Accident Details
Probable Cause and Findings
The pilot's failure to follow airplane flight manual procedures for an antiskid failure in flight and his failure to immediately retract the lift dump after he elected to attempt a go-around on the runway. Contributing to the accident were the pilot's lack of systems knowledge and his fatigue due to acute sleep loss and his ineffective use of time between flights to obtain sleep. Member Sumwalt filed a concurring statement that can be found in the public docket for this accident. Member Weener joined the statement.
Aircraft Information
Registered Owner (Historical)
Analysis
HISTORY OF FLIGHTOn February 20, 2013, about 2006 eastern standard time (EST), a Beechcraft Corporation 390 Premier (Premier IA), N777VG, collided with a utility pole, trees, and terrain following a go around at Thomson-McDuffie County Airport (HQU), Thomson, Georgia. The airline transport-rated pilot and copilot were seriously injured, and the five passengers were fatally injured. The airplane was registered to the Pavilion Group, LLC, and was operated under the provisions of 14 Code of Federal Regulations (CFR) Part 91 as a business flight. Night visual meteorological conditions prevailed, and an instrument flight rules (IFR) flight plan was filed. The flight originated at John C. Tune Airport (JWN), Nashville, Tennessee, about 1827 central standard time (1927 EST).
On the morning of the accident, the pilot and copilot left their respective homes in South Carolina about 0230 for the 1-hour drive to HQU (where the airplane was based) to fly five passengers, who were employees of Vein Guys®, to JWN. (The National Transportation Safety Board [NTSB] notes that while the copilot is referred to as such in this report, his role in the cockpit is not required by federal regulations.) The airplane departed HQU about 0406 and arrived at JWN about 0459. (Although JWN is located in the central time zone, all subsequent times in this report are in EST unless otherwise noted.) Both pilots stated in postaccident interviews that the flight to JWN was uneventful and the weather was good. They reported that at the JWN terminal, they slept in the crew break room, completed paperwork, and worked on the computer. They left for a late lunch about 1500 and returned to the airport about 1630.
According to security camera footage from the JWN terminal, both pilots were observed walking toward the airplane about 1913, and about 1918, the five passengers were seen walking toward the airplane while one crewmember performed an external walk-around inspection. About 1923, the airplane taxied from the parking area and departed JWN at 1927. The pilot was the pilot flying and was in the left cockpit seat.
About 1927, the flight crew contacted departure control while climbing through 3,500 ft mean sea level (msl) and requested an IFR clearance to HQU. About 1930, the flight crew contacted the Memphis air route traffic control center (ARTCC) while climbing through 14,000 ft msl, and about 1933, the flight was cleared to climb and maintain a cruising altitude of flight level (FL) 270. According to flight crew interviews, the en route weather was good, and a tailwind in excess of 70 knots was observed.
About 1948, the flight crew contacted the Atlanta ARTCC and was cleared to descend to FL240. About 1953, the flight crew was given a further descent clearance to 11,000 ft msl along with the Athens, Georgia, altimeter setting. About the same time, the copilot tuned in the HQU automated weather observation system (AWOS) to receive the most current weather at the destination airport. The AWOS at 1935 reported calm wind, temperature 10 degrees C, 10 statute miles visibility or greater, scattered clouds at 12,000 ft, and an altimeter setting of 30.13 inches of mercury. The pilot then set up the flight management guidance system for a visual approach to runway 10 at HQU with a 3.4-degree descent to the runway from a 5-mile final approach. The copilot tuned the instrument landing system for runway 10 as a backup.
About 1956, the flight crew advised the Atlanta ARTCC that they were descending through 18,500 ft, and 2 minutes later, they cancelled their IFR flight plan. About 1958, the copilot stated to the pilot, "ten thousand comin' up captain and you blowin' through." About 1959, the copilot told the pilot to adjust his altimeter. The pilot responded, "say, I'm kinda out of the loop or something. I don't know what happened to me there but I appreciate you lookin' after me there." The flight crew was then directed to contact Augusta approach control, and about 2000, the flight crew contacted Augusta approach control and advised that they were descending out of 8,400 ft and had HQU in sight. About 2002, the flight crew advised Augusta approach control that they would switch to the local HQU advisory frequency.
Concurrently, the pilot began to perform an "S" turn along the final approach path to the runway. About 1 minute later, the enhanced ground proximity warning system (EGPWS) aural alert announced that the airplane was 1,000 ft above the ground, and the pilot lowered the landing gear. According to the cockpit voice recorder (CVR), after the landing gear was lowered, about 2004, the copilot noted that the "ANTI SKID FAIL" annunciator light illuminated. The pilot continued the approach, and, about 2005, the airplane touched down on runway 10. Witnesses reported that after the airplane touched down, they heard or saw it go around. According to the CVR, the takeoff warning horn sounded about 0.3 seconds before the pilot stated that he was performing a go-around. The airplane lifted off near the departure end of the runway. The copilot directed the pilot to increase pitch. According to EGPWS data, as the airplane climbed to an altitude of about 63 ft above the ground, about 9 seconds after liftoff, the left wing struck a utility pole located about 0.25 miles east of the departure end of the runway. The airplane continued about 925 ft before colliding with trees and terrain. It was destroyed by impact forces and a postcrash fire.
During a postaccident interview, when asked about the approach, landing, and go-around at HQU, the pilot recalled checking the airplane's landing light switches to prepare for the landing. The next thing he remembered was waking up in the hospital on February 24, 2013. He did not recall any additional details about the approach, landing, or go-around or any airplane system anomalies, including any antiskid problems, during the flight.
In postaccident interviews, the copilot did not recall anything unusual about the glidepath and recalled being about 1 or 2 knots above reference speed. The copilot thought that the airplane touched down on runway 10 within 200 ft of the 1,000-ft runway marker. As he began to reference the after landing checklist, he heard the pilot announce a go-around, but the copilot did not know the reason for the go-around. He stated that he began to monitor the airspeed indicator, saw that they were at 105 knots approaching the end of the runway, and thought "it was going to be close." The engines sounded like they always did on a normal takeoff. He thought something hit the airplane on his side and recalled seeing trees in the windshield. The next thing he remembered was seeing someone with a flashlight at the accident scene. He did not recall any alarm or aural caution before the go-around and indicated that everything looked normal. PERSONNEL INFORMATIONThe Pilot
The pilot, age 56, held an airline transport pilot (ATP) certificate with a single pilot type rating on the Premier IA. (The 390 Premier is the same as the Premier I/IA series.) He also held a flight instructor certificate with airplane single engine land, airplane multiengine land, and instrument airplane privileges. He was the director of operations for Sky's the Limit, doing business as Executive Shuttle, a 14 CFR Part 135 operator based in Greenwood, South Carolina. He was hired by the Pavilion Group to provide private pilot services for their Premier IA under the provisions of 14 CFR Part 91. The pilot reported 13,319 hours total flying time, including 12,609 hours as pilot-in-command (PIC). He reported 198 hours, all as PIC, in the Premier IA. The pilot held a second-class Federal Aviation Administration (FAA) medical certificate, issued October 29, 2012, with a limitation to possess glasses for near/intermediate vision.
According to interviews and training records, the pilot attended the FlightSafety Premier I Series (RA-390) initial training course at the FlightSafety Wichita Learning Center, Wichita, Kansas, from June 7, 2012, through June 22, 2012. The ground instruction consisted of 58 hours of ground training and 11.5 hours of briefing/debriefing. The pilot also attended flight simulator training, which consisted of 15 hours of simulator training. He was type rated on the Premier IA on June 22, 2012, following a 2.2-hour simulator session and a 2.5-hour oral/written examination.
The pilot also attended the FlightSafety Premier I Series (RA-390) recurrent PIC course at the FlightSafety Greater Philadelphia/Wilmington Learning Center, Wilmington, Delaware, from January 3, 2013, through January 5, 2013. The ground instruction consisted of 12 hours of training and 4.5 hours of briefing/debriefing. The simulator portion of the training consisted of 7 hours of simulator time.
A copilot who previously flew with the pilot stated that the pilot was experienced, professional, and possessed good flying skills. Both copilots who flew with the pilot, including the accident copilot, stated that they did not have a specific role on the flights they flew with him in the Premier IA.
On February 15, the pilot flew the owner of Vein Guys® and his family to Orlando, Florida, and remained in Orlando until Monday, February 18. He did not use a copilot for the Orlando trip. On February 18, he flew the family to HQU and then drove to his residence, going to bed about 2100. On February 19, he awoke about 0500 for a 0930 flight to Olive Branch, Mississippi, with the accident copilot and Vein Guys® staff. The return flight landed at HQU about 1700 that evening. He arrived at his residence about 1820 and went to bed about 2100.
On the day of the accident, the pilot awoke about 0200 and arrived at HQU about 0330 for the 0400 flight to JWN. He described February 20 as a "tough, tough day" because of the early departure time. After arriving at JWN, he slept for about 4 hours in a chair in the pilot lounge. He did not sleep again that day. A review of t...
Data Source
Data provided by the National Transportation Safety Board (NTSB). For more information on this event, visit the NTSB Records Search website. NTSB# ERA13MA139