N338AS

HISTORY OF FLIGHT

On September 3, 1999, about 0325 eastern daylight time, a Beech B-90, N338AS, call sign Lifeguard 8AS, registered to CP Horizons Corporation, struck a building (pool warehouse) and crashed while on approach to Palm Beach International Airport, West Palm Beach, Florida, while on a Title 14 CFR Part 91 corporate flight. Visual meteorological conditions were reported, and an IFR flight plan was filed. The airplane was destroyed. There were no injuries to anyone on the ground. The airline transport-rated pilot-in-command, pilot/owner/passenger, seated in the right front seat, and six passengers were fatally injured. The flight had originated at 2231 from Pontiac, Michigan, en route to Boca Raton, Florida.

According to the flight plan, the pilot filed for a cruise altitude of 15,000 feet, with a time en route of 5 hours, and fuel on board 6 hours. The flight proceeded without incident until 0314, when the pilot of N338AS made initial contact with the Palm Beach Air Traffic Control (ATC) Tower, and was told that there was no weather information for Boca Raton.

Air traffic control recorded the following flight sequence before radio contact was established with West Palm Beach Tower.

At 2201, the pilot of N338AS called Lansing Automated Flight Service Station (AFSS) by phone and filed an IFR plan for a flight from Pontiac, Michigan to Boca Raton, Florida, and received the clearance at 2226, from Pontiac Clearance delivery. The initial clearance was issued "via the Pontiac 8 Departure, direct, maintain 3,000.

At 2231, Pontiac Tower cleared N338AS for takeoff on Runway 27L.

At 2244, the flight was cleared to 15,000 feet. At 2248, the pilot reported to the Cleveland ARTCC (Air Route Traffic Control Center), Litchfield (LFD) sector that he was leaving 13,000 for 15,000, and reported to the Cleveland ARTCC, Carleton Sector (CRL-R) at 2303, that he was at 15,000 feet.

There were three frequency changes from 2303 until 0112 when the pilot of N338AS made initial radio contact with Jacksonville Center, Sector R72, level at 15,000 feet, and he was given the Savannah, Georgia, altimeter setting.

At 0237, the pilot made radio contact with Miami ARTCC and was issued a clearance direct Boca Ration. At 0302, Miami assigned the flight an altitude of 6,000 feet.

At 0314, the flight was handed off to Palm Beach Tower, and the pilot reported on frequency that he was descending from 7,000 to 6,000 feet.

At 0323, the pilot radioed, "...we'd like to land at Palm Beech International if we can." The flight was cleared to 1,500 feet, the pilot was told that the airport was at his 10 to 11 o'clock position, at 5 miles, and was asked if he had the airport in sight. He answered "affirmative," was cleared for a visual approach to runway 13, told that the winds were calm, and was cleared to land.

At 0325:27, a radio transmission came from the flight, "...Alpha Sierra, we need, ah, we got MAYDAY, A/Sierra...MAYDAY."

At 0325.40, a sheriff's department helicopter reported to the control tower that they had sited the aircraft wreckage, and requested that the fire department be sent.

Witnesses that saw the airplane just before impact said that the airplane was low, and they did not see any fire while the airplane was in-flight. According to a Palm Beach County Sheriff's deputy assigned to a perimeter about a 1/4 of a mile northeast of the crash site, "...I observed a twin engine aircraft at a low altitude pass overhead on what appeared to be an approach to Palm Beach County International Airport. From my position the aircraft was only in view for a second, however I did note that when the aircraft passed overhead, the sound of the aircraft appeared to be a fluttering sound as if air passing through the propeller. I was unable to determine if the engine was running at this time. A few seconds later, I heard a very loud concussion of what sounded to be an explosion...." (See Page 5 of the Palm Beach County Sheriff's Offense Report an attachment to this report).

The accident occurred during the hours of darkness about 26 degrees, 40 minutes north, and 080 degrees, 05 minutes west.

PERSONNEL INFORMATION

The pilot-in-command's flight logs were not found. Based on insurance company records the pilot's flight hours as of July 1999 were 11,562 hours of total flight time in all aircraft, and 11,062 hours as pilot-in-command of multi engine airplanes. In addition, 9,800 hours in turbine engine aircraft. It was not known how much flight time the pilot had in this make model airplane; however, associates of the pilot estimated that he had about 200 hours in this make and model aircraft.

AIRCRAFT INFORMATION

A review of the available aircraft records indicated that Beechcraft Aircraft Company manufactured the airplane in 1970. The available aircraft records indicated that the airframe had accumulated about 8,996 flight hours and about 7,510 cycles. The airplane records obtained from the FAA indicated that it had been exported to France in 1993, returned to the United States in 1995, exported to LaPaz, Bolivia in 1995, then returned to the United States in February 1999. Extensive maintenance was performed from February 1999 through June 1999. The FAA issued a new airworthiness certificate in February 1999. The airplane had been weighed in February 1999 and its empty weight 6,255 pounds. The airplane was in an airworthy condition before the flight began.

METEOROLOGICAL INFORMATION

The reported weather at West Palm Beach for 0340; wind calm, visibility 10 sm, few clouds at 3,500, temperature 73 degrees F, dew point 72 degrees F, and the altimeter was 29.90 inches Hg. The en route winds aloft at the airplane's altitude indicated a slight tailwind for half the flight and a headwind of about 15 knots for the remainder of the flight.

COMMUNICATIONS

The pilot made several frequency changes during the flight, and there were no reported communication problems.

MEDICAL AND PATHOLOGICAL INFORMATION

Dr. Noel Palma performed autopsies on the pilot and the pilot/passenger, on September 4, 1999, at the Palm Beach County Medical Examiner's Office, West Palm Beach, Florida. According to the autopsy reports, the cause of death for both victims was "Multiple Injuries."

Toxicological tests were conducted at the Federal Aviation Administration, Research Laboratory, Oklahoma City, Oklahoma, and revealed, "No ethanol or drugs detected."

WRECKAGE AND IMPACT INFORMATION

The airplane struck a building, power lines, and came to rest in a cluster of trees about 1/2 mile short of runway 13, at the Palm Beach International Airport. There was a post crash fire. The airplane's left wing and empennage were separated from the fuselage, but remained attached by cables. All essential components to sustain flight were found in the immediate vicinity of the main wreckage. The airplane was found with the cabin inverted, and with the left wing folded forward along the fuselage. The empennage had rotated 180 degrees about the longitudinal axis and to the left of the fuselage. The right wing was resting on a fence and up against a palm tree. There was no evidence of metal splattering, soot streaking, or heat damage along any horizontal plane. All the heat damage was vertical and the melted metal was found directly beneath the fuselage. No evidence of an in-flight structural failure or an in-flight fire was found at the accident site. The post crash fire and impact forces destroyed about 80 percent of the fuselage structure.

The airframe fuel system was examined for evidence of failures, malfunctions or contaminants. The left nacelle, main, and right nacelle tanks had been breached and a faint odor of fuel was left near the resting place of the tanks. About 2 gallons of fuel was recovered from the right nacelle tank the fuel was straw colored, clear, and free of extensive particles. The fuel did not contain any contamination. There was no evidence of fuel staining or discoloration aft of any fuel components or caps indicating that there was no in-flight fuel leak. There was no evidence of fuel leak in the engine compartments. The fuel panel was examined for switch position. The upper outer switches for the left and right systems (Firewall Shutoff Valve-Open, Boost Pumps-On) were in the up position. The inner upper switches (Transfer Pump-Off, left and right) were in the down position. The lower switch (Crossfeed-Open) was in the full up and locked position. The upper center switch (Transfer-Test) was in the neutral position. The normal in-flight crossfeed switch position should have been the auto (middle) position. The open position corresponds to a position that is for fuel leveling in-flight but on approach would be an indication that the fuel was gone in one of the (left or right) systems and the pilot was attempting to operate both engines on one fuel system.

The fuselage displayed fire damaged, and the floor of the cabin was consumed by fire. The radar assembly and its mounting points were separated and found with the nose gear structure assembly near the front of the fuselage. The lower forward fuselage was crushed from the nose radome aft to the wing root. The remainder of the lower forward fuselage was consumed by fire and torn from the fuselage during recovery.

The stair door was stowed and locked. During the hangar examination the door was unlatched and it opened. No evidence was found to indicate that there was an attempt to use the stair door for egress.

The nose landing gear displayed dirt and scrapings on the piston, and was found before the fence line, next to a dumpster about 25 feet from the main wreckage.

The left main landing gear's outboard attachment to the main spar displayed minor damage to the outer flange. There was ash colored fire damage in this area. The down locking arm was broken. The actuator was extended 8 1/2 inches from the center of the...