     **Air Carrier  **Corporate   **Corporate   **Corporate   **Total**
                  Carrier   Turbo-Prop**   Jet**         Turboprop**   Heavy Piston  
                  Jet**                                                Twin**        

  **1993-2002**   5         0              0             2             0             7
  --------------- --------- -------------- ------------- ------------- ------------- -----------

While similar evaluation was attempted for the three airports in Alaska
that were included in this analysis, no accidents were found that might
have been prevented by the presence of a Cat I precision approach
capability for the time period of 1993-2002. Consequently, the balance
of findings presented in this section is limited to the CONUS.

Table 3 presents the distribution of occupant injuries resulting from
the approach accidents included for study within the CONUS. These
accidents resulted in only two serious injuries among the 437 passengers
and crew. No fatalities resulted from the accidents.

> **Table 3: Distribution of Occupant Injuries for Accidents in the
> CONUS**
>
> **that Would Have Benefited From LAAS, 1993-2002**

  --------------- ------------ -------------- -------------- ---------------
  **Year**        **Fatal**    **Serious**    **None or      **Total
                                              Minor**        Occupants**

  **1993-2002**   0            2              435            437
  --------------- ------------ -------------- -------------- ---------------

Figure 3 provides average rate per 1 million departures for accidents
and serious injury cases for approach accidents that occurred in the
CONUS for the time period of 1993-2002. Calculations were not conducted
for fatal accidents or fatal injury case rates because there were no
fatalities among the seven accidents that might have been prevented with
precision approach capability. These rates represent the baseline rates
of accident risk for the study airports without LAAS or WAAS that would
have benefited from a Cat I precision approach. These rates were based
on accidents that occurred while on approaches without precision
guidance. These values are used as a baseline reference for the risk
benefit calculations for the future benefit of LAAS and WAAS providing
Cat I precision approach capability.

![](media/image4.wmf){width="6.495138888888889in"
height="4.450694444444444in"}

**Figure 3:** **Accident and Injury Rates in the CONUS**

Figure 3 demonstrates that the risk of an accident where Cat I precision
approach capability was not available for the time period of 1993-2002
at the CONUS study airports is 0.066 accidents per 1 million departures.
The serious injury case rate (total number of serious injuries) was
0.019 per 1 million departures.

Figure 4 provides estimates of the future number of accidents with and
without the Cat I precision approach capability provided LAAS only and
by WAAS only. The chart displays the cumulative number of accidents that
are projected to occur in the CONUS if LAAS or WAAS are not introduced
in 2009 (solid line). As can be seen, the number of accidents increases
each year. This increase is a function of the increasing number of
operations projected for the time period of 2009 -- 2028. A total of 34
accidents where precision approach capability would have proven
beneficial are projected for this time period.

![](media/image5.wmf){width="6.498611111111111in"
height="4.461805555555555in"}

**Figure 4: Projected Number of Approach Accidents LAAS and WAAS
2009-2028.**

The small dashed line provides an estimate of the number of accidents
that would occur in the CONUS if LAAS capability is introduced in 2009.
The number of accidents projected for each year decreases steadily
between 2009 (the planned implementation of LAAS) and 2013 when LAAS
installation and avionics equipage will be complete. This projected
decrease occurs even though the number of departures during this time
period is forecast to increase. The total number of approach accidents
projected with LAAS for 2009-2028 is a total of 3.2 a 91% reduction in
anticipated approach accident risk from the estimate of 34 accidents
without LAAS.

The heavy dashed line provides an estimate of the number of approach
accidents that would occur in the CONUS with WAAS only. The curve
follows the implementation schedule for WAAS which begins in 2015. As
can be seen, WAAS without LAAS would result in approximately 12
accidents, a 67% reduction in accident risk of no LAAS or WAAS.

Of most importance is the additional benefit provided by LAAS over WAAS.
One way to evaluate this issue is to calculate the number of accidents
that prevented by LAAS over that provided by WAAS. This value in
presented in Table 4. The anticipated number of accidents with WAAS only
for the time period of 2009-2028 is 12.38. The anticipated number of
accidents with LAAS for the same time period is 3.2. The difference of
preventable accident that can therefore be attributed to LAAS is 9.18
accidents

Table 4 presents the same information as Figure 4, in tabular format.

**Table 4: Number of Accidents With and Without LAAS and WAAS,
2009-2028**

  ---------------------------------- ------------------------------------
  **Level of LAAS or WAAS Coverage** **Projected Number of Approach
                                     Accidents 2009-2028**

  With No LAAS (or WAAS)             34

  With LAAS Only                     3.2

  With WAAS Only                     12.38

  Number of accidents prevented by   9.18
  LAAS implementation                
  ---------------------------------- ------------------------------------

Figure 5 provides an estimate of the number of serious injuries that
would occur to accident occupants in the CONUS with and without LAAS.
The projected number of serious injuries among occupants of accident
aircraft is 8 for the time period of 2025 to 2028 without LAAS. The
estimated number of serious occupant injuries is 1 with LAAS only during
the same period, a reduction of serious occupant injuries of 78%. With
WAAS only, it is anticipated that there will be approximately 3 serious
injuries. Therefore, the serious injury reduction that can be attributed
to LAAS is 2 serious injuries prevented during the time period of 2009
through 2008.

![](media/image6.wmf){width="6.498611111111111in"
height="4.461805555555555in"}

**Figure 5: Projected Number of Serious Injuries with LAAS in the
CONUS**

Table 5 lists the cost savings associated with the safety benefits that
can be reasonably expected to occur with the introduction of LAAS in the
CONUS due to the introduction of precision approach capability. The cost
of accidents prevented with LAAS only totaled \$38.122 million. The cost
savings associated with WAAS only is \$23.248 million. Therefore, the
savings that can be associated with LAAS with 100% WAAS equipage is the
difference between the two which equals \$14.874 million.

**Table 5: Distribution of Safety Benefits for LAAS in 2004** Dollars

  ------------------ ---------------- -------------- ---------------------
  **Benefit          **LAAS Only**    **WAAS Only**  **LAAS Benefits
  Category**                                         Remaining With 100%
                                                     WAAS Equipage**

  Serious Injuries   \$0.554 million  \$0.315        \$0.239 million
  Prevented                           million        

  Accident Losses    \$37.568 million \$22.933       \$14.635 million
  Prevented (Hull                     million        
  Loss and Damage)                                   

  Total Benefits in  \$38.122 million \$23.248       \$14.874 million
  2004 Dollars                        million        
  ------------------ ---------------- -------------- ---------------------

**2) Analysis of Accidents that Would Have Benefited from LAAS
Capabilities Other Than the Precision Approach Capability:** LAAS is
anticipated to have additional safety benefits other than the provision
of precision approach capability. These potential benefits have been
described earlier and include the ability to provide precise surface
navigational guidance, complex approach and departure navigational
guidance, positive guidance for wake turbulence in the airport area, and
much more. These potential safety benefits have been studied closely by
the FAA and the aviation industry but have not yet been demonstrated in
operation since LAAS has not yet been implemented. Consequently, the
benefits described in this section are based on benefits that are
likely, but not yet operationally in practice. These benefits include
precision surface guidance, precision guidance in the airport area
primarily associated with wake turbulence avoidance, and precision
missed approach navigational guidance. These benefits have not been
attributed to WAAS since they require the high-level precision guidance
anticipated for LAAS, but not currently envisioned for WAAS.
Consequently, the following analyses and results do not include WAAS in
the calculations or results.

Table 6 provides the distribution of non-approach accidents in the CONUS
stratified by aircraft category that would have been unlikely to occur
if LAAS had been operational and the accident aircraft had been equipped
with appropriate LAAS receivers. These accidents were selected as
described in Section II.B., (Presumptions for Quantitative Analyses) and
were limited to events that occurred at the 117 CONUS airports selected
for analysis (Appendix 2).

As can be seen, two turbo-jet aircraft 1 turbo-jet and 1 corporate
turbo-prop aircraft were involved in accidents that would have benefited
from LAAS non-precision approach capability during the study period. The
actual make and model of the aircraft are listed in Appendix 5.

**Table 6: Distribution of non-Approach** Accidents in the CONUS That
Would Have Benefited From LAAS, 1993-2002

  --------------- --------- -------------- ------------- ------------- ------------- -----------
  **Year**        **Air     **Air Carrier  **Corporate   **Corporate   **Corporate   **Total**
                  Carrier   Turbo-Prop**   Jet**         Turboprop**   Heavy Piston  
                  Jet**                                                Twin**        

  **1993-2002**   0         2              1             1             0             4
  --------------- --------- -------------- ------------- ------------- ------------- -----------

While similar evaluation was attempted for the three airports in Alaska
that were included in this analysis, no accidents were found that might
have been prevented by the presence of LAAS non-approach benefits for
the time period of 1993-2002. Consequently, the balance of findings
presented in this section is limited to the CONUS.

Table 7 presents the distribution of occupant injuries resulting from
the non-approach accidents included for study within the CONUS. These
accidents resulted in 6 fatalities, and three serious injuries among the
48 passengers and crew.

> **Table 7: Distribution of Occupant Injuries for non-Approach
> Accidents in the CONUS** that Would Have Benefited From LAAS,
> 1993-2002

  --------------- ------------ -------------- -------------- ---------------
  **Year**        **Fatal**    **Serious**    **None of      **Total
                                              Minor**        Occupants**

  **1993-2002**   6            3              39             48
  --------------- ------------ -------------- -------------- ---------------

Figure 6 provides average rate per 1 million departures for accidents
and serious injury cases for non-approach accidents that occurred in the
CONUS for the time period of 1993-2002. These rates represent the
baseline rates of accident risk for the study airports without LAAS that
would have benefited from LAAS capabilities not associated with
"straight-in" precision approaches. These values are used as a baseline
reference for the risk benefit calculations for the future non-approach
benefits of LAAS.

![](media/image7.wmf){width="6.49375in" height="4.4631944444444445in"}

**Figure 6: Accident and Injury Rates in the CONUS for Non-Approach
Accidents, 1993-2002**

Figure 6 shows that the risk of an accident where the non-approach
safety benefits of LAAS might have proven beneficial during the time
frame of 1993-2002 was 0.037 per 1 million departures. The fatal
accident rate was 0.019. The fatal case rate was 0.056 per million
departures while the serious injury case rate was 0.0289 per 1 million
departures. [^26]

Figure 7 provides estimates of the future number of accidents with and
without the non-approach safety benefits provided by LAAS. The chart
displays the cumulative number of non-approach accidents that are
projected to occur in the CONUS if LAAS is not introduced in 2009 (solid
line). As can be seen, the number of accidents increases each year. This
increase is a function of the increasing number of operations projected
for the time period of 2009 -- 2028. A total of 20 non-approach
accidents where LAAS capability would have proven beneficial are
projected for this time period.

![](media/image8.wmf){width="6.495138888888889in"
height="4.450694444444444in"}

**Figure 7: Projected Number of Non-Approach Accidents With and Without
LAAS, 2009-2028.**

The dashed line provides an estimate of the number of non-approach
accidents that would occur in the CONUS if LAAS is introduced between
2009 and 2028. LAAS implementation will start in 2009 and be fully
implemented at the targeted 117 airports described earlier by the end of
2013. The total number of non-approach accidents at the 117 study
airports projected for the time period of 2009 -- 2028 with LAAS is a
total of 2, a 90% reduction in the 20 non-approach accidents that are
anticipated to occur if LAAS is not implemented.

Figure 8 provides a depiction of the anticipated number of fatal
non-approach accidents projected with and without LAAS implementation.
As with earlier depictions, the benefits of LAAS are seen relatively
early with full benefits in place by the end of 2013. The anticipated
reducing of fatal non-approach accident risk appears to be reduced by
90%.

![](media/image9.wmf){width="6.495138888888889in"
height="4.450694444444444in"}

**Figure 8: Projected Number of Non-Approach Fatal Accidents With and
Without LAAS 2009-2028.**

Table 8 presents the same information as contained in Figures 7 and 8
but in tabular format.

**Table 8: Number of non-Approach Accidents With and Without LAAS,
2009-2028**

  ---------------------------------- ------------------------------------
  **Level of LAAS Coverage**         **Projected Number of non-Approach
                                     Accidents 2009-2028**

  All Accidents With No LAAS         20

  All Accidents With LAAS            2

  Fatal Accidents with No LAAS       10

  Fatal Accidents with LAAS          1
  ---------------------------------- ------------------------------------

Table 9 provides a depiction of the anticipated number of fatal and
serious injuries among occupants of aircraft that might be involved in
non-approach accidents at the 117 study airports in the CONUS for the
time period of 2009-2028. As with other depictions, it is anticipated
that the introduction of LAAS would reduce the risk of serious or fatal
injuries by approximately 90%.

**Table 9: Number of Anticipated Injuries With and Without LAAS,
2009-2028**

  ---------------------------------- ------------------------------------
  **Level of LAAS Coverage**         **Projected Number of Injuries Due
                                     to non-Approach Accidents
                                     2009-2028**

  Fatalities Anticipated With No     23
  LAAS                               

  Fatalities Anticipated with LAAS   2

  Serious Injuries Anticipated with  11
  No LAAS                            

  Serious Injuries Anticipated with  1
  LAAS                               
  ---------------------------------- ------------------------------------

Table 10 presented the anticipated safety benefits of LAAS preventing
non-approach related accidents at the 117 study airports in the CONUS.
As can be seen, the total anticipated benefit is \$40.351 million.

**Table 10: Distribution of LAAS Safety Benefit**

**for Non-Approach Accident Reduction** in 2004 Dollars

  ------------------------------------- ---------------------------------
  **Benefit Category**                  **LAAS Benefit**

  Accidents Prevented (hull loss and    \$10.244 million
  damage)                               

  Fatal Injuries Prevented              \$29.268 million

  Serious Injuries Prevented            \$0.839 million

  Total Benefits                        \$40.351 million
  ------------------------------------- ---------------------------------

**3) Benefits of LAAS for Both Precision Approach and Non-Approach
Related Accident Reduction:** The desire to account for the anticipated
benefits of WAAS is due to the fact that many of the benefits of WAAS
and LAAS are the same, primarily the ability to provide Cat I precision
approach capability to runways currently not equipped with that
capability, but this capability will not become available for WAAS until
2015 while the LAAS capability will begin to appear in 2009.
Consequently, the best way to evaluate the anticipated benefits of LAAS
in the presence of 100% WAAS equipage is to look at their respective
anticipated benefits separately and then calculate the difference
between these two values.

Table 11 provides a summary of the various benefits attributed to LAAS,
WAAS and LAAS with 100% aircraft equipage combined under the two
analysis scenarios of precision approach benefits and non-approach
benefits. As can be seen, the anticipated benefits of LAAS alone total
\$78.473 million for the time frame of 2009-2028 at the 117 study
airports in the CONUS without consideration of WAAS. The benefits of
LAAS with WAAS equipage are \$14.874 million for the precision approach
capability and \$40.351 million for the LAAS anticipated benefits not
associated with the precision approach capability. The total value of
the benefits of this scenario is \$55.225 million.

**Table 11: Summary of Safety Benefits for the Precision Approach and
Non- Approach Scenarios.**

+----------------------+------------+--------------+------------------+
| **Precision Approach |            |              |                  |
| Benefits**           |            |              |                  |
+----------------------+------------+--------------+------------------+
| **Benefit Category** | **LAAS     | **WAAS       | **LAAS With**    |
|                      | With**     | Only**       |                  |
|                      |            |              | **100% WAAS      |
|                      | **0% WAAS  |              | Equipage**       |
|                      | equipage** |              |                  |
+----------------------+------------+--------------+------------------+
| Accidents Prevented  | \$37.568   | \$22.933     | \$14.635 million |
|                      | million    | million      |                  |
| (Hull loss and       |            |              |                  |
| damage)              |            |              |                  |
+----------------------+------------+--------------+------------------+
| Serious Injuries     | \$0.       | \$0.315      | \$0.239 million  |
| Prevented            | 554million | million      |                  |
+----------------------+------------+--------------+------------------+
| **Total Benefits**   | **\$38.122 | **\$23.248   | **\$14.874       |
|                      | million**  | million**    | million**        |
+----------------------+------------+--------------+------------------+
|                      |            |              |                  |
+----------------------+------------+--------------+------------------+
| **Non --Approach     |            |              |                  |
| Benefits**           |            |              |                  |
+----------------------+------------+--------------+------------------+
| **Benefit Category** | **LAAS     |              |                  |
|                      | Only**     |              |                  |
+----------------------+------------+--------------+------------------+
| Accidents Prevented  | \$10.244   |              |                  |
|                      | million    |              |                  |
| (Hull loss and       |            |              |                  |
| damage)              |            |              |                  |
+----------------------+------------+--------------+------------------+
| Fatal Injuries       | \$29.268   |              |                  |
| Prevented            | million    |              |                  |
+----------------------+------------+--------------+------------------+
| Serious Injuries     | \$0.839    |              |                  |
| Prevented            | million    |              |                  |
+----------------------+------------+--------------+------------------+
| **Total Benefits**   | **\$40.351 |              |                  |
|                      | million**  |              |                  |
+----------------------+------------+--------------+------------------+

## **B) Findings from Qualitative Analyses**

**1) Runway Incursions:**

Since 1978, air traffic volume in the NAS has more than doubled and is
predicted to double again in the next 10 years. Along with this increase
in air traffic, there has been a corresponding increase in runway
incursion (RI) mishaps and "near misses". According to the NTSB, runway
incursions are the number one aviation safety hazard today, and have
been so since 1990.[^27]

Unfortunately there are still many "close calls" or near mishaps. A
solution to the runway incursion problem is the Number 1 item on the
NTSB "Most Wanted" list of safety improvements. In response to this
need, the FAA created the Office of Runway Safety, which has
investigated and analyzed mishap data and initiated a number of
corrective actions involving education, training, procedures, and the
development of new technologies.

The FAA Office of Runway Safety has compiled a summary runway incursion
database categorized by type that was presented on June 26, 2001 to the
House of Representatives Subcommittee on Aviation, which was holding
hearings that focused on technology to prevent ground collisions.[^28]

The information prepared by the FAA is presented in Table 12. As can be
seen, runway incursions have been steadily increasing since 1994 except
for 2001. Pilot deviation was the most common cause of runway incursions
in every year except 1994. This is the type of runway incursion that
will most likely benefit most from the application of LAAS-enabled
technologies.

**Table 12**: Runway Incursion Number by Year and Causation Type

  ------------ --------------- -------------- ---------------------- --------------
  **Calendar   **Operational   **Pilot        **Vehicle/Pedestrian   **Total Runway
  Year**       Errors**        Deviations**   Deviations**           Incursions**

  1994         83              66             51                     200

  1995         65              125            50                     240

  1996         69              146            60                     244

  1997         69              132            87                     288

  1998         91              183            51                     325

  1999         78              182            61                     321

  2000         87              259            85                     431

  2001         39              104            23                     166
  ------------ --------------- -------------- ---------------------- --------------

Table 13 provides a summary of the runway incursions that might have
been prevented if a LAAS surface guidance system had been available. As
can be seen, approximately 64% of the FAR 121 related runway incursions
might have been prevented while 43% of the corporate runway incursions
were potentially preventable. The majority of these potentially
preventable events occurred in darkness or in poor visibility
conditions.

**Table 13: Results of Manual Review of Runway Incursion Reports**

  ----------------------- -------------- --------------- ----------------
  **Type Operation**      **\# Reports   **Applicable    **Applicable
                          Reviewed**     Reports**       Report
                                                         Percentage**

  FAR Part 121 Air        72             46              64%
  Carrier                                                

  FAR Part 91 Corporate   23             10              43%
  Operations                                             

  Total                   95             56              59%
  ----------------------- -------------- --------------- ----------------

Using the values presented in Table 13, an annual runway incursion rate
was calculated for air carriers where LAAS-enabled technologies might
have been useful in preventing the incursion. This rate was calculated
for the years 1987-2002 which was the time period of this RI analysis
for the CONUS. Using this approach, it was determined that approximately
2.15 runway incursions for each 1 million air carrier operations might
have been prevented if LAAS-enabled surface guidance systems had been
available. This rate was applied to the airport activity projections for
air carriers in the CONUS for the time period of 2005-2028. The number
of projected runway incursions were calculated for two cases: 1) with no
LAAS-based RI reduction safety benefit, and 2) with the LAAS safety
benefits projections as described in Section II.D.2.

Figure 9 displays the results of this analysis. As can be seen,
approximately 792 air carrier runway incursions are projected to occur
between 2009 and 2028 where LAAS enabled surface guidance might have
some positive benefit in reducing their occurrence. With LAAS-enabled
surface guidance, 460 air carrier runway incursions are projected to be
prevented. It is anticipated that 332 air carrier RIs will still occur
over this time period.

According to the FAA, past experience indicates that roughly 0.2% of all
incursions result in a collision, a very low number.[^29] If this rate
is applied to the projected numbers provided in Figure 9, it is
estimated that LAAS enabled surface guidance technology will prevent
approximately one major air carrier runway incursion during the time
frame of 2009-2028.[^30]

**Figure 9: Future Runway Incursions Among Air Carriers**

![](media/image10.wmf){width="6.493055555555555in"
height="4.1506944444444445in"}

# **IV) Discussion**

The three-dimensional and precise guidance offered by LAAS in the
terminal area will have definitive and positive safety benefits. The
findings from this analysis indicate that LAAS will prevent
approximately 49 accidents for the time period of 2009-2028 without
consideration of WAAS benefits in the NAS. The estimated benefit from
preventing these accidents is approximately \$78.473 million dollars
(adjusted to 2004 dollars).

If WAAS is considered, LAAS benefits are decreased, if it is assumed
that all the credit for risk reduction due to the additional of
precision approaches are credited to WAAS. In that situation, where LAAS
and WAAS co-exist with their respective implementation schedules
starting in 2009 and 2015 respectively, LAAS will provide \$55.225
million in benefits due to reduced accidents and injuries for the time
period of 2009-2028.

These estimates are quite conservative since it is likely that many
accidents that would have benefited from LAAS type guidance were not
included in the analyses. Exclusion of these accidents was due to a very
conservative inclusion criteria for accidents included in the analyses.
These quantifiable findings are predicated on a model that specifies
that the main measurable benefit of LAAS is the additional benefit of
precision guidance to the runway.

There are many other safety benefits associated with LAAS that are not
easily quantifiable. Most of these are multiplicative in that the
benefits will influence many different aspects of operations. In this
study, these non-measurable benefits include curved approaches and
improved situational awareness of high obstacles in the terminal
environment thereby reducing the risk of CFIT. In both cases, LAAS will
enable existing technology (primarily integrated FMS and aircraft
automated systems) to make large improvements in aircraft control in the
terminal environment and pilot situational awareness.

**Appendix 1: Alaska Airports**

Only three airports were designated as possible candidates for LAAS
installation for the time frame of 2009-2028. The three airports are

  -------- --------------------------------------------------------------
  ANC      TED STEVENS ANCHORAGE INTL, ALASKA

  JNU      JUNEAU INTL, ALASKA

  FAI      FAIRBANKS INTL, ALASKA
  -------- --------------------------------------------------------------

**Appendix 2: CONUS Airports**

The 117 airports listed below are the airports used for evaluation of
LAAS benefits in the CONUS for the time frame of 2009-2028.

  -------- --------------------------------------------------------------
  ABQ      ALBUQUERQUE INTL SUNPORT, NEW MEXICO

  ACK      NANTUCKET MEMORIAL, MASSACHUSETTS

  AFW      FORT WORTH ALLIANCE, TEXAS

  ALB      ALBANY INTL, NEW YORK

  ATL      THE WILLIAM B HARTSFIELD ATLANTA INTL, GEORGIA

  AUS      AUSTIN-BERGSTROM INTL, TEXAS

  AVL      ASHEVILLE REGIONAL, NORTH CAROLINA

  BDL      BRADLEY INTL, CONNECTICUT

  BFI      BOEING FIELD/KING COUNTY INTL, WASHINGTON

  BGR      BANGOR INTL, MAINE

  BHM      BIRMINGHAM INTL, ALABAMA

  BNA      NASHVILLE INTL, TENNESSEE

  BOI      BOISE AIR TERMINAL/GOWEN FLD, IDAHO

  BOS      GENERAL EDWARD LAWRENCE LOGAN INTL, MASSACHUSETTS

  BUF      BUFFALO NIAGARA INTL, NEW YORK

  BUR      BURBANK-GLENDALE-PASADENA, CALIFORNIA

  BWI      BALTIMORE-WASHINGTON INTL, MARYLAND

  CAE      COLUMBIA METROPOLITAN, SOUTH CAROLINA

  CHA      LOVELL FIELD, TENNESSEE

  CHS      CHARLESTON AFB/INTL, SOUTH CAROLINA

  CLE      CLEVELAND-HOPKINS INTL, OHIO

  CLT      CHARLOTTE/DOUGLAS INTL, NORTH CAROLINA

  CMH      PORT COLUMBUS INTL, OHIO

  COS      CITY OF COLORADO SPRINGS MUNI, COLORADO

  CVG      CINCINNATI/NORTHERN KENTUCKY INTL, KENTUCKY

  DAB      DAYTONA BEACH INTL, FLORIDA

  DAL      DALLAS LOVE FIELD, TEXAS

  DAY      JAMES M COX DAYTON INTL, OHIO

  DCA      RONALD REAGAN WASHINGTON NATIONAL, DIST. OF COLUMBIA

  DEN      DENVER INTL, COLORADO

  DFW      DALLAS/FORT WORTH INTL, TEXAS

  DLH      DULUTH INTL, MINNESOTA

  DSM      DES MOINES INTL, IOWA

  DTW      DETROIT METROPOLITAN WAYNE COUNTY, MICHIGAN

  DVT      PHOENIX DEER VALLEY, ARIZONA

  ELP      EL PASO INTL, TEXAS

  EUG      MAHLON SWEET FIELD, OREGON

  EWR      NEWARK INTL, NEW JERSEY

  EYW      KEY WEST INTL, FLORIDA

  FAT      FRESNO YOSEMITE INTL, CALIFORNIA

  FLL      FORT LAUDERDALE/HOLLYWOOD INTL, FLORIDA

  FWA      FORT WAYNE INTL, INDIANA

  FXE      FORT LAUDERDALE EXECUTIVE, FLORIDA

  GEG      SPOKANE INTL, WASHINGTON

  GRR      GERALD R. FORD INTL, MICHIGAN

  GSO      PIEDMONT TRIAD INTL, NORTH CAROLINA

  GSP      GREENVILLE-SPARTANBURG INTL, SOUTH CAROLINA

  HNL      HONOLULU INTL, HAWAII

  HOU      WILLIAM P HOBBY, TEXAS

  HPN      WESTCHESTER COUNTY, NEW YORK

  HSV      HUNTSVILLE INTL-CARL T JONES FIELD, ALABAMA

  IAD      WASHINGTON DULLES INTL, DIST. OF COLUMBIA

  IAH      GEORGE BUSH INTERCONTINENTAL ARPT/HOUSTON, TEXAS

  ICT      WICHITA MID-CONTINENT, KANSAS

  ILN      AIRBORNE AIRPARK, OHIO

  IND      INDIANAPOLIS INTL, INDIANA

  JAN      JACKSON INTL, MISSISSIPPI

  JAX      JACKSONVILLE INTL, FLORIDA

  JFK      JOHN F KENNEDY INTL, NEW YORK

  LAS      MC CARRAN INTL, NEVADA

  LAX      LOS ANGELES INTL, CALIFORNIA

  LCK      RICKENBACKER INTL, OHIO

  LGA      LA GUARDIA, NEW YORK

  LGB      LONG BEACH /DAUGHERTY FIELD/, CALIFORNIA

  LIT      ADAMS FIELD, ARKANSAS

  MCI      KANSAS CITY INTL, MISSOURI

  MCO      ORLANDO INTL, FLORIDA

  MDT      HARRISBURG INTL, PENNSYLVANIA

  MDW      CHICAGO MIDWAY, ILLINOIS

  MEM      MEMPHIS INTL, TENNESSEE

  MHT      MANCHESTER, NEW HAMPSHIRE

  MIA      MIAMI INTL, FLORIDA

  MKE      GENERAL MITCHELL INTL, WISCONSIN

  MMU      MORRISTOWN MUNICIPAL, NEW JERSEY

  MSP      MINNEAPOLIS-ST PAUL INTL/WOLD-CHAMBERLAIN/, MINNESOTA

  MSY      LOUIS ARMSTRONG NEW ORLEANS INTL, LOUISIANA

  OAK      METROPOLITAN OAKLAND INTL, CALIFORNIA

  OKC      WILL ROGERS WORLD, OKLAHOMA

  OMA      EPPLEY AIRFIELD, NEBRASKA

  ONT      ONTARIO INTL, CALIFORNIA

  ORD      CHICAGO O\'HARE INTL, ILLINOIS

  ORF      NORFOLK INTL, VIRGINIA

  PBI      PALM BEACH INTL, FLORIDA

  PDX      PORTLAND INTL, OREGON

  PHL      PHILADELPHIA INTL, PENNSYLVANIA

  PHX      PHOENIX SKY HARBOR INTL, ARIZONA

  PIE      ST PETERSBURG-CLEARWATER INTL, FLORIDA

  PIT      PITTSBURGH INTL, PENNSYLVANIA

  PVD      THEODORE FRANCIS GREEN STATE, RHODE ISLAND

  RDU      RALEIGH-DURHAM INTL, NORTH CAROLINA

  RFD      GREATER ROCKFORD, ILLINOIS

  RIC      RICHMOND INTL, VIRGINIA

  RNO      RENO/TAHOE INTL, NEVADA

  ROC      GREATER ROCHESTER INTL, NEW YORK

  RSW      SOUTHWEST FLORIDA INTL, FLORIDA

  SAN      SAN DIEGO INTL-LINDBERGH FLD, CALIFORNIA

  SAT      SAN ANTONIO INTL, TEXAS

  SDF      LOUISVILLE INTL-STANDIFORD FIELD, KENTUCKY

  SEA      SEATTLE-TACOMA INTL, WASHINGTON

  SFB      ORLANDO SANFORD, FLORIDA

  SFO      SAN FRANCISCO INTL, CALIFORNIA

  SHV      SHREVEPORT REGIONAL, LOUISIANA

  SJC      NORMAN Y. MINETA SAN JOSE INTL, CALIFORNIA

  SLC      SALT LAKE CITY INTL, UTAH

  SMF      SACRAMENTO INTL, CALIFORNIA

  SNA      JOHN WAYNE AIRPORT-ORANGE COUNTY, CALIFORNIA

  STL      LAMBERT-ST LOUIS INTL, MISSOURI

  SWF      STEWART INT\'L, NEW YORK

  SYR      SYRACUSE HANCOCK INTL, NEW YORK

  TEB      TETERBORO, NEW JERSEY

  TLH      TALLAHASSEE REGIONAL, FLORIDA

  TPA      TAMPA INTL, FLORIDA

  TRI      TRI-CITIES RGNL TN/VA, TENNESSEE

  TUL      TULSA INTL, OKLAHOMA

  TUS      TUCSON INTL, ARIZONA

  TYS      MC GHEE TYSON, TENNESSEE

  VNY      VAN NUYS, CALIFORNIA
  -------- --------------------------------------------------------------

**Appendix 3: Activity Interpolation for years 2021-2026**

The FAA's Office of Aviation Policy and Plans (APO) provides activity
estimates for airports through calendar year 2020. As mentioned in the
text, the data prepared by the APO can be found at their website at
<http://www.apo.data.faa.gov/>. These data are provided for use in
analyses such as that reported from this study.

Since estimated airport activity data is not provided for the years of
2021 -2028, a procedure was followed to estimate these values for this
study. The procedure followed was based on interpolation from previous
year estimates.

As mentioned in the text, the amount of change in airport activity
(measured in departures) was determined from one year to the next. This
was accomplished for years 1980 through 2020. The average (mean) change
was then determined for all of the years combined (observed changes
between years summed and divided by the number of years observed). This
calculation was done separately for air carrier and general aviation
activity. The mean change value for the time period of 1980-2020 was
then used to develop activity estimates for 2021-2028. The values used
for this adjustment are provided below.

  ---------------------------- ------------------ ------------------------
                               **CONUS Air        **CONUS General
                               Carrier**          Aviation**

  Adjustment value for airport 1.7% increase per  1% increase per year
  activity 2021-2028           year               
  ---------------------------- ------------------ ------------------------

**Appendix 4: Study Accident Summaries**

**CONUS Accident Summaries**

The following 7 accidents involved aircraft that might have benefited
from precision approach guidance.

**NASDAC BRIEF REPORT**

**GENERAL INFORMATION**

  -- ------------ -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- ------------------------------
     Data Source:                                                                                                                                                                                     NTSB AVIATION
                                                                                                                                                                                                      ACCIDENT/INCIDENT DATABASE

     Event Id:                                                                                                                                                                                        20001207X04839

     Local Date:                                                                                                                                                                                      11/12/1995

     Local Time:                                                                                                                                                                                      55

     State:                                                                                                                                                                                           CT

     City:                                                                                                                                                                                            EAST GRANBY

     Airport                                                                                                                                                                                          BRADLEY INTL
     Name:                                                                                                                                                                                            

     Event Type:                                                                                                                                                                                      ACCIDENT

     Injury                                                                                                                                                                                           MINOR
     Severity:                                                                                                                                                                                        

     Report                                                                                                                                                                                           FINAL
     Status:                                                                                                                                                                                          

     Mid Air                                                                                                                                                                                          NO
     Collision:                                                                                                                                                                                       

     Event                                                                                                                                                                                            OFF AIRPORT/AIRSTRIP
     Location:                                                                                                                                                                                        

                                                                                                                                                                                                      
  -- ------------ -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- ------------------------------

**WEATHER INFORMATION**

  -- ----------------------------------- -- -- ---------------------------------
     Weather Briefing Complete:                FULL

     Brief Source:                             

     Basic Weather Conditions:                 INSTRUMENT METEOROLOGICAL COND

     Light Condition:                          NIGHT/DARK

     Cloud Condition:                          SCATTERED

     Cloud Height above Ground Level           1700
     (ft):                                     

     Ceiling Height above Ground Level         2800
     (ft):                                     

     Cloud Type:                               OVERCAST

     Visibility RVR (ft):                      

     Visibility RVV (sm):                      

     Visibility (sm):                          3

     Wind Direction (deg):                     170

     Wind Condition Flag:                      Y

     Wind Speed (knots):                       25

     Wind Condition Indicated:                 

     Visibility Restrictions:                  

     Precipitation Type:                       
  -- ----------------------------------- -- -- ---------------------------------

**AIRCRAFT INFORMATION**\
\
**Aircraft 1**

  -- --------------------------- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- --------------------------
     Category of Operation:                                                                                                                                                                           SCHEDULED

     Aircraft Type:                                                                                                                                                                                   AIRPLANE

     Aircraft Homebuilt:                                                                                                                                                                              NO

     Aircraft Damage:                                                                                                                                                                                 SUBSTANTIAL

     Phase of Flight:                                                                                                                                                                                 

     Aircraft Make:                                                                                                                                                                                   MCDONNELL-DOUGLAS-BOEING

                                                                                                                                                                                                      

     Aircraft Model:                                                                                                                                                                                  MD-80

                                                                                                                                                                                                      

     Aircraft Series:                                                                                                                                                                                 83

     Operator Doing Business As:                                                                                                                                                                      

     Operator Name                                                                                                                                                                                    AMERICAN AIRLINES

     Owner Name                                                                                                                                                                                       AMERICAN AIRLINES INC

                                                                                                                                                                                                      

     NTSB Report Number:                                                                                                                                                                              DCA96MA008

     Number of Seats:                                                                                                                                                                                 

     Number of Engines:                                                                                                                                                                               2

     ELT Installed:                                                                                                                                                                                   NO

     ELT Operated:                                                                                                                                                                                    UNKNOWN

     Aircraft Use:                                                                                                                                                                                    UNKNOWN

     Type of Operation:                                                                                                                                                                               PART 121: AIR CARRIER

     Departure Airport Id:                                                                                                                                                                            ORD

     Departure City:                                                                                                                                                                                  CHICAGO

     Departure State:                                                                                                                                                                                 ILLINOIS

     Last Departure Point:                                                                                                                                                                            NO

     Destination Local:                                                                                                                                                                               

     Destination Airport Id:                                                                                                                                                                          BDL

     Destination City:                                                                                                                                                                                WINDSOR LOCKS

     Destination State:                                                                                                                                                                               CONNECTICUT

     Runway Id:                                                                                                                                                                                       15

     Runway Length:                                                                                                                                                                                   6846

     Runway Width:                                                                                                                                                                                    150

     Flight Plan Filed:                                                                                                                                                                               IFR

     Domestic/International:                                                                                                                                                                          DOMESTIC

     Passenger/Cargo:                                                                                                                                                                                 PASSENGER ONLY

     Registration Number:                                                                                                                                                                             N566AA

     Air Carrier Operating                                                                                                                                                                            UNKNOWN
     Certificates:                                                                                                                                                                                    

     Air Carrier Other Operating                                                                                                                                                                      UNKNOWN
     Certificates:                                                                                                                                                                                    

     Rotocraft/Agriculture                                                                                                                                                                            
     Operating Certificate:                                                                                                                                                                           

     Cert Max Gross Wgt:                                                                                                                                                                              

     Aircraft Fire:                                                                                                                                                                                   IN-FLIGHT

     Aircraft Explosion:                                                                                                                                                                              NONE

     Landing Gear:                                                                                                                                                                                    RETR

     ATC Clearance                                                                                                                                                                                    

     Landing Gear                                                                                                                                                                                     

     Runway Condition                                                                                                                                                                                 

     Landing Surface                                                                                                                                                                                  
  -- --------------------------- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- --------------------------

**ENGINE INFORMATION**\
\
\
**Aircraft 1 - Engine #:1**

  -- ----------------------------------------- -- -- ------------------------
     Engine Type:                                    TURBO FAN

     Engine Group                                    

     Engine Manufactuer                              P&W

     Engine Make                                     P & W

     Engine Model                                    JT8D-219

     Engine Cert Type                                

     Engine Horsepower                               21000

     Engine Thrust                                   LBS

     Carb/Injection                                  

     Propeller Type                                  
  -- ----------------------------------------- -- -- ------------------------

**Injury Summary for Aircraft 1**

  ----------- -- ----------- -- ---------------- -- ------------ -- ------------
                 **Fatal**      **Serious**         **Minor**       **None**

  Crew           0              0                   0               5

  Pass                                              1               72

  Total          0              0                   1               77
  ----------- -- ----------- -- ---------------- -- ------------ -- ------------

**Pilot-in-Command for Aircraft 1**

  --------------- -- -- ---------------------------------------------------------
  Certificates:         AIRLINE TRANSPORT,COMMERCIAL,FLIGHT ENGINEER,MILITARY

  --------------- -- -- ---------------------------------------------------------

  -----------------------------------------------------------------------
  Ratings:

  -----------------------------------------------------------------------

  ---- -------------------------------------------------------- --- --- ----
       Plane:                                                           

       Non-Plane:                                                       

       Instrument:                                                      

       Instruction:                                                     
  ---- -------------------------------------------------------- --- --- ----

  ------------------------------- -- -- -------------------------------------
  Had Current BFR:                      Y

  Months Since Last BFR:                

  Medical Certificate:                  CLASS 1

  Medical Certificate Validity:         VALID MEDICAL\--NO WAIVERS/LIM.
  ------------------------------- -- -- -------------------------------------

  -------------------------------------------- ---- -- -- -----------------
  Flight Time (hours)                                     

  Total                                        :          8000

  Make/Model                                   :          4200

  Instrument                                   :          0

  Multi-Engine                                 :          0

  Last 24 Hours                                :          10

  Last 30 Days                                 :          20

  Last 90 Days                                 :          55

  Rotocraft                                    :          0
  -------------------------------------------- ---- -- -- -----------------

**Sequence of Events**\
**Aircraft 1**\
Occurrence #: 1\
UNDERSHOOT\
Phase of Operation: APPROACH - FAF/OUTER MARKER TO THRESHOLD (IFR)

  -------------- --------- ---------------------- -------------- --------------- ------------------
  **Findings**                                                                   

  **Event Seq    **Event   **Subject**            **Modifier**   **Personnel**   **Cause/Factor**
  \#**           Group                                                           
                 Code**                                                          

  1              1         LIGHT CONDITION        DARK NIGHT                     

  2              1         WEATHER CONDITION      RAIN                           

  3              1         WEATHER CONDITION      HIGH WIND                      

  4              1         WEATHER CONDITION      GUSTS                          

  5              2         APPROACH/DEPARTURE     INADEQUATE     ATC PERSONNEL   FACTOR
                           CONTROL SERVICE                       (DEP/APCH)      

  6              2         ALTIMETER SETTING      NOT OBTAINED   FLIGHTCREW      FACTOR

  7              2         MINIMUM DESCENT        BELOW          FLIGHTCREW      CAUSE
                           ALTITUDE                                              
  -------------- --------- ---------------------- -------------- --------------- ------------------

Occurrence #: 2\
IN FLIGHT COLLISION WITH OBJECT\
Phase of Operation: APPROACH - FAF/OUTER MARKER TO THRESHOLD (IFR)

  -------------- ----------------- ------------- -------------- --------------- ------------------
  **Findings**                                                                  

  **Event Seq    **Event Group     **Subject**   **Modifier**   **Personnel**   **Cause/Factor**
  \#**           Code**                                                         

  1              1                 OBJECT        TREE(S)                        

  2              1                 OBJECT        ANTENNA                        
  -------------- ----------------- ------------- -------------- --------------- ------------------

**AIRCRAFT 1 PRELIMINARY REPORT**\
\
On November 12, 1995, at 0057 est, an American Airlines McDonnell
Douglas MD-80, registered in the US as N566AA, struck trees on a ridge
line 2.65 miles from the end of runway 15 at Bradley International
Airport, Windsor Locks, CT. The airplane then landed safely at the
airport. One of the 72 passengers received a minor injury during the
emergency evacuation. None of the 5 crewmembers were injured. The flight
was operating under CFR Part 121 in instrument meteorological
conditions. It originated at O\'Hare International Airport about two
hours before the accident. See NTSB/AAR-96/05 for details.

**AIRCRAFT 1 FINAL REPORT**\
\
The airplane impacted trees, then an ILS antenna as it landed short of
the runway on grass, even terrain during a night VOR approach in strong,
gusty wind conditions. At the time of the accident, the indicated
altitude (height above airport elevation) that the airplane\'s QFE
altimeter was indicating was about 76 feet too high (based on the
altimeter setting received at 0030), resulting in the airplane being 76
feet lower than indicated on the primary altimeters. Because the
flightcrew knew that the atmospheric pressure was falling rapidly, they
should have requested a current altimeter setting from the approach
controller when was not given, as required, upon initial radio contact.
Although the flightcrew did not use the most current QNH setting they
had available (29.40 inches of Hg.) in the standby altimeter, this error
did not affect the accident sequence of events because the flightcrew
had the correct, but outdated, QFE setting (29.23 inches Hg.) in the
altimeters they were using when the accident occurred. If the first
officer had monitored the approach on instruments until reaching minimum
descent altitude (MDA) and delayed his search for the airport until
after reaching the MDA, he would have been better able to notice and
immediately call the captain\'s attention to the altitude deviation
below the MDA.

**AIRCRAFT 1 CAUSE REPORT**\
\
the flightcrew\'s failure to maintain the required minimum descent
altitude until the required visual references identifiable with the
runway were in sight. Contributing factors were the failure of the BDL
approach controller to furnish the flightcrew with a current altimeter
setting, and the flightcrew\'s failure to ask for a more current
setting. (NTSB Report AAR-96/05 adopted 11/13/96)

**END REPORT**

**NASDAC BRIEF REPORT**

**GENERAL INFORMATION**

  -- ------------ -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- ------------------------------
     Data Source:                                                                                                                                                                                     NTSB AVIATION
                                                                                                                                                                                                      ACCIDENT/INCIDENT DATABASE

     Event Id:                                                                                                                                                                                        20001208X06262

     Local Date:                                                                                                                                                                                      07/15/1996

     Local Time:                                                                                                                                                                                      545

     State:                                                                                                                                                                                           NH

     City:                                                                                                                                                                                            MANCHESTER

     Airport                                                                                                                                                                                          MANCHESTER
     Name:                                                                                                                                                                                            

     Event Type:                                                                                                                                                                                      ACCIDENT

     Injury                                                                                                                                                                                           NONE
     Severity:                                                                                                                                                                                        

     Report                                                                                                                                                                                           FINAL
     Status:                                                                                                                                                                                          

     Mid Air                                                                                                                                                                                          NO
     Collision:                                                                                                                                                                                       

     Event                                                                                                                                                                                            OFF AIRPORT/AIRSTRIP
     Location:                                                                                                                                                                                        

                                                                                                                                                                                                      
  -- ------------ -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- ------------------------------

**WEATHER INFORMATION**

  -- ----------------------------------- -- -- ---------------------------------
     Weather Briefing Complete:                FULL

     Brief Source:                             

     Basic Weather Conditions:                 INSTRUMENT METEOROLOGICAL COND

     Light Condition:                          DAWN

     Cloud Condition:                          THIN OVERCAST

     Cloud Height above Ground Level           600
     (ft):                                     

     Ceiling Height above Ground Level         600
     (ft):                                     

     Cloud Type:                               OVERCAST

     Visibility RVR (ft):                      5000

     Visibility RVV (sm):                      0

     Visibility (sm):                          .25

     Wind Direction (deg):                     180

     Wind Condition Flag:                      U

     Wind Speed (knots):                       4

     Wind Condition Indicated:                 Unknown

     Visibility Restrictions:                  

     Precipitation Type:                       
  -- ----------------------------------- -- -- ---------------------------------

**AIRCRAFT INFORMATION**\
\
**Aircraft 1**

  -- -------------------------- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- --------------------
     Category of Operation:                                                                                                                                                                          

     Aircraft Type:                                                                                                                                                                                  AIRPLANE

     Aircraft Homebuilt:                                                                                                                                                                             NO

     Aircraft Damage:                                                                                                                                                                                SUBSTANTIAL

     Phase of Flight:                                                                                                                                                                                APPROACH

     Aircraft Make:                                                                                                                                                                                  BEECH

                                                                                                                                                                                                     

     Aircraft Model:                                                                                                                                                                                 BE-100

                                                                                                                                                                                                     

     Aircraft Series:                                                                                                                                                                                BE-100-A100

     Operator Doing Business                                                                                                                                                                         
     As:                                                                                                                                                                                             

     Operator Name                                                                                                                                                                                   CAUSEY AVIATION
                                                                                                                                                                                                     SERVICE INC

     Owner Name                                                                                                                                                                                      CAUSEY AVIATION
                                                                                                                                                                                                     SERVICE INC.

                                                                                                                                                                                                     

     NTSB Report Number:                                                                                                                                                                             IAD96LA117

     Number of Seats:                                                                                                                                                                                10

     Number of Engines:                                                                                                                                                                              2

     ELT Installed:                                                                                                                                                                                  YES

     ELT Operated:                                                                                                                                                                                   NO

     Aircraft Use:                                                                                                                                                                                   POSITIONING

     Type of Operation:                                                                                                                                                                              PART 91: GENERAL
                                                                                                                                                                                                     AVIATION

     Departure Airport Id:                                                                                                                                                                           2A5

     Departure City:                                                                                                                                                                                 LIBERTY

     Departure State:                                                                                                                                                                                NORTH CAROLINA

     Last Departure Point:                                                                                                                                                                           NO

     Destination Local:                                                                                                                                                                              SAME AS
                                                                                                                                                                                                     ACCIDENT/INCIDENT
                                                                                                                                                                                                     LOC

     Destination Airport Id:                                                                                                                                                                         MHT

     Destination City:                                                                                                                                                                               

     Destination State:                                                                                                                                                                              

     Runway Id:                                                                                                                                                                                      35

     Runway Length:                                                                                                                                                                                  7001

     Runway Width:                                                                                                                                                                                   150

     Flight Plan Filed:                                                                                                                                                                              IFR

     Domestic/International:                                                                                                                                                                         

     Passenger/Cargo:                                                                                                                                                                                

     Registration Number:                                                                                                                                                                            N4391W

     Air Carrier Operating                                                                                                                                                                           NO
     Certificates:                                                                                                                                                                                   

     Air Carrier Other                                                                                                                                                                               NO
     Operating Certificates:                                                                                                                                                                         

     Rotocraft/Agriculture                                                                                                                                                                           UNKNOWN
     Operating Certificate:                                                                                                                                                                          

     Cert Max Gross Wgt:                                                                                                                                                                             11500

     Aircraft Fire:                                                                                                                                                                                  NONE

     Aircraft Explosion:                                                                                                                                                                             NONE

     Landing Gear:                                                                                                                                                                                   RETR

     ATC Clearance                                                                                                                                                                                   

     Landing Gear                                                                                                                                                                                    

     Runway Condition                                                                                                                                                                                

     Landing Surface                                                                                                                                                                                 
  -- -------------------------- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- --------------------

**ENGINE INFORMATION**\
\
\
**Aircraft 1 - Engine #:1**

  -- --------------------------------------- -- -- --------------------------
     Engine Type:                                  TURBO PROP

     Engine Group                                  

     Engine Manufactuer                            P&W

     Engine Make                                   P & W

     Engine Model                                  PT6A-28

     Engine Cert Type                              

     Engine Horsepower                             680

     Engine Thrust                                 HP

     Carb/Injection                                

     Propeller Type                                
  -- --------------------------------------- -- -- --------------------------

**Injury Summary for Aircraft 1**

  ----------- -- ----------- -- ---------------- -- ------------ -- ------------
                 **Fatal**      **Serious**         **Minor**       **None**

  Crew           0              0                   0               1

  Pass                                                              

  Total          0              0                   0               1
  ----------- -- ----------- -- ---------------- -- ------------ -- ------------

**Pilot-in-Command for Aircraft 1**

  -------------------------- -- -- -----------------------------------------
  Certificates:                    AIRLINE TRANSPORT

  -------------------------- -- -- -----------------------------------------

  -----------------------------------------------------------------------
  Ratings:

  -----------------------------------------------------------------------

  ---- -------------------------------------------------------- --- --- ----
       Plane:                                                           

       Non-Plane:                                                       

       Instrument:                                                      

       Instruction:                                                     
  ---- -------------------------------------------------------- --- --- ----

  ------------------------------- -- -- --------------------------------------
  Had Current BFR:                      Y

  Months Since Last BFR:                

  Medical Certificate:                  CLASS 1

  Medical Certificate Validity:         VALID MEDICAL\--W/ WAIVERS/LIM.
  ------------------------------- -- -- --------------------------------------

  -------------------------------------------- ---- -- -- -----------------
  Flight Time (hours)                                     

  Total                                        :          7991

  Make/Model                                   :          249

  Instrument                                   :          0

  Multi-Engine                                 :          3822

  Last 24 Hours                                :          0

  Last 30 Days                                 :          10

  Last 90 Days                                 :          40

  Rotocraft                                    :          3990
  -------------------------------------------- ---- -- -- -----------------

**Sequence of Events**\
**Aircraft 1**\
Occurrence #: 1\
IN FLIGHT COLLISION WITH OBJECT\
Phase of Operation: APPROACH

  -------------- ----------- -------------------- -------------- --------------- ------------------
  **Findings**                                                                   

  **Event Seq    **Event     **Subject**          **Modifier**   **Personnel**   **Cause/Factor**
  \#**           Group                                                           
                 Code**                                                          

  1              1           OBJECT               UTILITY POLE                   FACTOR

  2              2           AIRCRAFT CONTROL     NOT MAINTAINED PILOT IN        CAUSE
                                                                 COMMAND         

  3              3           COMPLACENCY                         PILOT IN        CAUSE
                                                                 COMMAND         

  4              1           APPROACH AIDS, ILS   INOPERATIVE                    FACTOR
                             GLIDE SLOPE                                         
  -------------- ----------- -------------------- -------------- --------------- ------------------

**AIRCRAFT 1 PRELIMINARY REPORT**\
\
HISTORY OF THE FLIGHT On July 15, 1996, at about 0545 eastern daylight
time, N4391W, a Beech A100, owned and operated by Causey Aviation
Service Inc., was substantially damaged when it collided with a light
pole about 2 miles beyond the departure end of the runway, while
attempting an instrument approach to the Manchester Airport (MHT),
Manchester, New Hampshire. The certificated airline transport pilot was
not injured. Instrument meteorological conditions existed, and an
Instrument Flight Rules (IFR) flight plan was filed. The positioning
flight originated from Liberty, North Carolina, about 0315, and was
operated under 14 CFR Part 91. In a written statement, the pilot stated
that he had departed Liberty for Manchester to pick up a NASCAR Race
Team, and was to then return to Liberty. He said that he received his
IFR clearance from Greensboro Approach, and had been cleared as filed.
The pilot noted on his instrument panel that while flying over
Philadelphia, Pennsylvania, the airplane\'s outer marker and middle
marker lights began flashing, and he noted the same occurrence when he
passed over New York City, New York. He said that approximately 120
miles from Manchester, he received the ATIS which stated the weather
conditions, which included an RVR of 5,000 feet with fog, a ceiling of
10,000 feet, a barometric pressure of 29.94, and that the ILS to runway
35 was unmonitored. About 45 miles from Manchester he received a special
weather report over the ATIS that the RVR had decreased to 3,000 feet.
Manchester approach gave the pilot radar vectors and a descent for the
ILS approach to runway 35. The pilot stated that his last instruction
from approach control was to turn left to 030 degrees to intercept the
localizer inbound, descend to 2,600 feet, and upon interception of the
localizer was cleared for the ILS approach to runway 35. He was also
instructed to contact the tower at that time. He said that he had
previously set in the ILS frequency on both VOR\'s and received a strong
ID signal. He said the localizer bar started moving from the right
toward center, and the glide slope bar was showing up. He said he
engaged the auto pilot for a coupled ILS approach and the airplane
captured the ILS and started turning inbound. The pilot stated that when
the airplane was within 100 feet of decision height the localizer bar
went hard right, the glide slope flag came out, and the airplane turned
hard right. He turned the yoke left to counter-act just as the localizer
bar went hard left. The airplane immediately tried to follow and was
still in a descent. He countered with opposite yoke and felt for the
autopilot disconnect button on the yoke. He said he never heard or saw
the middle marker and he never saw runway lights or the ground. He said
that he had no idea how low or where he was because he was struggling to
gain control of the aircraft as he disconnected the autopilot. The pilot
further stated: \"I knew I was in serious extremus \[trouble\] as I
pushed the props and throttles forward, pulled the nose up and hit the
flap handle up. I was reaching for the gear handle when I looked out and
saw a tree line coming toward me out of the fog. At the same time I
glimpsed two light poles (similar to street lights) out my left window.
There was a loud and solid thump on the nose of the aircraft just as I
brought the gear handle up.\" The pilot stated that following the
collision with the light pole, he proceeded to the Burlington Airport,
Burlington, Vermont. He said that although the weather was VFR, he
elected to fly the ILS approach to runway 15 in order to \"..check my
equipment.\" The pilot stated, that he did not perform a auto pilot
approach but just monitored localizer, glide slope, and marker beacon
indications. The pilot said the ILS performed just as it should during
his practice approach. The pilot landed at Burlington on the main
landing gear and allowed the nose section of the fuselage to settle to
the runway as the speed decreased. There was no post-landing fire. The
airplane struck a light pole approximately 1.5 miles beyond the
departure end of runway 35. EXAMINATION OF THE ILS The FAA Airways
Facilities Office in Manchester, New Hampshire, revealed that the
Manchester area had experienced thunderstorm activity the evening of
July 14, 1996, and electrical activity from the storms had disabled the
ILS monitoring equipment. An Airways Facilities technician dispatched to
investigate the problem found the ILS monitoring equipment out of
service, but the localizer and glideslope equipment operational. The
technician departed the site around midnight. The ILS monitoring
equipment was notamed out-of-service. Following the accident, an Airways
Facilities technician arrived back on site approximately 0730, July 15,
1996. The technician found the glideslope equipment out of service. The
localizer, outer marker, and middle marker equipment were found
operational. The ILS monitoring equipment remained out of service. The
technician was unable to ascertain the time of failure of the glideslope
equipment. A Saab 340 commuter airplane on a positioning flight
following N4391W, reported they did not receive a glideslope signal.
Following a repair of the glideslope equipment, an operational flight
check was performed on the runway 35 ILS by a FAA Flight Inspection
airplane, which showed the ILS to be operating normally.

**AIRCRAFT 1 FINAL REPORT**\
\
While executing a coupled ILS approach to runway 35, at about 100 feet
above decision height the localizer bar went hard right, the glide slope
flag came out and the aircraft turned hard right. The pilot turned the
yoke left to counter-act just as the localizer bar went hard left. The
aircraft immediately tried to follow and was still in a descent. The
pilot countered with opposite yoke and felt for the autopilot disconnect
button on the yoke. While attempting to climb the aircraft struck a
light pole approximately 1.5 miles off the departure end of runway 35,
causing substantial damage to the nose landing gear wheel assembly and
left wing spar. Examination of the ILS by the FAA found that the
glideslope equipment was out of service, but that the localizer, outer
marker, and middle marker equipment was operational.

**AIRCRAFT 1 CAUSE REPORT**\
\
The pilots failure to maintain control of the aircraft during a coupled
approach. A related factor was the unmonitored inoperative glide slope.

**END REPORT**

**NASDAC BRIEF REPORT**

**GENERAL INFORMATION**

  -- ------------ -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- ------------------------------
     Data Source:                                                                                                                                                                                     NTSB AVIATION
                                                                                                                                                                                                      ACCIDENT/INCIDENT DATABASE

     Event Id:                                                                                                                                                                                        20001211X12763

     Local Date:                                                                                                                                                                                      07/27/1993

     Local Time:                                                                                                                                                                                      1620

     State:                                                                                                                                                                                           SC

     City:                                                                                                                                                                                            CHARLESTON

     Airport                                                                                                                                                                                          CHARLESTON AFB-INTL
     Name:                                                                                                                                                                                            

     Event Type:                                                                                                                                                                                      INCIDENT

     Injury                                                                                                                                                                                           NONE
     Severity:                                                                                                                                                                                        

     Report                                                                                                                                                                                           FINAL
     Status:                                                                                                                                                                                          

     Mid Air                                                                                                                                                                                          NO
     Collision:                                                                                                                                                                                       

     Event                                                                                                                                                                                            ON AIRPORT
     Location:                                                                                                                                                                                        

                                                                                                                                                                                                      
  -- ------------ -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- ------------------------------

**WEATHER INFORMATION**

  -- ------------------------------------- -- -- ------------------------------
     Weather Briefing Complete:                  FULL

     Brief Source:                               

     Basic Weather Conditions:                   VISUAL METEOROLOGICAL COND

     Light Condition:                            DAY

     Cloud Condition:                            SCATTERED

     Cloud Height above Ground Level (ft):       4000

     Ceiling Height above Ground Level           25000
     (ft):                                       

     Cloud Type:                                 BROKEN

     Visibility RVR (ft):                        0

     Visibility RVV (sm):                        0

     Visibility (sm):                            10

     Wind Direction (deg):                       160

     Wind Condition Flag:                        U

     Wind Speed (knots):                         7

     Wind Condition Indicated:                   Unknown

     Visibility Restrictions:                    

     Precipitation Type:                         
  -- ------------------------------------- -- -- ------------------------------

**AIRCRAFT INFORMATION**\
\
**Aircraft 1**

  -- -------------------------- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- --------------------------
     Category of Operation:                                                                                                                                                                          SCHEDULED

     Aircraft Type:                                                                                                                                                                                  AIRPLANE

     Aircraft Homebuilt:                                                                                                                                                                             NO

     Aircraft Damage:                                                                                                                                                                                MINOR

     Phase of Flight:                                                                                                                                                                                LANDING

     Aircraft Make:                                                                                                                                                                                  MCDONNELL-DOUGLAS-BOEING

                                                                                                                                                                                                     

     Aircraft Model:                                                                                                                                                                                 MD-80

                                                                                                                                                                                                     

     Aircraft Series:                                                                                                                                                                                88

     Operator Doing Business                                                                                                                                                                         
     As:                                                                                                                                                                                             

     Operator Name                                                                                                                                                                                   DELTA AIR LINES

     Owner Name                                                                                                                                                                                      DELTA AIR LINES

                                                                                                                                                                                                     

     NTSB Report Number:                                                                                                                                                                             ATL93IA135

     Number of Seats:                                                                                                                                                                                149

     Number of Engines:                                                                                                                                                                              2

     ELT Installed:                                                                                                                                                                                  NO

     ELT Operated:                                                                                                                                                                                   UNKNOWN

     Aircraft Use:                                                                                                                                                                                   UNKNOWN

     Type of Operation:                                                                                                                                                                              PART 121: AIR CARRIER

     Departure Airport Id:                                                                                                                                                                           ATL

     Departure City:                                                                                                                                                                                 ATLANTA

     Departure State:                                                                                                                                                                                GEORGIA

     Last Departure Point:                                                                                                                                                                           NO

     Destination Local:                                                                                                                                                                              SAME AS ACCIDENT/INCIDENT
                                                                                                                                                                                                     LOC

     Destination Airport Id:                                                                                                                                                                         CHS

     Destination City:                                                                                                                                                                               

     Destination State:                                                                                                                                                                              SOUTH CAROLINA

     Runway Id:                                                                                                                                                                                      21

     Runway Length:                                                                                                                                                                                  7000

     Runway Width:                                                                                                                                                                                   150

     Flight Plan Filed:                                                                                                                                                                              IFR

     Domestic/International:                                                                                                                                                                         DOMESTIC

     Passenger/Cargo:                                                                                                                                                                                PASSENGER ONLY

     Registration Number:                                                                                                                                                                            N948DL

     Air Carrier Operating                                                                                                                                                                           YES
     Certificates:                                                                                                                                                                                   

     Air Carrier Other                                                                                                                                                                               NO
     Operating Certificates:                                                                                                                                                                         

     Rotocraft/Agriculture                                                                                                                                                                           UNKNOWN
     Operating Certificate:                                                                                                                                                                          

     Cert Max Gross Wgt:                                                                                                                                                                             128000

     Aircraft Fire:                                                                                                                                                                                  NONE

     Aircraft Explosion:                                                                                                                                                                             NONE

     Landing Gear:                                                                                                                                                                                   RETR

     ATC Clearance                                                                                                                                                                                   

     Landing Gear                                                                                                                                                                                    

     Runway Condition                                                                                                                                                                                

     Landing Surface                                                                                                                                                                                 
  -- -------------------------- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- --------------------------

**ENGINE INFORMATION**\
\
\
**Aircraft 1 - Engine #:1**

  -- ----------------------------------------- -- -- ------------------------
     Engine Type:                                    TURBO FAN

     Engine Group                                    

     Engine Manufactuer                              P&W

     Engine Make                                     P & W

     Engine Model                                    JT8D219

     Engine Cert Type                                

     Engine Horsepower                               21000

     Engine Thrust                                   LBS

     Carb/Injection                                  

     Propeller Type                                  
  -- ----------------------------------------- -- -- ------------------------

**Injury Summary for Aircraft 1**

  ----------- -- ----------- -- ---------------- -- ------------ -- ------------
                 **Fatal**      **Serious**         **Minor**       **None**

  Crew           0              0                   0               6

  Pass                                                              99

  Total          0              0                   0               105
  ----------- -- ----------- -- ---------------- -- ------------ -- ------------

**Pilot-in-Command for Aircraft 1**

  -------------------------- -- -- -----------------------------------------
  Certificates:                    AIRLINE TRANSPORT

  -------------------------- -- -- -----------------------------------------

  -----------------------------------------------------------------------
  Ratings:

  -----------------------------------------------------------------------

  ---- -------------------------------------------------------- --- --- ----
       Plane:                                                           

       Non-Plane:                                                       

       Instrument:                                                      

       Instruction:                                                     
  ---- -------------------------------------------------------- --- --- ----

  ------------------------------- -- -- --------------------------------------
  Had Current BFR:                      Y

  Months Since Last BFR:                

  Medical Certificate:                  CLASS 1

  Medical Certificate Validity:         VALID MEDICAL\--W/ WAIVERS/LIM.
  ------------------------------- -- -- --------------------------------------

  ------------------------------------------ ---- -- -- -------------------
  Flight Time (hours)                                   

  Total                                      :          18000

  Make/Model                                 :          3099

  Instrument                                 :          0

  Multi-Engine                               :          0

  Last 24 Hours                              :          8

  Last 30 Days                               :          0

  Last 90 Days                               :          195

  Rotocraft                                  :          0
  ------------------------------------------ ---- -- -- -------------------

**Sequence of Events**\
**Aircraft 1**\
Occurrence #: 1\
LOSS OF CONTROL - IN FLIGHT\
Phase of Operation: LANDING - FLARE/TOUCHDOWN

  -------------- ------------- -------------- -------------- --------------- ------------------
  **Findings**                                                               

  **Event Seq    **Event Group **Subject**    **Modifier**   **Personnel**   **Cause/Factor**
  \#**           Code**                                                      

  1              1             TERRAIN        RUNWAY                         
                               CONDITION                                     

  2              2             AIRSPEED       NOT MAINTAINED PILOT IN        CAUSE
                                                             COMMAND         

  3              2             STALL          INADVERTENT    PILOT IN        CAUSE
                                                             COMMAND         
  -------------- ------------- -------------- -------------- --------------- ------------------

Occurrence #: 2\
IN FLIGHT COLLISION WITH TERRAIN/WATER\
Phase of Operation: DESCENT - UNCONTROLLED

  -------------- ------------------ ------------- -------------- --------------- ------------------
  **Findings**                                                                   

  **Event Seq    **Event Group      **Subject**   **Modifier**   **Personnel**   **Cause/Factor**
  \#**           Code**                                                          
  -------------- ------------------ ------------- -------------- --------------- ------------------

**AIRCRAFT 1 PRELIMINARY REPORT**\
\
On July 27, 1993, at 1620 eastern daylight time, a McDonnell Douglas
MD88, N948DL, operating as Delta Air Lines Flight 822, collided with the
runway during a landing at Charleston International Airport, Charleston,
South Carolina. The scheduled domestic passenger flight operated under
14 CFR Part 121 with a valid instrument flight clearance. Visual weather
conditions prevailed at the time of the incident. The airplane received
minor damage and the occupants were not injured. The flight departed
Atlanta, Georgia, at approximately 1520 hours. According to the pilot,
the flight was cleared for a VOR approach to runway 21 into Charleston.
When they reached the visual descent point on the approach, the flight
crew transitioned to the Visual Approach Slope Indicating system (VASI).
The pilot further said that the airplane was stabilized on the approach
above the prescribed airspeed stated in the MD-88 takeoff and landing
booklet. As the airplane approached the touchdown point on the runway
the first officer informed the pilot of a sink rate, and the pilot
applied power. According to the pilot, the aircraft touched down firmly
on the runway sooner than he expected. Examination of the aircraft tail
section revealed compression damage aft of fuselage station 1338 through
station 1351. The structural damage included the vertical displacement
of the tail skid, and deformation of surrounding skin material. Digital
Flight Data Recorder (DFDR) Readout The following comparative data was
recovered from the DFDR for three previous landings: \* the noseup stab
trim during the incident landing was approximately twice that maintained
during the three previous landings, \* the touchdown airspeed during the
incident landing was 8 to 14 KIAS lower than that of the three previous
landings, \* the nose-up elevator deflections made during the incident
landing were two to three times larger than those made during the three
previous landing, \* the maximum pitch attitude at touchdown during the
incident landing was two to five times larger than the maximum pitch
attitude at touchdown during the three previous landings. Summary of
Incident and Prior Landing
\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*
Comparison Item \| Incident landing \| Landing Prior to
\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*
max nose-up stab\| -10.9 \| -5.8 trim, degrees
\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\--
speed at \| 120.5 \| 134.8 touchdown, KIAS
\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\--
pitch ,degrees, \| +11.2 \| +4.1 at touchdown
\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\--
max nose-up, \| 10 \| 3 elevator during 3 seconds prior to touchdown,deg
\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\--
Max Vertical Gs \| 1.89 \| 1.16 at touchdown
\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\--
max flaps during\| 28 degrees \| 28 degrees final approach & at
touchdown
\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*
According to the MD-88 takeoff and landing speed booklet, at an aircraft
weight of 122,500 pounds and 28 degrees of landing flaps the landing
airspeed is 133 knots indicated (see attached copies from the MD-88
Takeoff And Landing Speed Booklet).

**AIRCRAFT 1 FINAL REPORT**\
\
THE FLIGHT WAS CLEARED FOR A VISUAL APPROACH. WHEN THE FLIGHT REACHED
THE VISUAL DESCENT POINT ON THE APPROACH, THE FLIGHT CREW TRANSITIONED
TO THE VASI. ACCORDING TO THE PILOT THE AIRPLANE WAS STABILIZED ON THE
APPROACH. AS THE AIRPLANE APPROACHED THE TOUCHDOWN POINT, THE FIRST
OFFICER ADVISED THE PILOT OF A HIGHER THAN NORMAL SINK RATE; THE
AIRPLANE TOUCHED DOWN HARD ON THE RUNWAY. THE PILOT STATED THAT THE
AIRPLANE TOUCHED DOWN SOONER THAN EXPECTED. EXAMINATION OF THE AIRFRAME
REVEALED STRUCTURAL DAMAGE BETWEEN FUSELAGE STATIONS 1338 THROUGH 1351.
THE DIGITAL FLIGHT DATA RECORDER READOUT FROM THE INCIDENT LANDING
REVEALED WHEN COMPARED TO THE THREE PERVIOUS LANDINGS THAT THE NOSEUP
STABILATOR TRIM WAS TWICE AS STEEP, TOUCHDOWN AIRSPEED WAS 8 TO 14 KNOTS
LOWER, NOSEUP ELEVATOR DEFLECTION WAS TWO TO THREE TIMES LARGER, AND THE
MAXIMUM PITCH ATTITUDE AT TOUCHDOWN WAS TWO TO FIVE TIMES HIGHER.
ACCORDING TO THE MD-88 TAKEOFF AND LANDING BOOKLET, THE LANDING AIRSPEED
FOR THE INCIDENT LANDING SHOULD HAVE BEEN 133 KNOTS.

**AIRCRAFT 1 CAUSE REPORT**\
\
WAS THE PILOT\'S FAILURE TO MAINTAIN ADEQUATE AIRSPEED DURING THE
LANDING ATTEMPT WHICH RESULTED IN A STALL AND THE SUBSEQUENT COLLISION
WITH THE RUNWAY.

**END REPORT**

**NASDAC BRIEF REPORT**

**GENERAL INFORMATION**

  -- ------------ -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- ------------------------------
     Data Source:                                                                                                                                                                                     NTSB AVIATION
                                                                                                                                                                                                      ACCIDENT/INCIDENT DATABASE

     Event Id:                                                                                                                                                                                        20010308X00561

     Local Date:                                                                                                                                                                                      03/04/2001

     Local Time:                                                                                                                                                                                      2030

     State:                                                                                                                                                                                           AZ

     City:                                                                                                                                                                                            PHOENIX

     Airport                                                                                                                                                                                          PHOENIX SKY HARBOR INTL
     Name:                                                                                                                                                                                            

     Event Type:                                                                                                                                                                                      INCIDENT

     Injury                                                                                                                                                                                           NONE
     Severity:                                                                                                                                                                                        

     Report                                                                                                                                                                                           FINAL
     Status:                                                                                                                                                                                          

     Mid Air                                                                                                                                                                                          NO
     Collision:                                                                                                                                                                                       

     Event                                                                                                                                                                                            ON AIRPORT
     Location:                                                                                                                                                                                        

                                                                                                                                                                                                      
  -- ------------ -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- ------------------------------

**WEATHER INFORMATION**

  -- ------------------------------------- -- -- ------------------------------
     Weather Briefing Complete:                  NOT PERTINENT

     Brief Source:                               

     Basic Weather Conditions:                   VISUAL METEOROLOGICAL COND

     Light Condition:                            NIGHT

     Cloud Condition:                            SCATTERED

     Cloud Height above Ground Level (ft):       18000

     Ceiling Height above Ground Level           25000
     (ft):                                       

     Cloud Type:                                 BROKEN

     Visibility RVR (ft):                        

     Visibility RVV (sm):                        

     Visibility (sm):                            10

     Wind Direction (deg):                       250

     Wind Condition Flag:                        Y

     Wind Speed (knots):                         4

     Wind Condition Indicated:                   

     Visibility Restrictions:                    

     Precipitation Type:                         
  -- ------------------------------------- -- -- ------------------------------

**AIRCRAFT INFORMATION**\
\
**Aircraft 1**

  -- -------------------------- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- --------------------
     Category of Operation:                                                                                                                                                                          SCHEDULED

     Aircraft Type:                                                                                                                                                                                  AIRPLANE

     Aircraft Homebuilt:                                                                                                                                                                             NO

     Aircraft Damage:                                                                                                                                                                                MINOR

     Phase of Flight:                                                                                                                                                                                LANDING - ROLL

     Aircraft Make:                                                                                                                                                                                  BOEING

                                                                                                                                                                                                     

     Aircraft Model:                                                                                                                                                                                 737

                                                                                                                                                                                                     

     Aircraft Series:                                                                                                                                                                                300

     Operator Doing Business                                                                                                                                                                         
     As:                                                                                                                                                                                             

     Operator Name                                                                                                                                                                                   SOUTHWEST AIRLINES

     Owner Name                                                                                                                                                                                      SOUTHWEST AIRLINES
                                                                                                                                                                                                     COMPANY

                                                                                                                                                                                                     

     NTSB Report Number:                                                                                                                                                                             LAX01IA109

     Number of Seats:                                                                                                                                                                                145

     Number of Engines:                                                                                                                                                                              2

     ELT Installed:                                                                                                                                                                                  NO

     ELT Operated:                                                                                                                                                                                   UNKNOWN

     Aircraft Use:                                                                                                                                                                                   

     Type of Operation:                                                                                                                                                                              PART 121: AIR
                                                                                                                                                                                                     CARRIER

     Departure Airport Id:                                                                                                                                                                           LAX

     Departure City:                                                                                                                                                                                 LOS ANGELES

     Departure State:                                                                                                                                                                                CALIFORNIA

     Last Departure Point:                                                                                                                                                                           NO

     Destination Local:                                                                                                                                                                              SAME AS
                                                                                                                                                                                                     ACCIDENT/INCIDENT
                                                                                                                                                                                                     LOC

     Destination Airport Id:                                                                                                                                                                         PHX

     Destination City:                                                                                                                                                                               PHOENIX

     Destination State:                                                                                                                                                                              ARIZONA

     Runway Id:                                                                                                                                                                                      8

     Runway Length:                                                                                                                                                                                  6000

     Runway Width:                                                                                                                                                                                   150

     Flight Plan Filed:                                                                                                                                                                              IFR

     Domestic/International:                                                                                                                                                                         DOMESTIC

     Passenger/Cargo:                                                                                                                                                                                PASSENGER ONLY

     Registration Number:                                                                                                                                                                            N335SW

     Air Carrier Operating                                                                                                                                                                           UNKNOWN
     Certificates:                                                                                                                                                                                   

     Air Carrier Other                                                                                                                                                                               UNKNOWN
     Operating Certificates:                                                                                                                                                                         

     Rotocraft/Agriculture                                                                                                                                                                           
     Operating Certificate:                                                                                                                                                                          

     Cert Max Gross Wgt:                                                                                                                                                                             130000

     Aircraft Fire:                                                                                                                                                                                  NONE

     Aircraft Explosion:                                                                                                                                                                             NONE

     Landing Gear:                                                                                                                                                                                   RETR

     ATC Clearance                                                                                                                                                                                   

     Landing Gear                                                                                                                                                                                    

     Runway Condition                                                                                                                                                                                

     Landing Surface                                                                                                                                                                                 
  -- -------------------------- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- --------------------

**ENGINE INFORMATION**\
\
\
**Aircraft 1 - Engine #:1**

  -- --------------------------------- -- -- ---------------------------------
     Engine Type:                            TURBO FAN

     Engine Group                            

     Engine Manufactuer                      GENERAL ELECTRIC

     Engine Make                             

     Engine Model                            CFM-56

     Engine Cert Type                        

     Engine Horsepower                       20000

     Engine Thrust                           LBS

     Carb/Injection                          

     Propeller Type                          
  -- --------------------------------- -- -- ---------------------------------

**Injury Summary for Aircraft 1**

  ----------- -- ----------- -- ---------------- -- ------------ -- ------------
                 **Fatal**      **Serious**         **Minor**       **None**

  Crew           0              0                   0               5

  Pass                                                              114

  Total          0              0                   0               119
  ----------- -- ----------- -- ---------------- -- ------------ -- ------------

**Pilot-in-Command for Aircraft 1**

  ----------------- -- -- ---------------------------------------------------
  Certificates:           AIRLINE TRANSPORT,FLIGHT ENGINEER

  ----------------- -- -- ---------------------------------------------------

  -----------------------------------------------------------------------
  Ratings:

  -----------------------------------------------------------------------

  ---- -------------------------------------------------------- --- --- ----
       Plane:                                                           

       Non-Plane:                                                       

       Instrument:                                                      

       Instruction:                                                     
  ---- -------------------------------------------------------- --- --- ----

  ---------------------------------- -- -- ----------------------------------
  Had Current BFR:                         

  Months Since Last BFR:                   09-JAN-01

  Medical Certificate:                     CLASS 1

  Medical Certificate Validity:            WITH WAIVERS/LIMITATIONS
  ---------------------------------- -- -- ----------------------------------

  ------------------------------------------ ---- -- -- -------------------
  Flight Time (hours)                                   

  Total                                      :          11848

  Make/Model                                 :          6829

  Instrument                                 :          0

  Multi-Engine                               :          11819

  Last 24 Hours                              :          8

  Last 30 Days                               :          93

  Last 90 Days                               :          218

  Rotocraft                                  :          0
  ------------------------------------------ ---- -- -- -------------------

**Sequence of Events**\
**Aircraft 1**\
Occurrence #: 1\
OVERRUN\
Phase of Operation: LANDING - ROLL

  -------------- ------------ --------------- -------------- --------------- ------------------
  **Findings**                                                               

  **Event Seq    **Event      **Subject**     **Modifier**   **Personnel**   **Cause/Factor**
  \#**           Group Code**                                                

  1              2            DISTANCE        MISJUDGED      PILOT IN        CAUSE
                                                             COMMAND         

  2              2            CREW/GROUP      NOT PERFORMED  FLIGHTCREW      FACTOR
                              BRIEFING                                       

  3              1            LIGHT CONDITION BRIGHT NIGHT                   

  4              1            WEATHER         TAILWIND                       
                              CONDITION                                      
  -------------- ------------ --------------- -------------- --------------- ------------------

Occurrence #: 2\
ON GROUND/WATER ENCOUNTER WITH TERRAIN/WATER\
Phase of Operation: LANDING - ROLL

  -------------- ------------- -------------- --------------- --------------- ------------------
  **Findings**                                                                

  **Event Seq    **Event Group **Subject**    **Modifier**    **Personnel**   **Cause/Factor**
  \#**           Code**                                                       

  1              1             TERRAIN        CONSTRUCTION                    
                               CONDITION      AREA                            
  -------------- ------------- -------------- --------------- --------------- ------------------

**AIRCRAFT 1 PRELIMINARY REPORT**\
\
On March 4, 2001, at 2030 hours mountain standard time, a Boeing
737-3H4, N335SW, continued off the end of runway 8 during landing roll
and came to a stop in a runway construction area at Phoenix Sky Harbor
International Airport, Arizona. The aircraft, operated by Southwest
Airlines Company as Flight 2021, departed Los Angeles, California, at
1833 Pacific standard time, and was a regularly scheduled domestic
passenger flight operated under 14 CFR Part 121. The aircraft received
minor damage. There were no injuries to the airline transport
certificated pilot, the First Officer, 3 cabin flight attendants or 114
passengers. The flight was operating on an instrument flight rules
flight plan; however, visual meteorological conditions prevailed.
According to the cockpit voice recorder transcript of the incident
flight, at 2000:34, the crew received the Automatic Terminal Information
Service (ATIS) information DELTA, which contained, in part, the
following: \"runway eight last six thousand feet closed. If unable
runway eight, advise Phoenix approach on initial contact. runway seven
right localizer/DME out of service. wind zero five zero at four. expect
visual approach runway seven right or visual approach eight.\" At
2015:06, the Captain briefed for a visual approach to runway seven right
with an \"ILS backup.\" At 2016:08, the crew learned that they would be
parking at gate B-17. At 2016:20, following a discussion with the First
Officer concerning the proximity of that gate with various runways, the
Captain said, \"I guess we want uh, eight if we can get it, huh?\" The
First Officer responded, \"yeah, yeah.\" At 2018:29, Phoenix Approach
Control advised the crew to \"join the Phoenix runway seven right
localizer. At 2018:46, asked approach, \"would the north be available by
any chance?\" Phoenix Approach responded, \"I\'ll put your request
down.\" At 2022:25, Approach advised the crew to \"report runway eight
in sight.\" The First Officer responded, \"uh, didn\'t quite understand
that, we are requesting runway eight.\" Approach responded, \"report it
in sight.\" There was no briefing for the approach to runway eight. At
2023:01, flight 2021 was cleared for the visual approach to runway
eight. Shortly thereafter, the crew began the before-landing checklist,
and at 2027:56, the First Officer noted that the checklist was complete.
At 2028:03, the flight was cleared to land on runway eight and the tower
controller advised that the wind was, \"two five zero at four.\" The
target airspeed was 135 knots, and the last airspeed callout, on final
approach, was 137 knots. Runway 8 at Phoenix Sky Harbor is 11,000 feet
long and 150 feet wide; however, runway enhancement construction was in
progress on the eastern 6,000 feet of the runway. Six thousand feet were
removed during construction, and 1,000 feet were added to the
non-construction section, leaving 6,000 feet available for landing. At
2056, the Phoenix surface wind was from 230 degrees at 4 knots.
According to an inspector from the Federal Aviation Administration
Arizona Flight Standards District Office, the aircraft came to a stop
approximately 75 feet off the usable landing surface. During
construction, runway 8 is a visual runway with a Precision Approach Path
Indicator (PAPI) visual glidepath guidance system, but without
electronic approach path guidance. A Notice to Airmen (NOTAM) was in
effect regarding the runway condition. After stopping in the
construction area, the passengers were deplaned via stairs. The Deputy
Aviation Director of the Sky Harbor Airport, Planning and Development
Department said that runway 8 was being used as a \"visual\" category
runway. It was lighted and marked as a visual runway in accordance with
FAA Advisory Circular AC 150/5340-24. This phase of the construction
(west portion of the runway in use) had been in progress since February
18, 2001, and there have been \"thousands\" of operations on the runway
without complaint from operators; although, there has been a
\"significant\" refusal rate among pilots offered the runway. The
instrument approach lighting system was not being operated. There were
runway end identifier lights (REIL) and a PAPI in operation serving each
end of the runway. There are high intensity runway edge lights (HIRL);
however, the last 2,000 feet of lighting is not colored amber because
this is a visual runway and the amber light requirement in the FAA AC
pertains to instrument runways. At the time of the incident there were
four runway threshold lights on each side of the runway. The outer-most
light was aligned with the runway edge lights and the other three lights
spaced inward, toward the center of the runway on 10-foot centers. After
the incident, the runway marking and lighting were examined by the FAA
and found to be incompliance with applicable ACs. After the incident the
number of threshold lights was increased to eight per side (16 total per
end), the lenses were replaced and the wattage of the light bulbs was
increased. The threshold lights are on a different dimming circuit from
the edge lights but were \"always brighter.\" The PAPI is positioned so
as to provide a 50-foot threshold crossing height using a 3-degree
glidepath. The morning after the Southwest incident the 4-box PAPI
serving runway 8 was checked. The first box was found positioned
correctly, the second box was 1 -minute off, the third box was
positioned correctly and the fourth box was 4-minutes off. Regarding the
pilot\'s report of glare, the Deputy Aviation Director said that the
evening hours construction is more than 1,000 feet beyond the end of the
runway and later at night they close the runway entirely before working
nearer the operational portion of the runway. The Phoenix Chief Pilot
for Southwest Airlines said that the west end of runway 8/26 was
completed first and the east end was being completed at the time of the
incident. Southwest\'s agreement with the airport was that there would
be 6,000 of usable runway kept open. He thought the PAPI was positioned
for a touchdown point about 1,300 feet from the threshold to accommodate
Boeing 757 aircraft, the largest aircraft anticipated to use the runway
during construction. The Chief Pilot further said that he examined the
runway end environment during hours of darkness approximately 24-hours
after the incident occurred. He observed that the red lights laterally
outboard of the runway end were not visually conspicuous because of
their position outside the pilot\'s primary field of visual interest
(the runway directly in front of him), because of relatively low light
bulb wattage and also because of the attenuating effects of the red
lens. He also noted that construction was on-going through the nighttime
hours on the eastern end of the runway between about the 7,000-foot and
the 10,000-foot locations. There was substantial glare directed back
toward the runway by construction floodlighting that was partially
directed to the west toward the portion of the runway that was
operational. As a result of these observations, he directed Southwest
Airline\'s concerns to the City of Phoenix Department of Airports and 3
changes were made: 1) The runway end threshold lights were repositioned
within the lateral confines of the width of the runway. The lights then
numbered 16 and started at the edge of the runway and were positioned
inward toward the center at 10-foot intervals leaving 30-feet clear in
the center; 2) The intensity of the light bulbs was increased from 125
watts to 175 watts; and 3) Additional direction was given to the runway
construction contractor to control the direction of construction
floodlights and reduce glare for aircraft operating on the runway.

**AIRCRAFT 1 FINAL REPORT**\
\
The flight was cleared for the approach to runway 7 and the Captain
briefed the First Officer for the approach. After getting their gate
assignment, the crew requested, and was cleared for, the approach to
runway 8. No briefing was conducted for the approach to runway 8, nor
was there any discussion about runway length or that runway 8 was a
visual runway and would not have lighting and markings associated with
an instrument runway. The target airspeed was 135 knots, and the last
airspeed callout was 137 knots. The flight data recorder indicated that
the approach speed was 137.5 knots. According to information on the
Flight Data Recorder, the airplane touched down approximately 2,000 feet
past the approach end of the 6,000 foot long runway. Upon landing, the
captain deployed the thrust reversers and applied the wheel brakes. When
he noticing the end of the runway approaching faster than anticipated,
he applied maximum braking and reverse thrust. The aircraft rolled
beyond the end of the pavement and came to rest within one airplane
length of the departure end of the runway with the empennage over the
end of the runway.

**AIRCRAFT 1 CAUSE REPORT**\
\
the pilot\'s misjudgment of distance, which resulted in a runway
overrun. A factor in the incident was the failure of the flightcrew to
conduct a briefing for the approach to runway eight.

**END REPORT**

**NASDAC BRIEF REPORT**

**GENERAL INFORMATION**

  -- ------------ -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- ------------------------------
     Data Source:                                                                                                                                                                                     NTSB AVIATION
                                                                                                                                                                                                      ACCIDENT/INCIDENT DATABASE

     Event Id:                                                                                                                                                                                        20020103X00009

     Local Date:                                                                                                                                                                                      01/01/2002

     Local Time:                                                                                                                                                                                      1057

     State:                                                                                                                                                                                           FL

     City:                                                                                                                                                                                            MIAMI

     Airport                                                                                                                                                                                          MIAMI INTL
     Name:                                                                                                                                                                                            

     Event Type:                                                                                                                                                                                      INCIDENT

     Injury                                                                                                                                                                                           NONE
     Severity:                                                                                                                                                                                        

     Report                                                                                                                                                                                           FINAL
     Status:                                                                                                                                                                                          

     Mid Air                                                                                                                                                                                          NO
     Collision:                                                                                                                                                                                       

     Event                                                                                                                                                                                            ON AIRPORT
     Location:                                                                                                                                                                                        

                                                                                                                                                                                                      
  -- ------------ -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- ------------------------------

**WEATHER INFORMATION**

  -- ------------------------------------- -- -- ------------------------------
     Weather Briefing Complete:                  FULL

     Brief Source:                               

     Basic Weather Conditions:                   VISUAL METEOROLOGICAL COND

     Light Condition:                            DAY

     Cloud Condition:                            

     Cloud Height above Ground Level (ft):       

     Ceiling Height above Ground Level           25000
     (ft):                                       

     Cloud Type:                                 BROKEN

     Visibility RVR (ft):                        

     Visibility RVV (sm):                        

     Visibility (sm):                            10

     Wind Direction (deg):                       360

     Wind Condition Flag:                        Y

     Wind Speed (knots):                         8

     Wind Condition Indicated:                   

     Visibility Restrictions:                    

     Precipitation Type:                         
  -- ------------------------------------- -- -- ------------------------------

**AIRCRAFT INFORMATION**\
\
**Aircraft 1**

  -- ------------------------- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- --------------------------
     Category of Operation:                                                                                                                                                                         SCHEDULED

     Aircraft Type:                                                                                                                                                                                 AIRPLANE

     Aircraft Homebuilt:                                                                                                                                                                            NO

     Aircraft Damage:                                                                                                                                                                               MINOR

     Phase of Flight:                                                                                                                                                                               LANDING - ROLL

     Aircraft Make:                                                                                                                                                                                 MCDONNELL-DOUGLAS-BOEING

                                                                                                                                                                                                    

     Aircraft Model:                                                                                                                                                                                MD-80

                                                                                                                                                                                                    

     Aircraft Series:                                                                                                                                                                               83

     Operator Doing Business                                                                                                                                                                        
     As:                                                                                                                                                                                            

     Operator Name                                                                                                                                                                                  BWIA WEST INDIES AIRWAYS
                                                                                                                                                                                                    LIMITED

     Owner Name                                                                                                                                                                                     PEGASUS AVIATION, INC.

                                                                                                                                                                                                    

     NTSB Report Number:                                                                                                                                                                            MIA02IA047

     Number of Seats:                                                                                                                                                                               138

     Number of Engines:                                                                                                                                                                             2

     ELT Installed:                                                                                                                                                                                 NO

     ELT Operated:                                                                                                                                                                                  NO

     Aircraft Use:                                                                                                                                                                                  

     Type of Operation:                                                                                                                                                                             PART 129: FOREIGN

     Departure Airport Id:                                                                                                                                                                          TBPB

     Departure City:                                                                                                                                                                                BRIDGETOWN

     Departure State:                                                                                                                                                                               

     Last Departure Point:                                                                                                                                                                          NO

     Destination Local:                                                                                                                                                                             SAME AS ACCIDENT/INCIDENT
                                                                                                                                                                                                    LOC

     Destination Airport Id:                                                                                                                                                                        KMIA

     Destination City:                                                                                                                                                                              MIAMI

     Destination State:                                                                                                                                                                             FLORIDA

     Runway Id:                                                                                                                                                                                     30

     Runway Length:                                                                                                                                                                                 9355

     Runway Width:                                                                                                                                                                                  150

     Flight Plan Filed:                                                                                                                                                                             IFR

     Domestic/International:                                                                                                                                                                        INTERNATIONAL

     Passenger/Cargo:                                                                                                                                                                               PASSENGER/CARGO

     Registration Number:                                                                                                                                                                           9Y-THQ

     Air Carrier Operating                                                                                                                                                                          UNKNOWN
     Certificates:                                                                                                                                                                                  

     Air Carrier Other                                                                                                                                                                              UNKNOWN
     Operating Certificates:                                                                                                                                                                        

     Rotocraft/Agriculture                                                                                                                                                                          
     Operating Certificate:                                                                                                                                                                         

     Cert Max Gross Wgt:                                                                                                                                                                            160000

     Aircraft Fire:                                                                                                                                                                                 NONE

     Aircraft Explosion:                                                                                                                                                                            NONE

     Landing Gear:                                                                                                                                                                                  RETR

     ATC Clearance                                                                                                                                                                                  

     Landing Gear                                                                                                                                                                                   

     Runway Condition                                                                                                                                                                               

     Landing Surface                                                                                                                                                                                
  -- ------------------------- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- --------------------------

**ENGINE INFORMATION**\
\
\
**Aircraft 1 - Engine #:1**

  -- ---------------------------------- -- -- --------------------------------
     Engine Type:                             TURBO FAN

     Engine Group                             

     Engine Manufactuer                       PRATT & WHITNEY

     Engine Make                              

     Engine Model                             JT8D-219

     Engine Cert Type                         

     Engine Horsepower                        21700

     Engine Thrust                            LBS

     Carb/Injection                           

     Propeller Type                           
  -- ---------------------------------- -- -- --------------------------------

**Injury Summary for Aircraft 1**

  ----------- -- ----------- -- ---------------- -- ------------ -- ------------
                 **Fatal**      **Serious**         **Minor**       **None**

  Crew           0              0                   0               6

  Pass                                                              119

  Total          0              0                   0               125
  ----------- -- ----------- -- ---------------- -- ------------ -- ------------

**Pilot-in-Command for Aircraft 1**

  -------------------------- -- -- -----------------------------------------
  Certificates:                    AIRLINE TRANSPORT

  -------------------------- -- -- -----------------------------------------

  -----------------------------------------------------------------------
  Ratings:

  -----------------------------------------------------------------------

  ---- -------------------------------------------------------- --- --- ----
       Plane:                                                           

       Non-Plane:                                                       

       Instrument:                                                      

       Instruction:                                                     
  ---- -------------------------------------------------------- --- --- ----

  ------------------------------- -- -- -------------------------------------
  Had Current BFR:                      

  Months Since Last BFR:                15-NOV-01

  Medical Certificate:                  CLASS 1

  Medical Certificate Validity:         VALID MEDICAL\--NO WAIVERS/LIM.
  ------------------------------- -- -- -------------------------------------

  ------------------------------------------ ---- -- -- -------------------
  Flight Time (hours)                                   

  Total                                      :          12636

  Make/Model                                 :          2022

  Instrument                                 :          0

  Multi-Engine                               :          12235

  Last 24 Hours                              :          0

  Last 30 Days                               :          0

  Last 90 Days                               :          0

  Rotocraft                                  :          0
  ------------------------------------------ ---- -- -- -------------------

**Sequence of Events**\
**Aircraft 1**\
Occurrence #: 1\
OVERRUN\
Phase of Operation: LANDING - ROLL

  -------------- ------------ ------------- -------------- ---------------- ------------------
  **Findings**                                                              

  **Event Seq    **Event      **Subject**   **Modifier**   **Personnel**    **Cause/Factor**
  \#**           Group Code**                                               

  1              2            PLANNED       IMPROPER       COPILOT/SECOND   CAUSE
                              APPROACH                     PILOT            

  2              2            AIRSPEED      EXCESSIVE      COPILOT/SECOND   CAUSE
                                                           PILOT            

  3              2            GO-AROUND     NOT PERFORMED  COPILOT/SECOND   CAUSE
                                                           PILOT            

  4              2            SUPERVISION   INADEQUATE     PILOT IN COMMAND CAUSE

  5              2            RUN ON        INADVERTENT    FLIGHTCREW       
                              LANDING                                       
  -------------- ------------ ------------- -------------- ---------------- ------------------

**AIRCRAFT 1 PRELIMINARY REPORT**\
\
HISTORY OF THE FLIGHT On January 1, 2002, about 1057 eastern standard
time, a McDonnell-Douglas MD-83, Trinidad registration 9Y-THQ, operated
by BWIA West Indies Airways, as flight 432, scheduled passenger service
from Bridgetown, Barbados, to Miami, Florida, overran the runway while
landing at Miami International Airport. Visual meteorological conditions
prevailed at the time and an instrument flight rules flight plan was
filed. The airplane received minor damage and the airline
transport-rated captain, first officer, 4 flight attendants, and 119
passengers were not injured. The flight originated from Barbados, at
0730. The captain stated the first officer was flying the airplane for
the approach and landing. He and the first officer performed a briefing
for the localizer 30 approach to Miami International Airport, prior to
beginning descent. During landing on runway 30, the airplane floated for
a while before touchdown, after the first officer flared for landing.
After a few seconds, he, the captain, took control of the airplane
during the landing roll. It appeared the airplane would over run the
runway and collide with an approach light structure. The captain steered
the airplane to the left side of the runway and brought it to a complete
stop with the nose wheel in a sandy area. He shut down the engines and
deplaned the passengers. The airplane was then towed to the gate. (See
captain statement). The first officer stated that before beginning
descent from 31,000 feet, that he and the captain briefed for the
localizer 30 approach to Miami International Airport. They crossed the
JUNUR intersection at 10,000 feet and 250 knots airspeed. They were
given a heading to fly by the air traffic controller to intercept the
localizer for runway 30 and then cleared for the approach. As they
rounded out into the landing flare, there was no contact with the
runway. He applied control column pressure and contacted the runway. He
applied engine reverse and firm brakes. The airplane did not decelerate
as it should. He applied more reverse and firm brakes and veered the
airplane slightly left of center as the approach lights at the end of
the runway came into view. The captain continued steering the airplane
90 degrees to the left and stopped with the nose wheel in sand. (See
first officer statement). A pilot-rated passenger stated the airplane
was flying extremely fast and at a much higher than normal airspeed
during the approach to land. They floated over the runway and finally
touched down hard on all three landing gear. The wheel brakes were
applied almost immediately and the tires were squealing. The smell of
burning rubber entered the cabin. About 2/3 of the way down the runway,
the flight attendant told them to brace for impact. As they approached
the end of the runway, the pilot hit the left brake hard and the
airplane turned to the left and skidded right side first. He saw the
approach lights approaching the right side of the airplane. The right
wing tip cleared the approach lights and the airplane came to a stop
with the nose wheel in sand. They exited the airplane via the aft air
stair and were taken to the terminal by bus. (See passenger statement).
Air traffic controllers stated the flight crossed the runway 30
threshold at a high rate of speed and touched down at the intersection
of the runway and taxiway Z. The airplane then rolled to the end of the
runway and turned to the left, coming to rest with the nose wheel off
the runway surface. (See air traffic controller statements). Recorded
radar data from the FAA, Miami Approach Control, showed the flight was
at 304 knots groundspeed when descending through 1,000 feet on the
approach to land. At 300 feet on the approach, the flight was at 262
knots groundspeed. The last radar contact was at 1055:55 and showed zero
feet altitude and 166 knots groundspeed. (See recorded radar data).
METEOROLOGICAL INFORMATION Visual meteorological conditions prevailed at
the time of the accident. The Miami International Airport, 1056 surface
weather observation was wind from 360 degrees at 8 knots, visibility 10
statute miles, clouds 25,000 feet broken, temperature 21 degrees C, dew
point temperature 15 degrees C, altimeter setting 30.10 in Hg. FLIGHT
RECORDERS The cockpit voice recorder was still operating when the NTSB
arrived at the airplane, which had already been towed to a gate, after
the incident. The cockpit voice recorder was retained by NTSB and
forwarded to the NTSB Vehicle Recorders Division, Washington, D.C., for
readout. The recorder did not contain any human voices or air noise
similar to an aircraft operation in flight or on the ground. The BWIA
International Airways Limited, Flight Operations Manual, states on page
2:6:3, under \"Procedures Following a Serious Incident\", item 10.3.6,
\"If relevant, items such as the Cockpit Voice Recorder, Flight Data
Recorder and ATC tapes should be preserved.\" (See Cockpit Voice
Recorder Group Chairman Report and Operations Manual Pages). The digital
flight data recorder was retained by NTSB and forwarded to the NTSB
Vehicle Recorders Division, Washington, D.C., for readout. The data
indicated that as the airplane was descending to land, the airspeed
began to increase. The spoilers were deployed for 16 seconds during the
approach to land. As the airplane descended through 1,980 feet, the
airspeed was 313 knots. The autopilot was switched off and the spoilers
were again deployed for 28 seconds. The wing slats and flaps were
extended followed by the landing gear. The airplane switched from air
mode to ground mode while at an airspeed of 153 knots and on a magnetic
heading of 305 degrees. The engine thrust reversers deployed and within
2 seconds, full brake pedal travel was reached. The wing spoilers did
not extend during landing. The airplane came to a stop on magnetic
heading 209 degrees. (See Specialist\'s Factual Report of Investigation,
Digital Flight Data Recorder). Analysis of the digital flight data
recorder data was performed by The Boeing Company. The approach
reference speed (Vref) for the airplane at the incident landing weight
was 128 knots with 40 degrees of wing flaps extended and 132 knots with
28 degrees of wing flaps extended. It would be expected that the final
approach speed would be stabilized at Vref + 5 knots. The decent from
cruise flight to 10, 000 feet appeared normal and at 10,000 feet the
airplane maintained 250 knots airspeed. During descent from 10,000 feet
the airspeed began to increase, reaching over 300 knots as the airplane
descended through 5,000 feet. An airspeed of over 300 knots was
maintained until within 4 miles of the runway and an altitude of 1,500
feet. The airplane crossed over the runway threshold at over 100 feet,
as measured by the radio altimeter, and over 200 knots airspeed, at
least Vref + 70 knots. The touchdown speed was approximately 150 knots.
Full wing spoilers or speed brakes were deployed from 4.5 to 2.5 miles
remaining to the runway or between 1,700 and 800 feet. Wing slat
extension began at an altitude of 1,200 feet and 290 knot airspeed. Wing
flap extension began at 900 feet and 280 knot airspeed. The landing gear
was extended at 1.5 miles from the runway at an altitude of 400 feet.
The ground spoilers were not deployed after landing. The airplane
appears to have touched down over 5,000 feet past the runway threshold.
The airplane came to rest about 90 degrees left of runway heading. (See
The Boeing Company Report). MEDICAL AND PATHOLOGICAL INFORMATION Post
incident drug and alcohol testing on specimens obtained from the captain
and first officer were negative. ADDITIONAL INFORMATION The airplane was
released by NTSB on January 1, 2002, to Steve Boyce, BWIA International
Airways, Station Manager, Miami, Florida. The retained cockpit voice
recorder was released to Steve Boyce on January 11, 2002, and the
retained digital flight data recorder was released to Steve Boyce on
February 20, 2002.

**AIRCRAFT 1 FINAL REPORT**\
\
The captain stated the first officer was flying the airplane for the
approach and landing. He and the first officer performed a briefing for
the localizer 30 approach to Miami International Airport, prior to
beginning descent. During landing on runway 30, the airplane floated for
a while before touchdown, after the first officer flared for landing.
After a few seconds, he, the captain, took control of the airplane
during the landing roll. It appeared the airplane would over run the
runway and collide with an approach light structure. The captain steered
the airplane to the left side of the runway and brought it to a complete
stop with the nose wheel in a sandy area. He shutdown the engines and
deplaned the passengers. The airplane was then towed to the gate.
Readout of the digital flight data recorder showed the decent from
cruise flight to 10, 000 feet appeared normal and at 10,000 feet the
airplane maintained 250 knots airspeed. During descent from 10,000 feet
the airspeed began to increase, reaching over 300 knots as the airplane
descended through 5,000 feet. An airspeed of over 300 knots was
maintained until within 4 miles of the runway and an altitude of 1,500
feet. The airplane crossed over the runway threshold at over 100 feet,
as measured by the radio altimeter, and over 200 knots airspeed, at
least Vref + 70 knots. The touchdown speed was approximately 150 knots.
Full wing spoilers or speed brakes were deployed from 4.5 to 2.5 miles
remaining to the runway or between 1,700 and 800 feet altitude. Wing
slat extension began at an altitude of 1,200 feet and 290 knot airspeed.
Wing flap extension began at 900 feet and 280 knot airspeed. The landing
gear was extended at 1.5 miles from the runway at an altitude of 400
feet. The ground spoilers were not deployed after landing. The airplane
appears to have touched down over 5,000 feet past the runway threshold.
The airplane came to rest about 90 degrees left of runway heading.

**AIRCRAFT 1 CAUSE REPORT**\
\
The failure of the first officer to fly a stabilized approach at the
correct airspeed and his failure to execute a missed approach resulting
in touchdown about 5,000 feet past the runway threshold at an excessive
airspeed and over run of the runway prior to stopping. Contributing to
the incident was the failure of the captain to properly supervise the
first officer and take corrective action.

**END REPORT**

**NASDAC BRIEF REPORT**

**GENERAL INFORMATION**

  -- ------------ -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- ------------------------------
     Data Source:                                                                                                                                                                                     NTSB AVIATION
                                                                                                                                                                                                      ACCIDENT/INCIDENT DATABASE

     Event Id:                                                                                                                                                                                        20020403X00453

     Local Date:                                                                                                                                                                                      03/13/2002

     Local Time:                                                                                                                                                                                      1940

     State:                                                                                                                                                                                           NV

     City:                                                                                                                                                                                            RENO

     Airport                                                                                                                                                                                          RENO-TAHOE INTERNATIONAL
     Name:                                                                                                                                                                                            

     Event Type:                                                                                                                                                                                      ACCIDENT

     Injury                                                                                                                                                                                           SERIOUS
     Severity:                                                                                                                                                                                        

     Report                                                                                                                                                                                           FINAL
     Status:                                                                                                                                                                                          

     Mid Air                                                                                                                                                                                          NO
     Collision:                                                                                                                                                                                       

     Event                                                                                                                                                                                            OFF AIRPORT/AIRSTRIP
     Location:                                                                                                                                                                                        

                                                                                                                                                                                                      
  -- ------------ -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- ------------------------------

**WEATHER INFORMATION**

  -- ----------------------------------- -- -- ---------------------------------
     Weather Briefing Complete:                FULL

     Brief Source:                             

     Basic Weather Conditions:                 INSTRUMENT METEOROLOGICAL COND

     Light Condition:                          NIGHT/DARK

     Cloud Condition:                          

     Cloud Height above Ground Level           
     (ft):                                     

     Ceiling Height above Ground Level         700
     (ft):                                     

     Cloud Type:                               BROKEN

     Visibility RVR (ft):                      

     Visibility RVV (sm):                      

     Visibility (sm):                          .5

     Wind Direction (deg):                     300

     Wind Condition Flag:                      Y

     Wind Speed (knots):                       10

     Wind Condition Indicated:                 

     Visibility Restrictions:                  

     Precipitation Type:                       
  -- ----------------------------------- -- -- ---------------------------------

**AIRCRAFT INFORMATION**\
\
**Aircraft 1**

  -- ------------------------- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- ---------------------
     Category of Operation:                                                                                                                                                                         NON-SCHEDULED

     Aircraft Type:                                                                                                                                                                                 AIRPLANE

     Aircraft Homebuilt:                                                                                                                                                                            NO

     Aircraft Damage:                                                                                                                                                                               DESTROYED

     Phase of Flight:                                                                                                                                                                               APPROACH - FAF/OUTER
                                                                                                                                                                                                    MARKER TO

     Aircraft Make:                                                                                                                                                                                 BEECH

                                                                                                                                                                                                    

     Aircraft Model:                                                                                                                                                                                BE-90

                                                                                                                                                                                                    

     Aircraft Series:                                                                                                                                                                               BE-90-E90

     Operator Doing Business                                                                                                                                                                        REGENT AIR, INC.
     As:                                                                                                                                                                                            

     Operator Name                                                                                                                                                                                  PILOT SERVICES CORP

     Owner Name                                                                                                                                                                                     PILOT SERVICES
                                                                                                                                                                                                    CORPORATION

                                                                                                                                                                                                    

     NTSB Report Number:                                                                                                                                                                            LAX02FA108

     Number of Seats:                                                                                                                                                                               8

     Number of Engines:                                                                                                                                                                             2

     ELT Installed:                                                                                                                                                                                 YES

     ELT Operated:                                                                                                                                                                                  YES

     Aircraft Use:                                                                                                                                                                                  

     Type of Operation:                                                                                                                                                                             PART 135: AIR TAXI &
                                                                                                                                                                                                    COMMUTER

     Departure Airport Id:                                                                                                                                                                          DRO

     Departure City:                                                                                                                                                                                DURANGO

     Departure State:                                                                                                                                                                               COLORADO

     Last Departure Point:                                                                                                                                                                          NO

     Destination Local:                                                                                                                                                                             

     Destination Airport Id:                                                                                                                                                                        RNO

     Destination City:                                                                                                                                                                              RENO

     Destination State:                                                                                                                                                                             CALIFORNIA

     Runway Id:                                                                                                                                                                                     34L

     Runway Length:                                                                                                                                                                                 11000

     Runway Width:                                                                                                                                                                                  150

     Flight Plan Filed:                                                                                                                                                                             IFR

     Domestic/International:                                                                                                                                                                        DOMESTIC

     Passenger/Cargo:                                                                                                                                                                               PASSENGER ONLY

     Registration Number:                                                                                                                                                                           N948CC

     Air Carrier Operating                                                                                                                                                                          UNKNOWN
     Certificates:                                                                                                                                                                                  

     Air Carrier Other                                                                                                                                                                              UNKNOWN
     Operating Certificates:                                                                                                                                                                        

     Rotocraft/Agriculture                                                                                                                                                                          
     Operating Certificate:                                                                                                                                                                         

     Cert Max Gross Wgt:                                                                                                                                                                            10500

     Aircraft Fire:                                                                                                                                                                                 NONE

     Aircraft Explosion:                                                                                                                                                                            NONE

     Landing Gear:                                                                                                                                                                                  RETR

     ATC Clearance                                                                                                                                                                                  

     Landing Gear                                                                                                                                                                                   

     Runway Condition                                                                                                                                                                               

     Landing Surface                                                                                                                                                                                
  -- ------------------------- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- ---------------------

**ENGINE INFORMATION**\
\
\
**Aircraft 1 - Engine #:1**

  -- ------------------------------- -- -- -----------------------------------
     Engine Type:                          TURBO PROP

     Engine Group                          

     Engine Manufactuer                    PRATT & WHITNEY

     Engine Make                           

     Engine Model                          PT6A-28

     Engine Cert Type                      

     Engine Horsepower                     550

     Engine Thrust                         HP

     Carb/Injection                        

     Propeller Type                        CONTROLLABLE PITCH
  -- ------------------------------- -- -- -----------------------------------

**Injury Summary for Aircraft 1**

  ----------- -- ----------- -- ---------------- -- ------------ -- ------------
                 **Fatal**      **Serious**         **Minor**       **None**

  Crew           0              0                   1               0

  Pass                          1                   4               

  Total          0              1                   5               0
  ----------- -- ----------- -- ---------------- -- ------------ -- ------------

**Pilot-in-Command for Aircraft 1**

  ---------------- -- -- ----------------------------------------------------
  Certificates:          AIRLINE TRANSPORT,FLIGHT INSTRUCTOR

  ---------------- -- -- ----------------------------------------------------

  -----------------------------------------------------------------------
  Ratings:

  -----------------------------------------------------------------------

  ---- -------------------------------------------------------- --- --- ----
       Plane:                                                           

       Non-Plane:                                                       

       Instrument:                                                      

       Instruction:                                                     
  ---- -------------------------------------------------------- --- --- ----

  ------------------------------- -- -- -------------------------------------
  Had Current BFR:                      

  Months Since Last BFR:                22-FEB-02

  Medical Certificate:                  CLASS 1

  Medical Certificate Validity:         VALID MEDICAL\--NO WAIVERS/LIM.
  ------------------------------- -- -- -------------------------------------

  -------------------------------------------- ---- -- -- -----------------
  Flight Time (hours)                                     

  Total                                        :          1610

  Make/Model                                   :          608

  Instrument                                   :          495

  Multi-Engine                                 :          856

  Last 24 Hours                                :          7

  Last 30 Days                                 :          54

  Last 90 Days                                 :          138

  Rotocraft                                    :          0
  -------------------------------------------- ---- -- -- -----------------

**Sequence of Events**\
**Aircraft 1**\
Occurrence #: 1\
LOSS OF CONTROL - IN FLIGHT\
Phase of Operation: APPROACH - FAF/OUTER MARKER TO THRESHOLD (IFR)

  -------------- ------------ -------------- -------------- --------------- ------------------
  **Findings**                                                              

  **Event Seq    **Event      **Subject**    **Modifier**   **Personnel**   **Cause/Factor**
  \#**           Group Code**                                               

  1              1            WEATHER        LOW CEILING                    
                              CONDITION                                     

  2              1            WEATHER        ICING                          FACTOR
                              CONDITION      CONDITIONS                     

  3              1            WEATHER        SNOW                           FACTOR
                              CONDITION                                     

  3              2            AIRSPEED       NOT MAINTAINED PILOT IN        CAUSE
                                                            COMMAND         

  4              2            REMEDIAL       DELAYED        PILOT IN        CAUSE
                              ACTION                        COMMAND         

  5              2            AIRSPEED (VS)  NOT MAINTAINED PILOT IN        CAUSE
                                                            COMMAND         

  6              2            STALL/MUSH     INADVERTENT    PILOT IN        
                                                            COMMAND         
  -------------- ------------ -------------- -------------- --------------- ------------------

Occurrence #: 2\
IN FLIGHT COLLISION WITH OBJECT\
Phase of Operation: APPROACH - FAF/OUTER MARKER TO THRESHOLD (IFR)

  -------------- -------------- ------------- --------------------- --------------- ------------------
  **Findings**                                                                      

  **Event Seq    **Event Group  **Subject**   **Modifier**          **Personnel**   **Cause/Factor**
  \#**           Code**                                                             

  1              1              OBJECT        BUILDING                              
                                              (NONRESIDENTIAL)                      
  -------------- -------------- ------------- --------------------- --------------- ------------------

**AIRCRAFT 1 PRELIMINARY REPORT**\
\
HISTORY OF FLIGHT On March 13, 2002, about 1940 Pacific standard time
(PST), a Beech E90, N948CC, descended into an unoccupied commercial
building during an in-flight loss of control, about 1 mile
south-southeast of the Reno/Tahoe International Airport, Reno, Nevada.
Pilot Services Corporation, d.b.a. Regent Air Service, Inc., Truckee,
California, operated the airplane. The accident occurred during a
nighttime instrument approach in instrument meteorological conditions.
The airline transport certificated pilot and four passengers sustained
minor injuries, and a fifth passenger sustained a serious injury. The
airplane was destroyed. The flight was operated under the provisions of
14 CFR Part 135 as an on-demand air taxi flight, which departed from
Durango, Colorado, about 1625 mountain standard time (1525 PST). Earlier
in the day, about 0518 PST, the pilot and passengers had departed from
the Truckee-Tahoe Airport, Truckee, California, for the planned round
trip flight to Durango. The pilot landed in Durango about 0850 mountain
standard time (0750 PST). The pilot reported to National Transportation
Safety Board investigators that thereafter, he ate lunch and retired at
the prearranged crew-rest hotel. The pilot further indicated that the
airplane was refueled, and he did not observe any discrepancies with the
airplane during his preflight inspection for the planned nonstop return
flight. According to the pilot, the flight was uneventful until he
attempted to land at the Truckee-Tahoe Airport, his home base. At 1905
PST, the pilot received a clearance to perform an instrument approach to
the Truckee-Tahoe Airport. Prior to commencement of the approach, the
pilot activated the airplane\'s anti-ice systems, and they remained on
throughout the remainder of the flight. The pilot activated the
pneumatic wing deice boots prior to reaching the final approach fix. The
pilot indicated that he initiated the approach but could not land
because of his inadequate visibility; it was snowing. The pilot executed
a missed approach at 1919. Thereafter, he requested and received a
clearance with radar vectors to proceed to the Reno/Tahoe International
Airport. The pilot further reported that snow showers also existed at
Reno, and on only one occasion did he activate the deice boots during
the approach. That occurred while on a vector to intercept the
localizer, distance measuring equipment (DME), back course instrument
approach to runway 34L. The pilot stated that he never observed an
appreciable amount of ice on the leading edge of the wing, but he felt
that there was enough to activate the boots. The pilot stated that when
he activated the boots, \"a little (ice) came off.\" He could see ice on
the side of the wing\'s stall strip. There was some thin ice on the
boot, but it did not extend beyond the boot. At 1925:27, the pilot was
cleared to perform the instrument approach. During the Safety Board
investigator\'s subsequent interview with the pilot, he indicated that
it was his belief that, upon reaching the final approach fix, the
airport\'s reported weather was at or above his landing minimums. At
1936:44, the pilot made his last recorded radio transmission during
which he acknowledged being cleared to land. The pilot stated that
everything on the approach was normal outside of the 2-mile DME fix.
However, control of the airplane became difficult inside the 2-mile DME
fix. The pilot further reported to Safety Board investigators that the
airplane\'s approach was initially stabilized upon reaching the minimum
descent altitude (MDA). At the MDA, he increased engine torque (power)
to 800 foot-pounds per engine in order to maintain altitude. According
to the pilot, a torque value between 700 and 900 foot-pounds is normal.
The pilot indicated that some ice was visible on the wing\'s leading
edge stall strip, but opined it was \"way less than 1/4-inch\" in depth.
He stated that the ice did not extend beyond the aft portion of the
wing\'s deicing boot. According to the pilot, during the final seconds
of flight, the controls started vibrating and he felt a yawing moment.
The pilot said that he instantly looked at the indicated airspeed, which
was between 111 and 115 knots. Thereafter, the airplane started to
shake. Previously, the airplane had been flying at 140 knots, the
recommended approach speed for icing conditions. The pilot said that he
applied full engine power; however, the airplane still shook and yawed.
He recalled that the rudder pedals appeared to move freely. Although the
vibration varied in intensity, once it started it never stopped. The
pilot further reported that he pitched forward on the yoke, and he did
not believe the airplane was stalling because the indicated airspeed was
still near the \"blue line.\" The pilot reported that he felt the
airplane sink. While the airplane was sinking he noticed that the stall
warning light was illuminated, and he attempted to stop the airplane\'s
descent. He did not \"yank back or push forward\" on the yoke; he just
maintained a level attitude. The pilot looked outside and saw buildings
\"coming up.\" The engine power was full, but the airplane was not
climbing. The pilot reported thinking that he was going to hit the
building and that he had to reduce the impact. Therefore, he pulled the
yoke full back. The left wing stalled, and the airplane banked left. The
pilot stated that there might have been ice on the tail because the tail
\"felt really weird.\" He said \"something made the airplane go down
when it shouldn\'t have.\" The airplane\'s last recorded radar position
was at 1939:53. At this time, the airplane had descended to about 4,500
feet, as indicated by its Mode C altitude reporting transponder. The
accident site\'s elevation is approximately 4,470 feet msl. PERSONNEL
INFORMATION Certification and Experience. The pilot held an airline
transport pilot certificate with an airplane multiengine land rating. He
had commercial privileges in single engine land and sea airplanes. The
pilot also possessed a certified flight instructor certificate with
airplane single engine, multiengine, and instrument airplane privileges.
He possessed advanced ground school instructor and aircraft dispatcher
certificates. The pilot\'s last first-class aviation medical certificate
was issued without limitations on May 14, 2001. The pilot\'s total
flight time was 1,610 hours, of which 608 hours were flown in the model
of the accident airplane. During the 30- and 90-day periods preceding
the accident, the pilot had flown the accident model of airplane as
pilot-in-command for 40 and 105 hours, respectively, of which 8 and 22
hours were in actual instrument meteorological conditions. Regent Air,
Inc., hired the pilot in August 2000. In July 2001, he began flying the
Beech E90 as pilot-in-command. The pilot\'s last FAR Part 135
competency, instrument proficiency, and line checks were performed by a
Federal Aviation Administration (FAA) inspector in February 2002. All of
the checks were completed satisfactorily. AIRPLANE INFORMATION The Beech
Aircraft Company began manufacturing the model E90 series of airplanes
in 1972, with serial number LW-1. The accident airplane, serial number
LW-236, was manufactured in 1977. Beech discontinued production of this
model of airplane in 1981, with serial number LW-347. According to the
Raytheon Aircraft Company participant, the interior configurations of
these airplanes varied. As of April 2, 2002, FAA registration records
indicated that 247 E90s were registered. Flight Manual and Check List
Information. The FAA approved Airplane Flight Manual (AFM) contained the
following statements regarding flight in icing conditions: \"CAUTION
Stalling airspeeds should be expected to increase when ice has
accumulated on the airplane due to the distortion of the wing airfoil.
For the same reason, stall warning devices are not accurate and should
not be relied upon. Keep a comfortable margin of airspeed above the
normal stall airspeed with ice on the airplane. Maintain a minimum of
140 knots during sustained icing conditions to prevent ice accumulation
on unprotected surfaces of the wing\....\" A 6-inch by 12-inch spiral
binder entitled \"Beechcraft King Air E90 PILOT\'S CHECK LIST\" was
recovered from the accident airplane. The binder\'s cover was imprinted
with the name \"Raytheon Aircraft Company,\" and all of the pages within
were printed with \"P/N 90-590012-7,\" and were dated \"5/8/72.\" In
part, the checklist identified actions the pilot should take in
preparation for departure. Checking the functionality of the deice boots
on the tail after the engines are started was not mentioned in the
checklist. Airplane Certification, Equipment, and Instrument Markings.
The pressurized, turboprop airplane was certificated by the FAA for
flight into known icing conditions. The airplane was equipped with deice
boots on its wings, and on the vertical and horizontal stabilizers.
Unlike the wing mounted boots, from the cockpit the pilot cannot see all
of the boots on the tail. The airplane is not equipped with an
annunciator light or indicator gauge that shows the functionality of the
tail-mounted boots. The airplane had been modified by installation of a
Raisbeck Engineering conversion, and its AFM had been amended. The
airplane\'s maximum gross weight was increased to 10,500 from its
previous 10,100 pounds. According to Raisbeck personnel, the
modification did not change the airplane\'s stall speed. Regarding the
airspeed indicator, a blue radial line is present on the airspeed
indicator. The line represents the best rate-of-climb airspeed (Vyse)
with one engine inoperative. The placarded airspeed is 111 knots.
Maintenance and Inspections. The pilot reported that, to the best of his
knowledge, during the accident flight none of the installed equipment
became dysfunctional. Moreover, no maintenance items had been deferred
pursuant to a minimum equipment list. The pilot personally performed the
pretakeoff, walk-around inspection of the airplane. The accident
airplane had been on Regent Air\'s Part 135 certificate since July 1994.
Regent Air\'s personnel reportedly maintained the accident airplane
pursuant to the manufacturer\'s (Raytheon) recommended maintenance
program. Maintenance inspections were reportedly accomplished in
accordance with Raytheon Aircraft\'s Beech King Air 90 Maintenance
Manual. This inspection program utilizes \"Phase Inspections\" and is
accomplished at 200-hour intervals, identified as Phase 1 through 4. The
complete program is scheduled to be accomplished at least one time every
24 calendar months. Each Phase Inspection is accomplished using a
checklist. The Safety Board\'s Maintenance Group Chairman reviewed the
checklists to identify the frequency of inspections to the environmental
and pneumatic systems. The review noted that all four Phase Inspections
checked the heating system. In part, the inspection included actions to
check all ducts for damage and deterioration and to check the bleed
ducts for damage. During all four inspections, the surface deice system
was to be checked for proper operation and cycling, and the
environmental system was to be checked for proper operation. The last
Phase Inspection accomplished on the airplane prior to the accident was
a Phase 4 Inspection. It was accomplished on February 28, 2002. At that
time, the airplane\'s total time was 8,748.7 hours. At the time of the
accident, the airplane\'s total time was 8,772.75 hours. A review of
Regent Air\'s maintenance records revealed that between 1999 and 2001,
the environmental air and pneumatic deice system had undergone
maintenance. In part, in January 1999, tubing was replaced. In December
2000, new boots were installed. In 2001, holes in the vertical
stabilizer were repaired, the cabin temperature controller was replaced,
and static air pneumatic tubing located near the aft lavatory, which was
found melted, was repaired. In September 2001, a Regent Air mechanic
reported that he found melted EVA tubing near the aft pressure bulkhead.
The mechanic determined that a leak was coming from a gasket at the rear
of the cargo compartment, which supplies heat to the cabin (referring to
the Station 277 heat vent). To stop the leak, the mechanic removed the
vent cover and wrapped some aluminum tape around the gasket to seal the
leak, and then he replaced the vent cover. The mechanic reported that it
was not a normal practice to check the environmental tubing itself,
which was wrapped inside of insulation material. Therefore, he did not
check the environmental tubing during installation of the aluminum tape.
He also stated that he only removed the aft floor panel to gain access
to the vent. He did not remove the panel immediately forward of that
location. (See the Safety Board\'s Maintenance Records Group Chairman\'s
report for additional details.) METEOROLOGICAL INFORMATION Ground
Personnel and Facility Reports. Nineteen minutes prior to the accident,
at 1921, Reno fire department personnel had responded to a medical call
about 3/4 mile southwest from where the accident would occur. The
personnel noted that it was snowing lightly. However, by 1931, it was
snowing heavily, the wind speed had increased, and the conditions
appeared like a \"squall blowing into the area with whiteout
conditions.\" At 1930, Reno\'s automatic terminal information service
(ATIS) was broadcasting \"information Oscar.\" In pertinent part, the
ATIS indicated that Reno\'s wind was from 290 degrees at 15 knots, and
the visibility was 1 1/4 miles in light snow and mist. At 1932:30, the
Reno south radar controller broadcast \"Reno ATIS Oscar current.\" The
controller advised the pilot, at 1933:16, that \"\...the last arrival
seven twenty seven got the runway in sight mile and a half
(unintelligible) south.\" The pilot was not provided with updated
visibility information during the remainder of his approach. At 1939,
the Reno/Tahoe International Airport\'s surface wind was from 300
degrees at 10 knots, and the visibility was 1/2 mile. There was moderate
snow and freezing fog. A broken ceiling existed at 700 feet above ground
level (agl), and an overcast sky condition existed at 2,500 feet agl.
The temperature and dew points were, respectively, minus 2 and minus 3
degrees Celsius. The altimeter setting was 30.04 inches of mercury.
After the accident, at 1956, Reno\'s visibility was also 1/2 mile in
moderate snow and freezing fog. The vertical visibility was reported at
300 feet. Pilot Observations. According to the pilot, the first and only
time he activated the deice boots going into Reno was on a radar vector
to intersect the back course. This occurred less than 5 minutes before
intercepting the back course. He activated the boots to get rid of the
\"residual\" ice. Ice did deploy from the airplane. The pilot stated
that he had also activated the deicing boots prior to the approach at
Truckee. Additional Ground Witness Observations. There were five
auditory witnesses to the accident. They all were located in the
building next to the one with which the airplane collided. Upon hearing
the collision they went outside and made the following statements
regarding the weather conditions that they observed. One witness
reported that the weather was a complete whiteout. It was snowing hard,
and the visibility was zero. A second witness also reported it was
snowing heavily and described it as a whiteout. He reported that he
could see \"quite a ways down the street,\" but visibility was poor
looking up. He described the snow as being heavy and wet. A third
witness also reported a storm had just come in and it was snowing
heavily. He described it as a \"wet, packed snow.\" Visibility was
terrible, maybe about 40 feet. A fourth witness stated that it was
snowing heavily and the snow was sticking. He could hardly see across
the street. He estimated visibility at 100 yards. A fifth witness said
she could not see across the street. The snow was not really wet and not
really dry, but was sticking. Airplane Passenger Observations. The five
airplane passengers reported the following information. Three of the
passengers reported that it was snowing on the approach to Reno. One of
these passengers recalled seeing ice fly off the wing between Truckee
and Reno. A fourth passenger indicated that he held a student pilot
certificate. He stated that during the approach to Reno it was snowing
hard. Snow and ice was forming on the wing. He described the ice as
being about 1-inch high on the wing deice boot, but it did not cover the
whole boot. The fifth passenger, who held a private pilot certificate,
reported that the airplane was flying just below clouds for about the
last 2 miles of its flight. Approaching Reno there was 1 1/2- to
2-inches (vertically) of ice on the wing\'s leading edge. There was ice
on the wing that was maybe 1/4-inch thick. He had observed ice coming
off the wing earlier while approaching Reno, but about the same amount
of ice had accumulated on the wing again. It was snowing, but the
turbulence was minimal to nonexistent. He said the airplane shuddered,
and he was absolutely certain the airplane stalled. COMMUNICATION AND
FACILITIES The FAA reported that all communications with the accident
airplane pilot were normal. All navigation aids associated with the
instrument approach to Reno were functioning normally. AIRPORT AND
INSTRUMENT APPROACH INFORMATION The airport\'s elevation is 4,412 feet
mean sea level (msl). Runway 34L\'s touchdown zone\'s elevation is 4,407
feet msl. The minimum descent altitude for the localizer, DME, back
course, instrument approach to runway 34L is 5,060 feet msl (653 feet
agl). During the accident flight, the straight-in landing minimum
visibility requirement for the pilot was 1 mile. The final approach fix
is located at an indicated DME distance of 9.7 nautical miles (nm) from
Reno. The missed approach point is located at a DME distance of 0.5 nm
from Reno, which is about 0.8 nm from the approach end of the runway.
WRECKAGE AND IMPACT INFORMATION The main wreckage was imbedded in the
top of a commercial building at an estimated elevation of 4,470 feet msl
at the following global positioning satellite (GPS) coordinates: north
39 degrees 28.22 minutes latitude by west 119 degrees 46.11 minutes
longitude. The magnetic bearing to runway 34L was about 343 degrees. The
accident site was about 0.96 nm south-southeast of the runway\'s
displaced threshold and an estimated 200 feet east of the runway\'s
extended centerline. The Safety Board investigator\'s examination of the
initial point of impact revealed white paint transfer signatures and
impact damage in the block wall structure of a rectangular shaped
two-story building, on its southeast side. The angle of the paint
signature was measured to be about 70 degrees. (A 90-degree angle would
be perpendicular to the horizon.) The airplane\'s separated
white-colored left wing was beneath the wall outside the building near
the separated left horizontal stabilizer. The left wing\'s leading edge
was crushed in an aft direction, consistent with the shape of the block
wall. The remainder of the airplane was partially penetrating the
building\'s roof. The airplane was in an estimated 70-degree left wing
low (left bank) attitude, and on a magnetic heading of approximately 315
degrees. The fuselage, which remained intact, was suspended from
building structure at the mezzanine level. The left engine was found
attached to the inboard wing structure principally by cables and skin.
The right engine separated from the airframe and was inside the building
at ground level. It had come to rest in the northwest corner of the
building. The nose cone area of the fuselage was crushed in an aft
direction. Responding fire department personnel reported noting a strong
odor of fuel in the vicinity of the main wreckage and at ground level
inside the building. The left wing\'s fuel tank was crushed, and no fuel
was noted. During the recovery procedure, fuel was draining from the
impact-damaged right wing and it pooled beneath the wreckage. The
propeller assemblies were attached to the engines. Fire department and
contract structural engineers reported to the Safety Board investigator
that the building\'s integrity had been compromised due to the impact.
After the building\'s walls were reinforced to preclude collapse and
roof sections removed, the wreckage was hoisted vertically out of the
building. Thereafter, Safety Board investigative personnel examined it.
MEDICAL AND PATHOLOGICAL INFORMATION The pilot reported that he does not
take any prescription or non-prescription drugs and that he does not
smoke. He stated that there have been no significant changes in his
health during the past year. TESTS AND RESEARCH Airframe Structure and
Control Examination. The airplane was initially examined on scene
immediately following its extrication from the building. Thereafter, it
was transported to a recovery facility where a detailed structural
examination was performed. In summary, all flight control surfaces were
found in the vicinity of the main wreckage. With the exception of the
separated left wing and left horizontal stabilizer, all flight controls
were attached to their respective hinges. No evidence was found of any
preimpact control system anomalies. The continuity of the flight control
system was confirmed. The wing flap jackscrews were examined and were
found in positions corresponding to fully retracted flaps, according to
the Raytheon (Beech Aircraft) participant. The rudder trim was in a
neutral position. Propeller Examination. The propeller blades were
observed attached to their hub assemblies, which were attached to the
propeller shaft flanges and engines. The propeller blades were
torsionally twisted, leading edge gouged, and scratched in a chordwise
direction. Additionally, they exhibited an \"S\" bend and several tips
were broken. Engine Examination. The Pratt & Whitney engine participant
reported that its records indicated the engines installed on the
accident airplane were original to the airframe. There was no history of
sudden stoppage, accidents, or incidents. The engines\' fuel controls
were set to the maximum power position. The air inlet screens were
covered with building-related debris, the compressors ingested
building-related debris, and debris exited the bleed valve assemblies.
Also, the exhaust ducts were twisted and wrinkled in a manner consistent
with absorption of high, propeller blade-like rotational energy.
Following the Safety Board investigator\'s supervised examination, the
participant opined the evidence indicated that \"both engines had been
commanded to maximum power via cockpit and engine control settings, and
at the time of impact both engines were running and producing power.\"
Avionics Examination. The pilot reported to Safety Board investigators
that the airplane\'s IFR certified GPS receiver had been turned on prior
to his initiation of the instrument approach into Reno. During the
accident investigation, the receiver was removed from the airplane\'s
instrument panel and sent to Northstar Technologies, Action,
Massachusetts, for examination under FAA supervision. In summary, the
receiver had a current Jeppesen Flight Card installed. The receiver was
approved by the FAA for IFR usage. It was in the \"approach enabled\"
operating mode. No \"breadcrumb\" flight track history was incorporated
in the software. The receiver updates its recorded position at 1-second
intervals. About the time the receiver lost electrical power, its last
known position (LKP) was automatically recorded. The coordinates of this
position were north 39 degrees 28.21 minutes latitude by west 119
degrees 46.12 minutes longitude. Pneumatic System Examination and Deice
Boots. With the exception of the majority of the left wing\'s destroyed
deice boot and the totally destroyed left horizontal stabilizer\'s deice
boot, all of the boots were tested to ascertain their ability to
pressurize utilizing an external air supply source. The air supply was
initially directed into the airplane\'s pneumatic air supply lines at
attachment points next to the inboard portion of each respective boot
assembly at the wing roots, and from the rear side of the aft pressure
bulkhead. Using pressurized air at these locations, all of the testable
boots inflated. However, further examination showed that air could not
reach the tail boots when it was pumped into the pneumatic system from a
location upstream of the boots. In one area of the airplane, a blockage
was noted to the pneumatic air supply line during its integrity
examination. The blockage was near the bottom of the right side aft
fuselage, near Station 277. At Station 277, a heat register is located
just forward of the aft lavatory. In this area the \"1010 EVA 5/8
Imperial\" tubing that supplies pneumatic pressure to the empennage
deice boots runs parallel to and approximately 2 inches away from the
heat ducting. This tubing collapsed and appeared melted, from
approximately 11 inches aft of Station 277 to approximately 9 inches
forward of Station 277. After finding the blockage in the pneumatic
line, the adjacent environmental heat ducting was examined. This
environmental heat ducting, which supplies hot air to the cabin, runs
the length of the right side fuselage under the floorboards from the
cockpit to the Station 277 heat register. The right side floorboard
panels were removed to provide complete access to the entire hot air
system. This system incorporates plastic tubular ducting, which varies
in size and shape throughout the length of the fuselage, and is
completely covered with insulation material. To test for leakage, smoke
was blown into the ducting utilizing a smoke generator. Smoke was
applied into the insulated plastic ducting at the floor outlet that was
located aft of the first officer\'s seat. When smoke was applied, smoke
leakage was observed at various locations along the plastic ducting
including the ducting vent by Station 277, near the blocked pneumatic
line. The insulation material was then removed in the areas of the
leakage to expose the tubing. Several locations of the tubing had
suffered severe heat distress, showing evidence of collapse and of a
splitting along a seam line. The heat distress was more severe in the
section of the ducting where the tubing necked down to the smaller
diameter necessary to connect to the floor outlets. (See the Safety
Board Maintenance Group Chairman\'s Factual Report for additional
information.) In summary, the examination revealed that the pneumatic
line that routes deice boot air, in the vicinity of the aft lavatory,
had been melted and was completely collapsed in one area (see
photographs). The collapse and blockage to this pneumatic line in this
area precluded the deice boots on all tail surfaces from inflating
during the post impact examination when the pressurized air source was
connected to the pneumatic line from a location forward of the aft
pressure bulkhead. Maintenance History and Records. A review of the
operator\'s maintenance records revealed that there were no outstanding
airworthiness directives or service bulletins on the airplane. The pilot
verbally reported that there were no outstanding squawks when he
departed from Truckee or Durango. In addition, the pilot stated that no
malfunctions were experienced during the accident flight. At no time
during the flight was there evidence of smoke in the cabin or the odor
of burning material. Also, the cabin\'s ambient air temperature and
pressure had been normal. Preflight Inspection Procedure.
Notwithstanding maintenance procedures, in order to inflate the deice
boots to perform a functionality check, a pilot is required to have an
engine operating. Most of the tail-mounted boots cannot be seen from
inside the cockpit. According to Regent Air\'s chief pilot, it is a
typical procedure to check the tail deice boots during the daytime.
However, they are not typically checked during nighttime operations, nor
are they checked before every flight. Radar and Performance Study. The
Safety Board\'s Washington, D.C., Office of Research and Engineering,
Vehicle Performance Division, performed a study of FAA recorded radar
data and analyzed the airplane\'s performance characteristics. The data
was processed and calculations for airplane heading (yaw), pitch, roll,
angle of attack, air speed, ground speed, and climb/descent rates were
calculated and plotted. Profile and plan view displays were produced
showing the flight altitude profile in line with the final approach
course, and the ground track in reference to the accident site as well
as orientation to the runway for the final portion of the flight. In
pertinent part, the data showed that the airplane was flying at a level
altitude of 9,000 feet msl between 1935 and 1936, as the pilot was
making his final turn toward the runway\'s final approach course.
Between these times, the airplane\'s estimated calibrated airspeed (CAS)
was between 160 and 175 knots. About 1936, the airplane started
experiencing significant yawing motions, of up to 20 and 30 degrees to
the left and right, and the airplane\'s estimated descent rate began to
vary between 1,100 and 1,500 feet per minute (fpm). Also about this
time, the airplane\'s estimated bank angle began to vary between 17
degrees to the right and 10 degrees to the left. Between 1936:30 and
1940:00, the airplane\'s estimated pitch attitude and angle of attack
varied slightly being about -3 degrees and 0 degrees, respectively,
until about 1938:00. At nearly 1940:00, the airplane\'s estimated pitch
attitude and angle of attack had increased to about 8 and 14 degrees,
respectively. About 1938:30, the airplane\'s estimated CAS had decreased
below the recommended minimum approach speed of 140 knots for icing
conditions. About this time, the airplane was approximately 3 1/2 miles
from the runway. The airplane\'s estimated CAS continued to decrease
rapidly to about 75 knots just prior to 1940:00, which is the estimated
time of impact. (See the Safety Board\'s specialist report for
additional information and for constraints of the data used in the
study.) ADDITIONAL INFORMATION On May 6, 2003, the Raytheon Aircraft
Company\'s participant advised the Safety Board investigator that, in
response to previous communications with the investigator, Raytheon had
begun revising its Model 90 King Air series Pilot\'s Operating Handbooks
and Pilot\'s Operating Manuals to include the following (checklist)
statement: \"Check both wing and both horizontal stabilizer boots
visually, if possible, for inflation and vacuum hold down.\" The
airplane wreckage was released to the operator\'s insurance company
representative on July 31, 2002.

**AIRCRAFT 1 FINAL REPORT**\
\
During an instrument approach, upon descending to the prescribed minimum
descent altitude, about 1/2 mile from the missed approach point, the
pilot failed to maintain flying airspeed. The airplane stalled, rolled
left, and in an uncontrolled descent collided with a commercial building
0.96 nm from the runway\'s displaced threshold. The accident occurred
during the return portion of a round trip flight, while on final
approach to the pilot\'s alternate airport due to a weather-induced
diversion. Moderate intensity snow showers and freezing fog existed.
During the initial approach, the reported visibility was 1 1/2 miles.
About the time the pilot passed the final approach fix, the visibility
decreased to 1/2 mile, but the pilot was not informed of the decrease
below his 1-mile minimum requirement. The pilot had maintained the
recommended 140-knot approach speed in the icing conditions until about
3 1/2 miles from the runway. Thereafter, the airplane\'s speed gradually
decreased until reaching about 75 knots. After the airplane started
vibrating, the pilot increased engine power, but his action was not
timely enough to avert stalling. Company mechanics maintained the
airplane. On previous occasions overheat conditions had occurred wherein
the environmental ducting melted and heat was conducted to the adjacent
pneumatic tube that provides deice air to the empennage boots. During
the accident investigation, the deice tube was found completely melted
closed, thus rendering all of the empennage deice boots dysfunctional.

**AIRCRAFT 1 CAUSE REPORT**\
\
The pilot\'s inadequate approach airspeed for the existing adverse
meteorological conditions followed by his delayed remedial action to
avert stalling and subsequent loss of airplane control. Contributing
factors were the pilot\'s reduced visibility due to the inclement
weather and the icing conditions.

**END REPORT**

  ---------------------- -----------------------------------------------------------------------------------------
  **Date**:              **26 JUL 2002**

  **Time**:              05:37 EDT

  **Type**:              [[Boeing 727-232F]{.underline}](http://aviation-safety.net/database/type/102.shtml)

  **Operator**:          [[FedEx]{.underline}](http://aviation-safety.net/database/operator/airline.php?var=737)

  **Registration**:      N497FE

  **Msn / C/n**:         20866/1067

  **Year built**:        1974

  **Total airframe       37980 hours
  hrs**:                 

  **Cycles**:            23195 cycles

  **Engines**:           3 Pratt & Whitney JT8D-15 (HK3)

  **Crew**:              0 fatalities / 3 on board

  **Passengers**:        0 fatalities / 0 on board

  **Total**:             0 fatalities / 3 on board

  **Airplane damage**:   Written off

  **Location**:          Tallahassee Municipal Airport, FL (TLH)
                         ([[USA]{.underline}](http://aviation-safety.net/database/country/N.shtml))

  **Phase**:             Landing

  **Nature**:            Cargo

  **Departure airport**: Memphis International Airport, TN (MEM)

  **Destination          Tallahassee Municipal Airport, FL (TLH)
  airport**:             

  **Flightnumber**:      1478
  ---------------------- -----------------------------------------------------------------------------------------

+-----------------------------------------------------------------------+
| **Narrative**:\                                                       |
| The pilots had initially briefed the approach to runway 27, but since |
| winds were calm a straight in visual approach to runway 09 was        |
| attempted. The crews\' statements indicate that the base leg was      |
| normal and the gear was down and flaps at 30 degrees when the plane   |
| impacted trees 3,650 feet short of the runway, generally along the    |
| runway centerline. The tops of the trees were broken about 50 feet    |
| above ground level. The plane descended through trees until impacting |
| the ground about 1,000 feet later. It slid an additional 1,100 feet - |
| most of it in open field - and came to rest about 1,000 feet from the |
| runway facing in the opposite direction of travel (approximately 260  |
| degrees). The plane struck construction vehicles that were parked on  |
| the field during the night. Burn marks on the ground indicate a fire  |
| on the plane for the last 1,000 feet or so of travel. METARs of 05:53 |
| and 06:43 local time were:\                                           |
| KTLH 260953Z 00000KT 8SM FEW001 SCT150 SCT250 22/22 A3011 RMK AO2     |
| SLP195 T02220217=\                                                    |
| KTLH 261053Z 00000KT 9SM FEW001 SCT015 SCT150 BKN250 22/22 A3013 RMK  |
| AO2 SLP200 VIS SW-NW 1/2 CB DSNT SE CB DSNT SW FU SCT015 FU PLUME OVR |
| APCH RWY 09 T02220217=\                                               |
| PROBABLE CAUSE: \"The National Transportation Safety Board determines |
| that the probable cause of the accident was the captain\'s and first  |
| officer\'s failure to establish and maintain a proper glidepath       |
| during the night visual approach to landing. Contributing to the      |
| accident was a combination of the captain\'s and first officer\'s     |
| fatigue, the captain\'s and first officer\'s failure to adhere to     |
| company flight procedures, the captain\'s and flight engineer\'s      |
| failure to monitor the approach, and the first officer\'s color       |
| vision deficiency. \"                                                 |
|                                                                       |
| **Follow-up / safety actions:**\                                      |
| Two safety recommendations were made to the FAA regarding color       |
| vision test protocols.                                                |
|                                                                       |
| **Related information/accidents:**\                                   |
| [[Result - CFIT - Level                                               |
| ground]{.underline}](http://aviation-safety.net/events/RECG.shtml)    |
|                                                                       |
| **Source**: (also check out                                           |
| [[sources]{.underline}](http://aviation-safety.net/database/ref.htm)  |
| used for every accident)\                                             |
| NTSB                                                                  |
+-----------------------------------------------------------------------+

![](media/image11.png){width="0.2604166666666667in"
height="0.10416666666666667in"}[[NTSB press release Aug 7,
2002]{.underline}](http://www.ntsb.gov/Pressrel/2002/020807.htm)\
![](media/image11.png){width="0.2604166666666667in"
height="0.10416666666666667in"}[[NTSB/AAR-04/02]{.underline}](http://www.ntsb.gov/publictn/2004/AAR0402.htm)

The following four accidents and incidents were events that may have
benefited from LAAS non-approach related benefits.

**NASDAC BRIEF REPORT**

**GENERAL INFORMATION**

  -- ------------ -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- ------------------------------
     Data Source:                                                                                                                                                                                     NTSB AVIATION
                                                                                                                                                                                                      ACCIDENT/INCIDENT DATABASE

     Event Id:                                                                                                                                                                                        20001206X01121

     Local Date:                                                                                                                                                                                      04/23/1994

     Local Time:                                                                                                                                                                                      909

     State:                                                                                                                                                                                           CA

     City:                                                                                                                                                                                            SANTA MONICA

     Airport                                                                                                                                                                                          LOS ANGELES INTL
     Name:                                                                                                                                                                                            

     Event Type:                                                                                                                                                                                      INCIDENT

     Injury                                                                                                                                                                                           MINOR
     Severity:                                                                                                                                                                                        

     Report                                                                                                                                                                                           FINAL
     Status:                                                                                                                                                                                          

     Mid Air                                                                                                                                                                                          NO
     Collision:                                                                                                                                                                                       

     Event                                                                                                                                                                                            OFF AIRPORT/AIRSTRIP
     Location:                                                                                                                                                                                        

                                                                                                                                                                                                      
  -- ------------ -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- ------------------------------

**WEATHER INFORMATION**

  -- ------------------------------------- -- -- ------------------------------
     Weather Briefing Complete:                  FULL

     Brief Source:                               

     Basic Weather Conditions:                   VISUAL METEOROLOGICAL COND

     Light Condition:                            DAY

     Cloud Condition:                            SCATTERED

     Cloud Height above Ground Level (ft):       1200

     Ceiling Height above Ground Level           0
     (ft):                                       

     Cloud Type:                                 NONE

     Visibility RVR (ft):                        0

     Visibility RVV (sm):                        0

     Visibility (sm):                            12

     Wind Direction (deg):                       0

     Wind Condition Flag:                        U

     Wind Speed (knots):                         0

     Wind Condition Indicated:                   Calm

     Visibility Restrictions:                    

     Precipitation Type:                         
  -- ------------------------------------- -- -- ------------------------------

**AIRCRAFT INFORMATION**\
\
**Aircraft 1**

  -- -------------------------- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- ----------------------
     Category of Operation:                                                                                                                                                                          SCHEDULED

     Aircraft Type:                                                                                                                                                                                  AIRPLANE

     Aircraft Homebuilt:                                                                                                                                                                             NO

     Aircraft Damage:                                                                                                                                                                                MINOR

     Phase of Flight:                                                                                                                                                                                APPROACH

     Aircraft Make:                                                                                                                                                                                  SWEARINGEN-FAIRCHILD

                                                                                                                                                                                                     

     Aircraft Model:                                                                                                                                                                                 SA-227

                                                                                                                                                                                                     

     Aircraft Series:                                                                                                                                                                                

     Operator Doing Business                                                                                                                                                                         
     As:                                                                                                                                                                                             

     Operator Name                                                                                                                                                                                   SKYWEST AIRLINES

     Owner Name                                                                                                                                                                                      EQUIPMENT ACCEPTANCE
                                                                                                                                                                                                     CORP.

                                                                                                                                                                                                     

     NTSB Report Number:                                                                                                                                                                             LAX94IA203

     Number of Seats:                                                                                                                                                                                21

     Number of Engines:                                                                                                                                                                              2

     ELT Installed:                                                                                                                                                                                  YES

     ELT Operated:                                                                                                                                                                                   NO

     Aircraft Use:                                                                                                                                                                                   UNKNOWN

     Type of Operation:                                                                                                                                                                              PART 135: AIR TAXI &
                                                                                                                                                                                                     COMMUTER

     Departure Airport Id:                                                                                                                                                                           SMX

     Departure City:                                                                                                                                                                                 SANTA MARIA

     Departure State:                                                                                                                                                                                CALIFORNIA

     Last Departure Point:                                                                                                                                                                           NO

     Destination Local:                                                                                                                                                                              

     Destination Airport Id:                                                                                                                                                                         LAX

     Destination City:                                                                                                                                                                               LOS ANGELES

     Destination State:                                                                                                                                                                              CALIFORNIA

     Runway Id:                                                                                                                                                                                      0

     Runway Length:                                                                                                                                                                                  

     Runway Width:                                                                                                                                                                                   

     Flight Plan Filed:                                                                                                                                                                              IFR

     Domestic/International:                                                                                                                                                                         DOMESTIC

     Passenger/Cargo:                                                                                                                                                                                PASSENGER ONLY

     Registration Number:                                                                                                                                                                            N27220

     Air Carrier Operating                                                                                                                                                                           YES
     Certificates:                                                                                                                                                                                   

     Air Carrier Other                                                                                                                                                                               NO
     Operating Certificates:                                                                                                                                                                         

     Rotocraft/Agriculture                                                                                                                                                                           UNKNOWN
     Operating Certificate:                                                                                                                                                                          

     Cert Max Gross Wgt:                                                                                                                                                                             14500

     Aircraft Fire:                                                                                                                                                                                  NONE

     Aircraft Explosion:                                                                                                                                                                             NONE

     Landing Gear:                                                                                                                                                                                   RETR

     ATC Clearance                                                                                                                                                                                   

     Landing Gear                                                                                                                                                                                    

     Runway Condition                                                                                                                                                                                

     Landing Surface                                                                                                                                                                                 
  -- -------------------------- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- ----------------------

**ENGINE INFORMATION**\
\
\
**Aircraft 1 - Engine #:1**

  -- --------------------------------------- -- -- --------------------------
     Engine Type:                                  TURBO PROP

     Engine Group                                  

     Engine Manufactuer                            GARRETT

     Engine Make                                   GARRET

     Engine Model                                  TPE-331-11

     Engine Cert Type                              

     Engine Horsepower                             1000

     Engine Thrust                                 HP

     Carb/Injection                                

     Propeller Type                                
  -- --------------------------------------- -- -- --------------------------

**Injury Summary for Aircraft 1**

  ----------- -- ----------- -- ---------------- -- ------------ -- ------------
                 **Fatal**      **Serious**         **Minor**       **None**

  Crew           0              0                   0               2

  Pass                                              1               17

  Total          0              0                   1               19
  ----------- -- ----------- -- ---------------- -- ------------ -- ------------

**Pilot-in-Command for Aircraft 1**

  -------------------------- -- -- -----------------------------------------
  Certificates:                    AIRLINE TRANSPORT

  -------------------------- -- -- -----------------------------------------

  -----------------------------------------------------------------------
  Ratings:

  -----------------------------------------------------------------------

  ---- -------------------------------------------------------- --- --- ----
       Plane:                                                           

       Non-Plane:                                                       

       Instrument:                                                      

       Instruction:                                                     
  ---- -------------------------------------------------------- --- --- ----

  ------------------------------- -- -- -------------------------------------
  Had Current BFR:                      Y

  Months Since Last BFR:                

  Medical Certificate:                  CLASS 1

  Medical Certificate Validity:         VALID MEDICAL\--NO WAIVERS/LIM.
  ------------------------------- -- -- -------------------------------------

  -------------------------------------------- ---- -- -- -----------------
  Flight Time (hours)                                     

  Total                                        :          9513

  Make/Model                                   :          1909

  Instrument                                   :          0

  Multi-Engine                                 :          0

  Last 24 Hours                                :          0

  Last 30 Days                                 :          0

  Last 90 Days                                 :          0

  Rotocraft                                    :          0
  -------------------------------------------- ---- -- -- -----------------

**Sequence of Events**\
**Aircraft 1**\
Occurrence #: 1\
VORTEX TURBULENCE ENCOUNTERED\
Phase of Operation: DESCENT

  -------------- --------- ------------------------ -------------- ---------------------- ------------------
  **Findings**                                                                            

  **Event Seq    **Event   **Subject**              **Modifier**   **Personnel**          **Cause/Factor**
  \#**           Group                                                                    
                 Code**                                                                   

  1              2         RADAR SEPARATION         INADEQUATE     FAA                    CAUSE
                                                                   (OTHER/ORGANIZATION)   

  2              4         INSUFFICIENT                            FAA (ORGANIZATION)     CAUSE
                           STANDARDS/REQUIREMENTS                                         

  3              2         WAKE TURBULENCE          ENCOUNTERED    PILOT IN COMMAND       
  -------------- --------- ------------------------ -------------- ---------------------- ------------------

Occurrence #: 2\
LOSS OF CONTROL - IN FLIGHT\
Phase of Operation: DESCENT

  -------------- ------------------ ------------- -------------- --------------- ------------------
  **Findings**                                                                   

  **Event Seq    **Event Group      **Subject**   **Modifier**   **Personnel**   **Cause/Factor**
  \#**           Code**                                                          
  -------------- ------------------ ------------- -------------- --------------- ------------------

**AIRCRAFT 1 PRELIMINARY REPORT**\
\
On April 23, 1994, at 0909:06 hours Pacific daylight time, a Fairchild
SA-227, N27220, operating as Skywest Airlines flight 5490 (SW 5490), a
scheduled domestic commuter flight to Los Angeles International Airport
(LAX), encountered wake turbulence from a preceding Boeing 747-400,
United Airlines (UAL) flight 2. The pilot momentarily lost control of
the airplane, but landed at LAX without further incident. Skywest
Airlines maintenance personnel determined that the airplane sustained
minor damage. Neither the 2 flight crewmembers nor 17 passengers were
injured; 1 passenger reported receiving minor injuries. Visual
meteorological conditions prevailed. The flight originated at Santa
Maria Airport, Santa Maria, California, at 0830 hours. Both SW 5490
pilots reported they encountered the wake turbulence while in a descent
about 5 miles behind UAL flight 2. The first officer was flying the
airplane. After encountering the wake turbulence, the airplane rolled to
the left. As the first officer applied full right aileron, the airplane
continued to roll to the left until it was inverted. During the recovery
from the inverted position, the airplane\'s nose pitched down, the
airplane rolled to the right, and the pilot recovered the airplane to
level flight. The flight continued to the airport without further
incident. The Federal Aviation Administration (FAA) Air Traffic Control
Handbook 7110.65 requires 3 nautical miles between aircraft. This
requirement increases to 5 nautical miles when a small or large aircraft
is operating directly behind a heavy jet aircraft (i.e., a Boeing 747
type airplane). The radar data shows that the closest separation between
SW 5490 and UAL flight 2 was 4.47 miles. This occurred north of the
Santa Monica \[California\] very high frequency omni range \[(VOR) - a
navigational facility\] before an \"in trail\" situation began and 2
minutes 47 seconds before the incident. The 5 nautical miles criteria,
in this instance, went into effect when SW 5490 turned onto the Los
Angeles International Airport downwind leg from over the Santa Monica
VOR. According to the FAA\'s Los Angeles Air Route Traffic Control
National Track Analysis Program (NTAP), at 0908:06 hours, SW 5490 was
0.69 miles east of the Santa Monica VOR. Skywest 5490 was descending
between 7,200 feet msl and 7,000 feet msl, and was 4.76 nautical miles
behind UAL flight 2. At 0908:18 hours, SW 5490 was 1.31 miles east of
the Santa Monica VOR at 7,000 feet msl. The flight was 4.88 nautical
miles behind UAL flight 2. At 0908:30 hours, the lateral separation
between SW 5490 and UAL flight 2 increased to 5.03 nautical miles; a
minimum of 5 nautical miles separation was maintained until the
incident. When SW 5490 encountered the wake turbulence at 0909:06 hours,
it was 5.01 nautical miles behind UAL flight 2 at 7,100 feet msl.

**AIRCRAFT 1 FINAL REPORT**\
\
WHILE DESCENDING INTO THE DOWNWIND LEG OF THE TRAFFIC PATTERN AT THE LOS
ANGELES INTL AIRPORT, THE COMMUTER AIRPLANE ENCOUNTERED WAKE TURBULENCE
FROM A PRECEDING BOEING 747-400, AND THE AIRPLANE ROLLED INVERTED. THE
PILOT RECOVERED THE AIRPLANE, AND THE FLIGHT CONTINUED AND LANDED
WITHOUT FURTHER INCIDENT. THE AIRPLANE SUSTAINED MINOR DAMAGE. RADAR
DATA SHOWED THAT THE CUMMUTER WAS APPROX 5 MI FROM THE B-747 UP TO AND
AT THE TIME IT ENCOUNTERED THE TURBULENCE, WHICH MET CURRENT SEPARATION
CRITERIA.

**AIRCRAFT 1 CAUSE REPORT**\
\
FAA INADEQUATE SEPARATION STANDARDS BETWEEN LARGE AND HEAVY CATEGORY
AIRCRAFT.

**END REPORT**

**NASDAC BRIEF REPORT**

**GENERAL INFORMATION**

  -- ------------ -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- ------------------------------
     Data Source:                                                                                                                                                                                     NTSB AVIATION
                                                                                                                                                                                                      ACCIDENT/INCIDENT DATABASE

     Event Id:                                                                                                                                                                                        20001208X07623

     Local Date:                                                                                                                                                                                      03/02/1997

     Local Time:                                                                                                                                                                                      1913

     State:                                                                                                                                                                                           UT

     City:                                                                                                                                                                                            SALT LAKE CITY

     Airport                                                                                                                                                                                          SALT LAKE CITY INTL
     Name:                                                                                                                                                                                            

     Event Type:                                                                                                                                                                                      ACCIDENT

     Injury                                                                                                                                                                                           FATAL
     Severity:                                                                                                                                                                                        

     Report                                                                                                                                                                                           FINAL
     Status:                                                                                                                                                                                          

     Mid Air                                                                                                                                                                                          NO
     Collision:                                                                                                                                                                                       

     Event                                                                                                                                                                                            OFF AIRPORT/AIRSTRIP
     Location:                                                                                                                                                                                        

                                                                                                                                                                                                      
  -- ------------ -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- ------------------------------

**WEATHER INFORMATION**

  -- ----------------------------------- -- -- ---------------------------------
     Weather Briefing Complete:                UNKNOWN

     Brief Source:                             

     Basic Weather Conditions:                 INSTRUMENT METEOROLOGICAL COND

     Light Condition:                          DUSK

     Cloud Condition:                          UNKNOWN

     Cloud Height above Ground Level           0
     (ft):                                     

     Ceiling Height above Ground Level         1100
     (ft):                                     

     Cloud Type:                               OBSCURED

     Visibility RVR (ft):                      0

     Visibility RVV (sm):                      0

     Visibility (sm):                          .5

     Wind Direction (deg):                     340

     Wind Condition Flag:                      U

     Wind Speed (knots):                       18

     Wind Condition Indicated:                 Unknown

     Visibility Restrictions:                  

     Precipitation Type:                       
  -- ----------------------------------- -- -- ---------------------------------

**AIRCRAFT INFORMATION**\
\
**Aircraft 1**

  -- -------------------------- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- ---------------------
     Category of Operation:                                                                                                                                                                          

     Aircraft Type:                                                                                                                                                                                  AIRPLANE

     Aircraft Homebuilt:                                                                                                                                                                             NO

     Aircraft Damage:                                                                                                                                                                                SUBSTANTIAL

     Phase of Flight:                                                                                                                                                                                APPROACH

     Aircraft Make:                                                                                                                                                                                  BEECH

                                                                                                                                                                                                     

     Aircraft Model:                                                                                                                                                                                 BE-200

                                                                                                                                                                                                     

     Aircraft Series:                                                                                                                                                                                

     Operator Doing Business                                                                                                                                                                         
     As:                                                                                                                                                                                             

     Operator Name                                                                                                                                                                                   

     Owner Name                                                                                                                                                                                      COAST HOTELS &
                                                                                                                                                                                                     CASINOS INC.

                                                                                                                                                                                                     

     NTSB Report Number:                                                                                                                                                                             SEA97FA067

     Number of Seats:                                                                                                                                                                                10

     Number of Engines:                                                                                                                                                                              2

     ELT Installed:                                                                                                                                                                                  YES

     ELT Operated:                                                                                                                                                                                   UNKNOWN

     Aircraft Use:                                                                                                                                                                                   EXECUTIVE/CORPORATE

     Type of Operation:                                                                                                                                                                              PART 91: GENERAL
                                                                                                                                                                                                     AVIATION

     Departure Airport Id:                                                                                                                                                                           LAS

     Departure City:                                                                                                                                                                                 LAS VEGAS

     Departure State:                                                                                                                                                                                NEVADA

     Last Departure Point:                                                                                                                                                                           NO

     Destination Local:                                                                                                                                                                              SAME AS
                                                                                                                                                                                                     ACCIDENT/INCIDENT LOC

     Destination Airport Id:                                                                                                                                                                         SLC

     Destination City:                                                                                                                                                                               

     Destination State:                                                                                                                                                                              

     Runway Id:                                                                                                                                                                                      34R

     Runway Length:                                                                                                                                                                                  

     Runway Width:                                                                                                                                                                                   

     Flight Plan Filed:                                                                                                                                                                              IFR

     Domestic/International:                                                                                                                                                                         

     Passenger/Cargo:                                                                                                                                                                                

     Registration Number:                                                                                                                                                                            N117WM

     Air Carrier Operating                                                                                                                                                                           NO
     Certificates:                                                                                                                                                                                   

     Air Carrier Other                                                                                                                                                                               NO
     Operating Certificates:                                                                                                                                                                         

     Rotocraft/Agriculture                                                                                                                                                                           UNKNOWN
     Operating Certificate:                                                                                                                                                                          

     Cert Max Gross Wgt:                                                                                                                                                                             12500

     Aircraft Fire:                                                                                                                                                                                  NONE

     Aircraft Explosion:                                                                                                                                                                             NONE

     Landing Gear:                                                                                                                                                                                   RETR

     ATC Clearance                                                                                                                                                                                   

     Landing Gear                                                                                                                                                                                    

     Runway Condition                                                                                                                                                                                

     Landing Surface                                                                                                                                                                                 
  -- -------------------------- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- ---------------------

**ENGINE INFORMATION**\
\
\
**Aircraft 1 - Engine #:1**

  -- --------------------------------------- -- -- --------------------------
     Engine Type:                                  TURBO PROP

     Engine Group                                  

     Engine Manufactuer                            P&W

     Engine Make                                   P & W

     Engine Model                                  PT6A-41

     Engine Cert Type                              

     Engine Horsepower                             850

     Engine Thrust                                 HP

     Carb/Injection                                

     Propeller Type                                
  -- --------------------------------------- -- -- --------------------------

**Injury Summary for Aircraft 1**

  ----------- -- ----------- -- ---------------- -- ------------ -- ------------
                 **Fatal**      **Serious**         **Minor**       **None**

  Crew           0              1                   0               0

  Pass           1              2                                   

  Total          1              3                   0               0
  ----------- -- ----------- -- ---------------- -- ------------ -- ------------

**Pilot-in-Command for Aircraft 1**

  -------------------------- -- -- -----------------------------------------
  Certificates:                    AIRLINE TRANSPORT

  -------------------------- -- -- -----------------------------------------

  -----------------------------------------------------------------------
  Ratings:

  -----------------------------------------------------------------------

  ---- -------------------------------------------------------- --- --- ----
       Plane:                                                           

       Non-Plane:                                                       

       Instrument:                                                      

       Instruction:                                                     
  ---- -------------------------------------------------------- --- --- ----

  ------------------------------- -- -- -------------------------------------
  Had Current BFR:                      Y

  Months Since Last BFR:                

  Medical Certificate:                  CLASS 2

  Medical Certificate Validity:         VALID MEDICAL\--NO WAIVERS/LIM.
  ------------------------------- -- -- -------------------------------------

  -------------------------------------------- ---- -- -- -----------------
  Flight Time (hours)                                     

  Total                                        :          8172

  Make/Model                                   :          1841

  Instrument                                   :          1500

  Multi-Engine                                 :          4142

  Last 24 Hours                                :          2

  Last 30 Days                                 :          25

  Last 90 Days                                 :          61

  Rotocraft                                    :          0
  -------------------------------------------- ---- -- -- -----------------

**Sequence of Events**\
**Aircraft 1**\
Occurrence #: 1\
LOSS OF CONTROL - IN FLIGHT\
Phase of Operation: APPROACH - FAF/OUTER MARKER TO THRESHOLD (IFR)

  -------------- ----------- ------------- -------------- --------------- ------------------
  **Findings**                                                            

  **Event Seq    **Event     **Subject**   **Modifier**   **Personnel**   **Cause/Factor**
  \#**           Group                                                    
                 Code**                                                   

  1              1           WEATHER       OBSCURATION                    FACTOR
                             CONDITION                                    

  2              2           APPROACH      IMPROPER       PILOT IN        FACTOR
                             RECEIVER                     COMMAND         

  3              2           PLANNED       NOT ATTAINED   PILOT IN        FACTOR
                             APPROACH                     COMMAND         

  4              2           AIRSPEED      NOT MAINTAINED PILOT IN        CAUSE
                             (VSO)                        COMMAND         

  5              2           STALL         NO MODIFIER    PILOT IN        
                                           SPECIFIED      COMMAND         

  6              2           REMEDIAL      NOT POSSIBLE   NO PERSON       
                             ACTION                       SPECIFIED       
  -------------- ----------- ------------- -------------- --------------- ------------------

Occurrence #: 2\
IN FLIGHT COLLISION WITH TERRAIN/WATER\
Phase of Operation: DESCENT - UNCONTROLLED

  -------------- --------------- ---------------- -------------- --------------- ------------------
  **Findings**                                                                   

  **Event Seq    **Event Group   **Subject**      **Modifier**   **Personnel**   **Cause/Factor**
  \#**           Code**                                                          

  7              1               TERRAIN          GROUND                         
                                 CONDITION                                       
  -------------- --------------- ---------------- -------------- --------------- ------------------

**AIRCRAFT 1 PRELIMINARY REPORT**\
\
HISTORY OF FLIGHT On March 2, 1997, approximately 1913 mountain standard
time, a Beech 200 Super King Air, N117WM, registered to Coast Hotels and
Casinos Inc. of Las Vegas, Nevada, collided with terrain approximately
1.3 nautical miles short of the runway while on an instrument landing
system (ILS) approach to runway 34R at Salt Lake City International
Airport, Salt Lake City, Utah. The airplane was substantially damaged
and, of the airplane\'s four occupants, one passenger was fatally
injured and the airline transport pilot-in-command and the aircraft\'s
other two passengers were seriously injured. The 14 CFR 91
executive/corporate flight originated at McCarran International Airport,
Las Vegas, Nevada. Night instrumental meteorological conditions existed
at the time, and the flight was on an instrument flight rules (IFR)
flight plan. The pilot reported that the flight proceeded uneventfully
to the Fairfield VOR, and initial approach fix (IAF) for the ILS runway
34R approach. The pilot stated that he was then given a vector by air
traffic control (ATC) to intercept the runway 34R localizer. A
transcript of the communications between N117WM and Salt Lake Approach
indicated that at 1859:56, after the pilot of N117WM checked in at an
altitude of 15,000 feet, Salt Lake Approach instructed N117WM:
\"\...roger two six miles from plage turn right heading zero one zero
cross plage at or above one one thousand cleared ILS runway three four
right approach.\" (NOTE: PLAGE, SCOER, and KERNN intersections are
successive fixes on the ILS approach. All are located on the runway 34R
localizer course, with KERNN being collocated with the outer marker.)
The Salt Lake approach controller then advised \"lear seven whiskey
mike\" that the runway visual range (RVR) for runway 34R was out of
service, and that the visibility was 1/2 mile. According to the ATC
transcript N117WM replied \"(unintelligible) seven whiskey mike\" to
this. ATC recorded radar data indicated the N117WM began its descent
from 15,000 feet at 1901:45, 18 nautical miles south of PLAGE. The pilot
indicated in his report of the accident that the aircraft\'s autopilot
was coupled in the approach mode for the approach. At 1901:48, Salt Lake
Approach asked N117WM to \"say air speed\", and the pilot of N117WM
replied that he was \"indicating one eight zero.\" Salt Lake Approach
then instructed N117WM to \"maintain best forward speed.\" According to
the ATC radar data, N117WM subsequently started a left turn to the
localizer, at about 1903:45. At 1904:49, Salt Lake Approach instructed
N117WM to \"\...maintain best forward speed until ah score \[sic\] cross
kernn at one seven zero knots contact tower now one one niner point
five.\" The transcript indicated that the best possible interpretation
of the pilot\'s reply was, \"(score \[sic\] forward speed) best forward
speed till score \[sic\]. At 1905:25, N117WM checked in with Salt Lake
Tower, reporting out of 12,500 feet for 11,000 feet. Salt Lake Tower
instructed \"king air one one seven whiskey mike\" to continue, at
1905:25, then corrected the call sign at 1906:16, instructing \"king air
one seven whiskey mike\" to continue. The pilot of N117WM replied \"say
again\" to this, at 1906:23 and again at 1906:28, and the controller
repeated the instruction to continue at 1906:40. The ATC radar data
indicated the N117WM passed abeam PLAGE about 1906:32, at an altitude of
11,800 feet (800 feet above the minimum altitude specified in the ATC
clearance and 1,300 feet above the published minimum altitude at PLAGE)
and abeam SCOER about 1907:55, at an altitude of 10,500 feet (1,500 feet
above the minimum altitude at SCOER depicted on the published approach
procedure.) At 1910:17, Salt Lake Tower called: king air one one seven
whiskey mike caution wake turbulence boeing seven fifty seven six miles
ahead wind three six zero at one five runway three four right cleared to
land.\" (N117WM was following DAL616, a Boeing 757 \[B-757\] aircraft,
on the ILS approach. ATC radar data showed that at the time DAL616
arrived over the runway threshold, N117WM was approximately 5.4 nautical
miles behind the B-757. ATC minimum radar separation distance for
landing, for a small aircraft following a B-757, is 5 miles.) The
approach procedure specifies that a descent to a glide slope intercept
altitude of 7,100 feet (minimum) is initiated at SCOER. Based on the
published glide slope angle of 3.00 degrees, threshold crossing height
(TCH) of 53 feet, and touchdown zone elevation (TDZE) of 4,222 feet,
glide slope intercept at 7,100 feet altitude was computed by
investigators to occur approximately 8.9 nautical miles from the runway
threshold, or about 6.5 nautical miles past SCOER. ATC radar data
indicated that N117WM crossed KERNN, the outer marker, at 1910:51, at
7,00 feet and a radar-indicated speed of 163 knots. The glide slope
altitude at KERNN, as depicted on the approach procedure profile view,
is 6,095 feet. At 1911:14, Salt Lake Tower informed N117WM of an Embraer
EMB-120 aircraft holding in position on the runway; the acknowledgment
of this call by N117WM, at 1911:20, was the last reported radio
transmission from the accident aircraft. ATC radar data indicated that
the aircraft remained above the glide slope from KERNN until attaining
the glide slope from above about 1.8 nautical miles from the threshold,
at 1912:42, 4,900 feet altitude (478 feet above decision height) and a
radar ground speed of 103 knots. The aircraft remained generally on the
glide slope for 28 seconds, from 1912:42 until 1913:10, at which point
its radar ground speed indicated 73 knots. During the 28-second period
the aircraft was on the glide slope, its average rate of radar
groundspeed decay increased from 0.54 knots per second (between KERNN
and the time of glide slope capture) to 1.07 knots per second. At
1913:14, the aircraft dropped well below the glide slope and its radar
speed reached its minimum value of 70 knots. The loss of 200 feet of
altitude (from 4,700 to 4,500 feet) from 1913:10 to 1913:14, in
combination with the radar ground speed of 70 knots during this
interval, was computed to correspond to an average downward vertical
flight path angle during the interval of 20.3 degrees below the
horizontal. The last radar return recorded was at 1913:18, at 4,400 feet
altitude (approximately 200 feet above the touchdown zone elevation) and
71 knots. The crash site was approximately 1.3 nautical miles short of
the runway 34R threshold, about 1/4 mile left of the localizer
centerline. The pilot\'s recollection of the accident sequence, as given
in the narrative in his report of the accident, was as follows:
\...Being slightly above the glide slope, the auto-pilot did not capture
the altitude. The rate of descent was increased and the auto-pilot
captured the glide slope. At this time, the aircraft was entering the
cloud deck, all anti-icing and de-icing systems were verified on,
approach flaps were lowered and the gear was extended. Power was
adjusted to approximately 600 ft. lbs. \[torque\] per engine in order to
maintain 140 \[k\]nots IAS. From this point until the last few seconds
of the flight I have no memory recall. My next recollection is
descending through 400 ft. AGL on the radar altimeter. The aircraft did
a sudden, uncommanded, skidding yaw to the left, with a following nose
down, wing down roll to the left. My instinctive reaction was full right
aileron, full right rudder, full power and nose up pitch. At this time I
had visual outside the aircraft. The control input slowed the rate of
roll and the aircraft started to return to level flight. As I began to
relax the controls \[inputs\], the rolling motion returned. At this time
I could see a large, white space in front of me, and I could visually
see that the aircraft was descending. I had full control input in,
attempting to level the aircraft prior to impact. I do not recall the
impact. The two surviving passengers, one of whom was sitting in the
copilot\'s seat, reported that the approach initially seemed normal to
them, and that they could see objects on the ground at first (the
reported weather at the time consisted of an obscuration with 1,100 feet
vertical visibility). They reported that at some point after the point
which ground objects became visible (none were visible directly out the
front of the windscreen, according to the copilot\'s seat passenger),
the aircraft suddenly rolled left and struck the ground. One passenger,
who was sitting in the back of the aircraft (on the right side, across
the aisle from the fatally injured passenger) at the time of the
accident, reported that the aircraft rolled left, straightened out, then
rolled left again (more severely) and struck the ground. The other
passenger, who was sitting in the copilot\'s seat at the time, reported
that the airplane rolled left and struck the ground approximately 2 to 3
seconds after the left roll, and that the aircraft rolled left despite
the pilot moving the control yoke noticeably to the right. Both
passengers reported briefly hearing what they thought was a warning horn
of some type during the event, but could not recall noting any
significant changes in the engine noise during the accident sequence.
The accident occurred during the hours of dusk, approximately 53 minutes
after local sunset and 7 minutes before the end of the evening twilight
(as computed by a U.S. Air Force astronomical data program), at
approximately 40 degrees 45.1 minutes North and 111 degrees 58.4 minutes
West. PERSONNEL INFORMATION The pilot was the chief pilot for the El
Cortez Hotel in Las Vegas, and also flew part-time for Coast Hotels &
Casinos, which owned the accident aircraft. He held an airline transport
pilot certificate with airplane multiengine land rating, and was
type-rated in the Cessna 500, Mitsubishi 300, and Beech 400 turbojet
aircraft. The pilot was also a certificated flight instructor with
airplane single engine and instrument instructor ratings. According to
his accident report, he had 8,172 hours total time, of which 1,841 were
in the Beech 200 aircraft. The pilot stated in an interview with
investigators on April 28, 1997, that he received initial training on
the type in 1986 and recurrent training on the aircraft in 1987, both
from Flight Safety International of Long Beach, California. The pilot
stated that he had not received any formal training of the Beech 200
since the 1987 recurrent training. He reported that his most recent
pilot proficiency check was a pilot proficiency evaluation conducted in
a Beech 400 jet aircraft simulator on April 6, 1996. The pilot stated
during the April 28, 1997, interview that he had flown 39.8 hours in the
Beech 200 (approximately 1/3 of which was instrument time) during the 6
months prior to the accident; and on his report of the accident, the
pilot indicated that he had flown 61 total hours in the past 90 days,
including 6 hours in the Beech 200, 20 hours at night, and 10 hours of
actual instrument time. Log book information supplied by the pilot
indicated that he was current for night, instrument and multi-engine
flight at the time of the accident, but had not flown into or out of
Salt Lake City within the past 6 months. AIRCRAFT INFORMATION The Beech
200 has a maximum takeoff weight of 12, 500 pounds for operations under
14 CFR 91, and does not require a type rating to operate as
pilot-in-command. The aircraft is approved for operation by a single
pilot in operations under 14 CFR 91. The accident aircraft was found to
be equipped with a Sperry SP-200 automatic flight control system with
Sperry AZ-241 air data computer, a King KNC-610 area navigation system,
and a Collins VIR-30A VOR/ILS receiver installed as NAV-1. The accident
aircraft was not equipped with a cockpit voice recorder (CVR) or flight
data recorder (FDR). An estimated weight-and-balance computation for the
aircraft at the time of the accident was performed by investigators. The
following parameters were used for the computation: aircraft empty
weight of 8,242 pounds (from aircraft maintenance records); pilot weight
of 210 pounds (from FAA records); passenger weights of 210, 235, and 132
pounds (from surviving passenger interviews and medical examiner
report); cargo weight of 360 pounds (weighed after accident); fuel load
of 2,400 pounds at takeoff (reported by pilot); and estimated fuel burn
of 983 pounds (based on reported time airborne and cruise fuel flow data
in Raisbeck supplemental pilot\'s operating handbook.) Using these
values, the estimated gross weight of the aircraft at the time of the
accident was computed to be 10,811 pounds. Based on the above weights
and reported aircraft loading, the aircraft was estimated to be within
center of gravity limitations at the time of the accident. The accident
aircraft was modified in accordance with supplemental type certificates
(STCs) held by Raisbeck Engineering INC. of Seattle, Washington.
Modifications to the aircraft included installation of four-bladed
Hartzell propellers, enhanced performance leading edges, a ram air
recovery system in engine intakes, fully enclosed main landing gear
doors, and dual ventral strakes on the aft fuselage. According to the
FAA-approved Raisbeck supplemental pilot\'s operating handbook (POH) for
the aircraft, a Raisbeck-modified Beech 200 at gross weight of 11,000
pounds and flaps extended 40% (the approach flap setting) has a stall
speed of 81 knots calibrated airspeed (KCAS). At a density altitude of
3,700 feet (the computed Salt Lake density altitude at the time of the
accident, based on reported temperature and altimeter setting), 81 KCAS
was computed to correspond to a true airspeed of 86 knots. Based on the
radar ground speed of the aircraft from the 1913:10 and 1913:14 radar
returns (73 and 70 knots, respectively) and the wind reported by Salt
Lake Tower to N117WM at the time of landing clearance (360 degrees at 15
knots), N117WM\'s true air speed at 1913:10 (immediately before it was
recorded well below glide slope) was computed to be 88 knots, dropping
to 85 knots at 1913:14 (at which time it was recorded well below glide
slope) The Raisbeck supplemental POH states that altitude loss
experienced while conducting stalls in accordance with 14 CFR 23.201 was
800 feet. At 1913:10, the aircraft\'s altitude (as recorded by radar)
was 4,700 feet or 478 feet above the TDZE of 4,222 feet. The Raisbeck
supplemental POH gives landing approach speeds at 11,000 pounds gross
weight of 113 KIAS at 0% flaps, and 90 KIAS at 100% flaps. According to
the Beech 200 FAA-approved POH, the normal operating range of engine
torque (marked by a green arc on the engine torque indicators) is 400 to
2,230 foot pounds. The FAA-approved airplane flight manual supplement
for the Sperry SP-200 automatic flight control system states that in the
event of an autopilot malfunction, the autopilot may be disengaged by
one of five different methods, or may be overpowered by the pilot. The
supplement states that maximum altitude losses during malfunction tests
were 80 feet for coupled ILS approaches. According to the aircraft
maintenance records, the airplane was on a manufacturer-approved
airworthiness inspection program. No discrepancies were noted in the
aircraft maintenance records regarding required inspections, to include
the altimeter and static system tests required for IFR operations.
METEOROLOGICAL INFORMATION An 1845 Salt Lake City SPECI observation gave
the conditions as: obscuration with 1,300 feet vertical visibility;
visibility 1 statue mile in light snow showers; temperature 1 degree C;
dewpoint 0 degrees C; and wind 350 degrees at 23 knots. The 1851 Salt
Lake METAR hourly observation gave conditions as : obscuration with
1,100 vertical visibility; visibility 1/2 statute mile in snow showers;
temperature 1 degree C; dewpoint 0 degrees C; and wind 340 degrees at 18
knots. During N117WM\'s approach, Salt Lake Approach advised \"lear
seven whiskey mike\" that the runway 34R RVR was out of service, and
visibility was 1/2 mile. Salt Lake Tower advised N117WM at the time of
landing clearance that winds were from 360 degrees at 15 knots.
Conditions reported in a Salt Lake SPECI observation taken at 1927,
approximately 14 minutes after the accident, were identical to those
reported in the 1851 METAR observation. The pilot of the accident
aircraft reported in the April 28, 1997, interview that his ride down
final was smooth, and that the aircraft did not accumulate any ice on
the windshield or wings of the aircraft during the approach. The pilot
further stated during this interview that the weather at the time was
\"exactly like the ATIS\", with very heavy snow. The Salt Lake City FAA
air traffic manager reported that there were no pilot reports of wind
shear or icing conditions to ATC during the time frame of the accident.
There were also no wind shear alerts recorded by the airport\'s low
level wind shear alerting system (LLWAS). An FAA inspector who responded
to the accident scene on the night of the accident reported by telephone
to the NTSB investigator-in-charge (IIC) that, although surface
temperature was near freezing and there was no fire, he observed no
evidence of ice on the aircraft. AIDS TO NAVIGATION The ILS to Salt Lake
runway 34R, identifier ISLC, operates of 109.5MHz. Approach minima for
this system are published down to ILS category IIIB. The ILS has an
associated, frequency-paired distance measuring equipment (DME) system,
with the ILS DME antenna located approximately 0.1 nautical mile south
of the runway 34R threshold. A telephone query to the FAA Northwest
Mountain Region air traffic procedures division disclosed that the ILS
DME was commissioned on or about September 11, 1996, approximately 6
months prior to the accident. The localizer course, in conjunction with
the ISLC ILS DME, is used to define the three successive fixes on the
ILS approach procedure; PLAGE (ISLC 20.5 DME), SCOER (ISLC 15.3 DME),
and KERNN (ISLC 5.5 DME, which is collocated with the outer marker.) The
runway 34R ILS approach procedure specifies that DME or radar is
required for the approach. There were no facility alarms or pilot
reports of anomalies with the ISLC ILS system, other than the reported
RVR outage, during the time frame of the accident. A post-accident
flight inspection of the ILS was not performed. The Salt Lake City
VORTAC (identifier SLC), a high-altitude class radio navigation aid
(NAVAID), provides civil VHF omnirange (VOR) azimuth, military tactical
air navigation (TACAN) azimuth, and military and civil DME signals. The
VOR operates on a frequency of 116.8 MHz; a DME paired to the frequency
is collocated with the VOR. This NAVAID is located approximately 4.7
nautical miles north of (i.e. beyond) the ISLC ILS DME antenna,
approximately on the Salt Lake runway 34R extended centerline. Prior to
the commissioning of the ILS DME, fixes on the ILS runway 34R approach
were defined using DME from the Salt Lake City VORTAC. The FAA Northwest
Mountain Region air traffic procedures division reported that the change
to the ILS approach procedure, in which the approach fixes were defined
by the ILS DME rather than by the Salt Lake City VORTAC, was published
on August 7, 1996, with an effective date of September 12, 1996.
COMMUNICATIONS According to the ATC communications transcript, at
1900:00, Salt Lake Approach transmitted to \"lear seven whiskey mike\"
that the runway 34R RVR was out of service and the visibility was 1/2
mile. N117WM responded: \"(unintelligible) seven whiskey mike.\" AT
1901:45, approximately the time that radar indicated N117WM beginning
its descent from 15,000 feet, Salt Lake Approach asked N117WM to \"say
air speed\", to which the pilot of N117WM replied that he was indicating
180 knots. The Salt Lake approach controller then again transmitted to
\" lear seven whisky mike:, instructing it to \"maintain best forward
speed.\" N117WM replied \"whiskey mike\" to this instruction, according
to the transcript. Following N117WM\'s initial check-in to the Salt Lake
tower frequency, at 1905:25, the Salt Lake tower controller replied
\"king air one one five whiskey mike salt lake tower roger continue.\"
The transcript indicated that 46 seconds later, Salt Lake Tower then
transmitted: \"king air one one seven whiskey mike continue\", to which
N117WM replied \"\... say again\" twice, at 1906:23 and again at
1906:28. Salt Lake Tower repeated the instruction to continue 12 seconds
after the pilot\'s second \"say again\" call, at 1906:40, and N117WM
then acknowledged. The ATC radar data indicated that N117WM passed abeam
PLAGE, 800 feet above the minimum altitude for which it was cleared, at
about 1906:32, while this exchange between the pilot of N117WM and the
Salt Lake tower controller was taking place. AERODROME AND GROUND
FACILITIES Salt Lake City International Airport is the primary airport
for a Class B airspace area. The airport serves as a hub in the Delta
Air Lines route system as well as that of its regional airline affiliate
Skywest, and is also served by several other 14 CFR 121 scheduled air
carriers. The Salt Lake ILS runway 34R approach procedure profile view
specifies that PLAGE is crossed at a minimum altitude of 10,5000 feet or
9,000 feet if authorized by ATC. (The ATC transcript indicated that
N117WM was instructed to cross PLAGE at or above 11,000 feet at the time
it was cleared for the ILS approach.) At PLAGE, a descent may be
initiated to a minimum of 9,000 feet until passing SCOER. At SCOER, a
descent to glide slope intercept altitude of 7,100 feet (minimum) is
initiated. The glide slope altitude depicted at KERNN on the profile
view is 6,095 feet. The published decision height (DH) is 4,422 feet
(200 feet above touchdown.) The published minima for the approach are
1,800 feet RVR or 3/8 mile visibility. The required descent gradients
from PLAGE to SCOER and from SCOER to glide path intercept at 7,100 feet
were computed by the NTSB IIC and were found to be close to, but within,
the 300 feet per mile maximum specified by FAA Order 8260.3B, U.S.
Standard for Terminal Instrument Approach Procedures (TERPS), for
intermediate approach segments. ATC radar data indicated that N117WM was
800 feet above the minimum cleared altitude) (1,300 feet above the
published minimum altitude) crossing PLAGE, 1,500 feet above the
published minimum altitude crossing SCOER, and 905 feet above the glide
slope at KERNN. The aircraft captured the glide slope from above
approximately 1.8 nautical miles from the runway threshold, about 500
feet above decision height, 36 seconds prior to the time of the
aircraft\'s last recorded radar return. N117WM\'s recorded radar
altitude at two additional positions, approximately 4.7 nautical miles
past PLAGE and 4.7 nautical miles past SCOER (corresponding to the
distance of the Salt Lake VORTAC north of ISLC ILS DME) on the approach,
was checked. The ATC radar data indicated that at 4.7 nautical miles
past PLAGE (i.e., 15.8 DME from ISLC, or 1/2 nautical mile prior to
SCOER), the aircraft was at approximately 10,600 feet, and 4.7 nautical
miles beyond SCOER (i.e., 10.6 DME from ISLC), the aircraft was between
8,900 and 9,00 feet. N117WM\'s recorded altitudes at these two positions
were within 100 feet of the published minimum altitudes at PLAGE and
SCOER, respectively. WRECKAGE The airplane wreckage was examined at the
accident site on March 3, 1997. The crash site was in a level livestock
pasture, approximately 1.3 nautical miles south of the runway 34R
threshold and 1/4 mile west of the runway 34R extended centerline. All
aircraft components were located at the crash site. The majority of the
aircraft wreckage was contained along a line approximately 225 feet long
and oriented 290 degrees magnetic from the first point of ground damage
observed to the main aircraft wreckage. The aircraft\'s tail light cover
and tail tie down were found within 20 feet to the west of the first
ground damage point. Additionally, the tail light was located 37 feet
west of the first ground damage point, and a ventral fin from the tail
of the aircraft was located 52 feet west of the first ground damage
point. The nose gear wheel and a nose gear door had separated from the
aircraft, and were located 31 feet west of the first ground damage
point. The left outboard flap had separated and was located 53 feet west
of the first ground damage point, to the left of the line from the first
ground damage point to the main wreckage. The right outboard flap had
also separated and was found 116 feet west of the first ground damage
point, to the right of the line from the first ground damage point to
the main wreckage. A major ground scar was located 87 feet west of the
first ground damage point. The main aircraft wreckage comprised the
complete primary structure of the aircraft, which had come to rest
upright, headed 030 degrees magnetic. The fuselage structure of the nose
and cabin remained largely intact. Investigators were able to enter the
cabin through the primary entry door and negotiate a path to the
pilot\'s and copilot\'s seats, although the cabin headliner had
collapsed and seats and interior cabin furnishings were damaged and/or
separated from their mountings. A variety of debris was scattered
throughout the cabin interior. The net for the cargo compartment was
found unsecured. Cargo carried in the aft cargo compartment included
pots and pans, dishes, various types of food, and beverages; some of
this cargo was found scattered in the cabin and outside the aircraft,
which was broken to the left immediately aft of the aft pressure
bulkhead but otherwise largely intact. The nose landing gear strut was
also separated, and was located immediately to the right of the nose.
The left wing was largely intact, although both flaps had separated (the
left inboard flap was located immediately aft of the left wing.) The
right wing was broken immediately outboard of the nacelle, but was
present in its entirety with the exception of the separated outboard
flap. Both engine nacelle were broken in a direction pointing to the
right of the aircraft. The flap actuators were found in a position
corresponding to approximately 20 degrees flap extension. Both main
landing gear struts were observed in the down position; however, both
main landing gear wheel trucks had separated from the struts. One main
gear wheel truck was located 63 feet off the aircraft\'s nose (030
degrees from the main wreckage), while the other main gear truck was
located 240 feet northwest of the main wreckage. No attempt was made by
investigators to match the main gear trucks to their struts. The left
propeller exhibited forward bending on two blades, leading edge gouging
on the third blade, and S-bending on the fourth blade. The power lever
linkage on the left engine was found 3/8 inch back from the maximum
stop, and on the aircraft instrument panel, the left engine torque
indicator was found frozen at an indication of 1,500 foot-pounds. The
left engine ice vane selector switch was found in the extend position.
Oil was found on the engine dipstick. No evidence of a containment
failure of the left engine was observed. A detailed internal examination
of the left engine was not performed. The right propeller exhibited
forward bending on two blades, leading edge gouging and slight S-bending
on a portion of the third blade, and torsional twisting, leading edge
polishing, and chordwise scratching on the fourth blade. The power lever
linkage on the right engine was found at the maximum stop, and on the
aircraft instrumental panel, the right engine torque indicator was found
frozen at an indication at 2,080 foot pounds. The right engine ice vane
selector switch was found in the extend position. Oil was found on the
engine dipstick. No evidence of a containment failure of the right
engine was observed. A detailed internal examination of the right engine
was not performed. One the aircraft instrument panel, the FLT DIR
DME-1/DME-2 selector switch , on the left side of the pilot\'s
instrumental panel, was found in the DME-2 position. This switch selects
which DME presents information on the DME display on the pilot\'s
horizontal situation indicator (HSI). The NAV-1 radio was tuned to
109.50 MHz (the ISLC ILS frequency), and the NAV-2 radio was tuned to
116.80 MHz (the Salt Lake City VORTAC frequency.) The stall warning and
two pitot heat switches (L and R) were found in the OFF position. (NOTE:
The stall warning and the pitot heat switches were located on the lower
right side of the pilot\'s instrument panel, immediately above the
pilot\'s right leg, which was trapped in the wreckage after the accident
and required extrication by rescue personnel in order to free the pilot
from the wreckage.) A loose sheaf of Jeppesen approach plates, secured
together by a paper slip, was found wedged behind the pilot\'s left
rudder pedal. The plate on top of this sheaf was the ILS category II/III
approach procedure to Salt Lake runway 34R (page 11-4A, dated September
27, 1996.) The approach fixes PLAGE, SCOER, and KERNN on this approach
plate were defined using the ISLC ILS DME. (NOTE: The category II/III
ILS approach, which requires special aircrew and aircraft certification,
is flown to the same altitudes at PLAGE, SCOER, and glide path intercept
as the category I ILS approach, but is flown to a radio altimeter DH of
100 or 151 feet \[for category II approaches\], or no DH is specified
\[for category IIIA and IIIB approaches.\]) The DH alert \"bug\" on the
aircraft\'s radio altimeter was set to 180 feet. The Salt Lake ILS
runway 34R approach (page 11.4) is printed on the other side of the page
from the category II/III ILS approach procedure, such that page 11-4
faced inward in the sheaf as it was found clipped together. Fuel was
found in the aircraft\'s left and right main tanks. The left and right
auxiliary fuel tanks were found empty. A strong odor of jet fuel was
present at the accident site, and fuel leakage was observed from the
aircraft. Flight control cable continuity was established at the
accident site from the break in the fuselage back of the elevators and
rudder, and was also established to both ailerons. There was no evidence
of fire anywhere in the aircraft wreckage. MEDICAL AND PATHOLOGICAL
INFORMATION Following the accident, the pilot was taken to LDS Hospital,
Salt Lake City, Utah, for emergency medical treatment. A consent to
release of records was obtained from the pilot, and the pilot\'s
treatment records were obtained from LDS Hospital. The pilot\'s
treatment records indicated that at the time of admission, a drug and
alcohol screen was performed on the pilot. The pilot tested negative for
all drugs screened, and also tested at less that 0.01% serum ethyl
alcohol volume. An autopsy on the fatally injured passenger was
performed by the Utah State Medical Examiner\'s Office, Salt Lake City,
Utah, on March 3, 1997. The immediate cause of death was given as blunt
force injuries to the head. The report stated the examiner\'s opinion
that \"She was apparently struck from behind by an object causing an
acute hyperflexion of the head forward.\" SURVIVAL ASPECTS Local fire
and rescue services responded to emergency calls from local citizens
regarding the crash and extricated the three survivors from the aircraft
wreckage. The fatally injured passenger was determined to be dead at the
scene. The survivors were taken to local hospitals for treatment. The
fatally injured passenger was seated in the left rear seat, immediately
forward of the aircraft entry door and cargo compartment. There was a
cabin bulkhead immediately behind her seat, between h er seat and the
cargo compartment; this bulkhead forms the entryway to the aircraft. No
objects containing evidence that they struck the fatally injured
passenger\'s head were identified by investigators. In the April 28,
1997, interview with the pilot, the pilot stated that her personally
secured the cargo compartment net before takeoff. TESTS AND RESEARCH The
pilot\'s HSI, attitude director indicator (ADI), and altimeter, and the
aircraft\'s air data computer, flight director computer, automatic
flight control computer, and autopilot servos were sent to the Honeywell
Central Support Center, Wichita, Kansas, for functional testing under
the supervision of the FAA Wichita Manufacturing Inspection District
Office (MIDO). Although isolated test failures were recorded on each of
these components, the FAA manufacturing inspector who supervised the
tests on these components reported: \"The general feeling of the test
personnel and me is that the instruments with the noted discrepancies
would not have placed the aircraft in jeopardy, would have caused
conditions that the pilot would be aware of, or may have been caused by
the impact.\" No failures of parameters identified as \"AW/PS CRITICAL\"
(which, according to the test documentation provided by Honeywell,
\"require 100% test\") were reported on any of the components. The
aircraft\'s NAV-1 VOR/ILS receiver was shipped to Rockwell Collins
Avionics, Melbourne, Florida, for functional testing under the
supervision of the FAA Orlando, Florida, Flight Standards District
Office (FSDO). The FAA inspector supervising this test reported:
\"Receiver sensitivity was weak at some parameters, but overall
indications were positive. The sensitivity issue was not deemed unusual
or overly significant by the engineers conducting the testing or the
bench technician. No other unusual circumstances were observed.\"
Rockwell Collins Avionics, in a letter to the FAA dated June 3, 1997,
further stated that despite the observed test failures, the overall test
findings \"indicate that the unit is capable of providing accurate
navigation guidance.\" The test data furnished by Collins indicated that
the unit passed the glide slope receiver sensitivity test at a glide
slope frequency of 332.60 MHz (the glide slope frequency paired with a
localizer frequency of 109.50 MHz, according to the FAA Aeronautical
Information Manual.) The Aircraft\'s pitot probe heater elements and
airspeed indicators were functionally tested at Aero-Mach Labs Inc.,
Wichita, Kansas, under supervision of the FAA Wichita MIDO. The FAA
inspector supervising this testing reported that the acceptance test for
the pitot probe heater, and functional testing of both airspeed
indicators, was completed with no discrepancies observed on these tests.
The aircraft\'s KNC-610 area navigation computer was functionally tested
by AlliedSignal General Aviation Avionics, Olathe, Kansas, under the
supervision of the FAA Kansas City, Missouri, FSDO. AlliedSignal
reported that the unit\'s mode select switch, as received, was in the
VOR/DME position, and that the DME window of the unit displayed a
reading of 1.5 nautical miles. The AlliedSignal report of the
examination stated that \"no problems or inaccuracies were noted that
would have precluded safe and normal operation\" of the unit. ADDITIONAL
INFORMATION The glide slope deviation of DAL616, the B-757 ahead of
N117WM, from KERNN to DH was computed by the NTSB IIC. It was found, in
comparing DAL616\'s ATC radar-recorded altitudes versus distances from
threshold to the computed ILS glide slop profile, that DAL616 did not
deviate more that 93 feet above the ILS glide slope at any point during
final approach. DAL616 was computed to be 52 feet above glide slope at
1.8 nautical miles from the threshold, and its average glide slope
deviation for its last 11 radar returns (corresponding to 1.8 nautical
miles from the threshold down to DH) was computed to be approximately 4
feet low. The ATC radar data indicated the DAL616 passed 1.8 nautical
miles from the threshold at 1910:09, approximately 2 minutes and 33
seconds ahead of N117WM. To evaluate the possibility of pitot icing, an
airspeed comparison was done for two reference points of known or
assigned airspeed, at 1901:50 (when the pilot reported he was indicating
180 knots) and a KERNN (which N117WM was assigned by ATC to cross at 170
KIAS.) For the 1901:50 comparison, the report of 180 KIAS was converted
to true airspeed (TAS) for a density altitude of 15,000 feet (the
aircraft\'s approximate radar-recorded altitude at the time.) For the
comparison at KERNN, the ATC-assigned crossing speed of 170 KIAS was
converted to TAS for a density altitude of 7,000 feet (the aircraft\'s
altitude as observed on ATC radar at the time of the crossing.) These
values were compared to the aircraft\'s radar-observed ground speed,
plus headwind component reported for the two respective altitudes
(calculated from WSR-88D Doppler radar wind data contained in the
meteorology group chairman\'s factual report.) For the 1901:50
comparison, the radar-derived TAS correlated to the true airspeed based
on the 180 KIAS pilot report to within 1 knot. For the comparison at
KERNN, the radar-derived TAS at the time of crossing was computed to be
10 knots slower that the TAS based on assigned crossing speed of 170
KIAS (at 7,000 feet.) The Jeppesen Instrument Commercial Manual states
that there are two possible effects of a pitot tube blockage. With both
the ram air input tube and drain hole obstructed, the airspeed indicator
will function as an altimeter (i.e. the airspeed indication decreases
with decreasing altitude), and with a blocked ram air input tube but an
unobstructed drain hole, the airspeed indication will drop to zero. The
airplane wreckage was released to Mr. Kelly McLendon of United States
Aviation Underwriters, Inc., Englewood, Colorado, on February 19, 1998.
Mr. McLendon is the insurance adjuster representing Coast Hotels &
Casinos. Additional Persons Participating in this Accident Investigation
(continued): James D. Raisbeck Raisbeck Engineering, Inc. Seattle, WA
98178

**AIRCRAFT 1 FINAL REPORT**\
\
The flight was on a coupled instrument landing system (ILS) approach
with 1/2 mile visibility in snow showers. Three successive fixes on the
localizer are defined by distance measuring equipment (DME) paired with
the ILS; prior to the ILS DME commissioning 6 months before the
accident, the DME fixes were defined by a VORTAC 4.7 nautical miles past
the ILS DME. The aircraft was 800 feet high at the first fix and 1,500
feet high at the second, but approximately on altitude 4.7 nautical
miles past the first and second fixes, respectively. It passed the outer
marker 900 feet high and captured the glide slope from above about 1.8
nautical miles from the threshold, 500 feet above decision height (DH)
and 700 feet above touchdown. The aircraft was on glide slope for 28
seconds, during which time its speed decayed to stall speed; it then
dropped below glide slope and crashed 1.3 nautical miles short of the
threshold. The pilot\'s FLT DIR DME-1/ DME-2 switch, which control the
DME display on the pilot\'s horizontal situation indicator (HSI), was
found set to DME-2; the NAV-2 radio was set to the VORTAC frequency. Up
to 800 feet may be required for stall recovery.

**AIRCRAFT 1 CAUSE REPORT**\
\
The pilot\'s failure to maintain adequate airspeed on the ILS approach,
resulting in a stall. Factors included: low visibility; the pilot\'s
selection of the improper DME for the approach; his resulting failure to
attain the proper descent profile for the approach; and insufficient
altitude available for stall recovery.

**END REPORT**

**NASDAC BRIEF REPORT**

**GENERAL INFORMATION**

  -- ------------ -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- ------------------------------
     Data Source:                                                                                                                                                                                     NTSB AVIATION
                                                                                                                                                                                                      ACCIDENT/INCIDENT DATABASE

     Event Id:                                                                                                                                                                                        20001211X13867

     Local Date:                                                                                                                                                                                      12/15/1993

     Local Time:                                                                                                                                                                                      1733

     State:                                                                                                                                                                                           CA

     City:                                                                                                                                                                                            SANTA ANA

     Airport                                                                                                                                                                                          JOHN WAYNE AIRPORT-ORANGE
     Name:                                                                                                                                                                                            COUNTY

     Event Type:                                                                                                                                                                                      ACCIDENT

     Injury                                                                                                                                                                                           FATAL
     Severity:                                                                                                                                                                                        

     Report                                                                                                                                                                                           FINAL
     Status:                                                                                                                                                                                          

     Mid Air                                                                                                                                                                                          NO
     Collision:                                                                                                                                                                                       

     Event                                                                                                                                                                                            OFF AIRPORT/AIRSTRIP
     Location:                                                                                                                                                                                        

                                                                                                                                                                                                      
  -- ------------ -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- ------------------------------

**WEATHER INFORMATION**

  -- ------------------------------------- -- -- ------------------------------
     Weather Briefing Complete:                  UNKNOWN

     Brief Source:                               

     Basic Weather Conditions:                   VISUAL METEOROLOGICAL COND

     Light Condition:                            NIGHT/BRIGHT

     Cloud Condition:                            CLEAR

     Cloud Height above Ground Level (ft):       0

     Ceiling Height above Ground Level           0
     (ft):                                       

     Cloud Type:                                 NONE

     Visibility RVR (ft):                        0

     Visibility RVV (sm):                        0

     Visibility (sm):                            15

     Wind Direction (deg):                       200

     Wind Condition Flag:                        U

     Wind Speed (knots):                         4

     Wind Condition Indicated:                   Unknown

     Visibility Restrictions:                    

     Precipitation Type:                         
  -- ------------------------------------- -- -- ------------------------------

**AIRCRAFT INFORMATION**\
\
**Aircraft 1**

  -- -------------------------- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- --------------------
     Category of Operation:                                                                                                                                                                          NON-SCHEDULED

     Aircraft Type:                                                                                                                                                                                  AIRPLANE

     Aircraft Homebuilt:                                                                                                                                                                             NO

     Aircraft Damage:                                                                                                                                                                                DESTROYED

     Phase of Flight:                                                                                                                                                                                APPROACH

     Aircraft Make:                                                                                                                                                                                  ISRAEL AIRCRAFT
                                                                                                                                                                                                     INDUSTRIES

                                                                                                                                                                                                     

     Aircraft Model:                                                                                                                                                                                 WESTWIND

                                                                                                                                                                                                     

     Aircraft Series:                                                                                                                                                                                1124A

     Operator Doing Business                                                                                                                                                                         
     As:                                                                                                                                                                                             

     Operator Name                                                                                                                                                                                   MARTIN AVIATION L P

     Owner Name                                                                                                                                                                                      MANAGEMENT
                                                                                                                                                                                                     ACTIVITIES, INC.

                                                                                                                                                                                                     

     NTSB Report Number:                                                                                                                                                                             LAX94FA073

     Number of Seats:                                                                                                                                                                                12

     Number of Engines:                                                                                                                                                                              2

     ELT Installed:                                                                                                                                                                                  YES

     ELT Operated:                                                                                                                                                                                   NO

     Aircraft Use:                                                                                                                                                                                   UNKNOWN

     Type of Operation:                                                                                                                                                                              PART 135: AIR TAXI &
                                                                                                                                                                                                     COMMUTER

     Departure Airport Id:                                                                                                                                                                           POC

     Departure City:                                                                                                                                                                                 LA VERNE

     Departure State:                                                                                                                                                                                CALIFORNIA

     Last Departure Point:                                                                                                                                                                           NO

     Destination Local:                                                                                                                                                                              SAME AS
                                                                                                                                                                                                     ACCIDENT/INCIDENT
                                                                                                                                                                                                     LOC

     Destination Airport Id:                                                                                                                                                                         SNA

     Destination City:                                                                                                                                                                               

     Destination State:                                                                                                                                                                              

     Runway Id:                                                                                                                                                                                      19R

     Runway Length:                                                                                                                                                                                  5700

     Runway Width:                                                                                                                                                                                   150

     Flight Plan Filed:                                                                                                                                                                              IFR

     Domestic/International:                                                                                                                                                                         DOMESTIC

     Passenger/Cargo:                                                                                                                                                                                PASSENGER ONLY

     Registration Number:                                                                                                                                                                            N309CK

     Air Carrier Operating                                                                                                                                                                           YES
     Certificates:                                                                                                                                                                                   

     Air Carrier Other                                                                                                                                                                               NO
     Operating Certificates:                                                                                                                                                                         

     Rotocraft/Agriculture                                                                                                                                                                           UNKNOWN
     Operating Certificate:                                                                                                                                                                          

     Cert Max Gross Wgt:                                                                                                                                                                             23000

     Aircraft Fire:                                                                                                                                                                                  GROUND

     Aircraft Explosion:                                                                                                                                                                             GROUND

     Landing Gear:                                                                                                                                                                                   RETR

     ATC Clearance                                                                                                                                                                                   

     Landing Gear                                                                                                                                                                                    

     Runway Condition                                                                                                                                                                                

     Landing Surface                                                                                                                                                                                 
  -- -------------------------- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- --------------------

**ENGINE INFORMATION**\
\
\
**Aircraft 1 - Engine #:1**

  -- ----------------------------------------- -- -- ------------------------
     Engine Type:                                    TURBO FAN

     Engine Group                                    

     Engine Manufactuer                              GARRETT

     Engine Make                                     GARRET

     Engine Model                                    731-3-1G

     Engine Cert Type                                

     Engine Horsepower                               3500

     Engine Thrust                                   LBS

     Carb/Injection                                  

     Propeller Type                                  
  -- ----------------------------------------- -- -- ------------------------

**Injury Summary for Aircraft 1**

  ----------- -- ----------- -- ---------------- -- ------------ -- ------------
                 **Fatal**      **Serious**         **Minor**       **None**

  Crew           2              0                   0               0

  Pass           3                                                  

  Total          5              0                   0               0
  ----------- -- ----------- -- ---------------- -- ------------ -- ------------

**Pilot-in-Command for Aircraft 1**

  --------------- -- -- --------------------------------------------------------
  Certificates:         AIRLINE TRANSPORT,COMMERCIAL,FLIGHT INSTRUCTOR

  --------------- -- -- --------------------------------------------------------

  -----------------------------------------------------------------------
  Ratings:

  -----------------------------------------------------------------------

  ---- -------------------------------------------------------- --- --- ----
       Plane:                                                           

       Non-Plane:                                                       

       Instrument:                                                      

       Instruction:                                                     
  ---- -------------------------------------------------------- --- --- ----

  ------------------------------- -- -- --------------------------------------
  Had Current BFR:                      Y

  Months Since Last BFR:                

  Medical Certificate:                  CLASS 1

  Medical Certificate Validity:         VALID MEDICAL\--W/ WAIVERS/LIM.
  ------------------------------- -- -- --------------------------------------

  -------------------------------------------- ---- -- -- -----------------
  Flight Time (hours)                                     

  Total                                        :          8228

  Make/Model                                   :          756

  Instrument                                   :          4200

  Multi-Engine                                 :          2300

  Last 24 Hours                                :          3

  Last 30 Days                                 :          22

  Last 90 Days                                 :          84

  Rotocraft                                    :          0
  -------------------------------------------- ---- -- -- -----------------

**Sequence of Events**\
**Aircraft 1**\
Occurrence #: 1\
VORTEX TURBULENCE ENCOUNTERED\
Phase of Operation: APPROACH

  -------------- --------- --------------------- -------------- ---------------------- ------------------
  **Findings**                                                                         

  **Event Seq    **Event   **Subject**           **Modifier**   **Personnel**          **Cause/Factor**
  \#**           Group                                                                 
                 Code**                                                                

  1              2         TRAFFIC ADVISORY      PERFORMED      ATC PERSONNEL          
                                                                (DEP/APCH)             

  2              3         PROCEDURE INADEQUATE                 FAA                    FACTOR
                                                                (OTHER/ORGANIZATION)   

  3              2         VISUAL SEPARATION     INADEQUATE     PILOT IN COMMAND       CAUSE

  4              2         WAKE TURBULENCE       ENCOUNTERED    PILOT IN COMMAND       CAUSE

  5              3         INADEQUATE TRAINING                  NO PERSON SPECIFIED    

  6              3         INFORMATION                          NO PERSON SPECIFIED    FACTOR
                           INSUFFICIENT                                                

  7              3         USE OF INAPPROPRIATE                 PILOT IN COMMAND       
                           MEDICATION/DRUG                                             
  -------------- --------- --------------------- -------------- ---------------------- ------------------

Occurrence #: 2\
LOSS OF CONTROL - IN FLIGHT\
Phase of Operation: APPROACH

  -------------- ------------------ ------------- -------------- --------------- ------------------
  **Findings**                                                                   

  **Event Seq    **Event Group      **Subject**   **Modifier**   **Personnel**   **Cause/Factor**
  \#**           Code**                                                          
  -------------- ------------------ ------------- -------------- --------------- ------------------

Occurrence #: 3\
IN FLIGHT COLLISION WITH TERRAIN/WATER\
Phase of Operation: DESCENT - UNCONTROLLED

  -------------- --------------- ---------------- -------------- --------------- ------------------
  **Findings**                                                                   

  **Event Seq    **Event Group   **Subject**      **Modifier**   **Personnel**   **Cause/Factor**
  \#**           Code**                                                          

  1              1               TERRAIN          OPEN FIELD                     
                                 CONDITION                                       
  -------------- --------------- ---------------- -------------- --------------- ------------------

**AIRCRAFT 1 PRELIMINARY REPORT**\
\
History of the Flight On December 15, 1993, at 1733 hours Pacific
standard time, an Israel Aircraft Industries 1124A, N309CK, experienced
an in-flight loss of control and crashed about 3.5 nautical miles north
of John Wayne Airport (SNA), Santa Ana, California. The airplane was on
the final approach course for runway 19R. The pilot initially obtained
an instrument flight rules (IFR) clearance, but was executing a visual
approach at the time of the accident. The flight was an on-demand air
taxi passenger operation under the provisions of Title 14 CFR Part 135
and was completing the final leg of a multileg passenger revenue
operation. The airplane, registered to Management Activities, Inc., Long
Beach, California, and operated by Martin Aviation, Santa Ana,
California, was destroyed by impact and the resulting postimpact fire.
Both flight crewmembers and three passengers sustained fatal injuries;
there were no ground injuries. Visual meteorological conditions
prevailed. The Federal Aviation Administration\'s (FAA) various air
traffic control tower records disclosed the airplane departed Long Beach
Airport, Long Beach, California, on December 15, 1993, at 0700 hours to
begin the multileg operation. The last flight leg departed Brackett
Airport, La Verne, California, at 1713 hours. National Transportation
Safety Board investigators reviewed the recorded radio communications
between N309CK, Coast terminal radar approach control (TRACON), and the
John Wayne Airport air traffic control tower (ATCT). The review revealed
that before departing Brackett Airport the flightcrew requested and
received a local tower en route IFR clearance to John Wayne Airport.
After departing Brackett Airport, the flight contacted the FAA, Ontario
\[California\] TRACON and received radar vectors toward John Wayne
Airport. At 1728 hours, the Ontario TRACON sector controller instructed
the flight to contact Coast TRACON. According to the cockpit voice
recorder (CVR), at 1727:41 hours, the first officer received the
automated terminal information service (ATIS) \"zulu.\" \[The times
noted for the CVR information differ from the FAA ATC communications
transcripts; the CVR information was adjusted in this report to match
the ATC transcripts.\] At 1728:34 hours, the flight contacted the Coast
TRACON Tustin Radar sector controller and reported \"\...climbing to
four thousand\...\" \[feet - all altitudes in this report are mean sea
level altitudes\]. The sector controller instructed the flight to reduce
its speed to 170 knots; the flight\'s first officer acknowledged the
clearance. The cockpit voice recorder established that the first officer
made all the transmissions to the sector controller. The sector
controller had previously instructed a preceding airplane, also landing
at John Wayne Airport, to reduce its speed to 170 knots. This aircraft
was United Airlines flight 103 (UAL 103), a Boeing 757-200. The Tustin
Radar computer data readout (CDR) showed that N309CK was at 3,700 feet.
At 1729:09 hours, the first officer contacted Martin Aviation and
informed the dispatcher that the flight would be landing within ten
minutes and would need fuel. At 1730:05 hours, the sector controller
instructed the flight to turn to a 100-degree heading (all
headings/bearings in this report are oriented toward magnetic north). He
then stated, \"westwind nine charlie kilo \[is\] following a united
boeing jet on base \[leg at\] two o\'clock four miles southeast bound
\[at\] four thousand \[feet\] descending.\" The first officer responded,
\"in sight charlie kilo.\" At 1730:12 hours, the sector controller
instructed N309CK to \"\...follow that traffic cleared visual approach
runway one niner right reduce speed to follow he\'s \[UAL 103\] slowing
through a hundred and seventy \[knots\].\" The first officer
acknowledged the clearance and the traffic \[UAL 103\]. The sector
controller then instructed UAL 103, \"\...cleared visual approach runway
one niner right reduce speed to one five zero and contact the
tower\....\" UAL 103 responded that the flight was below 150 knots. The
CDR showed that N309CK was at 3,900 feet, and about 3.8 nautical miles
to the left (north) of UAL 103 which was at 3,800 feet. At 1730:26
hours, the first officer then told the captain \"\...eh he\'s pretty
close\....\" The captain responded, \"\...okay I\'m ah lets go flaps
twelve.\" The CDR showed that at this time N309CK was at 3,900 feet and
about 3.3 nautical miles to the left (north) of UAL 103 which was now
about 3,700 feet. The first officer then pointed out UAL 103 to the
captain. The captain responded, \"\...I got him - okay we can do
it\...no problem.\" At 1730:42 hours, the sector controller advised
N309CK that \"\...traffic you\'re following is at a hundred and fifty
knots you can s-turn as necessary to follow that traffic contact john
wayne tower\....\" At 1730:49 hours, the first officer responded, \"ok
we\'ll slow it up and do what we have to\....\" Meanwhile, at 1730:47
hours, UAL 103 contacted the John Wayne ATCT local controller and
reported \"\...turning final abeam lemon.\" At 1731:01 hours, N309CK
contacted the local controller and reported, \"\...on a visual behind
the ah i believe it\'s united \....\" The CVR indicated a sound similar
to the landing gear being lowered. The local controller responded,
\"westwind three zero nine charlie kilo john wayne tower number three
behind the united he\'s indicating thirty knots slower.\" The first
officer responded, \"ok we\'re slowing ah three zero nine charlie
kilo.\" The CDR now indicated that N309CK was at 3,700 feet and about
2.2 miles behind or north of UAL 103 which was about 3,100 feet. There
were no further communications between N309CK and the FAA air traffic
control facility. The CVR showed that the flightcrew proceeded to
complete the prelanding checklist and that the landing gear was fully
extended. At 1731:43 hours, the captain told the first officer that he
was going to slow the airplane to Vref (123 knots) and that he was going
to descend the airplane at that speed. The first officer then told the
captain that UAL 103 was \"\...a little too high on the ah\....\" The
captain responded, \"\...yeah we\'ll just sit here and slow down\....\"
He also said, \"\...I\'ll slightly \"s\" \[turn\] back and forth\...\",
and later said, \"\...we\'ll run this a dot high \[fly the glide slope
one dot above the three degree glide slope\]\....\" The first officer
responded, \"\...yeah we might still get a little wake turbulence
there\....\" At 1732:31 hours, the first officer remarked, \"I don\'t
know looks kinda close.\" The captain responded, \"yeah it\'s close but
I think we\'ll be okay.\" At this time, the CVR indicated that both
pilots saw UAL 103, and the captain asked the first officer, \"what are
the surface winds.\" The first officer responded, \"two hundred degrees
at ah six knots.\" At 1733:02 hours, the captain queried the first
officer, \"\...and we got gear and full flaps\....\" The first officer
responded, \"yup yaw damper will complete it\....\" At 1733:10 hours,
the CVR indicated that the captain took a deep breath, which was
followed by the first officer saying, \"keep it goin\' around keep it
goin\' around\....\" The CVR recording ended at 1733:15 hours. The last
CDR radar target on N309CK was at 1733:07 hours. At this time, N309CK
was at 1,100 feet, 2.1 nautical miles behind UAL 103. Safety Board
investigators interviewed several ground witnesses. The consensus of the
witnesses was that while on final approach the airplane suddenly pitched
downward, rolled 360 degrees about its longitudinal axis, and crashed.
Two witnesses, both commercial pilots, reported seeing sparks/flames
emanating from the airplane during the accident sequence. Other
witnesses reported a strange whining sound emanating from the airplane.
Crew Information Captain: The captain was an employee of Management
Activities, Inc., and was trained under the provisions of the
operator\'s Title 14 Part 135 Air Taxi Certificate. According to the
operator, the pilot always flew the airplane as the captain when the
accident airplane was used in connection with the operator\'s air taxi
operations. The operator would provide the second-in-command (SIC)
during these operations. The captain held an airline transport pilot
certificate with airplane multiengine land, CE-500, HS-125, CL-600, and
IA-Jet type ratings. The certificate was endorsed for commercial
privileges with an airplane, single-engine land rating. He also held a
first-class medical certificate dated December 3, 1993; the certificate
contained a \"must have corrective lenses\" limitation endorsement.
Safety Board investigators did not obtain the captain\'s personal flight
hours logbook. The flight hours reflected in this report were provided
by the operator. According to the operator, the pilot accrued 8,227.5
total flight hours. The captain accrued 756 hours in the accident
airplane make and model of which 700 hours were logged as
pilot-in-command. According to the captain\'s training records provided
by the operator, the pilot satisfactorily completed a 6-month recurrent
training flight on July 8, 1993, conducted by SimuFlite, Dallas-Fort
Worth Airport, Texas, in a Westwind II simulator. On August 27, 1993,
the pilot satisfactorily completed an annual recurrent training flight
conducted by the operator in a Beech F-90, a turbopropeller driven
airplane. First Officer (F/O): The F/O was an employee of the operator.
The operator conducted all of his required training and recurrency
flight tests. The training and flight tests were accomplished under the
supervision of the FAA, Long Beach Flight Standards District Office. The
F/O held an airline transport pilot certificate with airplane
multiengine land, CE-650, LR-Jet, and IA-Jet type ratings. The
certificate was endorsed for commercial privileges with an airplane,
single-engine land rating. He also held an unrestricted first-class
medical certificate which was issued on September 3, 1993. Safety Board
investigators did not obtain the F/O\'s personal flight hours logbook.
The flight hours reflected in this report were provided by the operator.
According to the operator, the pilot accrued 5,447 total flight hours.
The F/O accrued 136 hours in the accident airplane make and model of
which 70 hours were logged as pilot-in-command. According to the
operator, the F/O was qualified as pilot-in-command in a Lear 35, Beech
F-90, and the accident airplane make and model. A review of the F/O\'s
flight training records revealed that the F/O received his last flight
and ground recurrency training in a Lear 35A on August 15 and August 23,
1993, respectively. The F/O received his last transition/recurrent
ground and flight training in the accident airplane on December 22,
1992. Martin Aviation\'s Director of Operations told Safety Board
investigators that the company\'s training syllabus does not include
wake turbulence avoidance. The training syllabus does address windshear
avoidance and other meteorological phenomenon. SimuFlite, Dallas-Fort
Worth Airport, Texas, provided the Safety Board with the captain\'s
flight training records. A review of the records revealed the captain\'s
simulator and ground school training complied with the required training
syllabus. Wake turbulence avoidance was not included; nor was it
required. Aircraft Information The registered owner, Management
Activities, Inc., maintained the airplane and provided the Safety Board
with the airplane\'s maintenance records. Company maintenance personnel
maintained the airplane in accordance with the manufacturer\'s
inspection program as approved by the FAA, Long Beach Flight Standards
District Office. The maintenance personnel performed the last 150-hour
inspection on June 10, 1993. At the time of the accident, the airplane
accrued 3,027 hours (including the flights made on the day of the
accident), which was 95 hours since the last inspection. Communications
There were no reported communications difficulties between N309CK and
any FAA air traffic control facility. The Safety Board investigators
from the Office of Research Engineering found the cockpit voice recorder
(CVR) recording medium undamaged. The recording started at 1702:29 hours
and continued uninterrupted until 1733:15 hours (as adjusted). A review
of the recorded ground operations at Brackett Airport were reviewed and
found to be routine and were not transcribed. Safety Board investigators
made a transcript of the crew receiving their IFR clearance and their
departure from Brackett Airport. The transcript continued from the
flight\'s departure until the crash. Radar Data Radar data from various
radar facilities were obtained and plotted. The flight profile radar
track shows that at a point 7 nautical miles from the airport, N309CK\'s
flight path was consistently below UAL 103. When N309CK was about 3.5
nautical miles from the airport, its flight path was about 400 feet
below UAL 103\'s flight path and was about 2.1 miles in-trail. The glide
path for N309CK and UAL 103 was 3 degrees and 5.6 degrees, respectively.
Wreckage and Impact Information The airplane crashed in a vacant lot
next to multiple surrounding buildings and was about 100 feet to the
right of the John Wayne Airport runway 19R extended centerline. Ground
scars and the wreckage examination showed that the airplane struck the
ground in about a 45-degree nose-down, wings level attitude, with the
nose of the airplane facing about 165 degrees. The airplane\'s flight
path was about 80 degrees downward. Debris from the airplane\'s wreckage
was found scattered from the main impact crater outward to about 100
feet in a 30-degree arc tangential to the centerline of the airplane.
All of the airplane\'s major components and flight control surfaces were
found at the main impact area. The cabin area was incinerated by the
postimpact fire/explosion. A 6-foot section of the upper cabin area was
found about 30 feet south of the main wreckage area. Both wings
separated from their respective wing-to-fuselage attach fittings and
remained next to the fuselage. Continuity of the flight control surfaces
could not be determined due to impact and postimpact fire damage. The
flight controls, however, remained connected at their respective attach
points. The empennage was found about 2 feet forward of the main
wreckage. The horizontal/vertical stabilizer connecting rod bolt was
missing, but the inner section of the eyebolts displayed gouging
signatures. The stabilizer trim actuator was found extended 10.45 inches
from the actuator body. According to the manufacturer, this extension
corresponds to a minus 4.2-degree horizontal stabilizer trim setting or
full nose-up. Both flaps were damaged, but remained partially connected
at their wing flap track assemblies. The flap motor actuators on the
left and right wing were found extended 6.875 and 7 inches,
respectively. According to the manufacturer, these measurements
correspond to a 40-degree flap extension or flaps fully extended. Both
main landing gear actuators were found fully extended which corresponds
to a landing gear-down position. The nose landing gear actuator was not
found. Both fuel tanks interconnect valves were found and examined. One
valve was open and the other was closed. The closed valve is designed so
that it could be manually closed; the other valve is electrically
controlled and cannot be manually closed. Both engines\' shutoff valves
were found in the open position. The upper fuselage auxiliary tank valve
is the same type of valve as the engine fuel shutoff valves and was
found in the closed position. Fire The Santa Ana Fire Department arrived
at the accident site at 1743 hours. The battalion chief reported that
fire personnel did not encounter any difficulties in extinguishing the
fire. The fire was suppressed at 1758 hours. Medical and Pathological
Information The Orange County Medical Examiner/Coroner\'s Office
performed postmortem examinations on both pilots. The pathologist
reported that neither pilot had any condition or disease which would
have affected his capability to perform his duties. The FAA, Civil
Aeromedical Institute (CAMI), Oklahoma City, Oklahoma, conducted
toxicological examinations on both pilots. The toxicologist reported
that the first officer\'s examinations were negative for alcohol or
drugs. Toxicological analysis of tissue specimen taken from the
pilot-in-command (PIC) showed that lung tissue contained 0.01 percent
(11 mg/dl) ethanol and 0.094 ug/g (0.094 mg/kg) of chlorpheniramine. The
toxicological report also noted that the specimen was putrefied (see
attachment). Analysis of kidney, gastric content, and body tissue was
not carried out. A blood specimen was not available for analysis.
Background medical information on the PIC was not available to determine
the reason for or the extent of his use of chlorpheniramine. However,
the pilot made application for a First Class Airman Medical Certificate
on June 1, 1993. On this application the pilot answered Item 17 {Do you
Currently Use Any medication (Prescription or Nonprescription)?} no. In
Item 18e under Medical History, he answered yes regarding a history of
hay fever or allergy. As a result of the findings of chlorpheniramine,
Safety Board investigators interviewed one of the captain\'s friends.
The captain\'s friend told investigators that the captain was in perfect
health, but had an unknown allergy. The Guide for Aviation Medical
Examiners prepared by the Office of Aviation Medicine of the Federal
Aviation Administration states that; \"Any airman who is undergoing
continuous treatment with antihistaminic, antiviral, ataraxic,
barbiturate, experimental, hypoglycemic, investigational,
mood-ameliorating, motion sickness, narcotic, sedative, tranquilizer, or
steroid drugs must be deferred certification unless the treatment has
previously been cleared by FAA medical authority.\" It is not known how
long the pilot used the antihistaminic drug, chlorpheniramine, or when
he last used the drug. However, according to the above guidance and
conversations with staff at Aviation Medicine, the use of this drug
while flying is not permitted. Tests and Research Engine(s) (S/n P-77449
and P-77550) Disassembly Examination: Both engines and their accessories
were transported to the manufacturer\'s facility in Phoenix, Arizona,
for disassembly and examination. The examination was conducted on March
10, 11, and 14, 1994, under the supervision of Mr. John Eller, Aviation
Safety Inspector (Airworthiness), FAA, Scottsdale \[Arizona\] Flight
Standards District Office. According to the engine manufacturer, \"No
preexisting conditions were found on either engine which would have
prevented normal operation.\" Aircraft Weight Categorization: The FAA
categorizes the various airplanes by its maximum gross takeoff weight.
Airplanes weighing less than 12,500 pounds are categorized as light
airplanes. Airplanes weighing between 12,500 pounds and 300,000 pounds
are categorized large airplanes. Airplanes weighing greater than 300,000
pounds are categorized as heavy airplanes. The Westwind and Boeing 757
are categorized as large aircraft. The FAA utilizes the airplane
categories as a basis for their IFR separation standards. As of the date
of the accident, the FAA separation standard between a large and heavy
airplane is 5 nautical miles. The standard between large airplanes is 3
nautical miles. The FAA Air Traffic Handbook 7110.65H, 7-10(a)(2),
Change 1, Visual Separation states in part, \"\...The tower shall not
provide visual separation between aircraft when wake turbulence
separation is required or when the lead aircraft is a B-757\....\"
Change 1 was to become effective January 6, 1994. The National Business
Aircraft Association (NBAA) provided the Safety Board with data
reflecting fly-by and other engineering tests conducted by the FAA
through independent investigators and by the British Civil Aviation
Authority (CAA) in 1992. These data, some of which was generated in
1991, showed several instances in which large turbine jets, i.e., Boeing
737, McDonnell-Douglas DC-8, and other corporate jet aircraft,
encountered a loss of control when following Boeing 757 aircraft.
Wreckage Release The wreckage was released to representatives of the
owner on February 4, 1994.

**AIRCRAFT 1 FINAL REPORT**\
\
A BEECH LINER, BOEING 757 & ISRAEL WESTWIND (WW) WERE VECTORED FOR
LANDINGS ON RWY 19R. THE 757 & WW WERE SEQUENCED FOR VISUAL APCHS BEHIND
THE BEECH. BEFORE BEING CLEARED FOR VISUAL APCH, THE WW WAS CLOSING 3.5
MI FROM THE 757 ON A CONVERGING COURSE. THE 757 & WW CREWS WERE TOLD TO
SLOW TO 150 KTS. THE 757 SLOWED BELOW 150 KTS & WAS HIGH ON FINAL
APPROACH WITH A 5.6 DEG DESCENT. THE WW CONTINUED TO CONVERGE TO ABOUT
2.1 MI BEHIND THE 757 ON A 3 DEG APCH. ATC DID NOT SPECIFICALLY ADVISE,
AND WAS NOT REQUIRED BY ATC HANDBOOK TO ADVISE, THE WW PILOTS THAT THEY
WERE BEHIND A BOEING 757. CAPT DISCUSSED POSSIBLE WAKE TURBULENCE, FLEW
ILS 1 DOT HIGH, NOTED CLOSENESS TO THE 757 & INDICATED THERE SHOULD BE
NO PROBLEM. WHILE DESCENDING THRU APRX 1100 FT MSL, THE WW ENCOUNTERED
WAKE TURBULENCE FROM THE 757, ROLLED INTO A STEEP DESCENT & CRASHED. THE
CREW LACKED SPECIFIC WAKE TURBULENCE TRAINING. CHLORPHENIRAMINE (COMMON
OVER-THE-COUNTER ANTI-HISTAMINE; NOT APPROVED FOR FLYING) DETECTED IN
PILOT\'S LUNG TISSUE (0.094 UG/ML). (SEE SPCL STUDY NTSB/SIR-94/01)

**AIRCRAFT 1 CAUSE REPORT**\
\
THE PILOT-IN-COMMAND\'S FAILURE TO MAINTAIN ADEQUATE SEPARATION BEHIND
THE BOEING 757 AND/OR REMAIN ABOVE ITS FLIGHT PATH DURING THE APPROACH,
WHICH RESULTED IN AN ENCOUNTER WITH WAKE VORTICES FROM THE 757. FACTORS
RELATED TO THE ACCIDENT WERE: AN INADEQUACY IN THE ATC PROCEDURE RELATED
TO VISUAL APPROACHES AND VFR OPERATIONS BEHIND HEAVIER AIRPLANES, AND
THE RESULTANT LACK OF INFORMATION TO THE WESTWIND PILOTS FOR THEM TO
DETERMINE THE RELATIVE FLIGHT PATH OF THEIR AIRPLANE WITH RESPECT TO THE
BOEING 757\'S FLIGHT PATH.

**END REPORT**

**NASDAC BRIEF REPORT**

**GENERAL INFORMATION**

  -- ------------ -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -------------------------------
     Data Source:                                                                                                                                                                                     NTSB AVIATION ACCIDENT/INCIDENT
                                                                                                                                                                                                      DATABASE

     Event Id:                                                                                                                                                                                        20001208X07286

     Local Date:                                                                                                                                                                                      01/07/1997

     Local Time:                                                                                                                                                                                      1947

     State:                                                                                                                                                                                           TX

     City:                                                                                                                                                                                            HOUSTON

     Airport                                                                                                                                                                                          GEORGE BUSH INTERCONTINENTAL
     Name:                                                                                                                                                                                            ARPT-HOUSTON

     Event Type:                                                                                                                                                                                      ACCIDENT

     Injury                                                                                                                                                                                           MINOR
     Severity:                                                                                                                                                                                        

     Report                                                                                                                                                                                           FINAL
     Status:                                                                                                                                                                                          

     Mid Air                                                                                                                                                                                          NO
     Collision:                                                                                                                                                                                       

     Event                                                                                                                                                                                            ON AIRPORT
     Location:                                                                                                                                                                                        

                                                                                                                                                                                                      
  -- ------------ -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -------------------------------

**WEATHER INFORMATION**

  -- ------------------------------------- -- -- ------------------------------
     Weather Briefing Complete:                  NOT PERTINENT

     Brief Source:                               

     Basic Weather Conditions:                   VISUAL METEOROLOGICAL COND

     Light Condition:                            NIGHT/DARK

     Cloud Condition:                            UNKNOWN

     Cloud Height above Ground Level (ft):       0

     Ceiling Height above Ground Level           1200
     (ft):                                       

     Cloud Type:                                 OVERCAST

     Visibility RVR (ft):                        0

     Visibility RVV (sm):                        0

     Visibility (sm):                            10

     Wind Direction (deg):                       100

     Wind Condition Flag:                        U

     Wind Speed (knots):                         6

     Wind Condition Indicated:                   Unknown

     Visibility Restrictions:                    

     Precipitation Type:                         
  -- ------------------------------------- -- -- ------------------------------

**AIRCRAFT INFORMATION**\
\
**Aircraft 1**

  -- -------------------------- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- --------------------
     Category of Operation:                                                                                                                                                                          SCHEDULED

     Aircraft Type:                                                                                                                                                                                  AIRPLANE

     Aircraft Homebuilt:                                                                                                                                                                             NO

     Aircraft Damage:                                                                                                                                                                                SUBSTANTIAL

     Phase of Flight:                                                                                                                                                                                TAXI

     Aircraft Make:                                                                                                                                                                                  ATR

                                                                                                                                                                                                     

     Aircraft Model:                                                                                                                                                                                 ATR 42

                                                                                                                                                                                                     

     Aircraft Series:                                                                                                                                                                                300

     Operator Doing Business                                                                                                                                                                         JET LINK
     As:                                                                                                                                                                                             

     Operator Name                                                                                                                                                                                   CONTINENTAL EXPRESS

     Owner Name                                                                                                                                                                                      CONTINENTAL EXPRESS

                                                                                                                                                                                                     

     NTSB Report Number:                                                                                                                                                                             FTW97LA081

     Number of Seats:                                                                                                                                                                                61

     Number of Engines:                                                                                                                                                                              2

     ELT Installed:                                                                                                                                                                                  YES

     ELT Operated:                                                                                                                                                                                   NO

     Aircraft Use:                                                                                                                                                                                   UNKNOWN

     Type of Operation:                                                                                                                                                                              PART 121: AIR
                                                                                                                                                                                                     CARRIER

     Departure Airport Id:                                                                                                                                                                           SHV

     Departure City:                                                                                                                                                                                 SHREVEPORT

     Departure State:                                                                                                                                                                                LOUISIANA

     Last Departure Point:                                                                                                                                                                           NO

     Destination Local:                                                                                                                                                                              SAME AS
                                                                                                                                                                                                     ACCIDENT/INCIDENT
                                                                                                                                                                                                     LOC

     Destination Airport Id:                                                                                                                                                                         IAH

     Destination City:                                                                                                                                                                               

     Destination State:                                                                                                                                                                              

     Runway Id:                                                                                                                                                                                      0

     Runway Length:                                                                                                                                                                                  

     Runway Width:                                                                                                                                                                                   

     Flight Plan Filed:                                                                                                                                                                              IFR

     Domestic/International:                                                                                                                                                                         DOMESTIC

     Passenger/Cargo:                                                                                                                                                                                PASSENGER ONLY

     Registration Number:                                                                                                                                                                            N14829

     Air Carrier Operating                                                                                                                                                                           YES
     Certificates:                                                                                                                                                                                   

     Air Carrier Other                                                                                                                                                                               NO
     Operating Certificates:                                                                                                                                                                         

     Rotocraft/Agriculture                                                                                                                                                                           UNKNOWN
     Operating Certificate:                                                                                                                                                                          

     Cert Max Gross Wgt:                                                                                                                                                                             35530

     Aircraft Fire:                                                                                                                                                                                  NONE

     Aircraft Explosion:                                                                                                                                                                             NONE

     Landing Gear:                                                                                                                                                                                   RETR

     ATC Clearance                                                                                                                                                                                   

     Landing Gear                                                                                                                                                                                    

     Runway Condition                                                                                                                                                                                

     Landing Surface                                                                                                                                                                                 
  -- -------------------------- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- --------------------

**ENGINE INFORMATION**\
\
\
**Aircraft 1 - Engine #:1**

  -- --------------------------------------- -- -- --------------------------
     Engine Type:                                  TURBO PROP

     Engine Group                                  

     Engine Manufactuer                            P&W

     Engine Make                                   P & W

     Engine Model                                  PW121

     Engine Cert Type                              

     Engine Horsepower                             2150

     Engine Thrust                                 HP

     Carb/Injection                                

     Propeller Type                                
  -- --------------------------------------- -- -- --------------------------

**Injury Summary for Aircraft 1**

  ----------- -- ----------- -- ---------------- -- ------------ -- ------------
                 **Fatal**      **Serious**         **Minor**       **None**

  Crew           0              0                   0               3

  Pass                                              3               10

  Total          0              0                   3               13
  ----------- -- ----------- -- ---------------- -- ------------ -- ------------

**Pilot-in-Command for Aircraft 1**

  -------------------------- -- -- -----------------------------------------
  Certificates:                    AIRLINE TRANSPORT

  -------------------------- -- -- -----------------------------------------

  -----------------------------------------------------------------------
  Ratings:

  -----------------------------------------------------------------------

  ---- -------------------------------------------------------- --- --- ----
       Plane:                                                           

       Non-Plane:                                                       

       Instrument:                                                      

       Instruction:                                                     
  ---- -------------------------------------------------------- --- --- ----

  ------------------------------- -- -- -------------------------------------
  Had Current BFR:                      Y

  Months Since Last BFR:                

  Medical Certificate:                  CLASS 1

  Medical Certificate Validity:         VALID MEDICAL\--NO WAIVERS/LIM.
  ------------------------------- -- -- -------------------------------------

  -------------------------------------------- ---- -- -- -----------------
  Flight Time (hours)                                     

  Total                                        :          4991

  Make/Model                                   :          2066

  Instrument                                   :          0

  Multi-Engine                                 :          3304

  Last 24 Hours                                :          5

  Last 30 Days                                 :          97

  Last 90 Days                                 :          240

  Rotocraft                                    :          0
  -------------------------------------------- ---- -- -- -----------------

**Sequence of Events**\
**Aircraft 1**\
Occurrence #: 1\
ON GROUND/WATER ENCOUNTER WITH TERRAIN/WATER\
Phase of Operation: TAXI - FROM LANDING

  -------------- ----------- ------------------------- -------------- --------------- ------------------
  **Findings**                                                                        

  **Event Seq    **Event     **Subject**               **Modifier**   **Personnel**   **Cause/Factor**
  \#**           Group                                                                
                 Code**                                                               

  1              1           AIRPORT FACILITIES,       SOFT                           
                             TAXIWAY CONDITION                                        

  2              1           LIGHT CONDITION           OTHER                          FACTOR

  3              2           WRONG TAXI ROUTE          SELECTED       PILOT IN        CAUSE
                                                                      COMMAND         
  -------------- ----------- ------------------------- -------------- --------------- ------------------

**AIRCRAFT 1 PRELIMINARY REPORT**\
\
On January 7, 1997, at 1947 central standard time, an Aerospatiale ATR
42-320, N14829, was substantially damaged while taxiing at the Houston
Intercontinental Airport, Houston, Texas. Three passengers sustained
minor injuries and there were no injuries to the 3 crewmembers, and the
remaining 10 passengers. The airplane, owned and operated by Continental
Express Airlines as Jet Link flight 3777, was on a scheduled revenue
flight from Shreveport, Louisiana, to the Houston Intercontinental
Airport. Night visual meteorological conditions prevailed for the
scheduled Title 14 CFR Part 121 flight for which an instrument flight
plan was filed. The airplane departed from Shreveport, Louisiana at
approximately 1900. According to the operator, after a night ILS
approach and landing on runway 8, flight 3777 was cleared to their gate
in Terminal \"C\" via taxiways NA to NK, the IAB ramp, and across the
east bridge to the Continental Express ramp. The taxiways were wet or
damp, and the captain reported that there was glare on the windshield
from the lights illuminating the terminal area. In an statement to the
FAA, the captain stated that after turning south on NK, he taxied the
airplane towards the IAB terminal, and saw what appeared to be a hard
surface ramp to the left and right of the airplane and he proceeded to
make a left turn believing that he was now taxiing on the IAB ramp. The
captain reported that the airport diagram on the Jeppesen charts showed
the intersection of NK and the IAB ramp to be a \"T\" or 90 degree turn,
but in reality, the intersection is constructed at a 45 degree angle to
the left of taxiway NK which joins the IAB ramp. A copy of the chart in
question is enclosed. The captain further stated that no lights were
available to outline the edge of the ramp area. The pilot added that he
continued to taxi in an east direction, believing that he was on the IAB
ramp. The airplane taxied off the hard surface into the grass, coming to
rest approximately 50 feet beyond the edge of the hard surface area of
the taxiway. According to the airport\'s operations personnel, the
taxiway is properly marked with a solid center line and the area is
bordered by a double yellow line delineating the edge of the taxiway.
Additionally, at the time of the accident, recessed taxiway lights were
in place to further delineate the edge of the taxiway. One of the
lights, located approximately 50 feet north of the point were the
airplane left the pavement, was reported out of service at the time of
the accident. The airport operations personnel further stated that the
taxiways were dry at the time of the accident. The last Metar weather
observation issued prior to the accident that reflected any type of
precipitation was the 1754 observation which confirmed that the rain
ended at 1711, approximately 2 hours and 26 minutes before the accident.
A copy of the recorded weather reports is enclosed in this report. The
passengers deplaned the aircraft by normal means and were bussed to the
terminal building without further incident. Examination of the airplane
by the operator and the FAA inspector confirmed that the pressured
bulkhead sustained structural damage. The operator added that the damage
incurred by the airframe and landing gear exceeded \$800,000. In the
enclosed NTSB Pilot/Operator Report, the operator stated that the
lighting on the east-west taxiway in question consist of centerline
lights only, with no edge lighting available. The operator also cites
that there are \"an inordinately high number of lights on the terminal
buildings directly in front of the taxi-way that could affect a pilot\'s
vision when entering the taxiway toward the terminal.\" The recessed
lights were converted by airport authorities to standard \"raised\"
lights after the accident.

**AIRCRAFT 1 FINAL REPORT**\
\
The airplane taxied off the hard surface into the soft grass, coming to
rest about 50 feet beyond the edge of the hard surface taxiway. The
captain stated that after turning south on NK, he taxied the airplane
towards the IAB terminal, and saw what appeared to be a hard surface
ramp to the left and right of the airplane and he proceeded to make a
left turn believing that he was now taxiing on the IAB ramp. The captain
reported that the airport diagram on the Jeppesen charts showed the
intersection of NK and the IAB ramp to be a \'T\' or 90 degree turn, but
in reality, the intersection is constructed at a 45 degree angle to the
left of taxiway NK which joins the IAB ramp. The pilot further stated
that no lights were available to outline the edge of the ramp area. He
added that he continued to taxi in an east direction, believing that he
was on the IAB ramp. According to the airport\'s operations personnel,
the taxiway is properly marked with a solid center line and the area is
bordered by a double yellow line delineating the edge of the taxiway.
Additionally, at the time of the accident, recessed taxiway lights were
in place to further delineate the edge of the taxiway.

**AIRCRAFT 1 CAUSE REPORT**\
\
The pilot\'s failure to follow the proper taxi route while taxiing back
to the terminal. A factor was the glare radiating from the airport\'s
terminal area.

**END REPORT**

**Appendix 5: Make Model Listing for Study Accidents**

+-----------+-----------+-----------+-----------+----------------------+
| **N       | **Make**  | **Model** | *         | **Description**      |
| Number**  |           |           | *NTSBID** |                      |
+-----------+-----------+-----------+-----------+----------------------+
| N566AA    | McDonnell | MD-83     | D         | Medium air carrier   |
|           | Douglas   |           | CA96MA008 | turbojet             |
+-----------+-----------+-----------+-----------+----------------------+
| N4391W    | Beech     | A100      | I         | Corporate turbo-prop |
|           |           | (King     | AD96LA117 |                      |
|           |           | Air)      |           |                      |
+-----------+-----------+-----------+-----------+----------------------+
| N948DL    | McDonnell | MD-88     | A         | Medium air carrier   |
|           |           |           | TL93IA135 | turbojet             |
|           | Douglas   |           |           |                      |
+-----------+-----------+-----------+-----------+----------------------+
| N335SW    | Boeing    | 737-3H4   | L         | Medium air carrier   |
|           |           |           | AX01IA109 | turbojet             |
+-----------+-----------+-----------+-----------+----------------------+
| 9Y-THQ    | McDonnell | MD-83     | M         | Medium air carrier   |
|           |           |           | IA02IA047 | turbojet             |
|           | Douglas   |           |           |                      |
+-----------+-----------+-----------+-----------+----------------------+
| N948CC    | Beech     | E90 (King | L         | Corporate turbo-prop |
|           |           | Air)      | AX02FA108 |                      |
+-----------+-----------+-----------+-----------+----------------------+
| N497FA    | Boeing    | 727-232F  | Pr        | Medium air carrier   |
|           |           |           | eliminary | turbojet             |
+-----------+-----------+-----------+-----------+----------------------+
| N27220    | Fairchild | SA-227    | L         | Small air carrier    |
|           |           |           | AX94IA203 | turbo-prop           |
+-----------+-----------+-----------+-----------+----------------------+
| N117WM    | Beech     | 200 (King | S         | Corporate turbo-prop |
|           |           | Air)      | ea97FA067 |                      |
+-----------+-----------+-----------+-----------+----------------------+
| N309CK    | IAI       | 1124A     | L         | Corporate turbo-jet  |
|           |           |           | AX94FA073 |                      |
+-----------+-----------+-----------+-----------+----------------------+
| N14829    | ATR       | ATR-42    | F         | Small air carrier    |
|           |           |           | TW97la084 | turbo-prop           |
+-----------+-----------+-----------+-----------+----------------------+

[^1]: *LAAS Concept of Operations*, Satellite Operational Implementation
    Team (SOIT), Federal Aviation Administration, 9/10/2002.

[^2]: Number derived from the following FAA website
    <http://www.api.faa.gov/strategic/docs/sup-sys-40-arpaccessgoal.html>.

[^3]: [FAA Navigation & Landing Transition Strategy
    Report](http://www1.faa.gov/asd/briefings/NavReport8-02.pdf):
    http://www1.faa.gov/asd/briefings/NavReport8-02.pdf

[^4]: Khatwa R, Helmreich R, *Analysis of Critical Factors During
    Approach and Landing in Accidents and Normal Flight,* Flight Safety
    Digest, Volume 17, No 11-12, Flight Safety Foundation, Alexandria,
    VA, pg 80.

[^5]: Enders et al, *Airport Safety: A Study of Accidents and Available
    Approach-and-landing Aids*, Flight Safety Digest, Flight Safety
    Foundation, Alexandria, VA., March 1996.

[^6]: Nordwall B D, *U.S. Changing to One Type of Instrument Approach*,
    Aviation Week and Space Technology, July 8^th^, 2002 pg 45-46.

[^7]: *LAAS Concept of Operations,* Ibid

[^8]: The WAAS description was obtained from the FAA's Satellite Office
    website <http://gps.faa.gov/programs/index.htm>.

[^9]: <http://gps.faa.gov/programs/index.htm>

[^10]: <http://www.api.faa.gov/apo_home.asp>

[^11]: *FAA Long-Range Aerospace Forecasts Fiscal Years 2015, 2020 and
    2025, Report No. FAA-APO-00-5.* FAA Office of Aviation Policy and
    Plans, Washington D.C. June 2000.

[^12]: This reference can be found on NBAA's website
    http://www.nbaa.org/factbook/.

[^13]: Statistical Package for the Social Sciences.

[^14]: NTSB accident briefs can be obtained at the NTSB's web site
    http://www.ntsb.gov/ntsb/query.asp.

[^15]: 24/year installation rate provided by FAA/AND-710.

[^16]: *Economic Value for Evaluation of Federal Aviation Administration
    Investment and Regulatory Decisions,* Report No. FAA-APO-98-8, June
    1998, Washington D.C.

[^17]: These values were determined by reviewing a sample of
    representative used aircraft prices in Trade-A-Plane, a used
    aircraft classified advertising service and prices advertised for
    used air carrier aircraft in Flight International Magazine. The
    website for Trade-A- Plane is http://www.trade-a-plane.com.

[^18]: Discussion with engineers from Honeywell and Boeing Commercial
    Airplane.

[^19]: Information derived from conversations with an avionics engineer
    at Rockwell Collins, a major aircraft instrument and avionics
    manufacturer.

[^20]: June 14, 2001 Memo from the Assistant Inspector General for
    Auditing at DOT to FAA.

[^21]: Proctor, P. *New Head-Up Tool Aims to Cut Runway Incidents*,
    Aviation Week and Space Technology, August 14, 2000. Washington D.C.

[^22]: Proctor P. Ibid.

[^23]: Khatwa R, Roelen A.L.C., *An Analysis of
    Controlled-flight-into-terrain (CFIT) Accidents of Commercial
    Operators, 1988 Through 1994*, Flight Safety Digest, Flight Safety
    Foundation, Alexandria, VA April-May 1996, pg 1.

[^24]: Ashford R, *A Study of Fatal Approach -- and -- landing Accidents
    Worldwide, 1980-1996,* Flight Safety Digest, Flight Safety
    Foundation, Alexandria, VA., March 1998.

[^25]: Nordwall, Ibid.

[^26]: The concept of a fatal or serious injury case rate is to provide
    an estimate of risk for occupants. In this study injury case rates
    were calculated per 1 million departures and account for the ratio
    of fatal or serious injuries among all occupants of the accident
    aircraft.

[^27]: NTSB Most Wanted Safety Improvements,
    http://www.ntsb.gov/Recs/mostwanted/aviation_issues.htm

[^28]: *FAA Runway Safety Report, Runway Incursion Trends at Towered
    Airports, CY1998-2001*, FAA's Office of Runway Safety, Washington,
    D.C.

[^29]: *FAA Runway Safety Report,* Ibid.

[^30]: The actual value is 0.7 collisions during the 2006-2025 time
    frame. This value was rounded to 1 major collision event.