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 Number: AAR-03-03
NTIS Number: PB2003-910403
November 18, 2003
PDF

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.

Probable Cause

The National Transportation Safety Board determines that the probable cause of this accident was the flight crew's 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.

Recommendations

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 panel's 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)

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 "Open-Acceptable Response") is classified "Closed-Superseded."