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IN THIS VERSION OF THE PUBLISHED REPORT

AIRCRAFT ACCIDENT BRIEF 

NTSB/AAB-06/01 (PB2006-104812) 

Controlled Flight Into Terrain 

Beech King Air 200, N501RH 

Stuart, Virginia 

October 24, 2004

• The front cover, title page, abstract, and table of contents were added to this version of the accident brief. 

(March 16, 2006)

The pages were originally missing from the brief. 
Aircraft Accident Brief

Controlled Flight Into Terrain

Beech King Air 200, N501RH

Stuart, Virginia

October 24, 2004

NTSB/AAB-06/01

PB2006-104812 National Transportation Safety Board

Adopted February 7, 2006 490 L’Enfant Plaza, S.W.

Washington, D.C. 20594
National Transportation Safety Board. 2006. Controlled Flight Into Terrain Beech King Air 200, N501RH 

Stuart, Virginia October 24, 2004. Aircraft Accident Brief NTSB/AAB-06/01. Washington, DC.

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

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Board reports related to an incident or accident in a civil action for damages resulting from a matter mentioned in the report. 
Contents

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

Pilot Information....................................................................................................... 6

The Captain........................................................................................................... 6

The First Officer.................................................................................................... 6

Airplane Information............................................................................................... 7

Meterological Information....................................................................................... 7

Aids to Navigation..................................................................................................... 8

Airport Information.................................................................................................. 8

Air Traffic Control................................................................................................ 8

Flight Recorders........................................................................................................ 9

Wreckage And Impact Information........................................................................ 9

Medical And Pathological Information................................................................. 10

Tests And Research................................................................................................. 11

Propellers............................................................................................................ 11

Engines................................................................................................................ 11

Aircraft Performance Study................................................................................ 11

Demonstration Flight.......................................................................................... 12

Organizational And Management Information................................................... 14

Postaccident Actions........................................................................................... 15

Additional Information.......................................................................................... 15

Analysis.................................................................................................................... 17

Probable Cause........................................................................................................ 18

iii

E PLURIBUS UNUM

NATIONAL TRA SPORTATION

B OARD

SAFE T Y

N

National Transportation Safety Board 

Washington, D.C. 20594 

Aircraft Accident Brief

Accident Number: IAD05MA006 

Aircraft and Registration: Beech King Air 200, N501RH 

Location: Stuart, Virginia 

Date: October 24, 2004 

Adopted on: February 7, 2006 

HISTORY OF FLIGHT 

On October 24, 2004, about 1235 eastern daylight time,1

 a Beech King Air 200, 

N501RH, operated by Hendrick Motorsports, Inc., crashed into mountainous terrain in 

Stuart, Virginia, during a missed approach to Martinsville/Blue Ridge Airport (MTV), 

Martinsville, Virginia. The flight was transporting Hendrick Motorsports employees and 

others to an automobile race in Martinsville, Virginia. The two flight crewmembers and 

eight passengers were killed, and the airplane was destroyed by impact forces and 

postcrash fire. The flight was operating under the provisions of 14 Code of Federal 

Regulations (CFR) Part 91 on an instrument flight rules (IFR) flight plan. Instrument 

meteorological conditions (IMC) prevailed at the time of the accident. 

The flight departed from Concord Regional Airport (JQF), Concord, North 

Carolina, about 1156. An examination of radar data and voice communications from the 

Federal Aviation Administration (FAA) revealed that, during the en route portion of the 

flight, a radar target identified as the accident airplane maintained all assigned altitudes 

and headings. 

As the airplane approached MTV, an air traffic controller advised the flight crew 

that the airplane was second in line for the localizer runway 30 approach. The controller 

instructed the pilots to hold “as published” on the localizer course at 4,000 feet mean sea 

level (msl)2 and to expect a 28-minute delay in the holding pattern. The flight crew 

requested 5-mile legs in the holding pattern, and the controller approved 5- or 10-mile 

legs at the crew’s discretion. 

The localizer runway 30 approach procedure (see figure 1) included an inbound 

course with a magnetic heading of 305o. The minimum descent altitude for the 

intermediate section of the approach and the holding pattern southeast of the BALES 

locator outer marker (LOM) was 2,600 feet. The BALES LOM is located at 6 distance 

 1

 All times in this brief are eastern daylight time based on a 24-hour clock. 

2

 All altitudes and elevations in this brief are expressed as msl unless otherwise noted. 
2 

NTSB/AAB-06/01

measuring equipment (DME)3 on the approach course. After crossing the BALES LOM 

on the inbound course, the minimum descent altitude on the final segment of the 

approach, for an airplane equipped with DME, was 1,340 feet. The missed approach point 

(MAP) was at 1 DME and near the approach end of the runway. The distance from the 

BALES LOM to the MAP was 5 nautical miles (nm). The published missed approach 

procedure instructed the pilot to make a “climbing right turn to 2,600 feet and proceed 

direct to BALES LOM and hold.” 

The accident airplane approached the BALES LOM from the south (see figure 2), 

crossed BALES at 4,000 feet, and turned right toward the outbound leg of the holding 

pattern. About that time, the flight crewmembers of the airplane that preceded the 

accident airplane on the approach announced that that they were canceling their IFR 

clearance after breaking out of the clouds during the approach and then proceeded to land 

at MTV. 

At 1224:19, while the accident airplane was still turning right to the outbound leg 

of the holding pattern, the controller asked the flight crew if the airplane was established 

in the holding pattern, and the crew confirmed, “we’re established.” At 1224:26, the 

controller cleared the airplane for the localizer runway 30 approach and requested that the 

flight crew advise him when the airplane was inbound on the approach. The airplane then 

completed a continuous right turn toward the inbound course and crossed the BALES 

LOM at an altitude of 3,900 feet. 

At 1226:53, the flight crew advised the controller that the airplane was 

“established inbound” on the approach. At 1227:04, the controller cleared the airplane for 

the approach and approved a radio frequency change from the approach control 

frequency to the common traffic advisory frequency (CTAF).4

 At 4 DME, or 2 nm after 

crossing the BALES LOM on the inbound course, the airplane started to descend from 

4,000 feet (see figure 3). The airplane leveled off at 2,600 feet as it passed the MAP. 

About 1 nm past the MAP and over the runway, the airplane began a descent to 1,400 feet 

and continued on an approximate heading of 305o. 

The airplane leveled at 1,400 feet, about 4 nm beyond MTV and 5 nm beyond the 

MAP. The airplane maintained level flight between 1,400 and 1,500 feet for the next 

1 minute 13 seconds. At 1232:13, about 8 nm beyond MTV, the airplane initiated a 

straight-ahead climb. 

At 1233:08, the flight crew informed the controller, “we’re going missed at this 

time.” The controller asked the flight crew to repeat the radio transmission. The flight 

crew repeated the information, and the controller acknowledged the radio transmission. 

The controller received no further radio transmissions from the flight crew. 

 3

 One DME equals 1 nautical mile. 

4

 According to FAA Order 7110.65, “Air Traffic Control,” paragraph 5-1-13, after a controller issues a 

frequency change to the CTAF, radar services are automatically terminated. 
3 

NTSB/AAB-06/01

Figure 1. Localizer runway 30 approach. 
4 

NTSB/AAB-06/01

Figure 2. Accident airplane’s flightpath. 
5 

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Figure 3. Accident airplane’s altitude profile. 

At 1233:21, the controller advised the flight crew to climb and maintain 

4,400 feet. At 1233:24, the radar target was lost. The accident occurred on Bull Mountain 

in Stuart, Virginia, at an elevation of about 2,400 feet and near the extended centerline of 

the runway. 

Witnesses at MTV said that they heard the airplane pass overhead but did not see 

it because of the cloud cover. They stated that the engine sound was smooth and 

continuous with no interruption. One witness said that the engines sounded as though 

they were at idle. Two witnesses stated that they heard no increase in engine sound at the 

time they perceived the airplane to be at a position that coincided with the MAP. 

Two witnesses who were about 3 to 4 miles southeast of Bull Mountain saw an 

airplane fly past them at a low altitude. One of the witnesses said that the airplane was 

flying “flat and level” about 60 to 70 feet above ground level and was heading northwest. 

This witness also stated that, other than flying “very low,” the airplane did not appear to 

be in distress, and the landing gear appeared to be up. The witness further stated that the 

speed of the airplane “wasn’t extremely fast.” In addition, the witness noted that the fog 

level was low but could not tell how much lower the airplane was from the fog. 

A trooper with the Virginia State Police stated that, at the time of the accident and 

throughout the search and recovery efforts (which spanned throughout the day and 
6 

NTSB/AAB-06/01

evening), Bull Mountain was completely obscured by clouds and fog. The trooper stated 

that the visibility was between 0 and 0.25 mile. 

PILOT INFORMATION 

The Captain 

The captain, age 51, held an airline transport pilot certificate with a rating for 

airplane multiengine land and a commercial pilot certificate with a rating for airplane 

single-engine land. The captain’s most recent FAA first-class medical certificate was 

issued on December 15, 2003, with the limitation that he “must have corrective lenses for 

near vision.” The captain was hired by Hendrick Motorsports on March 25, 2001. 

A review of company training records revealed that the captain had accumulated 

10,733 hours total flying time, including 8,600 hours in the Beech 1900. His total flying 

time in the Beech King Air 200 was 210 hours, with 152 hours as pilot-in-command 

(PIC). The captain had flown 67 hours in the last 90 days, 18 hours in the last 30 days, 

and about 30 minutes (the accident flight) in the last 24 hours. 

On May 20, 2001, the captain attended SimuFlite’s King Air 200 and King Air 

1900 recurrent differences training, which included ground and flight simulator training. 

He received a PIC proficiency check in accordance with 14 CFR 61.56 and an instrument 

competency check in accordance with 14 CFR 61.57. On May 16, 2002, the captain 

attended SimuFlite’s recurrent ground and flight simulator training for the King Air 300 

and 350. He received a PIC proficiency check in accordance with 14 CFR 61.58. On 

May 22, 2003, the captain attended FlightSafety’s Beech 1900 recurrent ground and flight 

simulator training. He received a PIC proficiency check in accordance with 14 CFR 

61.58. 

From January 19 to March 2, 2004, the captain attended FlightSafety’s Saab 2000 

initial second-in-command (SIC) training, which included ground and flight simulator 

training. He completed a SIC proficiency check in accordance with 14 CFR 61.55. 

The captain’s most recent flight review was on May 27, 2004. He completed 

Beech 1900 recurrent PIC ground and flight simulator training with FlightSafety and a 

PIC proficiency check in accordance with 14 CFR 61.58. 

The First Officer 

The first officer, age 31, held a commercial pilot certificate with ratings for 

airplane single-engine land, multiengine land, and instrument airplane. Her most recent 

FAA first-class medical certificate was issued on April 1, 2004, with no limitations. She 

was hired by Hendrick Motorsports on November 19, 2001. 

A review of company training records revealed that the first officer had 

accumulated 2,090 hours of total flying time, including 1,200 hours in single-engine 

airplanes and 860 hours in multiengine airplanes. Hendrick Motorsports reported that the 
7 

NTSB/AAB-06/01

first officer had accumulated 640 hours of flying time since her date of hire, 121 hours of 

which were in the Beech King Air 200. The first officer had flown 67 hours in the last 

90 days, 27 hours in the last 30 days, and about 30 minutes (the accident flight) in the last 

24 hours. 

On April 8, 2001 (before she was hired by Hendrick Motorsports), the first officer 

attended SIMCOM’s initial training for the Beech 200. On May 16, 2002, the first officer 

attended SimuFlite’s ground and flight training for the King Air 300 and 350 and received 

a SIC proficiency check in accordance with 14 CFR 61.55. On June 26, 2003, the first 

officer attended FlightSafety’s Beech 1900 ground and flight recurrent training. She 

completed a proficiency check in accordance with 14 CFR 61.55. 

The first officer’s most recent flight review was on May 27, 2004. She completed 

FlightSafety’s Beech 1900 ground and flight recurrent SIC training, which satisfied the 

provisions of 14 CFR 61.55. 

AIRPLANE INFORMATION 

The accident airplane, a Beech King Air 200, was manufactured in 1981 and had 

accumulated 8,140 total flight hours. The airplane was equipped with Pratt & Whitney 

Canada turbopropeller engines and Hartzell four-bladed, hydraulically operated, 

constant-speed, feathering-type propellers. 

The airplane was being maintained in accordance with the manufacturer’s 

inspection program. The airplane’s most recent inspection was completed on June 25, 

2004, at 8,079 flight hours. 

The airplane was equipped with a Bendix/King KLN 90B global positioning 

system (GPS) receiver and a Mid-Continent Instruments MD-41 series GPS annunciation 

control unit. The GPS database was not current and therefore was not certified for IFR 

navigation. The airplane was not equipped with an enhanced ground proximity warning 

system (EGPWS). 

The airplane had been for sale, so a decision had been made to “park” the 

airplane; upgrade another King Air 200, N502RH, with an EGPWS; and certify that 

airplane’s GPS for IFR flight. The intended buyer for N501RH preferred N502RH and 

was allowed to purchase that airplane instead. As a result, the accident airplane was “put 

back out on the line” and was scheduled for a GPS upgrade and an EGPWS installation at 

the end of the 2004 racing season. 

METEROLOGICAL INFORMATION 

A National Transportation Safety Board meteorologist conducted a study of the 

weather conditions in southwestern Virginia and northern North Carolina on the day of 

the accident. The study depicted a warm front that produced overcast clouds, high relative 

humidity, patchy fog, and mist, which resulted in IMC across the region. 
8 

NTSB/AAB-06/01

About 1140, the weather recorded at MTV included an overcast ceiling at 400 feet 

with 1 1/4 miles of visibility5

 and wind from 200o at 3 knots. The temperature was 55o 

Fahrenheit (F), and the dew point was 55o F. The altimeter setting was 29.99 inches of 

mercury (Hg). 

About 1200, the weather recorded at MTV included an overcast ceiling at 600 feet 

with 5 miles of visibility and wind from 220o at 3 knots. The temperature was 57o F, and 

the dew point was 55o F. The altimeter setting was 29.98 inches of Hg. 

About 1220, the weather recorded at MTV included an overcast ceiling at 600 feet 

with 5 miles of visibility and calm winds. The temperature was 57o F, and the dew point 

was 55o F. The altimeter setting was 29.98 inches of Hg. 

The captain of the airplane that preceded the accident airplane on the approach 

stated that his airplane descended below the cloud layer about 150 feet above the 

published minimums. He also stated that the visibility below the clouds was “pretty 

clear” with about 2 miles visibility. The captain further stated that he did not recall the 

reported weather but did recall that the actual weather fluctuated as the airplane 

descended toward MTV and was “a little better” than reported. 

AIDS TO NAVIGATION 

After the accident, FAA and State of Virginia personnel conducted a ground 

inspection of all navigational equipment at MTV. The inspection revealed that the 

equipment functioned satisfactorily. Also, the FAA conducted a flight check inspection of 

the equipment at MTV, and no problems were noted. 

AIRPORT INFORMATION 

Air Traffic Control 

On October 25, 2004, a Safety Board air traffic control (ATC) specialist requested 

voice communication tapes, transcript information, and radar data from the FAA. 

Examination of voice communication tapes revealed that the air traffic controller issued 

the holding instructions, the approach clearance, and the frequency change in accordance 

with FAA Order 7110.65, “Air Traffic Control.” Radar data were derived from the 

Greensboro Airport Surveillance Radar-9 radar. Additional radar data were obtained from 

the U.S. Air Force 84th Radar Evaluation Squadron and the Roanoke Air Route 

Surveillance Radar. 

The Safety Board’s ATC specialist conducted a postaccident interview with the 

certified professional controller who provided ATC services to the flight crew before the 

accident. At the time of the accident, the controller was working the west radar and final 

 5

 In this section, cloud cover is expressed in feet above ground level, and visibility is expressed in 

statute miles. 
9 

NTSB/AAB-06/01

radar positions at the Greensboro/Winston-Salem ATC tower. The controller was 

responsible for approach control services for the Greensboro/Winston-Salem airport and 

11 satellite airports, including MTV. This area of responsibility extended about 30 nm 

north, 25 nm east, and 25 nm west of the Greensboro/Winston-Salem airport from the 

ground to 12,000 feet. MTV was located in the northern portion of the controller’s area of 

responsibility. The controller stated that the MTV runway was shown on the ATC tower’s 

radar display map. He also explained that controllers could select an additional map that 

depicted the final approach courses for the satellite airports (including MTV). In addition, 

the controller stated that, when an aircraft executed a localizer runway 30 approach to 

MTV according to the published descent profile, radar contact would normally be lost 

when the aircraft reached 2,000 feet, which occurred about 2 nm before the airport. 

The controller stated that he observed the accident airplane’s radar track when the 

airplane was about 3 nm southeast of MTV and was descending from 3,600 feet. He 

thought that the airplane was high for the approach but could not question the pilots 

because they had already been cleared to change to the CTAF and, as a result, the 

controller no longer had responsibility for the flight. 

At 1230:07, when the airplane was 2.5 nm northwest of the airport and at an 

altitude of 1,800 feet, the controller’s computer system generated a minimum safe 

altitude warning (MSAW) alert that lasted for 15 seconds. MSAW provides visual and 

aural alerts to controllers if a mode C-equipped aircraft is, or is projected to be, below an 

appropriate terrain clearance altitude. A review of the radar data indicated that an MSAW 

alert had sounded and was visually displayed on the controller’s radar display as a 

flashing “LA” (low altitude) in the data block for the accident airplane. The controller 

stated that he did not observe or hear the MSAW alert. 

At 1230:12, the last radar return from the airplane was received. The MSAW 

predicted the projected path of the airplane for another 10 seconds, and the alert ended at 

1230:22. The airplane continued to fly beneath radar coverage for about 3 minutes before 

the flight crew declared the missed approach on the approach control radio frequency. 

FLIGHT RECORDERS 

The airplane was not equipped with a cockpit voice recorder (CVR) or flight data 

recorder (FDR) and was not required by Federal regulations to be so equipped. 

WRECKAGE AND IMPACT INFORMATION 

The airplane wreckage was found on October 25, 2004, and all major components 

were accounted for at the accident scene. The airplane came to rest on the southeast face 

of Bull Mountain at an elevation of about 2,450 feet. The initial impact point was in trees, 

and the treetops were cut off at an angle that was parallel to the horizon. The distance 

from the first tree strikes to the initial ground scar was about 105 feet. The tree strikes 

and the ground scar were both at an elevation of about 2,400 feet. The distance from the 
10 

NTSB/AAB-06/01

initial ground scar to the main wreckage was about 95 feet. Several pieces of angularly 

cut wood were found along the debris path beneath the trees. 

The main wreckage was found in an upright position. The cockpit and cabin were 

destroyed by impact forces and postcrash fire. The empennage and tail sections were still 

attached to the fuselage but were twisted and in an inverted position. The vertical fin and 

rudder were damaged by impact forces and postcrash fire. The left horizontal stabilizer 

was mostly intact with the elevator attached. The right horizontal stabilizer was damaged 

by impact forces, with the inboard section of the elevator still attached and pieces of the 

outboard section of the elevator scattered along the wreckage path. 

Both wings were still attached to the fuselage at points just outside of the engine 

nacelle on each wing. The wings’ outboard sections and their associated parts were 

scattered along the wreckage path. The inboard sections were essentially intact but were 

damaged by impact forces and postcrash fire. The left and right wing flaps were retracted, 

and the left and right main landing gear were retracted and in their respective wheel 

wells. 

The left engine was in its nacelle and was still attached to the wing by cables and 

wires. The engine was damaged by impact forces and postcrash fire. The left propeller 

assembly had separated from the engine and was found beneath the fuselage and 

entangled with the wreckage. Each blade showed similar twisting and bending, leading 

edge gouging, and chordwise scratching. Two blades were bent over almost 180o at 

midspan. Another blade was fractured, and the outboard one-third had separated. Another 

blade had a blade tip that was wrinkled and torn. The propeller shaft was fractured with 

fracture surfaces that were consistent with impact forces and overload. 

The right engine had separated from its wing and was found uphill from the main 

wreckage. The engine was damaged by impact forces and postcrash fire. The propeller 

shaft was fractured and had fracture surfaces that were consistent with impact forces and 

overload. The right propeller assembly was located adjacent to the initial impact crater in 

an upright position and with all four propeller blades attached. Three of the four blades 

displayed similar twisting, bending, leading edge gouging, and chordwise scratching. 

Two of these blades had blade tips that were fractured. One blade was bent aft. 

Control cable continuity was established from the cockpit to the flight control 

surfaces, except for the ailerons. Aileron cable continuity was established from the 

cockpit to the point of left and right wing separation outside of the engine nacelles. The 

breaks in the aileron cables displayed evidence of overload. 

MEDICAL AND PATHOLOGICAL INFORMATION 

The Office of the Chief Medical Examiner, Roanoke, Virginia, performed 

autopsies on the flight crew and passengers. The Chief Medical Examiner determined that 

the cause of death for the airplane occupants was blunt force trauma. 
11 

NTSB/AAB-06/01

The FAA’s Bioaeronautical Sciences Research Laboratory, Oklahoma City, 

Oklahoma, performed toxicological testing on the captain and the first officer. According 

to the toxicological testing report for the captain, metoprolol (a prescription blood 

pressure medication that is also used to reduce the risk of a heart attack) was detected in 

his blood and liver. The captain had indicated his use of ToprolTM (metoprolol) on his 

most recent application for an FAA airman medical certificate. 

According to the toxicological testing report for the first officer, diphenhydramine 

(a sedating, over-the-counter antihistamine that is often known as BenadrylTM and is 

typically used for allergy symptoms) was detected in her liver and kidney. 

TESTS AND RESEARCH 

Propellers 

On December 1, 2004, the propellers were examined at an aircraft recovery 

facility in Clayton, Delaware. The propellers’ hub and blades were made of aluminum, 

and the propellers rotated in a clockwise direction (when viewed from the back). Neither 

propeller was feathered, which was consistent with normal operation. All of the damage 

(significant twisting, bending, leading edge gouging, and tearing of the blades) was 

consistent with impact forces, and no evidence indicated a mechanical anomaly. 

Engines 

From January 26 to 28, 2005, the engines were examined at the Pratt & Whitney 

factory in Montreal, Canada, under the supervision of the Transportation Safety Board of 

Canada. No anomalies or mechanical deficiencies were found. 

Aircraft Performance Study 

An aircraft performance study was conducted by a Safety Board aircraft 

performance specialist. The study used data from three separate radar facilities to depict 

the flightpath of the accident airplane from the en route phase of flight to the BALES 

LOM, throughout the approach, and beyond the airport to the crash site. 

The published missed approach procedure called for a climbing right turn at the 

MAP, which is over the runway threshold. Radar data indicated that the flight crew 

initiated the missed approach 7.5 nm beyond the MAP. The airplane then entered a 

straight-ahead climb on the runway heading. 

The aircraft performance study also presented the flightpath that the airplane 

would have flown if it had entered a climbing right turn at the point where the climb was 

initiated. Interpolation of nominal climb rates and a standard turn rate depicted a 

flightpath that would have kept the airplane clear of terrain. Figure 4 compares the 

airplane’s flightpath (in blue) with the flightpath that would have resulted if the airplane 

had entered a standard-rate right turn during the climb (in red). 
12 

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Figure 4. Depiction of the accident flightpath (blue) and the flightpath incorporating a 

climbing right turn (red) along with terrain elevations. 

Demonstration Flight 

On January 7, 2005, the Operations Group Chairman participated in a 

demonstration flight in a Hendrick Motorsports Beech 1900 (N503RH) with two 

company pilots aboard. One purpose of the flight was to demonstrate the operation and 

functions of the Bendix/King KLN 90B GPS, the Mid-Continent Instruments MD-41 

series GPS annunciation control unit, and other associated instrument displays. Another 

purpose of the flight was to observe the GPS runway 30 approach and the localizer 

runway 30 approach to MTV and other airplane navigation and system features that were 

available in the accident airplane. 

If the database were current, the GPS unit would display the expiration date. If the 

database were expired, the GPS unit would indicate so, and the pilot would have to 

acknowledge the database’s expiration. On powerup, the database displayed a date of 

September 3, 2003, with the message “non-current database.” The database also 

displayed a message indicating that “all data must be confirmed before use,” which was 

acknowledged by the pilot. 

The pilots stated that they always used the “track up” feature versus the “north 

up” feature on the GPS. The track up feature showed the airplane flying to the top of the 

GPS screen, which provided better situational awareness than showing the airplane’s 

relation to north at the top of the screen. 
13 

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With the GPS selected on the GPS annunciation control unit, the horizontal 

situation indicators (HSI) displayed GPS information, including to/from indications, 

course needle steering, and distance to waypoint. However, when a localizer or 

instrument landing system frequency was tuned on the No. 1 NAV (navigation) radio, 

which is displayed on the captain’s (left) side, the autoselect frequency feature 

automatically replaced the GPS information from the captain’s HSI with information 

pertaining to the NAV mode. (According to the flight crew, the GPS features functioned 

identically in the accident airplane.) 

On the demonstration airplane, the GPS was installed in the front instrument 

panel. As a result, the flight crew could easily view the GPS screen.6

After the demonstration airplane took off from Henderson Oxford Airport, 

Oxford, North Carolina, the pilots selected the Danville very high frequency 

omnidirectional range (VOR), BALES LOM, and MTV as waypoints. While the airplane 

was approaching the Danville VOR, a flashing waypoint light illuminated on the GPS 

annunciation control unit on the front instrument panel. The light flashed for about 1.5 

nm until the airplane passed the Danville VOR. The GPS autosequenced to the next 

waypoint, which was the BALES LOM, and drew a course line from the Danville VOR 

to BALES, which was depicted on the GPS screen. A message light then illuminated on 

the annunciation control unit, and the message on the GPS screen instructed the pilot to 

set the course deviation indicator (CDI) on the course to the BALES LOM. Once the CDI 

was set, the message light extinguished. 

The GPS autoscale feature automatically chose the smallest map scale that 

displayed the active waypoint and the waypoint after the active waypoint if one existed. 

At this point of the flight, the BALES LOM and MTV were depicted on the GPS screen. 

When the airplane was about 1.5 nm from the BALES LOM, the flashing 

waypoint light illuminated on the GPS annunciator panel, and the waypoint identifier 

(BALES) flashed on the GPS screen. When the airplane was over the BALES LOM, the 

automatic direction finder (ADF), which was tuned to BALES, indicated a needle swing 

on both the captain’s and the first officer’s radio magnetic indicators. The needle swing 

confirmed that the airplane was passing directly over the BALES LOM. After the 

airplane crossed the BALES LOM, the flashing waypoint light went out. The GPS 

autosequenced to the MTV waypoint, and the HSI showed that the distance to the 

waypoint was 5.2 nm. 

The message light on the annunciation control unit illuminated, and the message 

reminded the pilot to set the CDI on a course of 305o (the inbound course for the localizer 

runway 30 approach). The pilot set the CDI on a course of 305o. 

 After the airplane crossed the BALES LOM, the pilot initiated a right turn and 

continued that turn to the inbound course. Once the airplane was established on the 

 6

 On the accident airplane, the GPS was installed between the cockpit seats below the level of the seat 

cushion. As a result, pilots in both seats were required to turn their heads 90o toward the center of the 

airplane and then downward to view the screen. 
14 

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inbound course, the captain’s HSI showed a 5.1 nm distance readout to the MTV 

waypoint, and the first officer’s HSI showed a 5.6 DME distance readout to the 

localizer/DME station. 

After the airplane had overflown the airport, the distance readouts increased on 

the captain’s and the first officer’s HSIs. After the airplane had passed the departure end 

of the runway, the distance readouts showed a 0.5 nm difference (which was the same as 

the difference shown inbound). On the GPS screen, no course line was depicted beyond 

the airport; only the moving airplane symbol was displayed with a line drawn from the 

airplane symbol back to the airport. Because no additional waypoints had been entered 

into the GPS, no further waypoints were available for autosequencing. 

During two approaches, when the airplane had overflown the localizer antenna, 

some CDI needle movement occurred to the right and back to center. During all of the 

runway overflights, the NAV flags did not appear on the captain’s or the first officer’s 

HSIs when the airplane passed over the localizer antenna. The GPS steering on the 

captain’s side remained steady at all times. 

Interviews with pilots at Hendrick Motorsports, including the pilot of the 

company’s identically equipped King Air 200, N502RH, revealed that the Bendix/King 

KLN 90B GPS was used for backup only and strictly for position awareness. Further, the 

pilots who had flown the accident airplane and N502RH to MTV on the localizer 

runway 30 approach had all used the GPS and had set up the BALES LOM and MTV as 

waypoints. 

The KLN 90B GPS Pilot’s Guide stated the following: “as you become proficient 

with using the KLN 90B, don’t be tempted to rely on it as the sole means of navigation. A 

good pilot never relies on just one source of navigation for either VFR [visual flight 

rules] or IFR flying. Cross check your position using VOR, DME, ADF, or other 

navigational devices you may have in the cockpit – including your eyes!” 

ORGANIZATIONAL AND MANAGEMENT INFORMATION 

Hendrick Motorsports, Inc., has operated under different names as the company 

grew and evolved. On February 1, 1980, the company hired its first pilot, who, at the time 

of the accident, was still employed by the company as a captain. At the time of the 

accident, the company employed 18 pilots (including the accident pilots): 15 were 

designated as captains, and 3 were designated as first officers. Over the years, Hendrick 

Motorsports bought and sold several airplanes, including the Piper Cheyenne II, 

Cessna 340, Challenger, Westwind, Falcon 20, Hawker 800, and Learjet 25 and 55. At the 

time of the accident, the company owned two King Air 200s, two Gulfstream IIs, two 

Beech 1900s, a Bell 407 helicopter, and three Saab 2000s. These aircraft were based at 

JQF. 

During a postaccident interview, the captain who was hired as Hendrick 

Motorsports’ first pilot stated that, before the accident flight, the company’s flight 

department had never experienced any accidents, incidents, or violations. He also stated 
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that the company never pressured any pilots to fly in bad weather and that the pilots 

always made the final decision regarding whether to fly in such conditions. The captain 

further stated that the flight department’s maintenance costs were never questioned and 

that the department’s budget was not limited because senior company management 

“wanted it done right.” 

Postaccident Actions 

After the accident, Hendrick Motorsports made immediate, short-term, and 

long-term changes to the company’s organization, practices, and equipment. Some of 

these changes had already been planned or were in progress at the time of the accident 

and were further enhanced as a result of the company’s participation in the investigation. 

Hendrick Motorsports installed an EGPWS on each aircraft. The EGPWS 

provides pilots with a pictorial view of terrain (displayed on the radar screen, the 

multifunction display, or the GPS screen) in addition to aural warnings (as provided by 

the EGPWS). The company also installed a traffic alert collision avoidance system in 

each aircraft. Further, the company installed new Garmin GPS 400 units (with EGPWS) 

in Beech 1900 airplanes. In addition, the company moved the terrain depiction on the 

Gulfstream II from the global navigation system screen, which is mounted on the center 

console, to the radar screen on the front instrument panel, which is directly in the pilot’s 

view. 

Hendrick Motorsports created three new positions: aviation director, safety 

program manager, and full-time dispatcher. (The company previously had a part-time 

dispatcher.) The company’s chief pilot was selected as aviation director and was 

responsible for the oversight of the entire aviation department. (The most senior company 

pilot was then promoted to chief pilot.) The responsibilities of safety program manager 

were added to the duties of a newly hired pilot who had a background in safety for a 

major airline. 

Along with the staffing changes, Hendrick Motorsports established a safety 

committee that comprised staff members from the company’s operations, flight, and 

maintenance departments and hired an independent safety consulting firm to review the 

flight department’s operations. Also, Hendrick Motorsports consolidated the company’s 

standard operating procedures for all aircraft in its fleet and issued addendums to the 

procedures for each aircraft model. In addition, Hendrick Motorsports revised the 

company’s training plan to include two training sessions per year for each pilot. One 

session consisted of recurrent training, with 1 week of academic and flight simulator 

training. The other session consisted of 1 day of academic training for special 

circumstances (for example, cold weather considerations and mountain flying) and 1 day 

of emergency procedures training in a flight simulator. 

ADDITIONAL INFORMATION 

The FAA’s Aeronautical Information Manual (AIM) chapter 5, “Air Traffic 

Control Procedures,” section 5, “Pilot/Controller Roles and Responsibilities,” 
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paragraph 5-5-7, “Safety Alert,” states that pilots should initiate appropriate action if they 

receive a safety alert7

 from ATC and that they should “be aware that this service is not 

always available, and that many factors affect the ability of the controller to be aware of a 

situation in which unsafe proximity to terrain, obstructions, or proximity to other aircraft 

may be developing.” 

AIM chapter 5, section 4, “Arrival Procedures,” paragraph 5-4-20, “Missed 

Approach,” states, in part, the following standard guidance for pilots: 

a. When a landing cannot be accomplished, advise ATC and, upon 

reaching the missed approach point defined on the approach procedure 

chart, the pilot must comply with the missed approach instructions for 

the procedure being used or with an alternate procedure specified by 

ATC. 

b. Protected obstacle clearance areas for missed approach are predicated 

on the assumption that the missed approach is initiated at...the missed 

approach point and not lower than the minimum descent altitude. 

f. Pilots must ensure that they have climbed to a safe altitude prior to 

proceeding off the published missed approach, especially in non-radar 

environments. 

 7

 According to the AIM, controllers are to issue a safety alert if they become aware that an aircraft 

under their control is at an altitude that, in their judgment, places the aircraft in unsafe proximity to terrain, 

obstructions, or other aircraft. 
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ANALYSIS 

The corporate Beech King Air 200 approached the nontowered destination airport 

on an IFR flight plan in IMC. The flight crew was instructed to hold at the BALES LOM 

on the localizer course at an altitude of 4,000 feet and was then cleared for the approach 

during the initial right turn over the LOM. The airplane continued the turn until it was 

established on the localizer course inside the LOM at an altitude of about 3,900 feet. The 

airplane would have been expected to initially cross the BALES LOM at 4,000 feet; turn 

outbound on an extended leg; then, after being cleared for the approach, turn to the 

inbound course with sufficient distance from the BALES LOM to descend to an altitude 

of 2,600 feet before crossing the BALES LOM. Once the airplane was established on the 

localizer course, ATC issued a radio frequency change to the CTAF, and ATC radar 

services were automatically terminated. Two nm after crossing the BALES LOM, the 

airplane descended from 4,000 to 2,600 feet near the MAP. During this flight segment, 

the airplane would have been expected to descend from 2,600 feet at the BALES LOM to 

1,340 feet at the MAP. However, an examination of the radar data showed that the 

airplane flew an approach that was displaced by about 5 nm compared with the published 

approach. 

The published missed approach procedure instructed pilots, at the MAP, to make a 

climbing right turn directly to the BALES LOM and hold at 2,600 feet. Radar data 

showed that the accident airplane did not make a climbing right turn, as required in the 

published missed approach procedure. Instead, after passing the MAP, the airplane 

continued to descend from 2,600 feet on a course of 305o and leveled off at 1,400 feet, 

which was again consistent with a 5-nm displacement. About 8 nm beyond the airport, 

the airplane initiated a straight-ahead climb and climbed about 700 feet over the next 

2 nm before the flight crew declared a missed approach on the approach control 

frequency. ATC acknowledged the call, and, about 3 seconds later, the airplane’s radar 

target was lost near the location of the crash site. The accident occurred in mountainous 

terrain at an elevation of about 2,400 feet. Examination of the airplane revealed no 

mechanical anomalies. The airplane was not equipped with an EGPWS. 

When the airplane was 2.5 nm northwest of the airport and at an altitude of 

1,800 feet, the controller’s computer system generated an MSAW alert, which lasted 

15 seconds. The controller stated that he did not observe or hear the MSAW alert. 

However, the MSAW alert was not a factor in this accident because, at the time of the 

alert, radar services had already been terminated, and the airplane was not under the 

control of ATC. In addition, the airplane continued to fly for about another 7 miles before 

the accident occurred. During this time, no further MSAW alerts were generated because 

the airplane was flying beneath radar coverage. 

Two distinct differences exist between the published approach procedure and the 

manner in which the accident pilots flew the approach. First, once the accident airplane 

was established on the inbound course, the descents to 2,600 and 1,400 feet appeared to 

be keyed to the MAP or MTV rather than to the BALES LOM. Second, the missed 

approach was initiated 7 to 8 nm past the MAP and was not properly executed. 
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An airplane performance study presented the flightpath that the airplane would 

have flown if it had entered a climbing right turn at the point that the straight-ahead climb 

was initiated. Interpolation of nominal climb rates and standard turn rates depicted a 

flightpath that was clear of terrain. 

The airplane was not equipped with a CVR or an FDR, which prevented the 

Safety Board from determining the events that occurred in the cockpit during the 

approach. However, the accident approach profile is consistent with the pilots using the 

GPS data to navigate to the BALES LOM and then failing to notice that the GPS had 

autosequenced to MTV after the airplane passed BALES. Once the airplane was inbound, 

the pilots might have mistakenly believed that the airplane was showing distance data to 

the BALES LOM when, in fact, the airplane was showing distance data to MTV. 

The airplane was equipped with an IFR-capable GPS receiver, but the database 

was not current, and the GPS was not certified for IFR navigation. GPS course guidance 

would be displayed on the pilots’ HSIs unless a localizer frequency was tuned on the 

No. 1 NAV radio. Postaccident interviews with company pilots revealed that the GPS was 

used for backup navigation and position awareness only. Pilots would typically program 

the LOM and the airport as waypoints, and the GPS would autosequence to the airport as 

the airplane passed the LOM and provide distance and navigation information to the 

airport. For approaches that required crossing the LOM twice, first to define the turn to 

the outbound leg and then to define the final approach fix on the inbound leg, the GPS 

would autosequence to the airport at the initial LOM crossing. 

PROBABLE CAUSE 

The National Transportation Safety Board determines that the probable cause of 

this accident was the flight crew’s failure to properly execute the published instrument 

approach procedure, including the published missed approach procedure, which resulted 

in controlled flight into terrain. Contributing to the cause of the accident was the flight 

crew’s failure to use all available navigational aids to confirm and monitor the airplane’s 

position during the approach.