Loss of Control and Impact With Terrain

Aviation Charter, Inc.

Raytheon (Beechcraft) King Air A100, N41BE

Eveleth, Minnesota

October 25, 2002

Aircraft Accident Report

NTSB/AAR-03/03

PB2003-910403

Notation 7602

National 

Transportation

Safety Board

Washington, D.C.

Aircraft Accident Report

Loss of Control and Impact With Terrain

Aviation Charter, Inc. 

Raytheon (Beechcraft) King Air A100, N41BE

Eveleth, Minnesota

October 25, 2002

NTSB/AAR-03/03

PB2003-910403 National Transportation Safety Board

Notation 7602 490 LíEnfant Plaza, S.W.

Adopted November 18, 2003 Washington, D.C. 20594

E PLUR IBUS UNUM

NATIONAL TRA S PORTATION

B OAR D

SAFE T Y

N
National Transportation Safety Board. 2003. Loss of Control and Impact With Terrain, Aviation

Charter, Inc., Raytheon (Beechcraft) King Air A100, N41BE, Eveleth, Minnesota, October 25, 2002.

Aircraft Accident Report NTSB/AAR-03/03. Washington, DC.

Abstract: This report explains the accident involving Aviation Charter, Inc., which crashed while

the flight crew was attempting to execute the VOR approach to runway 27 at Eveleth-Virginia

Municipal Airport, Eveleth, Minnesota, on October 25, 2002. The safety issues discussed in this

report include flight crew proficiency, Aviation Charter operational and training issues,

inadequate crew resource management (CRM) training, Federal Aviation Administration (FAA)

surveillance, and the need for improved low-airspeed awareness. Safety recommendations

concerning CRM training, FAA surveillance, and low-airspeed alert systems are addressed to the

FAA. 

The National Transportation Safety Board is an independent Federal agency dedicated to promoting aviation, railroad, highway, marine,

pipeline, and hazardous materials safety. Established in 1967, the agency is mandated by Congress through the Independent Safety Board

Act of 1974 to investigate transportation accidents, determine the probable causes of the accidents, issue safety recommendations, study

transportation safety issues, and evaluate the safety effectiveness of government agencies involved in transportation. The Safety Board

makes public its actions and decisions through accident reports, safety studies, special investigation reports, safety recommendations, and

statistical reviews.

Recent publications are available in their entirety on the Web at <http://www.ntsb.gov>. Other information about available publications also

may be obtained from the Web site or by contacting:

National Transportation Safety Board

Public Inquiries Section, RE-51

490 LíEnfant Plaza, S.W.

Washington, D.C. 20594

(800) 877-6799 or (202) 314-6551

Safety Board publications may be purchased, by individual copy or by subscription, from the National Technical Information Service. To

purchase this publication, order report number PB2003-910403 from:

National Technical Information Service

5285 Port Royal Road

Springfield, Virginia 22161

(800) 553-6847 or (703) 605-6000

The Independent Safety Board Act, as codified at 49 U.S.C. Section 1154(b), precludes the admission into evidence or use of Board reports

related to an incident or accident in a civil action for damages resulting from a matter mentioned in the report. 
iii Aircraft Accident Report

Contents

Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vi

Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix

1. Factual Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

1.1 History of Flight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

1.2 Injuries to Persons. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

1.3 Damage to Airplane . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

1.4 Other Damage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

1.5 Personnel Information. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

1.5.1 The Pilot. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

1.5.1.1 The Pilot’s 72-Hour History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

1.5.1.2 The Pilot’s Logbook History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

1.5.2 The Copilot . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

1.5.2.1 The Copilot’s 72-Hour History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

1.6 Airplane Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

1.7 Meteorological Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

1.7.1 National Weather Service Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

1.7.2 Airport Weather Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

1.7.3 Additional Icing and Cloud Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

1.8 Aids to Navigation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

1.8.1 EVM VOR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

1.8.1.1 Preaccident Flight Checks of the EVM VOR . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

1.8.1.2 Postaccident Ground and Flight Checks of the EVM VOR . . . . . . . . . . . . . . . . 20

1.8.1.3 VOR Navigation System Special Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

1.9 Communications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

1.10 Airport Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

1.10.1 Air Traffic Control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

1.11 Flight Recorders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

1.12 Wreckage and Impact Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

1.12.1 General . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

1.12.2 Cockpit Instrumentation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

1.13 Medical and Pathological Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

1.14 Fire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

1.15 Survival Aspects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

1.16 Tests and Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

1.16.1 Airplane Performance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

1.16.2 Operational Factors and Human Performance Simulations. . . . . . . . . . . . . . . . . . . 28

1.17 Organizational and Management Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

1.17.1 Company Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

1.17.1.1 Crew Resource Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

1.17.1.2 Stall Recovery Maneuvers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

1.17.1.3 Instrument Approaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

1.17.1.4 Standard Operating Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Contents iv Aircraft Accident Report

1.17.2 Operational Guidance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

1.17.2.1 Manufacturer’s Guidance on Operation in Icing Conditions. . . . . . . . . . . . . . . . 36

1.17.2.2 Company Guidance on Operation in Icing Conditions . . . . . . . . . . . . . . . . . . . . 36

1.17.2.3 Weight and Balance Load Manifest Procedures . . . . . . . . . . . . . . . . . . . . . . . . . 37

1.17.3 FAA Surveillance. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

1.17.3.1 General. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

1.17.3.2 FAA Surveillance Guidance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

1.17.3.3 Minneapolis FSDO Oversight of Aviation Charter . . . . . . . . . . . . . . . . . . . . . . . 39

1.17.3.4 FAA En Route Inspections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

1.17.3.5 Preaccident FAA Regional Aviation Safety Inspection Program Inspection . . . 40

1.18 Additional Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

1.18.1 Previous Aviation Charter Operations-Related Accident . . . . . . . . . . . . . . . . . . . . 41

1.18.2 Previous CRM-Related Safety Recommendation . . . . . . . . . . . . . . . . . . . . . . . . . . 41

2. Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

2.1 General . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

2.2 Determination of Flying Pilot . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

2.3 Accident Sequence of Events . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

2.3.1 Flight Crew’s Inadequate Setup for the Approach. . . . . . . . . . . . . . . . . . . . . . . . . . 44

2.3.2 Flight Crew’s Failure to Stabilize the Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

2.3.3 Summary of Flight Crew’s Performance During the Approach . . . . . . . . . . . . . . . 46

2.4 Weather Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

2.4.1 Clouds . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

2.4.2 Airframe Icing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

2.5 ATC Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

2.6 EVM VOR Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

2.7 Flight Crew Proficiency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

2.8 Aviation Charter Operational and Training Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

2.8.1 Operational Guidance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

2.8.2 CRM Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52

2.9 FAA Surveillance Issues. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52

2.9.1 FAA Surveillance of Aviation Charter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52

2.9.2 FAA Surveillance of Part 135 On-Demand Operations. . . . . . . . . . . . . . . . . . . . . . 53

2.9.3 FAA CRM Training Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54

2.10 Low-Airspeed Alert Systems. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54

2.10.1 Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54

2.10.2 Need for Improved Low-Airspeed Awareness . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56

3. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58

3.1 Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58

3.2 Probable Cause . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59

4. Recommendations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60

4.1 New Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60

4.2 Previously Issued Recommendation Classified in This Report . . . . . . . . . . . . . . . . . . . 61

5. Appendix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63

A: Investigation and Public Hearing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
v Aircraft Accident Report

Figures

1. The published EVM VOR approach chart. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

2. Ground track of the accident flight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

3. Profile view of the accident flight. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

4. Reconstruction of pilotís reported flight hours. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
vi Aircraft Accident Report

Abbreviations

AC advisory circular

AFM Aircraft Flight Manual

AFSS Automated Flight Service Station

agl above ground level

AIM Aeronautical Information Manual

AIRMET airmenís meteorological information

ARAC Aviation Rulemaking Advisory Committee

ASOS automated surface observing system

ATC air traffic control

ATCT air traffic control tower

ATP airline transport pilot

ATSS Airway Transportation System Specialist

AWC Aviation Weather Center

AWOS automated weather observing system

BIS Bismarck Municipal Airport

C Celsius

CAMI Civil Aerospace Medical Institute

CDI course deviation indicator

CFI certified flight instructor

CFR Code of Federal Regulations

CG center of gravity

CRM crew resource management

CVR cockpit voice recorder

DLH Duluth International Airport

DME distance measuring equipment

EVM Eveleth-Virginia Municipal Airport
Abbreviations vii Aircraft Accident Report

FA area forecast

FAA Federal Aviation Administration

FAF final approach fix

FAR Federal Aviation Regulations

FBO fixed-base operator

FCM Flying Cloud Municipal Airport

FGS flight guidance system

fpm feet per minute

FSDO Flight Standards District Office

FSI Flight Safety International

ft-lbs foot-pounds

GOM General Operations Manual

HSI horizontal situation indicator

IFR instrument flight rules

ILS instrument landing system

IMC instrument meteorological conditions

JAR Joint Aviation Requirements

KCAS knots calibrated airspeed

MAP missed approach point

MDA minimum descent altitude

msl mean sea level

NASA National Aeronautics and Space

Administration

NCAR National Center for Atmospheric Research

NOTAM notice to airmen

NWS National Weather Service

PIC pilot-in-command

PIREP pilot report

POI principal operations inspector
Abbreviations viii Aircraft Accident Report

RASIP Regional Aviation Safety Inspection

Program

ROC Rochester International Airport

RTCA Radio Technical Commission of

Aeronautics

SLD supercooled large droplets

SOPs Standard Operating Procedures

STP St. Paul Downtown Airport

TAF terminal aerodrome forecast

UTC coordinated universal time

VOR very high omnidirectional range
ix Aircraft Accident Report

Executive Summary

On October 25, 2002, about 1022 central daylight time, a Raytheon (Beechcraft)

King Air A100, N41BE, operated by Aviation Charter, Inc., crashed while the flight crew

was attempting to execute the VOR approach to runway 27 at Eveleth-Virginia Municipal

Airport, Eveleth, Minnesota. The crash site was located about 1.8 nautical miles southeast

of the approach end of runway 27. The two pilots and six passengers were killed, and the

airplane was destroyed by impact forces and a postcrash fire. The airplane was being

operated under the provisions of 14 Code of Federal Regulations Part 135 as an

on-demand passenger charter flight. Instrument meteorological conditions prevailed for

the flight, which operated on an instrument flight rules flight plan. 

The National Transportation Safety Board determines that the probable cause of

this accident was the flight crewís failure to maintain adequate airspeed, which led to an

aerodynamic stall from which they did not recover. 

The safety issues discussed in this report include flight crew proficiency, Aviation

Charter operational and training issues, inadequate crew resource management (CRM)

training, Federal Aviation Administration (FAA) surveillance, and the need for improved

low-airspeed awareness. Safety recommendations concerning CRM training, FAA

surveillance, and low-airspeed alert systems are addressed to the FAA.

1 Aircraft Accident Report

1. Factual Information

1.1 History of Flight

On October 25, 2002, about 1022 central daylight time,1 a Raytheon (Beechcraft)

King Air A100,2 N41BE, operated by Aviation Charter, Inc., crashed while the flight crew

was attempting to execute the VOR3 approach to runway 27 at Eveleth-Virginia Municipal

Airport (EVM), Eveleth, Minnesota. The crash site was located about 1.8 nautical miles4

southeast of the approach end of runway 27. The two pilots and six passengers were

killed, and the airplane was destroyed by impact forces and a postcrash fire. The airplane

was being operated under the provisions of 14 Code of Federal Regulations (CFR)

Part 135 as an on-demand passenger charter flight. Instrument meteorological conditions

(IMC) prevailed for the flight, which operated on an instrument flight rules (IFR) flight

plan.

The accident flight was chartered for U.S. Senator Paul Wellstone. The flight was

scheduled to depart St. Paul Downtown Airport (STP), St. Paul, Minnesota, about 0920

and arrive at EVM around 1020. The flight crew planned to drop off the passengers at

EVM and then ferry the accident airplane from EVM to Duluth International Airport

(DLH), Duluth, Minnesota, with a scheduled arrival of about 1054. The passengers were

to be transported by car to DLH after their activities were concluded in Eveleth. The flight

crew planned to remain at DLH until the flight back to STP, which was scheduled to

depart at 2115.

According to Federal Aviation Administration (FAA) records, the pilot called the

Princeton Automated Flight Service Station (AFSS) for an abbreviated weather briefing

about 0716. The AFSS specialist informed the pilot that AIRMETs [airmenís

meteorological information] for IFR and icing conditions were current over the entire

route.5

 He added that IFR conditions were reported throughout central and northern

Minnesota and that cloud conditions near STP were reported as broken between 800 and

1,000 feet6

 and overcast between 1,300 and 1,600 feet. He also stated that cloud

1 Unless otherwise indicated, all times in this report are central daylight time, based on a 24-hour clock.

2 Raytheon Aircraft Company acquired Beech Aircraft Corporation in February 1980.

3 VOR stands for very high frequency omnidirectional range.

4 Unless otherwise indicated, all distances in this report are reported in nautical miles.

5 An AIRMET is an in-flight weather advisory issued by the National Weather Service (NWS) to

indicate weather that may be hazardous to single-engine and other light aircraft and visual flight rules pilots.

Operators of large aircraft may also be concerned with the information included in an AIRMET. For more

information about the meteorological conditions that existed surrounding the time of the accident, see

section 1.7.

6 Altitudes referenced in this report from surface weather observations and terminal aerodrome

forecasts (TAF) are reported as height above ground level (agl). Unless otherwise indicated, all other

altitudes referenced in this report are reported as height above mean sea level (msl).
Factual Information 2 Aircraft Accident Report

conditions at EVM were reported as scattered at 1,000 feet and overcast at 2,000 feet and

that visibility was reported as 4 statute miles in light snow. He added that between STP

and EVM the cloud ceilings were reported between 300 and 600 feet and visibility was

reported as between 1 to 4 statute miles in light snow and mist.

The pilot then asked for freezing level information7 and weather information for

DLH in case he had to land there as an alternate to EVM. The AFSS specialist indicated

that at that time, DLH was reporting an overcast cloud ceiling of 500 feet and visibility of

2 statute miles in light snow and mist. He added that the terminal forecast indicated an

overcast cloud ceiling of 500 to 900 feet and visibility of 1 to 3 statute miles in rain or

snow. About 0719, the pilot stated, ìyou know what[,] I donít think Iím going to take this

flight.î

According to the Senatorís campaign scheduler, the pilot contacted her about 0720

and informed her that they might experience icing conditions during the flight. She stated

that the pilot did not indicate that he was thinking of canceling the flight. The campaign

scheduler stated that when she asked the pilot what he would do if icing became a

problem, he told her that the airplane was equipped with deicing equipment and, if

necessary, that he could turn the airplane back toward warmer air to melt the ice or divert

to DLH. She stated that the pilot then reassured her that he was an experienced and

conservative pilot.

About 0730, the pilot contacted Aviation Charterís headquarters in Eden Prairie,

Minnesota, and asked the receptionist who answered his call to inform the companyís

scheduling office that the Senatorís flight would be delayed because of the weather.

The pilot then contacted the Million Air fixed-base operator (FBO) at STP and told its

general manager that he would be departing about 1300 instead of 0920 and asked her to

ensure that the airplane would be available at that time. However, the Senatorís campaign

scheduler stated that when she talked to the pilot again about 0800, he indicated that the

cloud ceiling had improved, and they agreed to go ahead with the flight as originally

scheduled.

According to FAA records, at 0817:57, the pilot contacted the Princeton AFSS and

asked, ìcan you give me Eveleth weather right now?î The AFSS specialist stated that the

latest automated weather for EVM was issued at 0754 and that it indicated calm winds,

visibility of 3 statute miles in light snow, and an overcast cloud ceiling at 900 feet.

He added that there was reported light mixed icing at 7,000 to 10,000 feet at Hibbing,

Minnesota, and that the AIRMETs for IFR and icing conditions were still current.

At 0818:38, the pilot began filing an IFR flight plan with an estimated departure

time from STP of 0920. While filing the flight plan, the pilot asked the AFSS specialist if

any turbulence was forecast, and the AFSS specialist replied, ìno just icing theyíve been

collecting in the tops andÖitís been running between ten and fifteen thousand.î The pilot

then asked for a cruise level of 13,000 feet.

7 The AFSS specialist stated that the freezing level was reported to be from the surface to 7,000 feet in

the northern portion of the area, sloping to 8,000 to 11,000 feet in the southern portion of the area.
Factual Information 3 Aircraft Accident Report

According to Aviation Charterís director of charter, sales, and marketing, the pilot

called her about 0840 and stated that he had done a weather check with the Senatorís

campaign staff and that they still wanted to depart as planned. He indicated that he was

getting conflicting guidance from another of the Senatorís staffs and that he did not feel

comfortable deciding whether or not to make the flight. The director of charter, sales, and

marketing stated that she told the pilot to contact the companyís chief pilot and that the

pilot indicated that he had tried to contact the chief pilot but had not been able to reach

him. She stated that she suggested to the pilot that he speak to the companyís director of

operations. She also stated that the pilot did not seem overly stressed, just concerned about

doing a good job.

Aviation Charterís director of operations stated that he did not speak with the pilot

that morning but that the pilot had left him a voice message stating that there was some

confusion about whether they should depart. He indicated that the pilot stated on the

message that icing conditions might prevent them from returning to STP later that day as

planned.

According to Million Airís general manager, the copilot checked with her before

the flight to ensure that the airplane had been fueled and then went to the hangar to get

catering items for the flight and to preflight the airplane. The airplane had been in the

hangar overnight and was towed from the hangar after the copilot arrived at STP.

According to Million Airís general manager and another King Air pilot, the

accident pilot arrived at STP shortly before 0900, and the Senator and his staff were

already at the airport. The other King Air pilot, who had just arrived at STP from the DLH

area, indicated that the accident pilot asked him about the weather conditions he had

encountered on his flight and then asked him if he would mind sharing this information

with the Senator. The other King Air pilot indicated that he told the Senator that the

weather was at minimums, but he was sure the pilots could handle the flight.

According to FAA air traffic control (ATC) records, the flight departed STP

about 0937 and was cleared to proceed directly to EVM at 13,000 feet. ATC services were

provided by the Minneapolis Terminal Radar Approach Control and the Minneapolis Air

Route Traffic Control Center for the en route portion of the flight, and these services were

routine.

About 1001, the copilot8

 contacted the DLH Air Traffic Control Tower (ATCT)9

and reported level at 13,000 feet proceeding direct to EVM. The DLH approach control

south radar controller responded, ìking air four one bravo echo duluth approach[,] when

you have eveleth weather advise what approach you [would] likeÖhad icing reports

8 The accident airplane was not equipped with a cockpit voice recorder (CVR); therefore, the

Operations Group listened to the recorded ATC voice communications to identify which flight crewmember

was operating the radios for each transmission. Although the group determined that the copilot made all but

one of the transmissions to ATC, it could not determine who was the flying pilot (that is, the pilot

manipulating the airplaneís flight controls) during the flight.

9 The DLH ATCT provides radar approach control services to EVM.
Factual Information 4 Aircraft Accident Report

through the morning[;] the last report was from a saabÖdescended into duluth had light

rime ice but earlier just about an hour agoÖa dc nine had moderate rime between niner

thousand and one one thousand.î10 The copilot acknowledged the transmission.

About 1002, the controller instructed the flight crew to descend to and maintain 4,000 feet

at pilotís discretion.

About 1004, the copilot contacted the DLH approach control south radar controller

indicating that he had the current EVM weather11 and that he would like the VOR

runway 27 approach. The controller advised, ìexpect vectors for the approach.î

The copilot acknowledged the transmission. About 1006, the controller asked the flight

crew what they intended to do in the event of a missed approach. The pilot responded,

ìwell letís hope we donít have that if weÖdo have a missed approach weíll go up and

circle and figure this out[;] Iíll hold at the vor.î12

About 1009, the copilot reported leaving 13,000 feet for 4,000 feet. Radar data

indicate that the airplane was approximately 34 miles south of EVM at this time.

About 1012, the DLH approach control south radar controller instructed the flight crew to

descend to 3,500 feet at pilotís discretion.13 Radar data indicate that at 1015:17, the

airplane was descending through 6,200 feet at about 194 knots calibrated airspeed

(KCAS)14 when the controller instructed the flight crew to turn right to a heading of 50°.

At 1017:21, the controller instructed the flight crew to turn left to a heading of 360°.

By 1017:35, the airplane had leveled off at 3,500 feet and was heading northward with the

airspeed decreasing through about 190 KCAS.

At 1018:13, when the airplane was less than about 1/2 mile south of the published

VOR runway 27 approach course (see figure 1), the DLH approach control south radar

10 In this report, the following terms are used to describe icing conditions: ìrime,î ìtrace,î ìlight,î and

ìmoderate.î According the to the Aeronautical Information Manual (AIM), rime ice is ìrough, milky,

opaque ice formed by the instantaneous freezing of small supercooled water droplets.î The AIM states that

the term ìtraceî should be used to describe ice that has become perceptible, the term ìlightî should be used

to describe ice that is accumulating at a rate that may create a problem if flight in such an environment is

prolonged (over 1 hour) and the occasional use of deice/anti-icing equipment prevents the problem, and the

term ìmoderateî should be used to describe ice that is accumulating at a rate that can become potentially

hazardous even in short encounters and use of deicing/anti-icing equipment or flight diversion becomes

necessary.

11 The 0954 weather observation from the automated weather observing system (AWOS)-3, which is

located at EVM about 2 miles northwest from the accident site, included a reported visibility of 2 1/2 statute

miles in light snow and a sky condition of 400 feet scattered, 700 feet overcast. Visibility of 1 statute mile

was required to execute the VOR runway 27 approach.

12 For more information about Aviation Charterís Abandoned Approach procedure, see section 1.17.1.3.

13 The VOR runway 27 approach procedure prescribes 2,800 feet as the initial approach altitude (within

10 miles of EVM). However, according to standard operating procedures for the DLH ATC facility,

controllers assign a greater initial approach altitude than prescribed because intermittent radar coverage and

radio communication exist below 3,000 feet in the vicinity of EVM. The DLH south radar controller stated

that he assigned an initial approach altitude of 3,500 feet to ensure that he did not lose radar contact with the

accident airplane.

14 KCAS was derived from FAA and U.S. Air Force 84th Radar Evaluation Squadron radar and

atmospheric data. Because of limitations inherent in radar data, all radar-derived calculations of the

airplaneís performance parameters presented in this report should be considered approximations.
Factual Information 5 Aircraft Accident Report

controller advised, ìone zero miles from the vor turn left heading three zero zero maintain

three thousand five hundred [un]til established on the final approach course cleared for the

vor runway two seven approach eveleth.î The copilot acknowledged the instruction

at 1018:31. Radar data indicate that shortly thereafter, the airplane began turning left while

maintaining 3,500 feet and slowing through about 164 KCAS. Almost immediately after

the airplane began its left turn, it overshot the approach course and traveled for almost

1 mile north of the course as it continued the turn toward the course until establishing a

ground track of about 262°. See figures 1 and 2 for the ground track and profile view of

the accident flight.

Figure 1. The published EVM VOR approach chart.
Factual Information 6 Aircraft Accident Report

Figure 2. Ground track of the accident flight.

Figure 3. Profile view of the accident flight.
Factual Information 7 Aircraft Accident Report

At 1019:12, the controller stated, ìking air one bravo echo change to advisory

frequency approved[;] advise cancellation of ifr with the princeton flight service when on

the ground.î The copilot acknowledged the instruction at 1019:20. This was the last

transmission received by ATC from the accident airplane. Radar data indicate that at this

time, the airplane began its descent from 3,500 feet and that its airspeed stopped

decreasing about 155 KCAS and began increasing.

The airplaneís airspeed increased to about 170 KCAS and its vertical speed

increased through 1,000 feet per minute (fpm) as it descended through 3,200 feet.

The airspeed stabilized briefly at about 170 KCAS and the vertical speed peaked at about

1,400 fpm. At 1020:06, as the airplane passed through (south of) the approach course

about 5 miles east of the runway 27 threshold, a slight right turn was initiated, and the

airplaneís airspeed and vertical speed began decreasing. The airplane established a ground

track of about 269° and maintained this track until the end of the radar data at 1021:42.

The last two radar returns indicate that the airplane had slowed to about 76 KCAS at

1,800 feet.15

One witness indicated that he saw the airplane to the west of his location

(approximately 4.5 miles east of the runway 27 threshold) ìjust beneath a low layer of

cloudsî and that ìthe top of the airplane may still have been in the clouds.î He stated that

he noticed the landing gear was down, but that he could not remember if any lights were

illuminated on the airplane.

The airplane impacted the ground about 1.8 miles southeast of the approach end of

runway 27. The main wreckage was found at 47° 24.36' north latitude and 92° 27.05' west

longitude at an elevation of 1,361 feet. The wreckage location was about 1/4 mile

south-southwest of the last radar return.

1.2 Injuries to Persons

Table 1. Injury chart.

15 Mode C radar data altitudes have a resolution of ± 50 feet.

Injuries Flight Crew Cabin Crew Passengers Other Total

Fatal 2 0 60 8

Serious 0 0 00 0

Minor 0 0 00 0

None 0 0 00 0

Total 2 0 6 0 8
Factual Information 8 Aircraft Accident Report

1.3 Damage to Airplane

The airplane was destroyed by impact forces and a postcrash fire.

1.4 Other Damage

Trees and other vegetation at and surrounding the crash site were damaged as a

result of this accident.

1.5 Personnel Information

1.5.1 The Pilot

The pilot, age 55, was hired by Aviation Charter on April 26, 2001. He held a

multiengine airline transport pilot (ATP) certificate, issued August 4, 1989, with a type

rating in the Cessna Citation (CE-500). (In April 1989, the pilot had been issued a notice

of disapproval by the FAA following a flight check for his ATP certificate because of his

unsatisfactory performance in several areas, including area arrivals, instrument landing

system [ILS] approaches, normal/abnormal procedures, and judgment. He received

additional training before retaking and passing the test on August 4, 1989.) The pilotís

most recent FAA first-class medical certificate was issued on December 17, 2001, and

contained the limitation that he must wear corrective lenses for near and distant vision.16

According to documentation provided by the pilotís wife, the pilot worked at

Simmons Airlines (doing business as American Eagle) from November 1989 until April 27,

1990. Simmons could not provide investigators with any documentation regarding his

employment at the company.17 However, the pilotís personal records indicate that he

reported for Simmonsí ground training on November 27, 1989. The pilotís personal records

indicated that Simmonsí ground training program consisted of 17 days of ground instruction,

3 days of training in a Frasca 121 flight-training device, more than 30 hours of flight

training, and about 20 hours of initial operating experience. One of the pilotís personal

logbooks indicated that he had completed only 13.6 hours of flight training in Avions de

Transport Regional 42 aircraft and that he had passed a checkride during this training.

The pilotís logbook also indicated that he had flown four revenue service flights as a first

officer for Simmons on January 29 and 30, 1990 (a total of 4.5 hours). The Safety Boardís

investigation was unable to determine if the pilot gained any additional flying experience

while employed at Simmons.

16 It could not be determined if the pilot was wearing corrective lenses at the time of the accident.

17 The Pilot Records Improvement Act of 1996 requires any company hiring a pilot for air transportation

to request and receive records from any aviation carrier, company, organization, or person that had employed

a pilot applicant during the previous 5 years. Simmons did not have the pilotís employment records because

he had last been employed at the company more than 5 years previously.
Factual Information 9 Aircraft Accident Report

From February 2 to 20, 1990, the pilot stood trial on criminal charges for mail and

wire fraud. He was convicted and sentenced to 2 years in prison and 5 years probation.

The pilot submitted a letter of resignation to Simmons dated April 27, 1990. He began his

prison sentence on June 8, 1990, and remained in prison until November 8, 1991, at which

time he started serving the probation sentence, which he completed on November 7, 1996.

According to the employment application the pilot filled out at Aviation Charter, he

worked as a registered nurse for four different employers between March 1992 and

March 2001. The pilotís employment application did not contain any information regarding

previous aviation-related employment.

According to Aviation Charter records, the pilot had flown approximately 5,116 total

flight hours, 598 hours of which he flew with the company, 200 hours of which were as a

company pilot-in-command (PIC) in King Airs.18 He had flown approximately 101, 53, and

36 hours in the 90, 60, and 30 days, respectively, before the accident. His last recurrent

ground training occurred on April 23, 2002. Since completion of his last simulator training

on August 21, 2002, the pilot had flown 32 flights for Aviation Charter, 21 as PIC in King

Airs and 11 as copilot in Cessna Citations. Six of the 21 King Air flights were conducted in

the A100, including one flight the day before the accident in the accident airplane. His last

proficiency and line checks occurred on October 23, 2002. A search of FAA and company

records showed no accident or incident history or enforcement or disciplinary actions, and a

search of the National Driver Register database found no record of driverís license

revocation or suspension.

Aviation Charterís lead ground instructor stated that the pilot was average on

learning airplane systems and that several company pilots had indicated that the pilotís

flying skills were below average. Several Aviation Charter pilots who had flown with the

accident pilot described him as ìvery meticulous,î ìby the book,î ìcalm,î and ìlaid back.î

The pilot was also described as ìfriendly,î ìcheerful,î ìpleasant,î ìcalm,î and ìdiligent in

his use of checklists.î According to several Aviation Charter copilots, the accident pilot was

generally well liked by them because he had a reputation for letting them fly the airplane.

A few copilots stated that because the pilot often let them handle the flight controls, they

were not certain of his skill level. Several Aviation Charter pilots indicated that the accident

pilot often allowed them to conduct the flights they flew with him as if they were

single-pilot operations (that is, he allowed them to handle the flight controls and

communications and perform all of the checklists without his assistance).

One Aviation Charter pilot expressed concerns about the pilotís flying skills,

monitoring capabilities, and tendency to become distracted. Some company pilots stated that

the accident pilot was not particularly assertive; however, other pilots stated that they

thought the accident pilot could be assertive, if necessary. One company pilot, who had

flown with the accident pilot shortly after Aviation Charter hired him, described him as ìtoo

timid to be a pilot.î An Aviation Charter King Air pilot indicated that he had taken the

airplane controls away from the accident pilot during an instrument approach because he

18 For more information about the pilotís logbook history, see section 1.5.1.2.
Factual Information 10 Aircraft Accident Report

could not maintain altitude. A company King Air copilot indicated that during level flight in

IMC, he had to take the controls away from the accident pilot because he allowed the

airplane to enter a 45° bank and a 1,000-fpm descent.

Further, another company King Air copilot indicated that during a flight with the

accident pilot about 2 months before the accident, the pilot did not have his navigational

radio tuned to the VOR in use for the approach, which caused the pilotís course deviation

indicator (CDI) to provide erroneous indications during the entire approach. The copilot was

the flying pilot and had his navigation radio tuned to the correct VOR and completed the

approach without incident. The copilot stated that he later had to explain to the accident pilot

the reason that his CDI was not indicating properly during the approach. According to

Aviation Charterís director of operations and the company pilots who told Safety Board

investigators about these incidents, none of them were ever reported to company

management.

According to Aviation Charter, the pilot and copilot had flown four flights together

before the accident flight, all of which were in King Airs.19 The pilotís wife indicated that he

had never mentioned having any problems flying with the copilot, and the copilotís fiancÈe

indicated that he had never mentioned having any problems flying with the pilot.

According to company records, the pilot had landed at EVM on four previous

occasions, twice in King Airs and twice in Citations.20

The pilotís wife indicated that he was generally ìhealthy,î exercised regularly, was a

nonsmoker, and did not drink alcohol or take prescription drugs. No significant life events

occurred in the previous 12 months, and his personal situation was reported to be stable. In

addition to working for Aviation Charter, the pilot occasionally worked as a nurse.

The pilotís logbook indicated that he had flown Senator Wellstone at least 12 times.

According to the pilotís wife, he got along well with the Senator, who would often call her

husband at home before scheduled trips.

1.5.1.1 The Pilotís 72-Hour History

On October 22, 2002, 3 days before the accident, the pilot flew Senator Wellstone

from STP to Rochester International Airport (ROC), Rochester, New York, in a King

Air 90.21 The copilot of this flight, who had flown with the pilot many times, indicated

that the pilot did not appear tired before the flight. The copilot, who was the flying pilot,

stated that during takeoff, instead of activating the yaw damper switch, the pilot activated

the adjacent autopilot switch, which caused the airplane to pitch down. The copilot stated

that he (the copilot) immediately applied back pressure and then disconnected the

19 Since the pilotís completion of simulator training in August 2002, the pilots had flown together in a

King Air A100 on September 9, 2002, and in a King Air 200 on October 4, 2002.

20 The pilotís most recent landings at EVM were in a Citation on September 19 and 20, 2002.

21 The flight crew had to fly a positioning flight from Flying Cloud Municipal Airport (FCM), Flying

Cloud, Minnesota, to STP to pick up the Senator for the flight to ROC.
Factual Information 11 Aircraft Accident Report

autopilot, which caused the airplane to pitch up erratically before it returned to normal

climb. The copilot stated that after the airplane was stabilized, he had to explain to the

pilot that he had engaged the autopilot instead of the yaw damper and that the pilot replied,

ìOh, that could have been pretty bad.î The copilot stated that the remainder of the flight

segment was uneventful.

The copilot reported that on the return flight to STP, the pilot repeatedly identified

the airplane as ìCitation 6356Kî instead of ìKing Air 6356K.î An air traffic controller

eventually asked, ìYou wouldnít happen to be in a King Air today would you?î The pilot

acknowledged his error and apologized to the controller. The copilot reported that the

remainder of the flight segment was uneventful. The copilot also stated that after the pilot

had completed the after-start and before-takeoff checklists at the beginning of each flight,

he took control of the radios and told the copilot to fly the airplane. After arriving at FCM

around 1830, the pilot returned home. The pilotís wife indicated that he engaged in routine

activities during the evening and that she was unsure what time he went to bed.

On October 23rd, the pilot met Aviation Charterís chief pilot for his 6-month

proficiency check. The chief pilot stated that the pilot was in a good mood when he arrived

for the check. Maneuvers performed during the check included a recovery from a stall,22 a

steep turn, a recovery from an unusual attitude, an ILS approach, a missed approach, a

go-around, a simulated engine failure during a VOR approach, and a no-flaps landing.

A vision-obscuring device was used to test the pilotís ability to conduct IFR approaches.

The chief pilot recalled that the checkride went smoothly and that the pilotís ILS and VOR

approaches were precise. The chief pilot stated that after the simulated engine failure, he

told the pilot to pick up the pace and to feather the engine ìa couple of seconds faster for

comfort.î The pilotís wife indicated that he returned home after the proficiency check,

engaged in routine activities, and went to bed early, between 1900 and 2000.

During the early morning of October 24th, the pilot was contacted by Aviation

Charter and asked to fly a charter flight from STP to Bismarck Municipal Airport (BIS),

Bismarck, North Dakota, for the Red Cross in the accident airplane; the flight was

scheduled to depart at 0340. The Red Cross team coordinator stated that the pilot had

indicated that he did not feel well that morning but that, although he looked tired, he did

not show any signs of having a cold or the flu. The copilot for this flight indicated that the

pilot slept in the BIS FBO from the time that they landed until about 20 minutes before

they were to return to STP, which was a little over 1 hour. The copilot indicated that after

the pilot had obtained their IFR clearance, he took over the radios and gave the copilot

control of the airplane for both flights. The copilot stated that both flights were routine.

The pilotís wife stated that he returned home later that morning and that he was

shortly thereafter contacted by his nursing supervisor at the North Memorial Medical

Center and asked if he wanted to perform dialysis on a patient. She stated that the pilot

indicated that he was interested but that he needed to get some sleep because he had just

completed an early morning flight. Two nurses at the medical center indicated that the

22 According to the chief pilot, the company did not allow its airplanes to enter a full stall during training

or proficiency checks because of safety reasons.
Factual Information 12 Aircraft Accident Report

pilot did not appear tired when he arrived at the center about 1500 to perform the dialysis.

While at the center, the pilot was contacted by Aviation Charter and informed about the

flight with Senator Wellstone the next morning. The customer service representative at

Aviation Charter who spoke to the pilot about the flight indicated that he did not sound

fatigued. According to the pilotís nursing supervisor, the pilot left the center about 2100.

The pilotís wife stated that he arrived home between 2130 and 2140 and went to

sleep right away. Although the pilotís wife did not know exactly what time he awoke, she

stated that he slept at least 8 hours the night before the accident flight.

1.5.1.2 The Pilotís Logbook History

After the accident, Safety Board investigators obtained five of the pilotís logbooks

from his wife, the most recent of which began with a statement signed by the pilot and a

notary public, dated January 23, 2001, which stated that the pilot had ìlost his logbook(s)

dating from 1979 to December 1994.î The letter summarized the pilotís flight hours from

1979 to 1994 as 4,518 total hours, 3,379 hours of which were in multiengine airplanes.

The notarized statement also stated that the pilot had ìnot operated an aircraft from 1994

to December 2000.î

Safety Board investigators reviewed all of the logbooks provided by the pilotís

wife. One logbook covered a period from December 1978, when the pilot received initial

flight training, through May 1986. The pilotís flight time from May 1986 to May 1990

was recorded in two separate logbooks, and these logbooks contained conflicting accounts

of his activity during this period. The disparities between these two logbooks included the

following:

ï different flight hours for the same flights;

ï different departure and arrival airports for the same flights;

ï different flight times and dates for the same flights;

ï some flight segments mentioned in one logbook were not mentioned in the

other logbook; and

ï one logbook indicated that the pilot had flown 1,600 total flight hours from

June 1986 to September 1987, and the other logbook indicated that he had

flown 1,850 total flight hours during the same period.23

In addition, the two logbooks contained multiple entries by a certified flight

instructor (CFI) who provided the pilot with training for his ATP certificate, but the

signatures in the two logbooks were different. According to the CFI named in the

logbooks, only one of the logbooks contained his actual signature.

The flight hours reported in the January 23, 2001, notarized statement contained in

the pilotís most recent logbook represent an increase of more than 1,460 undocumented

23 On FAA medical forms, the pilot listed ìconstructionî as his primary occupation and ìpleasureî as his

primary purpose for flying during this period.
Factual Information 13 Aircraft Accident Report

hours from the flight hour totals in the final entries of the two conflicting logbooks.

Further, in August 1992, the pilot reported on an FAA medical certificate application form

that he had a total of 3,250 flight hours, which is 1,268 fewer hours than he claimed in the

notarized statement to have acquired as of December 1994.24 Safety Board investigators

did not find any records that could verify the hours reported by the pilot in his private

logbooks. See figure 4 for a reconstruction of the pilotís reported flight hours.

Figure 4. Reconstruction of pilotís reported flight hours.

1.5.2 The Copilot

The copilot, age 30, was hired by Aviation Charter on February 7, 2001.

The copilot held a single- and multi-engine land, instrument airplane commercial pilot

certificate, which was issued in May 1997. The copilotís most recent FAA first-class

medical certificate was issued on August 2, 2002, with no restrictions.

24 As mentioned previously, the pilot indicated on his employment application for Aviation Charter that

he was working as a nurse during this period.
Factual Information 14 Aircraft Accident Report

According to Aviation Charter employment records, the copilot had never been

employed previously as a pilot. However, his logbook entries and other records indicated

that he worked as a pilot for a skydive operator from October 1998 through March 1999.

According to the skydive operator, the copilot was let go when he did not meet pilot

qualifications standards for flying the Cessna 182.

In February 1999, Northwest Airlines hired the copilot to provide instruction to

company pilots on Airbus A320 systems and procedures and cockpit procedures during

initial and recurrent ground school. As part of his employment, the copilot observed two

complete sequences of systems training lessons and one complete sequence of flight-training

lessons. He also received seven flight-training lessons in an A320 simulator. The copilotís

instructor during these lessons twice noted that the copilot needed to be reminded to keep his

hands on the throttles during approaches.

After observing Northwestís systems and flight training, the copilot was trained to

teach each of the systems and procedures lessons. During this training, the copilot had to

thoroughly learn the systems of the A320 one at a time and then demonstrate his ability to

teach each system before moving onto the next system. Northwest records indicate that the

copilot was not able to successfully complete this stage of the training program. According

to his supervisor, the copilotís ability to learn and retain the details of the A320 systems was

far lower than that of fellow trainees with comparable flying experience. He added that, by

the time the other trainees finished learning to teach all of the A320 systems lessons, the

copilot had mastered less than half of the lessons. The company provided the copilot with

special assistance, but he was still unable to master the material. He resigned from the

company in October 1999 and began working as a customer service representative for

another company located at the same training facility.

According to Aviation Charter records, the copilot had flown approximately

701 total flight hours, 304 hours of which were with the company, 107 hours of which were

in King Airs.25 He had flown approximately 69, 54, and 36 hours in the 90, 60, and 30 days,

respectively, before the accident. His last recurrent ground training occurred on August 2,

2002. His last proficiency check occurred on August 3 and 4, 2002, and records from the

check indicated that the check was satisfactorily completed.26 A search of FAA and

company records showed no accident or incident history or enforcement or disciplinary

actions, and a search of the National Driver Register found no record of driverís license

revocation or suspension.

Aviation Charterís lead ground instructor characterized the copilotís performance in

ground school as below average and stated that he spent extra time working with him.

He stated that the copilot had problems remembering memory items, calculating weights

25 Aviation Charter did not have a minimum flight-hour requirement for copilot applicants; therefore, it

was not uncommon for the company to hire a copilot with fewer than 1,000 total flight hours.

26 The copilotís training records revealed that the proficiency check was discontinued on August 3rd

because of weather. The records showed that the copilot did not perform a missed approach during the

check. The record of the copilotís initial proficiency check, which occurred on July 18, 2001, also showed

that the copilot did not perform a missed approach during the check. FAA guidance only requires that PICs

demonstrate proficiency on this maneuver during checkrides.
Factual Information 15 Aircraft Accident Report

and balances, and applying formulas. He added that the copilotís performance was

acceptable at the conclusion of ground training. Pilots who had flown with the copilot

described him as ìfriendly,î ìhappy,î ìorganized,î ìmotivated,î and ìeager to learn.î

Several pilots who had flown with the copilot described him as ìnot assertiveî and expressed

concern about his flying skills, especially his inability to land the airplane without assistance.

Two pilots stated that the copilot had difficulties with power management when flying an

approach and that he had to be reminded to keep one hand on the throttles and to monitor his

power gauges. One of these two pilots, who had been mentoring the copilot and flew with

him often, stated that this was a consistent problem for the copilot.

1.5.2.1 The Copilotís 72-Hour History

On October 22nd, the copilot flew to Ontario, Canada, for Aviation Charter. The

pilot of that flight, who had flown with the copilot on two previous occasions, stated that the

copilot was in a good mood, looked healthy, and seemed rested and excited about the trip.

The pilot added that the flight was uneventful. The copilot flew the return leg of the trip and

logged two-tenths of an hour of instrument time for this flight, which was the only flight

flown by the copilot in the 3 days before the accident.

The copilotís fiancÈe described his activities in the 3 days before the accident as

routine. The copilotís fiancÈe stated that he went to sleep about 2200 the night before the

accident, slept until about 0630 or 0645, and left the house some time after 0830.

She indicated that the copilot was in great health, was a nonsmoker, and did not drink

alcohol or take prescription drugs. The copilot was laid off from his job as a customer

service representative at a flight-training academy in September 2002, but his fiancÈe

reported that his financial situation remained stable. She reported that other aspects of his

personal life were also stable.

1.6 Airplane Information

The accident airplane, serial number B245, was manufactured on January 28,

1979. The airplane was equipped with Pratt & Whitney Canada PT6A-28 turbine engines

and Hartzell model HC-B4TN-3 four-bladed, constant-speed propellers. The time since

new for the No. 1 (left) engine was 12,726.1 hours, and the time since overhaul was

6,102.5 hours. The time since new for the No. 2 (right) engine was 13,039.4 hours, and the

time since overhaul was 6,102.5 hours. The time since overhaul for both the No. 1 (left)

propeller and the No. 2 (right) propeller was 1,637.3 hours.

Aviation Charter and Raytheon provided Safety Board investigators with the

estimated weight and balance information for the accident airplane.27 According to these

27 The original and a copy of the weight and balance load manifest that the two pilots completed before

the accident flight were on board the airplane and destroyed by postcrash fire. The estimates provided by

Aviation Charter and Raytheon were calculated using applicable information and graphs contained in the

Raytheon King Air A100 Aircraft Flight Manual (AFM). For more information about Aviation Charterís

weight and balance load manifest procedures, see section 1.17.2.3.
Factual Information 16 Aircraft Accident Report

estimates, the accident airplaneís takeoff weight was 11,052 pounds, including

2,345 pounds of fuel and 1,050 pounds of passenger weight,28 and the airplaneís takeoff

center of gravity (CG) was 184 inches.29

The airplane was equipped with several ice protection systems, including heating

elements in the windshield and pneumatic deicer boots on the wings and horizontal and

vertical stabilizers, to prevent ice accumulation during flight.30 The cockpit had a selector

switch that allowed the pilot to select either automatic single cycle or manual operation of

the deicer boots. The propellers were equipped with electrothermal boots on each blade

that automatically cycle to prevent ice accumulation.

The airplane had a stall warning system designed to sound a horn in the cockpit 5

to 8 knots before the actual stall speed of the airplane in any configuration. The stall

warning system included a heated lift transducer vane and faceplate on the leading edge of

the left wing.31 When the aerodynamic pressure on the lift transducer vane indicates that a

stall is imminent, a switch is actuated to complete the circuit to the stall warning horn in

the cockpit.

1.7 Meteorological Information

1.7.1 National Weather Service Information

NWS surface analysis chart station models showed that at 1000 the sky was

overcast, dew point depressions32 were less than or equal to 2° Celsius (C), surface winds

ranged from calm to about 5 knots throughout most of the State of Minnesota, and surface

temperatures were below freezing over most of northern Minnesota.

28 This total does not include the weight of the flight crew. The combined weight of the flight crew is

figured into the basic operating weight of the airplane.

29 The maximum certificated takeoff gross weight for the accident airplane was 11,500 pounds, and the

takeoff CG limits were between 182.8 and 191 inches.

30 Regulated bleed air pressure and vacuum are cycled to the pneumatic boots for the inflation and

deflation portions of the deicing cycle.

31 The lift transducer vane and faceplate are protected from ice accumulation by heaters. The heater for

the lift transducer receives power while the master switch is ON. The heater for the faceplate is activated by

positioning the right pitot and stall warning switch to ON. Although the heaters on the lift transducer vane

and faceplate protect them from ice accumulation, buildup of ice on the wing can disrupt the airflow and

prevent the stall warning system from providing an adequate stall margin. For more information about

Aviation Charterís guidance regarding operation in icing conditions, see section 1.17.2.2.

32 Dew point depression is the difference between the atmospheric temperature and the dew point

temperature. This value can be used as a measure of relative humidity.
Factual Information 17 Aircraft Accident Report

A TAF33 prepared by the Duluth Forecast Office for Hibbing, Minnesota (the

closest TAF location to the accident site), which was valid starting at 0900 and transmitted

at 0917, stated, in part, the following:34 Wind variable at 5 knots, visibility 3 statute miles

with mist, overcast 500 feet; Temporary conditions from 1400Z to 1800Z, visibility

2 statute miles, mist, overcast 200 feet.

An area forecast (FA)35 covering northern Minnesota was issued about 0945 by the

NWS Aviation Weather Center (AWC), Kansas City, Missouri, and was valid at the time

of the accident. The FA stated, in part, the following:

Northern MinnesotaÖAGLÖscattered at 2,000 feet, scattered to broken at 4,000

feet, tops at 6,000 feet. 1200ZÖAGLÖscattered to broken at 1,500 feet, ceiling

broken at 4,000 feet, broken at 7,000 feet and tops at 12,000 feet. Occasional

visibility from 3 to 5 [statute] miles with mist. 1600Z ceiling broken at 1,500 to

2,500 feet, overcast at 4,000 feet. Occasional light snow.

An AIRMET prepared by the NWS AWC was issued about 0745 and covered the

area surrounding the airplaneís flightpath and the accident site. The AIRMET, which was

valid at the times the pilot received the two preflight weather briefings, warned of

occasional moderate rime or mixed icing in clouds and precipitation above freezing level

to 20,000 feet. The AIRMET warned that the freezing level was from the surface to

7,000 feet over northern portions of the area and sloping to between 8,000 to 10,000 feet

over southern portions of the area. According to the meteorologist responsible for issuing

the next scheduled AIRMET at 0845, shortly after he issued it, he received a pilot report

(PIREP) of moderate icing at 10,000 feet. He stated that, about 0905, he issued an updated

AIRMET, which was valid at the time of the accident, warning of occasional moderate

rime to mixed icing in clouds and precipitation below 10,000 feet.

 The 0700 upper air sounding (that is, a vertical profile of atmospheric conditions)

from Chanhassen, Minnesota (160 miles south-southeast of the accident site), showed a

saturated boundary layer, with a surface temperature of 3° C and an easterly wind of about

3 knots. Freezing level was approximately 2,700 feet. The 1300 upper air sounding from

International Falls, Minnesota (79 miles north-northwest of the accident site), did not

show a completely saturated near-surface environment.36 The sounding showed a surface

temperature of -2° C and south-southeasterly surface winds of about 5 knots.

The sounding also showed a saturated layer from about 3,400 to 7,000 feet, with

southwesterly winds in this layer ranging from 10 to 23 knots. The NWS also provided

33 TAFs are normally issued every 6 hours with amendments issued as conditions warrant.

34 Weather forecasts are transmitted in coordinated universal time (UTC). The ìZî designation that

follows the time in the weather observation stands for Zulu, which indicates UTC time. Central daylight

time is 5 hours behind UTC time.

35 The NWS AWC issues FAs at regular intervals and special reports as necessary, usually in the form of

AIRMETs.

36 Radiosonde balloons are typically launched a little after 0600 and 1800, and the nominal times of the

data are 0700 and 1500. Because of problems with equipment at International Falls, a 0700 sounding was

not accomplished. After notification of the accident, the DLH NWS office instructed staff at International

Falls to launch a radiosonde balloon, and the sounding was accomplished at 1300.
Factual Information 18 Aircraft Accident Report

Safety Board investigators with the Eta model37 1000 forecasted profile for Hibbing,

Minnesota, which was consistent with the upper air sounding profiles. Specifically, the

profile confirmed the existence of below-freezing temperatures and verified that saturated

conditions existed between about 3,000 and 7,000 feet.

1.7.2 Airport Weather Information

Weather observations at EVM are made by an AWOS,38 which is located about

2 miles northwest of the accident site at an elevation of about 1,380 feet. Observations

from this station are reported every 20 minutes. At 1014 on the day of the accident, the

AWOS reported that the visibility was 3 statute miles in light snow and that the sky

condition was scattered clouds at 400 feet and overcast at 700 feet. At 1034, the AWOS

reported that the visibility was 4 statute miles in mist and that the sky condition was

overcast at 400 feet. Both AWOS reports indicated calm winds and temperatures of 1° C.

The Hibbing, Minnesota, ASOS, which is located about 16 miles west of the

accident site at an elevation of 1,351 feet, provides high-resolution data that is recorded

every 5 minutes. At 1005 on the day of the accident, the ASOS reported that the visibility

was about 3 statute miles in mist and that the sky condition was overcast at 500 feet.

At 1025, the ASOS reported that the visibility was 4 statute miles in mist and that the sky

condition was overcast at 300 feet. Both ASOS reports indicated temperatures of 1° C.

1.7.3 Additional Icing and Cloud Information

On December 2, 2002, Safety Board investigators met with three scientists from

the National Center for Atmospheric Research (NCAR), Boulder, Colorado, regarding the

potential icing environment around the time of the accident. These scientists use an icing

diagnostic program called the Current Icing Potential algorithm, which incorporates

multiple sources of weather data to determine the icing and supercooled large droplets

(SLD) potential. One of the scientists reported that his analysis of the programís output for

the day of the accident indicated a high potential for icing from St. Paul to Eveleth but

suggested a low potential for SLD around Eveleth. The scientist added that because of the

increase in temperature and the lower water content expected at lower levels of the

atmosphere, moderate icing was not likely to extend to the lower levels of the atmosphere.

37 The Eta model is a numerical weather model used by the NWS.

38 AWOS and ASOS (ASOS stands for automated surface observing system) are systems that

continuously measure weather information, including wind speed and direction, visibility, precipitation,

cloud cover, temperature, dew point, and altimeter setting.
Factual Information 19 Aircraft Accident Report

Several PIREPs were transmitted around the time of the accident in the area

surrounding EVM. One PIREP, received about 0810 from a pilot flying a Piper

Cheyenne around Ely, Minnesota, which is 43 miles northeast of EVM, reported

moderate mixed icing between 11,000 and 8,000 feet and light rime icing below

8,000 feet. Another PIREP, received about 0908 from a pilot flying a DC-9 about

10 miles southeast of DLH, reported cloud tops at 11,000 feet and trace rime icing

from 4,500 to 7,000 feet, light rime icing from 7,000 to 9,000 feet, and moderate

rime icing from 9,000 to 11,000 feet. Another PIREP, received about 1118 from a

pilot flying an RJ Avroliner in the Duluth area, reported the sky was overcast at

1,600 feet with cloud tops at 10,800 feet, trace icing from 5,000 to 7,000 feet, and

light rime icing from 7,500 to 10,800 feet.

The first two PIREPs were discussed at the December 2002 NCAR meeting.

According to an NCAR scientist, the reports indicate that icing was occurring around the

time of the accident at two distinct altitude bands with differing intensities: moderate icing

was present at upper elevations (8,000 to 11,000 feet), and light icing was present at lower

elevations (4,500 to 8,000 feet).

Additionally, the last two pilots who landed at EVM before the accident (both

pilots were flying QueenAire BE-80s) provided statements to Safety Board investigators.

One of these pilots stated the following:

I left Minneapolis for EvelethÖat 7 a.m. I climbed to 7,000 [feet] MSL and I was

IMC all the way to Eveleth. The tops were at approximately 10,000 [feet] MSL.

No icing was encountered until approximately 60 miles south of the Hibbing

VOR. The temperature was 28 degrees [Fahrenheit] at 7,000 [feet] MSL. I started

getting light to moderate rime ice at 7,000 [feet].

He added that as he descended to 5,000 feet, at which altitude he recorded the

temperature to be about -1.1° C, the ice began to shed off the airplaneís surfaces and that

as he continued his descent to 3,500 feet, at which altitude he recorded the temperature to

be about -0.5° to 0° C, most of the remaining ice shed off the airplaneís surfaces during the

approach. He concluded, ìI did get the airport in sight at approximately 5 miles from the

airport. I then landed at approximately 8 a.m.î

The other pilot who landed at EVM before the accident stated the following:
Factual Information 20 Aircraft Accident Report

I flew at 5,000 feet en route and was IMC with light rime ice in the clouds. I flew

the VOR/DME [distance measuring equipment]-A approach and circled to

[runway] 27. I donít remember getting any more ice after descending from

5,000 feet. On the approach, I broke out of the clouds a little above the MDA

[minimum descent altitude, which for the EVM VOR/DME-A final approach is

2,120 feet39]Öand the best I can rememberÖthe visibility was probably 1 1⁄2 to

2 1⁄2 miles. I landed in EVM at approximately 8:30 a.m. I do remember that the

weather that the AWOS was reporting seemed accurate at the time and the VOR ñ

both [Hibbing] and EVM seemed to work fine.

The first pilot to depart EVM after the accident also told Safety Board

investigators that he experienced trace to light icing below 6,000 feet.

EVMís assistant airport manager stated that, when he was looking for the crash site

from the air, he was flying at 1,800 feet (that is, about 420 feet agl), and he never entered

the clouds. He stated that the AWOS (which was reporting a 700-foot overcast ceiling)

seemed to be reporting correctly because the cloud tops appeared to be about 200 to 300

feet above his airplane. He added that the cloud bases were somewhat ragged and variable

in height. He stated that he could see landmarks on the ground up to 4 to 5 miles away.

The Geostationary Operational Environmental Satellite 8 visible and infrared

satellite imagery taken at 1015 showed a large distribution of clouds along the airplaneís

flightpath. Satellite-derived cloud top temperatures along the airplaneís flightpath ranged

from -11° to -16° C. During the descent portion of the airplaneís flight, cloud top

temperatures were mainly near -15° C. Comparisons between satellite-derived cloud top

temperatures and sounding data indicated that the cloud tops were approximately

12,000 feet.

1.8 Aids to Navigation

1.8.1 EVM VOR 

The EVM VOR is a low-power (50 watts), terminal-type VOR owned and

maintained by the State of Minnesota. The EVM VOR is located on the airport property

just north of runway 27, about 1,134 feet from the runwayís departure end. A State of

Minnesota technician ground checks the facility annually under oversight of an FAA

representative, and the FAA flight checks the facility every 540 days.

According to postaccident interviews with the State of Minnesota technician and

the FAA Airway Transportation System Specialist (ATSS) responsible for maintenance

and oversight of the EVM VOR, the EVM VOR is continuously monitored using an

39 For the EVM VOR runway 27 approach, which is the approach the accident flight crew was flying, if

the airplane does not have DME, then the MDA for the final approach to EVM is 1,840 feet. If the airplane

does have DME, then the MDA is 1,840 feet between 2 and 10 miles from the EVM VOR and 1,740 feet

inside of 2 miles from the EVM VOR. 
Factual Information 21 Aircraft Accident Report

external receiver with an antenna located on the outer edge of the VOR counterpoise

(elevated ground plane). If the radial position indicated by the monitoring receiver varies

by >1°, or the modulation deviates appreciably from the nominal 85 percent, the facility

will automatically shut down. Reactivation requires intervention and a ground check by a

State of Minnesota technician.

1.8.1.1 Preaccident Flight Checks of the EVM VOR

The FAAís most recent periodic flight check of the EVM VOR occurred on

June 12 and 13, 2001, and the facility status was listed as ìsatisfactoryî on FAA Form

8240-2; however, the form also indicated that the EVM VOR remained restricted per a

December 4, 1996, notice to airmen (NOTAM), which was still in effect at the time of the

accident. The NOTAM indicated that the EVM VOR was unusable in the area from the

204° radial through the 264° radial and in the area from the 264° radial through the

204° radial beyond 20 miles and below 4,000 feet.

1.8.1.2 Postaccident Ground and Flight Checks of the EVM VOR

About 1530 on the day of the accident, technicians from the State of Minnesota

conducted a standard ground check of the EVM VOR and found it to be transmitting

normally.

On October 26 and 27, 2002, the FAA conducted a series of flight checks on the

EVM VOR using a King Air A100. On both days, the signal was found to be misaligned

about 2.3° to the north, but within tolerance (a maximum variation of ±2.5° is permitted)

in the region between 5 to 10 miles from the station. However, the signal was found to be

out-of tolerance for bends40 (a maximum distortion of +4.1° was measured; a maximum

distortion of ± 3.5° is allowed) in this same region.41 On October 28th, a State of

Minnesota technician conducted another, more comprehensive postaccident ground check

of the EVM VOR under the supervision of the FAA ATSS. The EVM VOR was again

found to be transmitting normally.

On December 16, 2002, the pilots who conducted the October 2002 flight checks

told Safety Board investigators that the VOR runway 27 approach took them

approximately 1 mile south of the field when hand-flying the approach, but that it took

them to the correct aiming point (the position from which a normal transition to landing

can be made) when flown coupled to the autopilot.42 Further, in a January 8, 2003, written

statement concerning the October 26, 2002, flight check, the PIC of the flights indicated

that during the first test, while hand-flying the approach,

40 Bends are fluctuations in the calculated VOR radial position that occur slowly enough to be followed

by a pilot under normal conditions.

41 For example, with a +4° error in the VOR signal, a pilot would need to fly the airplane inbound on the

physical 100° radial from the station to center the CDI needle on an indicated 096° radial inbound.

42 According to the FAAís Flight Inspection Standard Operating Procedures Manual, approaches should

be flown by autopilot whenever possible during flight checks.
Factual Information 22 Aircraft Accident Report

approximately 7 miles from the runway we noticed that the approach radial was

leading us to the right of runway centerline extended. As we continued the

approach, we remained to the right of runway centerline extended until about

4 miles out. Then the approach radial began to lead us to the left of centerline. We

crossed centerline extended and continued left of centerline. We ended up

between 1 to 2 miles to the left of the runway at the MAP [missed approach

point].[43] We completed the approach again and the results were close to the same

as the first run. On our third run we coupled the autopilot to the flight director and

let it fly the approach. For most of the approach the autopilot held us

approximately 1⁄2 dot left of course. The autopilot took us to the runway, just left

of centerline[;] however[,] the approach radial was found to have an out of

tolerance bend.

On December 23, 2002, a special demonstration flight was conducted at the Safety

Boardís request to resolve the discrepancy between the hand-flown and autopilot-flown

approaches made in October 2002. On this demonstration flight, the pilots reported to

Safety Board investigators that the airplane was brought to a position at the approach end

of runway 27 appropriate for normal transition to landing.

1.8.1.3 VOR Navigation System Special Study

To further study the accuracy of the EVM VOR, the Safety Board requested that

the December 23rd demonstration flight be flown using an airplane capable of digitally

storing the signal obtained by the on-board VOR receiver. The study also used data

derived from the October 2002 flight checks.

The results of the study confirmed that the EVM VOR was misaligned to the north

by about 2.3° in the area between 5 to 10 miles from the station, which caused the

on-board VOR receiver to calculate that the airplane was at a radial position north of its

actual physical location with respect to the station. This is consistent with flight check

radar data from the October 2002 flight tests. Further, the study showed that the VOR

signal measured on December 23rd had changed little in character from the signal

measured on the flight checks in October; however, the misalignment was slightly smaller,

deviating about 1.5° to the north.

Data collected from the October 2002 flight tests and radar data were analyzed to

estimate what was likely indicated by the CDI needle in the accident airplaneís cockpit

during the approach to EVM. The computations estimated that the CDI needle was likely

about three dots to the left (indicating the airplane was north of course) when the airplane

was approximately 8.5 miles from the EVM VOR. The computations also estimated that

the CDI likely indicated on-course at a position approximately 5 miles from the station

and that the needle would have continued to move to the right (indicating the airplane was

now moving off-course to the south). Finally, computations estimated that the CDI needle

was likely fully deflected approximately 2.6 miles from the EVM VOR.44

43 Radar data from the FAAís October 26th flight checks show that the check airplane maintained a track

slightly south of course throughout the approach and that it passed within 1/2 mile of the field at the end of

all three approaches.
Factual Information 23 Aircraft Accident Report

1.9 Communications

No communication problems were reported with any of the ATC facilities that

handled the accident flight.

1.10 Airport Information

EVM is located 3 miles southeast of Eveleth, Minnesota, near the western shore of

Lake Superior and is bordered by dense forest to the east and west. EVM has an elevation

of 1,378 feet and is a nontowered airport. Because the EVM VOR is located slightly north

of and near the middle of runway 27, the published EVM VOR approach course is aligned

about 2° south of the runway centerline to bring aircraft in near the runway threshold.

Runway 27 is 4,215 feet long and 100 feet wide with no displaced threshold.

Runway 27ís magnetic heading was determined to be 274°. Runway 27 is equipped with a

medium-intensity approach lighting system, a runway-end identifier light system, and a

four-light precision approach path indicator, which is located on the left side of the

runway. The runway lights are pilot-controlled on the common traffic advisory

frequency 122.7, which is monitored at EVM in the airport managerís office. The EVM

assistant airport manager stated in postaccident interviews that he heard the accident pilots

report their position before the accident and the runway lights being activated on 122.7

after the pilotsí position report and that he saw that the runway lights were on at the time

of the accident.

1.10.1 Air Traffic Control

The Duluth ATCT has three radar positions: approach control south, approach

control north, and approach control local. At the time of the accident, all of the radar

positions were combined at the approach control south workstation, which is located in the

facilityís radar room. The approach control south radar controller was responsible for

airspace within a 30-mile radius of DLH from the surface to 12,000 feet and for airspace

that extended 20 miles northwest of Hibbing, Minnesota, from the surface to 8,000 feet;

EVM lies within this area of airspace.

The DLH approach control south radar controller began working for the FAA on

December 2, 1984, and was assigned to the Duluth ATCT on March 21, 1985. He became

fully certified at the Duluth ATCT on February 27, 1987.

The DLH approach control south radar controller stated that at the time he was

handling the accident airplane, the range of his radar display was set at 60 miles. He stated

that he remembered observing the accident airplaneís radar target intercepting the final

approach course about 9 miles from the runway threshold and that it appeared to him that

the radar target was aligned correctly on final approach at a steady 3,500 feet.

44 The error bands for these calculations could not be determined with certainty.
Factual Information 24 Aircraft Accident Report

The controller stated that he was surprised to see the accident airplane off course when he

reviewed the radar playback at a closer range after the accident.

The DLH approach control south radar controller stated that about 1019, he

instructed the flight crew to report cancellation of IFR with the Princeton AFSS, and he

noted the airplaneís estimated arrival time at EVM on the flight progress strip. He stated

that when he did not receive an IFR cancellation after about 15 minutes had passed, he

called the flight data controller via the interphone and asked him to check to see if the

airplane had landed at EVM; the flight data controller responded that the airplane had not

landed.

The DLH approach control south radar controller stated that he did not recall any

NOTAMs reporting problems with the EVM VOR and added that the VOR runway 27

approach was the most commonly used approach at the airport. The controller stated that

NOTAMs were provided to the Duluth ATCT by the Princeton AFSS and that any

NOTAMs are annotated in the facilityís daily log and on the system information area in

the tower cab and radar room. The controller indicated that if the facility does receive a

PIREP about a malfunctioning navigational aid, a second PIREP would be solicited and, if

the reports were the same, the information would be forwarded to the facilityís flight data

controller and then to Mid States Operations for Airways Facilities.

1.11 Flight Recorders

The accident airplane was not equipped with either a CVR or a flight data recorder

nor was either required by Federal regulations.

As a result of a previous investigation of an accident involving a Cessna 208B,

operating as an on-demand charter flight for the Department of the Interior, on February 8,

2000, the Safety Board issued Safety Recommendation A-99-60, which asked the FAA to

ìrequire, within 5 years of a technical standard orderís issuance, the installation of a

crash-protective video recording system on all turbine-powered nonexperimental,

nonrestricted-category aircraft in 14 Code of Federal Regulations Part 135 operations that

are not currently required to be equipped with a crashworthy flight recorder device.î

Safety Recommendation A-99-60 is on the Safety Boardís Most Wanted List.45

On May 3, 2000, the FAA responded that this issue should be submitted to the

Radio Technical Commission of Aeronautics (RTCA) Future Flight Data Collection

Committee for consideration. The FAA added that the committee will look at future trends

in flight data collection to support safety investigations and operational efficiencies, with a

primary focus on the appropriateness, timing, economic impact, and social acceptance of

the proposed data collection concepts.

45 In October 1990, the Safety Board adopted a program to identify the ìmost wantedî safety

improvements. The purpose of the Boardís Most Wanted List, which is drawn up from safety

recommendations previously issued, is to bring special emphasis to the safety issues the Board deems most

critical.
Factual Information 25 Aircraft Accident Report

On September 8, 2000, the Safety Board replied to the FAA that it disagreed with

the FAA on the appropriateness of the RTCA committeeís involvement in the

implementation of this safety recommendation because the committeeís goal is to look 10

to 15 years into the future to set the course for recorder technology and determine how it

will be used to solve problems. The Board stated that it had no evidence that the RTCA

committee was going to address the use of video recorders in the near term for the small

aircraft for which this recommendation was targeted. Pending the implementation of the

recommended actions, Safety Recommendation A-99-60 was classified ìOpenó

Unacceptable Response.î

1.12 Wreckage and Impact Information

1.12.1 General

The accident airplaneís wreckage was located about 1.8 miles southeast of the

EVM runway 27 threshold. The majority of the airplane sustained severe damage

consistent with impact forces and/or postimpact fire. Several of the airplaneís systems,

including the stall warning and deicing systems, were too damaged by postimpact fire and

impact forces to determine their preimpact configuration and operability.

The horizontal distance from the point at which the airplane entered the trees to the

resting place of the aft section of the fuselage was about 130 feet. Crash site damage

included blunt force tree damage consistent with airframe impact and cleanly severed

trunks and limbs consistent with cuts resulting from propeller blade strikes. Handheld tape

measurements, survey data, and aerial observations indicated that the airplane descended

through the trees wings level and upright on about a 26° downward flightpath angle on a

ground track of about 180°.

The majority of the wreckage, which consisted of the forward fuselage, the

cockpit, and most of the wings, was found at the southern end of the main wreckage field.

The left horizontal stabilizer was found essentially intact with a substantial crease

approximately 41 inches from its root. The horizontal stabilizer trim actuator was found

still attached to the tail structure, and the exposed actuator lengths were both found to be

3.25 inches. (According to Raytheon documentation, this measurement equals a horizontal

stabilizer trim setting of 1° airplane nose down.) The left elevator was found intact and

attached to the horizontal stabilizer at both hinges. The vertical stabilizer was found intact

with damage to the leading edge. None of these components exhibited evidence of

in-flight fire or preimpact structural damage. The right elevator was found attached to the

stabilizer and exhibited severe impact and fire damage.

Sections of both wings were recovered and exhibited postimpact fire damage.

The flap actuators were recovered. (According to Raytheon documentation, the

measurements taken of the flap actuators were consistent with the flaps being in the

approach position [about 30 percent] at the time of the accident.)
Factual Information 26 Aircraft Accident Report

Inspections of the nose and main landing gear found indications consistent with

the gear having been down at the time of impact. However, because of extensive impact

and fire damage, it could not be determined if the gear were in the locked position.

From November 19 to 22, 2002, the engines were examined at Pratt & Whitney

Canadaís facility in Longueuil, Quebec, under Safety Board supervision. These

examinations revealed evidence of normal engine operation at the time of impact. From

November 12 to 14, 2002, the propellers were examined at Hartzell Propellerís facility in

Piqua, Ohio, under Board supervision. These examinations revealed evidence of

low-power system operation at the time of impact. The blade angles calculated from the

propellersí piston positions (19.3° and 21.3°) correspond to power settings just above

flight idle at the time of impact. (As installed in a properly rigged King Air A100,

selection of the flight-idle power setting will result in a blade angle of 19.0° ±0.1°.)

Most of the components of the deicing system were destroyed by postimpact fire.

Deicer boots were present on the remaining leading edges of the horizontal and vertical

stabilizers. All of the surviving pneumatic deicing lines leading to the tail deicer boots

were assessed visually and determined to be in good condition. The deicer boots were also

present on the leading edges of the wings; however, they were extensively damaged.

1.12.2 Cockpit Instrumentation

The cockpit instrument panel was extensively damaged by postimpact fire, and all

of the instruments were found settled into a large pile under the cockpit window frame.

Several of the instruments were recovered and transported to the Safety Boardís Materials

Laboratory for further examination. Several of the cockpit instruments were too damaged

to warrant further examination.

The left-side airspeed indicatorís case was severely burned, melted, and distorted,

and the indicatorís data plate was missing. All of the exterior markings and paint were

burned off, and the glass face was broken and discolored. The dial assembly was found

attached to the mechanism assembly and had distinct blackened areas on it, one of which

was located directly above a small screw that is above the 100-knots-airspeed mark

(despite the fire damage, the airspeed numbers were still legible on the dial assembly).

The airspeed indicator needle was not found with the indicator; however, the maximum

airspeed indicator needle was still attached and was pointing to 195 knots.46 The right-side

vertical speed indicator was found with the indicator needle pointing to about 2,200 fpm

(rate of descent).

The right-side horizontal situation indicator (HSI) was badly damaged by fire but

exhibited less severe impact damage than the pilot-side HSI. The right-side CDI faceplate

was found contained within the indicator and dial ring. The head of the course indicator

needle was not found; however, the needle base was still attached to the CDI faceplate,

46 The maximum airspeed pointer is designed to indicate the ìnever exceedî airspeed limit for an

aircraft at a given altitude. 
Factual Information 27 Aircraft Accident Report

and the tail of the needle was located adjacent to the number 9 on the heading dial.

The heading bug was visible on the heading dial at a position of approximately 307°.

The heading warning flag was not found; however, the flag needle was found in the

retracted position.47

The right-side radio magnetic indicator was severely damaged by impact forces

and fire, the glass plate was shattered, and the flag positions could not be determined.

The compass card and both indicator needles were contained within the plate display and

were damaged by heat; however, the numbers were legible. The compass card was

positioned with the number 180 directly beneath the lubber line. Indicator needle No. 1

was pointing to approximately 335°, and needle No. 2 was pointing to

approximately 332°.

1.13 Medical and Pathological Information

Tissue and fluid specimens from both pilots were transported to the FAAís Civil

Aerospace Medical Institute (CAMI) for toxicological analysis. The CAMI laboratory

performed analysis for a wide range of legal and illegal drugs,48 and the results were

negative. The analysis detected no ethanol or carbon monoxide in either of the pilotís

blood and tissue specimens.

1.14 Fire

A fuel-fed fire erupted after the airplane impacted the ground.

1.15 Survival Aspects

According to the Saint Louis County Medical Examinerís autopsy reports, the

cause of death for the pilot, copilot, and all of the passengers was multiple traumatic

injuries sustained during impact. Three of the individuals showed evidence of postimpact

smoke and soot inhalation.

47 According to the Honeywell (Sperry) Component Maintenance Manual for the HSI, the unit requires

both a.c. and d.c. power to operate. The heading warning flag is displayed when power is lost to either the

primary a.c. power supply or the d.c. signal for the instrument. 

48 The drugs tested for included the following: marijuana, cocaine, opiates, phencyclidine,

amphetamines, benzodiazapines, barbiturates, antidepressants, antihistamines, meprobamate, mathaqualone,

and nicotine.
Factual Information 28 Aircraft Accident Report

1.16 Tests and Research

1.16.1 Airplane Performance

The Safety Board conducted an airplane performance study to establish a history

of the accident airplaneís motions and the pilotís actions. As stated in section 1.1, radar

data from the last two recorded radar returns indicate that the accident airplane had slowed

to about 76 KCAS at 1,800 feet. The Raytheon King Air A100 AFM and Raytheon

calculations indicate that the wings-level, gear-down stall speed, assuming an estimated

landing weight of about 10,500 pounds with the flaps in the approach setting, would have

been about 77 KCAS with the power at flight idle.

Safety Board investigators also planned and executed flight simulations at Flight

Safety International (FSI) using a King Air C90B simulator.49 These simulator tests were

conducted to determine whether the airplaneís flightpath and time histories, as shown by

the radar data during the final approach, could be matched or approximated with and

without simulated airframe icing and which configurations and control inputs were

required to match the data. To conduct the test, the accident airplaneís weight and CG

values (about 10,500 pounds and 184 inches, respectively) were scaled to equivalent

values for the C90B.

Several tests were performed starting at 3,500 feet and descending to 1,800 feet to

try to match the final approach descent of the accident airplane as shown by the radar data.

An additional test was conducted starting at 13,000 feet and descending to 3,500 feet as

the airplane was vectored onto the approach course. For simulation purposes, the

airplaneís descent from 3,500 feet was broken down into three time periods, each with

linear approximations of vertical speed and airspeed decay based on the radar data. During

the tests, the landing gear was extended just after the airspeed decreased below the

maximum gear extension speed of 156 KCAS, which occurred as the accident airplane

was descending through 2,200 feet. Various engine power and pitch control inputs and

simulated icing effects were used to try to match the radar data.

The tests conducted without simulated airframe icing showed that the flightpath

and speed of the accident airplane, as indicated by the radar data, could be reasonably

matched making minor pitch control inputs and engine power reductions. The stall

warning occurred during these tests between 81 and 84 KCAS. During the tests,

increasing the power quickly resulted in an increase in airspeed and no further stall

warnings.

The tests conducted with light to moderate simulated airframe icing50 showed that

the flightpath and speed of the airplane, as indicated by the radar data, could also be

49 According to Raytheon and FSI, no known King Air A100 simulators exist. The Airplane

Performance Group chose the King Air C90B model for simulations because it has a similar configuration

and stall speeds to the A100 model; however, it is not fully certified to replicate the A100ís flight

characteristics.
Factual Information 29 Aircraft Accident Report

reasonably matched making minor pitch control inputs and engine power reductions.

However, occasional use of the deicer boots was required, and the engine power settings

were significantly higher between the boot cycles than they were during the tests

conducted without simulated airframe icing. Tests conducted with heavy icing required

frequent cycling of the deicer boots, and the engine power settings often exceeded the

power limits shown on the cockpit gauges.51

1.16.2 Operational Factors and Human Performance Simulations

In April 2003, the Operational Factors/Human Performance Group conducted

flight simulations at FSI using a U-21, which is the military version of the C90 and has

similar cockpit controls and displays to the accident airplane,52 to observe and evaluate

Aviation Charterís procedures and interaction between a company pilot and copilot. In

addition, flight characteristics were observed during slow flight, stall recovery, and

various airplane configurations.

The Aviation Charter pilot who participated in the simulations had worked for the

company for over 5 years and had about 5,200 hours total flight time, about 2,400 hours of

which were in King Airs. The Aviation Charter copilot who participated in the simulations

had worked for the company for over 3 years and had about 2,100 hours total flight time,

about 600 hours of which were in King Airs. These two crewmembers nearly always flew

together during revenue operations for Aviation Charter.

The simulator was programmed with weight and CG parameters scaled to match

those of the accident airplane and used to fly simulated VOR approaches to runway 27 at

EVM.53 During the simulations, both pilots were given the opportunity to act as the pilot

flying during the approach. Numerous approaches were executed to observe company

procedures and piloting techniques, including briefing the approach and preparing and

executing the VOR runway 27 approach. Particular attention was focused on cockpit

setup, duties for the flying pilot and the nonflying pilot, callouts, and checklist usage.

During the simulations, approach procedures and callouts were in accordance with

Aviation Charterís procedures. The simulator exhibited normal characteristics during slow

flight and stall maneuvers and immediately recovered from a stall when power was

increased.

50 The FSI King Air simulators allow selection of simulated airframe icing as a percentage of a

maximum, with the selection of 0 percent resulting in no simulated icing and selection of 100 percent

resulting in maximum simulated icing. The FSI King Air C90B icing model introduces lift, drag, and other

aerodynamic degradations based on FSI data. 

51 The King Air A100 has about 130 horsepower more per engine than the C90B; therefore, the A100

power settings may not exceed the limits in heavy icing, as occurred during the C90B simulations. 

52 Although the U-21 has cockpit controls and displays similar to the A100, it is not certified to fully

replicate the A100ís flight characteristics.

53 The simulator was not capable of displaying EVM or its surrounding terrain.
Factual Information 30 Aircraft Accident Report

To observe flight crew workload, the following three VOR approaches to

runway 27 were conducted consecutively with simulated weather conditions matching

those reported at EVM at the time of the accident:54

ï a straight-in approach from 13.5 miles east of the runway 27 threshold,

ï an approach using ATC vectors similar to those given to the accident flight

crew, and

ï an approach using ATC vectors similar to those given to the accident flight

crew during which the flight crew was instructed to delay the descent from

3,500 feet until 7.5 miles from the runway 27 threshold and to delay landing

gear extension until 3.5 miles from the runway 27 threshold.

During each scenario, the flight crew made a successful approach and landing.

During the second and third scenarios, the flight crew initially overshot the approach

course but was able to reintercept the course from the north, establish a stabilized

approach, and land successfully.55

After each approach, the pilots completed a National Aeronautics and Space

Administration (NASA) Task Load Index questionnaire, which gave them the opportunity

to rate the following six aspects of workload: mental and physical demand, time pressure,

effort, performance, and frustration level.56 The questionnaire completed by the flying

pilot after the second approach indicated that it was more difficult than the first approach

in terms of time pressure, effort, and frustration level. The questionnaire completed by the

flying pilot after the third approach indicated that it was more difficult than the second

approach in terms of mental and physical demand, time pressure, effort, and frustration

level. Regarding the third approach, the flying pilot commented that there was a

ìnoticeably higher workload ñ with gear delayed, I felt behind the airplane.î

The questionnaire completed by the nonflying pilot after the third approach indicated that

the ìfast, late turn, [at] high altitude increased workload.î

Another scenario was flown to duplicate the descent profile and ground track of

the accident flight. Investigators noted that when the pilots were attempting to maintain a

low-descent rate at a low-torque setting (about 400 foot-pounds [ft-lbs]) with the airspeed

lower than 100 knots, a gradual, significant pitchup was necessary to maintain altitude.

The stall warning horn sounded when the airplane was at 82 knots.

54 During these approaches, the Aviation Charter pilot was the flying pilot.

55 The distance by which the flight crew overshot the approach course to the north was not precisely

measured during these simulations.

56 S.G. Hart and L.E. Staveland, ìDevelopment of NASA-TLX (Task Load Index): Results of Empirical

and Theoretical Research,î eds. P.A. Hancock and N. Meshkati, Human Mental Workload (Amsterdam:

North-Holland, 1988) 139-183.
Factual Information 31 Aircraft Accident Report

1.17 Organizational and Management Information

At the time of the accident, Aviation Charter,57 which is headquartered in Eden

Prairie, Minnesota, operated about 120 flights per month with a fleet of 24 turbojet,

turboprop, and piston-powered airplanes, 4 of which were King Air A100s. According to

FAA documents, the company employed 25 pilots, 8 copilots, and 3 check airmen.

The company also used copilots employed by Eagle Jet International, which had an airline

first officer program through which it would place both new and experienced pilots with

various companies so that they could gain additional flying experience.

Following an accident in December 1997 involving a King Air A100,58 Aviation

Charter instituted a policy to have two flight crewmembers in the cockpit for all 14 CFR

Part 135 charter flights, even though the King Air A100 is certified to operate for Part 135

on-demand revenue flights with only one pilot in visual flight rules conditions and with one

pilot and an operable, FAA-approved autopilot in IFR conditions. (See 14 CFR 135.105.)

Further, according to Aviation Charterís director of operations, the company changed

insurance carriers in April 2000, and the new carrier required that all Part 135 flights have

two flight crewmembers.

1.17.1 Company Training

Aviation Charter had a Part 135 Multiengine Turbopropeller Aircraft Maneuvers

Guide59 and a Part 135 Aircraft Training Manual, which received approval from the FAA

on March 3, 1995, and September 19, 1996, respectively. All pilots hired by the company

were required to attend its FAA-approved, in-house ground and flight training at its

headquarters. All company pilots were also required to take and pass the appropriate

Part 135 checkrides, which were conducted by a company check airman, before being

assigned line flights.

In addition, Aviation Charterís insurance carrier required company PICs to receive

flight simulator training.60 Aviation Charter contracted with SimuFlite, Inc., to provide all

PICs additional training in a flight-training device, which satisfied the insurance

requirement for simulator training (about 8 to 10 hours of training in the simulator was

required), at SimuFliteís Quick Turn subsidiary in Dallas, Texas. PICs received this

additional training after successfully completing the companyís FAA-approved, in-house

ground and flight training. Company copilots were not required to and did not attend the

training at Quick Turn.61

57 Aviation Charter operates as an on-demand charter operation in partnership with Executive Aviation,

which operates as an FBO at FCM.

58 For more information about this accident, see section 1.18.1.

59 Pilots were not provided copies of the Maneuvers Guide; however, copies of the guide were provided

to the chief pilot and each company flight instructor, who used the guide to train and evaluate pilots. Pilots

were expected to adhere to the procedures contained in the Maneuvers Guide during line operations. Copies

were maintained at the companyís headquarters (the master copy) and the FAAís Minneapolis Flight

Standards District Office (FSDO). 

60 This training was not required by the FAA.
Factual Information 32 Aircraft Accident Report

According to a Quick Turn instructor, SimuFlite offered 3- and 2-day recurrent

training courses in the flight-training device; Aviation Charter sent its PICs to the 3-day

course annually. The instructor added that when two PICs attended training, the pilot in

the right seat was responsible for operating the gear, flaps, and radios, and the pilot in the

left seat received training and was evaluated on single-pilot operations. According to

Aviation Charterís chief pilot, when two PICs attended training, the pilot in the right seat

performed Aviation Charterís normal copilot duties (for example, standard callouts and

checklist assistance routinely performed during 14 CFR Part 135 on-demand charter

flights).

1.17.1.1 Crew Resource Management

On May 21, 1997, the FAA approved Aviation Charterís ground school training

module on crew resource management (CRM), and the module was subsequently added to

the companyís training manual. The CRM training module did not indicate a specific

hourly requirement for instruction and completion.62

The suggested CRM curriculum topics included the following: communication

processes and decision behavior; briefings; inquiry, advocacy, and assertion; crew self

critique (decisions and actions); team building and maintenance;63 theory and practice in

using communication, decision-making, and team building techniques and skills; training

for new copilots in performing the nonflying-pilot role to establish a positive attitude

toward monitoring and challenging errors made by the flying pilot; training for pilots in

giving and receiving challenges of errors; and training for all crewmembers that identifies

conditions in which additional vigilance is required, such as holding in icing or near

convective activity (the manual states that this training should emphasize the need for

maximum situational awareness and the appropriateness of sterile cockpit discipline,

regardless of altitude).

According to Aviation Charterís training manual, pilots were required to complete

an oral or written examination given by a company instructor to determine adequate

knowledge of CRM. Further, according to the training manual, instructors and check

airmen evaluated a pilotís CRM knowledge and techniques during company flight training

and checkrides, and the pilots were graded as either satisfactory or unsatisfactory in that

area.64 According to Aviation Charterís director of operations and its agent for service,

CRM training was also incorporated into the training at Quick Turn, and pilots received

CRM evaluations during this training. However, the chief pilot stated that he could not

recall being briefed on CRM at Quick Turn. Further, according to a Quick Turn instructor,

61 Subsequent to the accident, Aviation Charter started sending all of its pilots to full-motion simulator

training at FSI.

62 For information about an April 1997 FAA Regional Aviation Safety Inspection Program (RASIP)

finding regarding CRM training at Aviation Charter, see section 1.17.3.5.

63 Subtopics of team building and maintenance included leadership, interpersonal relationships,

workload management and situational awareness, and individual factors and stress reduction.

64 Both accident pilotsí most recent proficiency check records indicated that they were evaluated on

CRM and graded as satisfactory.
Factual Information 33 Aircraft Accident Report

pilots who attended training at Quick Turn were not evaluated on CRM because its

training specifically evaluated pilot competency during single-pilot operations.

During postaccident interviews, Aviation Charterís lead ground instructor stated

that he was not aware of the CRM module but that he did teach CRM techniques,

including standard callouts and operating procedures, during ground school. The FAA

principal operations inspector (POI) at the time the CRM module was added to the

training manual stated that he did not remember if he had ever reviewed the CRM training

module or observed the training.65 He also stated that because a CRM module was in the

companyís training manual, the lead ground instructor should have been aware of it.

Aviation Charterís chief pilot and its director of operations stated that even though its

training manual contained a module on CRM, it was not required by any rule or

regulation.66

The FAA POI for Aviation Charter at the time of the accident stated that,

subsequent to the accident, he encouraged Aviation Charter to conduct line checks during

nonrevenue flights to evaluate CRM procedures. Further, he stated that he encouraged the

company to put an instructor in the left seat and a copilot in the right seat during

proficiency checks so that the company could monitor CRM procedures.

1.17.1.2 Stall Recovery Maneuvers

Aviation Charterís Multiengine Turbopropeller Maneuvers Guide contains

guidance on stall recovery maneuvers to ìafford familiarization with the airplane handling

characteristics in the initial stall buffet region and provide training in stall recognition and

proper recovery techniques.î The Maneuvers Guide contains guidelines to determine

acceptable pilot performance during training of the stall recovery maneuver. According to

the Maneuvers Guide, a pilotís performance of the stall recovery maneuver is acceptable if

the following conditions, in part, are met:

a. Exhibits adequate knowledge of the factors, which influence stall

characteristics, including the use of various drag configurations, power

settings, pitch attitudes, weights, and bank angles. Also, exhibits adequate

knowledge of the proper procedure for resuming normal flightÖ

e. Initiates recovery [from stall] at the first indication of buffeting, decay of

control effectiveness, other cues related to specific aircraft design

characteristics, or as directed by the instructor.

f. Recovers to a reference airspeed, altitude and heading, allowing only the

acceptable altitude, airspeed, heading loss, or deviation.

65 This POI was replaced by another POI in June 2002, who was responsible for the oversight of

Aviation Charterís operating certificate at the time of the accident. The original POI was reassigned to

Aviation Charter in December 2002. 

66 For information about a previously issued CRM-related recommendation to the FAA, see

section 1.18.2.
Factual Information 34 Aircraft Accident Report

g. Demonstrates smooth, positive airplane control during entry, stall regime, and

recovery.

Specific stall recovery initiation procedures, including how to respond if the stall

warning horn sounds in flight, were not noted in any of Aviation Charterís manuals.

However, one Aviation Charter copilot stated that during company flight training, she was

instructed to initiate stall recovery when the stall warning horn sounded. Further, a Quick

Turn instructor indicated that because the flight-training device was not a motion-based

device, pilots were expected to initiate stall recovery when the stall warning horn sounded.

1.17.1.3 Instrument Approaches

Aviation Charterís Multiengine Turbopropeller Maneuvers Guide states that the

flying pilot must brief the nonflying pilot before executing an instrument approach. The

Maneuvers Guide indicates that the instrument approach briefing should include the type

of approach, minimums, missed approach procedure, and the required callouts, including

altitudes, times, airport in or not in sight, MDA, and deviations. Although the Maneuvers

Guide states that an instrument approach briefing is a required item that must be

accomplished by the flight crew before executing an instrument approach, Aviation

Charterís General Operations Manual (GOM) did not contain this requirement, and none

of its company checklists called for conducting an approach briefing.67

The Maneuvers Guide also contains procedures for making an approach when the

PIC is the flying pilot.68 The guide states that the nonflying pilot should tune and identify

the VHF navigational receiver and set the course selector for the approach. The guide

further states that an in-range checklist69 must be accomplished immediately before

commencing an approach to reduce workload and permit the flying pilot to concentrate on

the approach. The guide states, ìthe landing checklist may be accomplished at any time

during the approach with the exception of landing gear and flaps.î The guide states that

upon passing the final approach fix (FAF), the flying pilot should begin the descent to the

MDA or step-down fix and that the landing gear should be extended at the FAF. The guide

adds that landing flap extension can be delayed until the landing is assured. Aviation

Charterís chief pilot stated that pilots were instructed to extend the landing gear and

reduce the power simultaneously once they have started the descent to the MDA.

Aviation Charterís Maneuvers Guide states that the recommended approach speed

for precision approaches is 120 knots. However, neither the guide nor any other Aviation

Charter manual specified the approach speed for nonprecision approaches.70 According to

Aviation Charterís chief pilot, he instructed pilots to fly all approaches at 130 knots and

67 At the time of the accident, the approach briefing was contained in SimuFliteís Standard Operating

Procedures (SOPs) located in Aviation Charterís Differences Manual. Subsequent to the accident, the

approach briefing was incorporated into the companyís FAA-approved GOM.

68 The Maneuvers Guide did not contain procedures for making an approach when the copilot is the

flying pilot.

69 No in-range checklist could be found by Safety Board investigators in any of Aviation Charterís

manuals, and the companyís chief pilot and agent for service acknowledged that the company did not have

an in-range checklist. 
Factual Information 35 Aircraft Accident Report

that 130 knots should be maintained from the FAF (or before starting descent) until the

runway is in sight. He added that he instructed pilots to cross the threshold and touch

down at 100 knots. The chief pilot further indicated that with the gear down, about

400 ft-lbs of torque, and 130 knots of airspeed, the airplane should descend at a rate just

under 1,000 fpm. He stated that 100 feet before reaching the MDA, the torque would

normally be brought up to 800 ft-lbs, and 130 knots would be maintained as the airplane

was leveled off. He added that, at that point, the flying pilot should have his eyes inside

the cockpit, not looking out, unless the nonflying pilot has called the airport in sight.

The Maneuvers Guide contains criteria to determine acceptable pilot performance

of a stabilized VOR approach. According to the guide, a pilotís performance of a

stabilized approach is acceptable if the following conditions, in part, are met:

f. Recognizes if heading indicator and/or attitude indicator is inaccurate or

inoperative, advises controller, and proceeds with approachÖ

i. Maintains, prior to beginning the final approach segment, altitude within

100 feet [of the initial approach or assigned altitude], heading within

10 degrees [of initial approach or assigned heading] and allows less than a

full-scale deflection of the CDIÖand maintains airspeed within 10 knots [of

initial approach or assigned airspeed]Ö

k. Establishes a rate of descent and track that will ensure arrival at the MDA prior

to reaching the MAP with the aircraft continuously in a position from which

descent to a landing on the intended runway can be made at a normal rate using

normal maneuvers.

l. Allows, while on the final approach segment, no more than a

three-quarter-scale deflection of the CDIÖand maintains airspeed within

10 knots [of the approach airspeed].

m. Maintains the MDA, when reached, within +100 feet, -0 feet to the MAP.

Standard callouts to be made during an approach and conditions that would

warrant abandoning an approach were contained in SimuFliteís SOPs, which were

contained in Aviation Charterís Differences Manual. The chief pilot stated that the

Differences Manual was provided to all pilots during initial training. According to the

Abandoned Approach procedure contained in the SOPs, within 500 feet agl, the airplane

must be within the following approach window: the airspeed must be within ±10 knots of

approach speed, and the vertical speed must be no greater than 1,000 fpm. If the airplane is

not within this window, the flight crew must execute a go-around.

1.17.1.4 Standard Operating Procedures

At the time of the accident, Aviation Charter did not have its own documented

SOPs; however, as mentioned, the company was using Simufliteís SOPs, which were in

the Aviation Charterís Differences Manual. The SOPs included the following: flying-pilot

70 According to Aviation Charter, it clarified its approach speed guidance subsequent to the accident by

making 120 knots the recommended speed for all approaches. 
Factual Information 36 Aircraft Accident Report

and nonflying-pilot responsibilities, challenges and standard callouts that the flight crew

should make during checklist completion in all phases of flight, emergency response

procedures, and instrument approach criteria and procedures.

According to Aviation Charterís chief pilot, who conducted most of Aviation

Charterís King Air flight training, company pilots were taught SOPs during ground and

flight instruction and were expected to use them. He added that since the accident, the

company had started reviewing and incorporating SimuFliteís SOPs into the companyís

training manual and GOM. A company check airman rated the companyís standardization

as 6 on a scale of 1 to 10. Another company pilot stated that the companyís standardization

was fair to good, and the lead ground instructor stated that it was fair. The lead ground

instructor also indicated that he suspected that some pilots were following SOPs and that

some were not. One company pilot indicated that if the company was going to continue

operating with two crewmembers, she would like to see the company adopt SOPs.

Regarding callouts, one Aviation Charter pilot stated that she used the callouts that

she used while employed at another company and added that she had never seen any

standard callouts documented in any company manual. A company copilot stated that no

formal airspeed callouts were required during an approach but that the companyís

Differences Manual did document the approach briefing format and airspeed callouts. 

On April 3, 2003, the FAA approved revision 14 to Aviation Charterís GOM. This

revision incorporated Aviation Charterís newly developed SOPs into its GOM, Section R,

ìCompany Policies.î According to the companyís chief pilot and director of operations,

following the accident, the company started teaching pilots SOPs during training and

implemented random line checks to evaluate SOPs, CRM, and crew coordination.

1.17.2 Operational Guidance

1.17.2.1 Manufacturerís Guidance on Operation in Icing Conditions

The Raytheon King Air A100 AFM, Section I, ìLimitations,î states that for

sustained operation in icing conditions, the minimum airspeed should be 140 knots and

adds that sustained flight in icing conditions with flaps extended is prohibited except for

approach and landing. Raytheonís AFM, Section II, ìNormal Procedures,î contains the

following caution regarding operation in icing conditions:

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 when ice is on the

airplane.

Further, Raytheonís AFM states that an airplaneís surface deicer system should be

operated when 1/2 to 1 inch of ice has accumulated on the airplaneís surfaces. The AFM

also states that when the temperature is 5° C or lower, pitot heat,71 engine heat, and stall

warning heat should be on before any visible moisture is encountered.
Factual Information 37 Aircraft Accident Report

1.17.2.2 Company Guidance on Operation in Icing Conditions

At the time of the accident, Aviation Charterís GOM, Section R, ìCompany

Policies,î Chapter R-2.4, ìEnroute Icing Conditions Procedures,î stated that its company

policy is to avoid moderate icing conditions if possible but that if moderate icing is

encountered, the flight crew should request an altitude change before the ice becomes

heavy. The GOM added that because the additional weight of the ice will make it harder

for the airplane to maintain airspeed, additional power will be needed. The GOM also

stated that the deicer boots ìshould be used only after the ice has accumulated to

1/2 inch.î The manual adds that if the deicer boots ìare prematurely activated the ice may

form a shell around the boot[s] and render them useless.î

Aviation Charterís lead ground instructor stated that the procedure for activating

the deicer boots was taught in ground school and that the company used to instruct pilots

to wait until 1/2 inch of ice had accumulated to activate the boots. However, he stated that

because of recent NASA research that recommended that deicer boots be activated at the

first sign of ice buildup, he was instructing his students to activate the boots once about

1/4 inch of ice had built up. The lead ground instructor indicated that he was aware that the

procedures taught in the companyís ground school were different from those contained in

Raytheonís AFM and the companyís GOM. He stated that this discrepancy was only

discussed with the pilots during ground school. He stated that the training included a test

on tailplane stall and icing conditions and that he covered winter operations as part of

recurrent and initial training. When asked about the companyís deicing procedures,

several Aviation Charter pilots indicated that there were no clear standardized procedures

regarding how much ice should accumulate before activating the deicer boots.

The POI responsible for Aviation Charter at the time of the accident told Safety

Board investigators that he believed that a bulletin had been issued stating that deicer

boots should be activated at the first sign of ice rather than waiting until 1/2 inch of ice had

accumulated. The POI stated that he thought the FAA had issued the bulletin but that he

was unsure if it was regulatory or overrode the AFM.72 The current POI also stated that a

bulletin had been issued regarding activation of the deicer boots immediately upon

encountering any kind of ice and that he believed that the lead ground instructor was

teaching in accordance with the bulletin.

Subsequent to the accident, Aviation Charter standardized its deicer boot

operations training and adopted the Raytheon AFM recommendation to wait until the

accumulation of 1/2 inch of ice before activating the deicer boots.

1.17.2.3 Weight and Balance Load Manifest Procedures

At the time of the accident, Aviation Charterís GOM, Section R, Chapter R-1.1,

ìLoad Manifest,î indicated that the pilot was responsible for preparing a load manifest in

71 According to Aviation Charterís chief pilot, company pilots were trained to use pitot heat for the

entire flight.

72 The POI could not locate the bulletin for Safety Board investigators.
Factual Information 38 Aircraft Accident Report

duplicate before each takeoff and ensuring its accuracy. The GOM added that the original

copy of the load manifest must be carried in the aircraft to the companyís base of

operations. It stated further that ìAlthough FAR [Federal Aviation Regulations] 135.63(c)

and (d) does not specify the disposition of the duplicate copy, it is Company policy to

either FAX or mail the duplicate to the company base of operationsî before station

departure. The GOM stated that if a pilot was unable to mail or fax a copy of the load

manifest, a copy should be carried in the most aft compartment of the airplane that is

accessible to the pilot.

As mentioned previously, the original and a copy of the accident airplaneís weight

and balance load manifest were destroyed by postcrash fire. Subsequent to the accident,

Aviation Charter issued revision 13 to the GOM to modify the load manifest form and to

require that pilots leave a copy of the manifest at each departure station in a place where it

could be located at a later time if needed. The FAA approved Aviation Charterís revised

manifest form on January 13, 2003.

1.17.3 FAA Surveillance

1.17.3.1 General

Aviation Charterís operating certificate was effective as of November 30, 1988,

and was managed by the FAAís Minneapolis FSDO. According to the FAA, at the time of

the accident, the POI was responsible for 8 Part 135 operators, 37 Part 137 operators

(agricultural airplanes), 1 Part 141 pilot school, 7 designated airmen, and 5 check airmen.

In a postaccident interview in January 2003, the POI told Safety Board investigators that

he was the only general aviation inspector in the Minneapolis FSDO and that he was

responsible for 37 Part 135 operators, 155 Part 137 operators (agricultural airplanes),

4 Part 133 operators (heavy-lift helicopters), 11 Part 141 pilot schools, 79 designated

airmen, 17 check airmen, and 168 Part 91 noncertificated operators.73

During an interview in January 2003, the Minneapolis FSDOís operations

supervisor told Safety Board investigators that the general aviation airworthiness unit,

which is authorized to have five inspectors, had three inspectors; the general aviation

operations unit, which is authorized to have six inspectors, had two inspectors; and the

general aviation avionics unit, which is authorized to have two inspectors, had two

inspectors. Both the FSDOís manager and its operations supervisor stated that the office

was not fully staffed with general aviation inspectors because of a hiring freeze and budget

constraints.74 The operations supervisor stated that if the POI could not complete his

73 Although this POI was not responsible for Aviation Charterís operating certificate from late

June 2002 through the date of the accident, he was responsible for conducting surveillance of the company

from about December 1997 through June 2002 and was reassigned the certificate in December 2002.

The POI responsible for Aviation Charter at the time of the accident did not perform any surveillance of the

company during the time he was responsible for the companyís operating certificate. For more information

about the Minneapolis FSDOís oversight of Aviation Charter, see section 1.17.3.3.

74 According to the FAA, the hiring freeze was lifted in March 2003, and three general operations

inspectors and three air carrier operations inspectors have been hired at its Minneapolis FSDO.
Factual Information 39 Aircraft Accident Report

current work program for 2003, certain items would be moved to other inspectors in the

office.

1.17.3.2 FAA Surveillance Guidance

FAA Order 1800.56C, ìNational Flight Standards Work Program Guidelines,î

contains guidance for the development and execution of annual surveillance work

programs, the planning and the performance of which was the responsibility of the

regional Flight Standards division. According to the order, ìthe primary objective of

surveillance is to provide the FAA with accurate, real-time, comprehensive information

for the evaluation of the safety status of the air transportation systemî and to ensure that

the ìhighest level of safety is maintained within the aviation community.î

FAA Order 1800.56C, Appendix 1, ìWork Program Activities,î states that the

Flight Standards work program comprises required (R-items) and planned (P-items)

surveillance activities. R-items comprise the mandatory core inspection program, which is

based on critical oversight issues that have been identified at a national level, and provide

an essential level of surveillance activity for certificate holders. Specifically, appendix 1,

Paragraph 5, ìRequired Surveillance,î states that one inspection in each of the following

areas is required for Part 135 on-demand charter operations: manual/procedures, training

program, crew/dispatcher records, and trip records. In addition to the R-items, each field

office is tasked to design a mandatory P-items inspection program to provide

comprehensive targeted inspections that meet special surveillance requirements for each

certificate holder operating within a field officeís geographic district.

1.17.3.3 Minneapolis FSDO Oversight of Aviation Charter

Each general aviation inspector at the Minneapolis FSDO was responsible for a

combined total of about 630 hours of surveillance (R- and P-items) at their assigned

operators. According to the Minneapolis FSDOís operations supervisor, inspectors were

required to complete at least 25 percent of their work program requirements every

3 months. The operations supervisor also stated that, in addition to their surveillance

responsibilities, POIs shared the following extra duties: accident standby, processing

enforcement actions and parachute waivers, assisting walk-in customers, approving and

supervising air shows, and other FAA support activities.

The POI responsible for the surveillance of Aviation Charter at the time of the

accident did not perform any surveillance activities at the company from June 2002, when

he was assigned the certificate, through the date of the accident (about 4 months).

He stated that he had not visited the company during this time because of his workload,

which he characterized as ìhigh.î The POI also stated that it was a struggle to ìkeep his

head above waterî and that he wished the office had more people. He added that Aviation

Charter still received a high level of surveillance compared to other operators because its

headquarters was near the Minneapolis FSDO.

According to the Minneapolis FSDOís manager, this POI was not required to

perform any surveillance activities from June to October 2002 because the previous POI
Factual Information 40 Aircraft Accident Report

had already completed all of Aviation Charterís R- and P-items before he left for his new

assignment. FAA work program records indicated that for fiscal year 2002 (October 1,

2001, to September 30, 2002),75 the previous POI conducted the following surveillance

activities at Aviation Charter: 1 operations manual inspection, 10 training program

inspections, 8 crewmember training records inspections, 1 trip records inspection, 1 ramp

inspection, and 2 operations inspections of aircraft/line operations. According to the

previous POI, he was prevented from attending to such things as approving manual

revisions because of his high workload.76

The Minneapolis FSDOís operations supervisor and its manager stated that,

subsequent to the accident, the principal inspectors for Aviation Charter were tasked to

visit the company once every week or two, and other inspectors in the office were also

encouraged to conduct surveillance of the company if time permitted.

1.17.3.4 FAA En Route Inspections

According to FAA Order 8400.10, ìAir Transportation Operations Inspectorís

Handbook,î the FAA conducts en route inspections to observe and evaluate a certificate

holderís in-flight operations. The order adds that en route inspections are the most

effective method for accomplishing surveillance objectives and responsibilities and that

such inspections can be conducted from either the forward observerís seat in the cockpit

(jumpseat) or from a forward cabin seat if no jumpseat is available. According to the

order, the following elements could be observed and evaluated during an en route

inspection: crewmember proficiency; operatorís use of manuals, checklists, approved

procedures, and safe operating practices; and crew coordination and resource

management. FAA Order 8400.10 also states that POIs are responsible for coordinating

with their assigned operators to ensure that established procedures are used by FAA

inspectors for scheduling the jumpseat/forward passenger seat and that the operatorís

procedures allow inspectors to have free and uninterrupted access to the jumpseat/forward

passenger seat. En route inspections are required to be conducted at Part 121 operations

and 135 scheduled (commuter) operations; however, they are not required to be conducted

at Part 135 unscheduled (on-demand) charter operations.

According to Aviation Charterís POI and the Minneapolis FSDOís operations

supervisor, en route inspections are rarely conducted at Aviation Charter because they are

not a required oversight item for POIs of 14 CFR Part 135 on-demand charter operators.

The POI added that other reasons that en route inspections are rarely conducted for such

operations were because on-demand charter flights are scheduled with little advance

notice, most of the smaller airplanes used in these operations do not have jumpseats

installed, and the passengers on such flights tended to desire privacy. He stated that he had

tried to perform surveillance of actual charter flights at Aviation Charter, but he stated that

75 As stated previously, the previous POI conducted his last surveillance activity before the accident on

June 27, 2002.

76 This POI was reassigned to Aviation Charter in December 2002.
Factual Information 41 Aircraft Accident Report

he found it difficult because of limited passenger accommodations on the airplanes. He

added that the best way for him to ensure adequate oversight of an operator was to monitor

ground training.

1.17.3.5 Preaccident FAA Regional Aviation Safety Inspection Program 

Inspection

A team of aviation safety inspectors conducted a RASIP inspection at Aviation

Charter from April 7 to 11, 1997. The RASIP Inspection Report included seven

operations-related findings (two Category A, three Category B, and two Category C

findings).77 Specifically, the report stated that CRM was only addressed in the training

curriculums for two types of airplanes flown by the company. The report added that CRM

should be addressed in all of the companyís training curriculums because, if not, ìit could

possibly result in improper crew coordination requirements in aircraft operated with a

flight crew of more than one member.î Another operations finding indicated that Aviation

Charterís GOM was contrary to 14 CFR 135.63(c), which states that it is the certificate

holderís responsibility for preparation and accuracy of the load manifest. The report noted

that the company used load computer and flight manuals for weight and balance

calculations, but that the information was not being retained to determine load manifest

accuracy at a later date.78 The RASIP report also noted that starting in January 1997,

Aviation Charter had a Safety Officer to heighten safety awareness throughout the

company; however, at the time of the accident, this position no longer existed. Subsequent

to the October 2002 accident, Aviation Charter hired a Director of Safety (this action was

not required by the FAA).

1.18 Additional Information

1.18.1 Previous Aviation Charter Operations-Related Accident

On December 21, 1997, an Aviation Charter King Air A100 crashed at Colorado

Springs, Colorado, after encountering ground fog during landing. The pilot and one

passenger were killed. The Safety Board determined that the probable causes of the

accident were the failure of the pilot to follow IFR procedures and maintain the MDA.

As mentioned previously, subsequent to the accident, the company began operating with

77 The FAA defines the three categories of findings as follows: a Category A finding is any

noncompliance with FARs; a Category B finding is a failure of the certificate holder to adhere to

documented company procedures regarding regulations and safety; and a Category C finding is a lack of

systems that would ensure that the certificate holder complies with continuing or reoccurring FAR

requirements. The RASIP Inspection Report notes that compliance issues raised during the inspection were

discussed with company personnel and principal inspectors and that issues that were not satisfactorily

resolved became findings in the body of the report.

78 Aviation Charterís agent for service indicated that this finding referred to the pilots not being required

to leave a copy of the manifest at the departure station.
Factual Information 42 Aircraft Accident Report

two flight crewmembers. According to the Minneapolis FSDOís manager, the FAA did

not implement any changes to its oversight of Aviation Charter after the Colorado Springs

accident.

1.18.2 Previous CRM-Related Safety Recommendation

As a result of its investigation of the March 29, 2001, accident involving a

Gulfstream III operated by Avjet Corporation as a Part 135 on-demand charter passenger

flight, the Safety Board issued Safety Recommendation A-02-12, which asked the FAA to

ìrevise 14 Code of Federal Regulations (CFR) Part 135 to require on-demand charter

operators that conduct operations with aircraft requiring two or more pilots to establish a

Federal Aviation Administration-approved crew resource management training program

for their flight crews in accordance with 14 CFR Part 121, subparts N and O.î

On February 3, 2003, the FAA announced a comprehensive regulatory review of

14 CFR Parts 125 and 135, including a review of CRM training. The FAA also stated that

it was finalizing its notice to inspectors who have oversight responsibility for Part 135

on-demand operators to remind them of the circumstances of the Avjet accident and to

direct them to point out to their assigned operators information contained in Advisory

Circular (AC) 120-5 lD, ìCrew Resource Management Training.î According to the FAA,

the notice will also state that the FAA strongly endorses CRM training. On August 7,

2003, the Board classified Safety Recommendation A-02-12 ìOpenóAcceptable

Response.î
43 Aircraft Accident Report

2. Analysis

2.1 General

The flight crewmembers were properly certificated and had received the training

for pilot certification prescribed by Federal regulations.79 No evidence indicated any

preexisting medical or other physical condition that might have adversely affected the

flight crewís performance during the accident flight. Fatigue most likely did not degrade

the performance of either pilot on the day of the accident.

The accident airplane was properly certificated, equipped, and maintained in

accordance with Federal regulations and approved company procedures. The recovered

components showed no evidence of preexisting powerplant, system, or structural failures.

The weight and balance of the airplane were within limits for dispatch, takeoff,

climb, cruise, and landing.

This analysis discusses the accident sequence, including weather, ATC, and EVM

VOR issues, and flight crew actions and competence. This analysis also discusses

operational and training issues at Aviation Charter, FAA surveillance of the company, and

the need for low-airspeed alert systems.

2.2 Determination of Flying Pilot

ATC recordings indicated that the accident copilot made all but one of the

transmissions to ATC during the approach and descent. Typically, dual-pilot operations are

conducted with the flying pilot handling the flight controls and the nonflying pilot

handling the communications. Aviation Charter company practices were in accordance

with this standard. However, several Aviation Charter pilots interviewed by Safety Board

investigators indicated that the accident pilot often allowed them to conduct the flights

they flew with him as if they were single-pilot operations (that is, he allowed them to

handle the flight controls and communications and perform all of the checklists without

his assistance). Therefore, the Safety Board could not determine who was flying the

airplane at the time of the accident.

79 As discussed in section 1.5.1.2, there were numerous discrepancies with the pilotís logbooks that

called into question the accuracy of his flight time record-keeping. However, the investigation found no

evidence indicating that the pilot lacked the required flight time or that these discrepancies in the logbooks

were related to the cause of this accident.
Analysis 44 Aircraft Accident Report

2.3 Accident Sequence of Events

2.3.1 Flight Crewís Inadequate Setup for the Approach

About 1009, 7 minutes after being instructed to descend from 13,000 feet to

4,000 feet at pilotís discretion, the copilot reported leaving 13,000 feet. About 1012, the

DLH approach control south radar controller cleared the flight to 3,500 feet. During the

descent to 3,500 feet, the airplane slowed from about 220 to about 190 KCAS.

By 1017:35, the airplane had leveled off at 3,500 feet with the airspeed continuing to

decrease. Shortly after 1018:31, as the airplane approached the published EVM VOR

runway 27 final approach course from the south at about 164 KCAS and decreasing, ATC

instructed the flight crew to turn left to a heading of 300° until established on the final

approach course.80 However, the flight crew overshot the approach course almost

immediately after being issued the turn, and the airplane ultimately traveled for almost

1 mile north of the course as it continued the turn toward the course until establishing a

ground track of about 262°.

The airplane began its descent from 3,500 feet, and the airspeed began increasing

about 1019:20. The airplane should have been at 130 knots at the start of the descent81

with flaps at the approach setting and the landing gear down. Because the airplane was fast

at this point in the approach, the flight crew had to lose a significant amount of airspeed

and altitude in a short amount of time. As the airplane descended through 3,200 feet, its

airspeed and vertical speed peaked at about 170 KCAS and 1,400 fpm, respectively.

At 1020:06, as the airplane descended through 2,700 feet about 5 miles east of the

runway 27 threshold, a right turn was initiated and the airspeed began decreasing from

about 170 KCAS. When the airplane was approximately 4 miles from the runway

threshold, it was still at 2,300 feet and about 160 KCAS; however, at this point in the

approach, the airplane still should have been at an airspeed of about 130 knots.

Further, Aviation Charterís chief pilot stated that the landing gear should be

extended when the flight crew starts the descent to the MDA and that the power should

simultaneously be reduced to get down to approach speed. However, the maximum speed

for landing gear extension is 156 knots. The airspeed exceeded 156 knots when the

airplane started its descent to the MDA and during most of the descent. The chief pilot and

other Aviation Charter pilots indicated that it would have been difficult to exceed

156 knots with the gear extended. Therefore, it appears that the flight crew did not

properly configure the airplane at the start of the approach (extending the landing gear or

reducing power before descending from 3,500 feet).

80 For analysis of this ATC instruction, see section 2.5.

81 As noted previously, according to Aviation Charterís chief pilot, the company instructed its pilots to

fly nonprecision approaches at 130 knots until short final and to cross the runway threshold and touch down

at 100 knots.
Analysis 45 Aircraft Accident Report

As previously discussed, simulations performed by the Safety Board indicated that

the later stages of the approach flown by the accident flight crew were more difficult in

terms of mental and physical demand and time pressure than it would have been if they

had not overshot the approach course and had not delayed their descent and landing gear

extension. The flying pilot of these simulations commented that during this approach there

was a ìnoticeably higher workload ñ with gear delayed, I felt behind the airplane.î

The flight crewís failure to monitor the airspeed and correct their course and airspeed

deviations early in the approach and the fact that the flight crew did not properly configure

the airplane at the start of the approach would have made the later stages of the approach

more difficult.

2.3.2 Flight Crewís Failure to Stabilize the Approach

As stated previously, the flight crew initiated a slight right turn at 1020:06, as the

airplane again passed through the final approach course (this time flying from north to

south) about 5 miles east of the runway 27 threshold. The airplane continued its slight

right turn until it established a ground track of 269°, which it maintained until the end of

the radar data. At this point, the airplane was south of the published approach course (of

276°); therefore, this turn did not allow the airplane to intercept the course, and the flight

crew never effectively maneuvered the airplane to remain near the approach course.82

At 1020:36, the airplaneís airspeed was about 156 knots about 3.7 miles from the

runway 27 threshold and it was descending through about 2,200 feet. At 1020:54, when

the airplane was 3 miles from the runway threshold, it was descending through about

2,100 feet and slowing through about 130 KCAS. The last two radar returns indicate that

the airplane was at approximately 1,800 feet83 and slowing through about 76 KCAS,

which is the approximate stall speed for the configuration in which the airplane was found

after the accident. The last radar return was about 2 miles southeast of the runway

threshold.

Airplane simulations showed (and the stall warning system design indicates) that

the flight crew should have received at least several seconds of aural stall warning in the

cockpit if the airspeed decreased below 81 to 84 knots, if the stall warning system was

working properly, and if the airplane was not affected by ice accumulation. Further, the

flight crew should have had other indications of low airspeed, such as increased pitch

attitude and a quieter slipstream, and might have experienced buffeting and less

responsive flight controls, depending on the airspeed and whether there was any ice

accumulation. However, because the airplane was not equipped with a CVR, because of

the approximate nature of the airspeed calculations, and because airplane maneuvering or

small amounts of ice accumulation can increase an airplaneís stall speed, the Safety Board

82 As further discussed in section 2.6, the bends (which, as noted previously, are fluctuations in the

calculated VOR radial position that occur slowly enough to be followed by a pilot under normal conditions)

in the VOR signal played no role in the flight crewís failure to intercept the course.

83 Because of the ± 50-foot accuracy of the radar data, it could not be determined exactly how close the

airplane was to the MDA of 1,840 feet at the time of the last radar returns.
Analysis 46 Aircraft Accident Report

was not able to determine when or whether the stall warning horn activated on the

accident flight or if buffeting or loss of flight control effectiveness occurred. Nevertheless,

it is clear that the flight crew failed to monitor the airplaneís airspeed and allowed it to

decrease to a dangerously low level (as low as about 50 knots below the companyís

recommended approach airspeed) and to remain below the recommended approach

airspeed for about 50 seconds. Further, the flight crew failed to recognize that a stall was

imminent.

According to the stabilized approach criteria contained in Aviation Charterís

Turbopropellers Maneuvers Guide, while on the final approach segment of a nonprecision

approach, pilots should allow no more than a three-quarter-scale deflection of the CDI

needle and maintain airspeed within 10 knots of the approach airspeed. Further, according

to the Abandoned Approach procedure contained in Aviation Charterís SOPs, when the

flight is within 500 feet agl, the airspeed must be within ± 10 knots of the recommended

approach speed. If the airplane does not meet these acceptable margins, the flight crew is

expected to execute a go-around. Computations showed that the airplaneís position

relative to the VOR course would result in the CDI needle likely at full deflection

approximately 2.6 miles from the VOR station. Further, at this point in the approach, the

airspeed had fallen to about 110 knots and was still decreasing, ultimately reaching a low

of about 76 knots. Therefore, the inadequate airspeed or the full CDI needle deflection

should have prompted the flight crew to execute a go-around.

2.3.3 Summary of Flight Crewís Performance During the 

Approach

In sum, the Safety Board concludes that the flight crew failed to maintain an

appropriate course and speed for the approach and did not properly configure the airplane

at the start of the approach, making the later stages of the approach more difficult. Further,

the Safety Board concludes that, during the later stages of the approach, the flight crew

failed to monitor the airplaneís airspeed and allowed it to decrease to a dangerously low

level (as low as about 50 knots below the companyís recommended approach airspeed)

and to remain below the recommended approach airspeed for about 50 seconds.

The Board further concludes that the flight crew failed to recognize that a stall was

imminent and allowed the airplane to enter a stall from which they did not recover.

The Board also concludes that the inadequate airspeed or the full CDI needle deflection

should have prompted the flight crew to execute a go-around; however, they failed to do

so.

Lastly, the Safety Board notes that if the flight crew had been adhering to Aviation

Charterís approach procedures and effectively applying CRM techniques in the cockpit, at

least one of the flight crewmembers should have been monitoring the instruments. The

evidence clearly indicates that neither flight crewmember was monitoring the airspeed

indicator or CDI during the approach. Therefore, the Safety Board concludes that the

flight crew was not adhering to Aviation Charterís approach procedures and was not

effectively applying CRM techniques during the approach segment of the flight.
Analysis 47 Aircraft Accident Report

2.4 Weather Issues

2.4.1 Clouds

Because the surface visibility around the time of the accident was about 3 statute

miles, the flight crew probably would have been able to see the airport to the right of their

course if the airplane had been completely clear of the clouds. However, EVM and

Hibbing surface observations and pilot statements indicate that around the time of the

accident, the cloud bases at and near EVM were somewhere between 1,800 and

2,100 feet.84 The last two recorded radar returns indicate that the airplane was at

approximately 1,800 feet and within 2 miles of the runway 27 threshold. Further, a witness

indicated that he saw the accident airplane ìjust beneath a low layer of cloudsî but that

ìthe top of the airplane may still have been in the clouds.î Therefore, because the airplane

was most likely in and out of the clouds before the accident, the Safety Board concludes

that clouds might have prevented the flight crew from seeing the airport.

2.4.2 Airframe Icing

The Safety Board considered whether airframe icing could have been a factor in

the accident. Several pilot reports made in the vicinity of EVM about the time of the

accident and an analysis of those reports indicated that icing was likely occurring in two

distinct bands around the time of the accident: moderate icing was present between

approximately 8,000 and 11,000 feet, and light/trace icing was present between

approximately 5,000 and 8,000 feet. Icing studies conducted for the Board indicated that

there was a low potential for SLD around Eveleth and, further, that moderate icing most

likely did not extend to the lower levels of the atmosphere.

One of the last two pilots who landed at EVM before the accident reported

experiencing light to moderate rime icing at 7,000 feet, at which level the temperature was

approximately -2° C. He added that after descending to 5,000 feet, the ice began to shed

off the airplane and that the temperatures at this level were between about -0.5° to 0° C.

The other pilot who landed at EVM stated that he encountered light rime icing at

5,000 feet. This pilot and the first pilot to depart EVM after the accident told Safety Board

investigators that they experienced very little icing below 5,000 feet.

Further, radar data show that the airplane was maintaining high airspeeds

throughout the region in which icing might have been accumulated and lost airspeed at

lower altitudes where performance would have been improving if any accumulated ice

was shedding (as a result of warmer temperatures or activation of the deicer boots),

indicating that icing was not affecting the airplaneís performance.

On the basis of cloud top and base values, investigators determined that the

airplane was in the clouds for approximately 9 1/2 minutes during the descent portion of

84 This equates to about 420 to 720 feet above the EVM runway 27 elevation.
Analysis 48 Aircraft Accident Report

the flight. Specifically, the airplane was in the clouds in which moderate icing was present

(between approximately 8,000 and 11,000 feet) for about 2 minutes 35 seconds, in the

clouds in which light/trace icing was present (between approximately 5,000 and

8,000 feet) for about 2 minutes 24 seconds, and in the clouds in which very little icing was

present and in which it was reported that any accumulated ice began shedding (below

5,000 feet) for about 4 minutes 23 seconds.

On the basis of all of this evidence, the airplane was most likely not in the cloud

layer in which moderate icing was present for enough time to accumulate any significant

airframe icing. Further, any icing that the airplane might have accumulated would have

been shed by the deicing equipment, or it would have begun shedding off the airplaneís

surfaces as it was descending through 5,000 feet because of the warming temperatures.

In addition, the airplaneís performance was not consistent with the effects of icing, and

flight simulations showed that the performance could be matched with and without

simulated icing with enough reserve engine power available to increase the airspeed

during the descent. Therefore, the Safety Board concludes that icing did not affect the

airplaneís performance during the descent.

2.5 ATC Issues

At 1018:13, when the accident airplane was about 9.5 miles from the runway 27

threshold and less than about 1/2 mile from the published EVM VOR runway 27 final

approach course at an airspeed of about 164 KCAS and a heading of about 360°, the DLH

approach control south radar controller instructed the flight crew to turn left to a heading

of 300° and issued an approach clearance for the EVM VOR runway 27 approach. The

controllerís instruction provided a final approach course interception angle of about 25°.

However, the airplane did not intercept the VOR approach course.85 Instead, it overshot

the intended course and then began turning back toward the approach course a few

seconds later.

The airplaneís speed and close proximity to the VOR final approach course when

the controller issued the 300° interception heading precluded the flight crew from

completing their left turn in time to initially intercept the final approach course. However,

the controllerís radar display was set at a range of 60 miles, which is an appropriate

resolution for normal coverage of the DLH airspace, and, at that range, the controller

would have had difficulty discerning the airplaneís exact position relative to the approach

course or even its overshoot of the course. Further, if the pilots were unsure of their ability

to intercept the approach course or safely execute the approach, they were responsible for

requesting additional vectors from ATC. No evidence exists that the flight crew expressed

any concerns about the execution of the approach to the DLH controller. Further, the

controllerís instruction should not have prevented the flight crew from correcting their

overshoot and properly intercepting and becoming established on the approach course.

Lastly, during postaccident airplane simulations, the flight crew that flew an approach

85 As previously mentioned, the approach course is 276°.
Analysis 49 Aircraft Accident Report

using ATC vectors similar to those given to the accident flight crew initially overshot the

approach course but were able to reintercept the course from the north, establish a

stabilized approach, and land successfully. Therefore, the Safety Board concludes that the

DLH approach control south radar controllerís instructions did not prevent the flight crew

from intercepting the EVM VOR runway 27 final approach course at a sufficient distance

to safely execute an approach and landing.

2.6 EVM VOR Issues

FAA flight checks indicated that the EVM VOR signal within the area between

5 to 10 miles from the station was out-of-tolerance for bends (a maximum distortion of

+4.1° was measured; a maximum distortion of ± 3.5° is allowed). Despite the slight

inaccuracy, the VOR signal positioned the airplane within an acceptable aiming point for

landing.

Within the area between 5 to 8 miles from the EVM VOR, the airplane was on a

fairly steady course of 262° moving toward 276°, which is the VOR inbound approach

course for runway 27. Therefore, because the airplane was converging on the inbound

course in the area between 5 to 10 miles from the VOR, it is clear that the slight bends in

the VOR signal were not misleading the flight crew or noticeably affecting the airplaneís

operation. Further, when following a VOR, flight crews are expected to maneuver the

airplane to keep the CDI needle centered. Accordingly, if they had been following the

VOR, the accident flight crew most likely would not have perceived a slight bend in the

course as they continued to maneuver the airplane to keep the CDI needle centered.

Therefore, the Safety Board concludes that the out-of-tolerance condition and slight bends

in the EVM VOR signal were not a factor in this accident.

2.7 Flight Crew Proficiency

Although several changes and adjustments would had to have been made in a

relatively short amount of time to stabilize the approach (with regard to speed, course, and

airplane configuration), the pilots should have been able to handle the changes and

successfully complete the approach.

As noted previously, because the flight crew did not properly configure the

airplane for the start of the approach and failed to monitor the airspeed and correct their

course and airspeed deviations early in the approach, they increased the difficulty of the

later stages of the approach. It is possible that the flight crew could not keep up with the

multiple concurrent tasks that they would have needed to complete during the final phase

of the flight. In addition, the multiple concurrent tasks would have required efficient

coordination between the two crewmembers; however, as concluded previously, the flight

crew likely was not effectively applying CRM techniques during the approach segment of
Analysis 50 Aircraft Accident Report

the flight. Therefore, these tasks likely were not being effectively handled during the

approach. Further, the Safety Boardís investigation revealed that the pilots often

performed poorly when flying approaches.

During the investigation, Safety Board investigators talked with company

instructors and with pilots and check airmen who had flown with the pilot and copilot.

These interviews identified several concerns about the flight proficiency of the pilot and

copilot. Aviation Charterís lead ground instructor, who was previously a check airman for

the company, stated that some company pilots indicated that the pilotís flying skills were

below average. Several company pilotsí statements indicated that the pilot performed below

average during flight operations. Specifically, one Aviation Charter pilot stated that he had

concerns about the accident pilotís flying skills, monitoring capabilities, and tendency to

become distracted. Other company pilots indicated that the pilot occasionally lost

awareness of the airplaneís altitude, attitude, and position during flight operations.

A company copilot indicated that during a flight with the pilot about 2 months before the

accident, he had to complete an approach for the pilot because the pilot did not have his

navigational radio tuned to the VOR in use for the approach, which caused the pilotís CDI

to provide erroneous indications, and that he then had to explain to the pilot the reason his

CDI was not indicating properly. Two pilots reported having to assume control of the

airplane when the pilot failed to adequately control the airplane during instrument

conditions. In addition, the pilot reportedly had a reputation for allowing his copilots to

perform most of the flying, which might have reduced his flight proficiency and skills.

Regarding the accident copilot, Aviation Charterís lead ground instructor reported

that the copilotís performance during ground school was below average. Several

statements made by company pilots indicated that the copilot performed below average

during flight operations. Specifically, two pilots stated that he had difficulties with power

management when flying an approach and that he had to be reminded to keep one hand on

the throttles and to monitor power settings. Several pilots expressed concern about the

copilotís inability to land the airplane without assistance and described him as ìnot

assertive.î Further, although the copilot claimed no previous aviation employment history

on his employment application for Aviation Charter, his logbook entries and rÈsumÈ

indicated that he had been employed previously at two aviation operations: a skydive

operator and Northwest Airlines. Records from the two companies indicate that he was let

go from the skydive operator because he could not meet its pilot qualifications standards

for flying the Cessna 182 and that he resigned from Northwest Airlines because he was

unable to complete its systems and procedures training program.

Postaccident statements from Aviation Charter pilots and other personnel indicate

that both pilots often exhibited potentially serious performance deficiencies during flight

operations. Therefore, the Safety Board concludes that both pilots had previously

demonstrated potentially serious performance deficiencies during flight operations

consistent with below-average flight proficiency.
Analysis 51 Aircraft Accident Report

2.8 Aviation Charter Operational and Training Issues

2.8.1 Operational Guidance

Although Aviation Charterís Multiengine Turbopropeller Maneuvers Guide stated

that the flying pilot must brief the nonflying pilot before executing an instrument

approach, its GOM did not contain this requirement, and none of its company checklists

called for issuing an approach briefing. Also, although the Maneuvers Guide stated that an

in-range checklist must be accomplished immediately before commencing an approach,

an in-range checklist was not contained in any of the companyís manuals. Further,

Aviation Charterís Maneuvers Guide does not contain specific stall recovery initiation

procedures, including how to respond if the stall warning horn sounds in flight, and such

procedures were not contained in any of Aviation Charterís other manuals. Further,

although Aviation Charterís GOM required pilots to either fax or mail a duplicate of the

weight and balance load manifest form for every flight to the company base of operations,

the company was not following this policy at the time of the accident. Lastly, company

guidance on when to operate the deicer boots was inconsistent.

On the basis of this evidence, the Safety Board concludes that at the time of the

accident, Aviation Charter was not operating in accordance with its weight and balance

load manifest procedures, it did not have adequate stall recovery guidance, it did not have

consistent deicer boot operational guidance, and it did not have an in-range checklist. The

Safety Board is aware that subsequent to the accident, Aviation Charter incorporated an

approach briefing as part of the descent procedures contained in the SOPs in the GOM and

revised the GOM to modify the weight and balance load manifest form and to require that

pilots leave a copy of the manifest at each departure station in a place where it can be

located at a later time if needed.

SOPs are typically developed for each airplane type within a companyís fleet to

ensure safe, logical, and efficient flight operations and to provide pilots with step-by-step

guidance for completing all phases of ground and flight operations, especially in

multicrew, complex, or high-performance aircraft. SOPs typically include flying-pilot and

nonflying-pilot responsibilities, challenges and standard callouts that the flight crew

should make during checklist completion in all phases of flight, emergency response

procedures, and instrument approach criteria and procedures.

The Safety Boardís review of the SOPs in effect at Aviation Charter at the time of

the accident revealed that its approach procedures were adequate and determined that if

the accident flight crew had adhered to these procedures, the accident might have been

prevented. As noted, these SOPs were SimuFliteís SOPs, which were located at the back

of the Aviation Charterís Differences Manual. The chief pilot indicated that SOPs were

being taught to and used by company pilots, and both he and the director of operations

stated that all pilots were given a Differences Manual during initial training. However,

according to a company check airman, on a scale of 1 to 10, the companyís

standardization was a 6. Another company pilot stated that the companyís standardization

was fair to good, and the lead ground instructor stated that it was fair. The lead ground
Analysis 52 Aircraft Accident Report

instructor also indicated that he suspected that some pilots were following SOPs and that

some were not. One company pilot indicated that if the company was going to continue

operating with two crewmembers, she would like to see the company adopt SOPs. In

addition, one company pilot stated that she had never seen any standard callouts

documented in any company manual, and a company copilot stated that no formal

airspeed callouts were required during an approach.

Therefore, on the basis of all of these statements and because the circumstances of

the accident indicate that the accident flight crew was most likely not adhering to the

SOPs for a nonprecision approach during the approach, the Safety Board concludes that

Aviation Charter was not adequately making company pilots aware of its SOPs. The

Safety Board is aware that subsequent to the accident, Aviation Charter incorporated the

SOPs, with some revisions, into its company GOM.

2.8.2 CRM Training

According to the FAA, Aviation Charter was not required by Federal regulations to

provide CRM training to its pilots. However, it became mandatory to teach CRM in

accordance with the CRM training module once the module was approved by the FAA.

However, postaccident interviews with Aviation Charterís lead ground instructor and its

chief pilot and the FAA POI for the company revealed that CRM was not being taught

during ground school in accordance with the training manual curriculum. Therefore, the

Safety Board concludes that at the time of the accident, Aviation Charter was not training

its pilots on CRM in accordance with its FAA-approved CRM training module.

2.9 FAA Surveillance Issues

2.9.1 FAA Surveillance of Aviation Charter

FAA Order 1800.56C, ìNational Flight Standards Work Program Guidelines,î lists

four required surveillance items for Part 135 on-demand charter operations, including

annual manual/procedures and training program inspections. Between October 1, 2001,

and June 27, 2002, the POI for Aviation Charter conducted 1 manual inspection, 2 line

checks, 1 ramp inspection, 10 training program inspections, and 9 other operations-related

inspections; however, during these inspections he failed to detect any of the operational

discrepancies determined by the investigation to have existed at Aviation Charter at the

time of the accident. On the basis of this evidence and the fact that the POI had not

conducted any en route inspections, the Safety Board concludes that although the FAAís

surveillance of Aviation Charter was in accordance with its standard guidelines, it was not

sufficient to detect the discrepancies that existed at Aviation Charter.
Analysis 53 Aircraft Accident Report

2.9.2 FAA Surveillance of Part 135 On-Demand Operations

FAA Order 8400.10, ìAir Transportation Operations Inspectorís Handbook,î

states that ìen route inspections are one of the most effective methods for accomplishing

surveillance objectives and responsibilitiesî and that the primary objective of these

inspections is to evaluate in-flight operations, including, but not limited to, crew

coordination, cockpit procedures, and crewmember proficiency, of a certificate holder.

However, although FAA Order 1800.56C requires inspectors to conduct en route

inspections at Part 121 operations and 135 scheduled (commuter) operations, it does not

require inspectors to conduct en route inspections at Part 135 unscheduled (on-demand)

charter operations. Further, the Safety Board is aware that POIs of Part 121 operations

routinely observe flight training and proficiency checks as a means to provide adequate

surveillance of these operations.

Aviation Charterís POI and the Minneapolis FSDOís operations supervisor

indicated that because there was no FAA requirement to conduct en route inspections of

14 CFR Part 135 on-demand charter flights, such inspections were rarely performed.

The POI added that the best way for him to ensure adequate oversight of an on-demand

Part 135 operator was to monitor ground training. The Safety Board does not concur with

the POIís statement. Although ground school surveillance is a valuable tool that allows

POIs to evaluate an instructor and the adequacy of course content, it does not allow POIs

to conduct comprehensive and in-depth assessments of an operatorís policies and

procedures or to determine how well the trained procedures are being assimilated into line

operations, which could be accomplished through en route inspections and through

observations of flight training and proficiency checks (in addition to ground school

observations).

The Safety Board is concerned that even though the FAAís surveillance of Aviation

Charter was in accordance with FAA Order 1800.56C, the POI did not detect the

discrepancies that existed at Aviation Charter during his manual/procedures or training

inspections, some of which might have been detected through en route inspections or

through observations of flight training or proficiency checks. The Board is also concerned

that the FAA requires en route inspections of Part 135 scheduled operations, but not for

Part 135 on-demand operations, despite its own acknowledgement that en route

inspections are one of the best means for ensuring adequate surveillance.

The Safety Board is aware that subsequent to the accident, Aviation Charter

implemented random line checks to evaluate SOPs, CRM, and crew coordination.

Although the Board commends the company for its actions, it is concerned about the

FAAís relying too much on company check airmen and not enough on its own staff to

evaluate these areas. Therefore, the Safety Board concludes that en route inspections,

combined with ground training, flight training, and proficiency check observations, are

essential for ensuring adequate oversight of a companyís operations and should be

conducted on flights operated by 14 CFR Part 135 on-demand charter operators.

Therefore, the Safety Board believes that the FAA should conduct en route inspections

and observe ground training, flight training, and proficiency checks at all 14 CFR Part 135
Analysis 54 Aircraft Accident Report

on-demand charter operations as is done at Part 121 operations and Part 135 commuter

operations to ensure the adequacy, quality, and standardization of pilot training and flight

operations.

2.9.3 FAA CRM Training Requirements

Most Part 121 and scheduled Part 135 operators provide several days of dedicated

CRM training in which accidents are reviewed and skills and techniques for effective crew

coordination, resource allocation, and error management are presented. CRM training

augments technical training and enhances pilotsí performance in the cockpit.

In its April 1997 RASIP report, the FAA stated that CRM should be addressed in

all of Aviation Charterís training curriculums because, if not, ìit could possibly result in

improper crew coordination requirements in aircraft operated with a flight crew of more

than one member.î On May 21, 1997, the FAA approved the companyís CRM training

module. However, as previously noted, the Safety Board concluded that Aviation Charter

was not teaching CRM in accordance with its CRM training module.

As a result of its investigation of the March 29, 2001, Avjet Corporation accident

in Aspen, Colorado, the Safety Board issued Safety Recommendation A-02-12, asking the

FAA to ìrevise 14 Code of Federal Regulations (CFR) Part 135 to require on-demand

charter operators that conduct operations with aircraft requiring two or more pilots to

establish an FAA-approved CRM training program for their flight crews in accordance

with 14 CFR Part 121, subparts N and O.î The Safety Board concludes that the

circumstances of the October 2002 Aviation Charter accident indicate that CRM training

should be extended to include all 14 CFR Part 135 on-demand charter operations that

conduct dual-pilot operations regardless of whether the aircraft requires two or more

pilots. Therefore, the Safety Board believes that the FAA should require that 14 CFR

Part 135 on-demand charter operators that conduct dual-pilot operations establish and

implement an FAA-approved CRM training program for their flight crews in accordance

with 14 CFR Part 121, subparts N and O. Because of the issuance of this recommendation,

Safety Recommendation A-02-12 is classified ìClosedóSuperseded.î

2.10 Low-Airspeed Alert Systems

2.10.1 Background

Current Federal airworthiness standards require that airplanes be equipped to

provide a clear and distinctive stall warning to the flight crew at a speed that is at least

5 knots higher than stall speed. However, stall warnings do not always provide flight

crews with timely notification of developing hazardous low-airspeed conditions. For

example, abrupt maneuvering can increase angle-of-attack so rapidly that a stall could
Analysis 55 Aircraft Accident Report

occur nearly simultaneously with the stall warning, and ice accumulation, which raises the

stall speed, could degrade the stall warning margin to the point at which little or no stall

warning is provided.

The accident airplane was equipped with a stall warning system designed to sound

a horn in the cockpit 5 to 8 knots before the actual stall speed of the airplane in any

configuration. However, as discussed previously, because the airplane was not equipped

with a CVR, because of the approximate nature of the airspeed calculations, and because

abrupt airplane maneuvering or even small amounts of ice accumulation can defeat the

airplaneís stall warning system, the Safety Board was not able to determine when or if the

stall warning horn activated before the onset of the stall. Regardless of when or whether

the stall warning horn activated, it is clear that the accident flight crew failed to maintain

airspeed during the approach. As discussed in section 2.3, radar data indicate that the

accident flight was operated below Aviation Charterís recommended approach speed for

about the last 50 seconds of the flight.

The Safety Board has investigated numerous accidents and incidents involving

commercial flight crews that inadvertently failed to maintain adequate airspeed.

For example, the Board has investigated at least 11 events since 1982 involving Part 135

flights and at least 7 events involving Part 121 flights in which stall or failure to maintain

airspeed during the approach or landing phases was cited as a causal or contributing factor

and in which icing was not cited as a factor. In addition, the Board has investigated other

events in which the drag associated with airframe ice and pilot inattention led to a critical

loss of airspeed. Failure to maintain airspeed during these flights resulted in catastrophic and

other unsafe circumstances, such as loss of control, impact with terrain or water, hard

landings, and tail strikes.

A 1996 FAA Human Factors Team86 Report titled, ìThe Interfaces Between Flight

Crews and Modern Flight Deck Systems,î expressed concern about the history of accidents

involving lack of low-airspeed awareness in the context of flight crews monitoring

automated systems. This report states the following:

flight crews may not be provided adequate awareness of airplane energy state,

particularly when approaching or trending toward a low energy stateÖTransport

category airplanes are required to have adequate warnings of an impending stall,

but at this point the airplane may already be in a potentially hazardous low energy

state. Better awareness is needed of energy state trends such that flight crews are

alerted prior to reaching a potentially hazardous low energy state.87

This accident history was also cited by the Flight Guidance System Harmonization

Working Group of the Aviation Rulemaking Advisory Committee (ARAC), when, in

March 2002, it proposed revisions to FAR 25.1329 and AC 25.132988 to provide

low-airspeed protection and alerting during autopilot operations for newly certified

86 This team comprised FAA and industry representatives.

87 Federal Aviation Administration, Human Factors Team Report, The Interfaces Between Flightcrews

and Modern Flight Deck Systems (Washington, DC: FAA, 1996).
Analysis 56 Aircraft Accident Report

transport-category airplanes. The proposed regulatory revision would require, ì[w]hen the

flight guidance system [FGS] is in use, a meansÖto avoid excursions beyond an

acceptable margin from the speed range of the normal flight envelope.î The proposed new

AC, which is intended to provide an acceptable means for showing compliance with this

new requirement, states the following:

The requirement for speed protection is based on the premise that reliance on

flight crew attentiveness to airspeed indications, alone, during FGSÖoperation is

not adequate to avoid unacceptable speed excursions outside the speed range of

the normal flight envelopeÖ.Standard stall warning and high speed alerts are not

always timely enough for the flight crew to intervene to prevent unacceptable

speed excursions during FGS operationÖ.A low speed alert and a transition to the

speed protection mode at approximately 1.2 Vs,

[89] or an equivalent speed defined

in terms of Vsr,

[90] for the landing flap configuration has been found to be

acceptable.

The proposed changes to FAR 25.1329 reflect the advanced avionics capabilities

characteristic of modern transport-category airplanes. However, the Safety Board notes that

a low-airspeed alert system has been developed for Embraer EMB-120 airplanes;

installation of the alert system was mandated by FAA Airworthiness

Directive 2001-20-17.91 The system is designed to alert flight crews of low-airspeed

conditions in certain airplane configurations and in icing conditions through the use of an

amber-colored indicator light installed in the control panel and an audible alert. The Board

is also aware that several avionics manufacturers offer low-airspeed alert devices

associated with approach and maneuvering speeds for use in less sophisticated general

aviation airplanes. This demonstrates that it may be feasible to develop low-airspeed alert

systems for most airplane types.

2.10.2 Need for Improved Low-Airspeed Awareness

The Safety Board recognizes that the development and requirement of a

low-airspeed alert system is a departure from the previously accepted premise that

adequate low-airspeed awareness is provided by flight crew vigilance and existing stall

warnings. However, the circumstances of this accident and the history of accidents

involving flight crew lack of low-airspeed awareness suggest that flight crew vigilance

and existing stall warnings are inadequate to reliably prevent hazardous low-airspeed

situations and that this unsafe condition is not unique to autopilot operations or flight in

88 Similar changes were also proposed to Joint Aviation Requirements (JAR) 25.1329 and Advisory

Circular Joint 25.1329. The FAR/JAR and ACs are currently titled, ìAutomatic Pilot Systemî; the proposed

new titles would be ìFlight Guidance System.î

89 Vs is the stall speed or the minimum steady flight speed at which the airplane is controllable.

90 Vsr is the reference stall speed.

91 This low-airspeed alert system was developed as a result of the January 9, 1997, accident involving

Comair flight 3272, an EMB-120RT that crashed near Monroe, Michigan, during a rapid descent after an

uncommanded roll excursion in icing conditions and the March 19, 2001, accident involving Comair

flight 5054, an EMB-120 that departed controlled cruise flight and descended 10,000 feet after it

encountered icing conditions.
Analysis 57 Aircraft Accident Report

icing conditions. If a low-airspeed alert system had been installed on the accident airplane,

it might have directed the attention of the flight crew to the airplaneís decaying airspeed in

time for them to initiate appropriate corrective action. For example, if a low-airspeed alert

had activated when the airspeed dropped below 1.2 Vs (about 92 knots for the accident

airplane), the flight crew would have received about 15 seconds advance notice before

reaching the airplaneís estimated stall speed. In addition, if the flight crew had maintained

an airspeed at or above the threshold set by such an early low-airspeed alert, the additional

airspeed could have prevented an accelerated stall initiated by an abrupt last-second

maneuver or provided an improved speed margin above a premature stall caused by ice

accumulation on the wings.

This change in philosophy is evident in the ARACís proposed changes to

FAR 25.1329 and AC 25.1329, Embraerís requirement for a low-airspeed alert system on

the EMB-120, and the fact that several avionics manufacturers offer low-airspeed alert

devices for general aviation airplanes. The Safety Board supports this change in

philosophy. A low-airspeed alert associated with the minimum operationally acceptable

speed for a particular phase of flight would likely help flight crews maintain airspeed

awareness in much the same way that altitude alert systems help flight crews maintain

altitude awareness. Enhanced airspeed awareness would also likely provide an additional

safety margin against stall and loss of control events at low altitudes where recovery is

difficult, as was the case in this accident.

The Safety Board recognizes that there are unresolved technical, operational, and

human factors issues that will need to be carefully evaluated and addressed in connection

with the design and implementation of a low-airspeed alert system.92 The Board

encourages the FAA to consult with representatives from NASA and other aviation

industry specialists in resolving and addressing these issues. Despite these unresolved

issues, the Safety Board concludes that the development of and requirement for the

installation of low-airspeed alert systems could substantially reduce the number of

accidents and incidents involving flight crew failure to maintain airspeed. Therefore, the

Safety Board believes that the FAA should convene a panel of aircraft design, aviation

operations, and aviation human factors specialists, including representatives from NASA,

to determine whether a requirement for the installation of low-airspeed alert systems in

airplanes engaged in commercial operations under 14 CFR Parts 121 and 135 would be

feasible, and submit a report of the panelís findings. The Safety Board further

recommends that if the requested panel determines that a requirement for the installation

of low-airspeed alert systems in airplanes engaged in commercial operations under

14 CFR Parts 121 and 135 is feasible, the FAA should establish requirements for

low-airspeed alert systems, based on the findings of this panel.

92 Some of the issues that should be addressed include the following: defining the target speed at which

the alert system would activate, effectively integrating such a system with other aircraft systems, preventing

nuisance alarms and flight crew over-reliance on such a system (see, for example, A.R. Pritchett,

ìReviewing the Role of Cockpit Alerting Systems,î Human Factors and Aerospace Safety Vol. 1, No. 1

[2001]: 5-38), differentiating such an alert from other kinds of cockpit alerts and warnings, and developing

flight crew procedures on and training for the use of such systems.
58 Aircraft Accident Report

3. Conclusions

3.1 Findings

1. The flight crewmembers were properly certificated and had received the training for

pilot certification prescribed by Federal regulations. No evidence indicated any

preexisting medical or other physical condition that might have adversely affected the

flight crewís performance during the accident flight. Fatigue most likely did not

degrade the performance of either pilot on the day of the accident.

2. The accident airplane was properly certificated, equipped, and maintained in

accordance with Federal regulations and approved company procedures. The

recovered components showed no evidence of preexisting powerplant, system, or

structural failures.

3. The weight and balance of the airplane were within limits for dispatch, takeoff, climb,

cruise, and landing.

4. The flight crew failed to maintain an appropriate course and speed for the approach

and did not properly configure the airplane at the start of the approach, making the

later stages of the approach more difficult.

5. During the later stages of the approach, the flight crew failed to monitor the airplaneís

airspeed and allowed it to decrease to a dangerously low level (as low as about 50

knots below the companyís recommended approach airspeed) and to remain below

the recommended approach airspeed for about 50 seconds.

6. The flight crew failed to recognize that a stall was imminent and allowed the airplane

to enter a stall from which they did not recover.

7. The inadequate airspeed or the full course deviation indicator needle deflection

should have prompted the flight crew to execute a go-around; however, they failed to

do so.

8. The flight crew was not adhering to Aviation Charterís approach procedures and was

not effectively applying crew resource management techniques during the approach

segment of the flight.

9. Clouds might have prevented the flight crew from seeing the airport.

10. Icing did not affect the airplaneís performance during the descent.
Conclusions 59 Aircraft Accident Report

11. The Duluth approach control south radar controllerís instructions did not prevent the

flight crew from intercepting the Eveleth-Virginia Municipal Airport VOR runway 27

final approach course at a sufficient distance to safely execute an approach and

landing.

12. The out-of-tolerance condition and slight bends in the Eveleth-Virginia Municipal

Airport VOR signal were not a factor in this accident.

13. Both pilots had previously demonstrated potentially serious performance deficiencies

during flight operations consistent with below-average flight proficiency.

14. At the time of the accident, Aviation Charter was not operating in accordance with its

weight and balance load manifest procedures, it did not have adequate stall recovery

guidance, it did not have consistent deicer boot operational guidance, and it did not

have an in-range checklist.

15. Aviation Charter was not adequately making company pilots aware of its Standard

Operating Procedures.

16. At the time of the accident, Aviation Charter was not training its pilots on crew

resource management (CRM) in accordance with its Federal Aviation

Administration-approved CRM training module.

17. Although the Federal Aviation Administrationís surveillance of Aviation Charter was

in accordance with its standard guidelines, it was not sufficient to detect the

discrepancies that existed at Aviation Charter.

18. En route inspections, combined with ground training, flight training, and proficiency

check observations, are essential for ensuring adequate oversight of a companyís

operations and should be conducted on flights operated by 14 Code of Federal

Regulations Part 135 on-demand charter operators.

19. The circumstances of the October 2002 Aviation Charter accident indicate that crew

resource management training should be extended to include all 14 Code of Federal

Regulations Part 135 on-demand charter operations that conduct dual-pilot operations

regardless of whether the aircraft requires two or more pilots.

20. The development of and requirement for the installation of low-airspeed alert systems

could substantially reduce the number of accidents and incidents involving flight

crew failure to maintain airspeed.

3.2 Probable Cause

The National Transportation Safety Board determines that the probable cause of

this accident was the flight crewís failure to maintain adequate airspeed, which led to an

aerodynamic stall from which they did not recover. 
60 Aircraft Accident Report

4. Recommendations

4.1 New Recommendations

As a result of its investigation of the October 25, 2002, Aviation Charter, Inc.,

accident, the National Transportation Safety Board makes the following recommendations

to the Federal Aviation Administration:

Conduct en route inspections and observe ground training, flight training,

and proficiency checks at all 14 Code of Federal Regulations Part 135

on-demand charter operations as is done at Part 121 operations and

Part 135 commuter operations to ensure the adequacy, quality, and

standardization of pilot training and flight operations. (A-03-51)

Require that 14 Code of Federal Regulations (CFR) Part 135 on-demand

charter operators that conduct dual-pilot operations establish and

implement a Federal Aviation Administration-approved crew resource

management training program for their flight crews in accordance with

14 CFR Part 121, subparts N and O. (A-03-52)

Convene a panel of aircraft design, aviation operations, and aviation

human factors specialists, including representatives from the National

Aeronautics and Space Administration, to determine whether a

requirement for the installation of low-airspeed alert systems in airplanes

engaged in commercial operations under 14 Code of Federal Regulations

Parts 121 and 135 would be feasible, and submit a report of the panelís

findings. (A-03-53)

If the panel requested in Safety Recommendation A-03-53 determines that

a requirement for the installation of low-airspeed alert systems in airplanes

engaged in commercial operations under 14 Code of Federal Regulations

Parts 121 and 135 is feasible, establish requirements for low-airspeed alert

systems, based on the findings of this panel. (A-03-54)
Recommendations 61 Aircraft Accident Report

4.2 Previously Issued Recommendation Classified in 

This Report

The following previously issued recommendation is classified in this report:93

Safety Recommendation A-02-12 (previously classified ìOpenó

Acceptable Response) is classified ìClosedóSuperseded.î

93 For the text of this recommendation, see section 2.9.3.

BY THE NATIONAL TRANSPORTATION SAFETY BOARD

ELLEN G. ENGLEMAN

Chairman

CAROL J. CARMODY

Member

MARK V. ROSENKER

Vice Chairman

JOHN J. GOGLIA

Member

RICHARD F. HEALING

Member

Adopted: November 18, 2003

63 Aircraft Accident Report

1. Appendix

Appendix A

Investigation and Public Hearing

Investigation

The National Transportation Safety Board learned about the accident about 1130

on October 25, 2002. A go-team was assembled, and it departed that same day and arrived

on scene about 2045 that evening. Accompanying the team was Acting Chairman Carol J.

Carmody and representatives from the Safety Boardís Offices of Government, Public, and

Family Affairs. 

Parties to the investigation were the Federal Aviation Administration; Aviation

Charter, Inc.; Raytheon Aircraft Company; and Hartzell Propeller, Inc. An accredited

representative from the Transportation Safety Board of Canada and a technical advisor

from Pratt & Whitney Canada also assisted in the investigation.

Public Hearing

No public hearing was held for this accident.