On Feb. 3, 2014, at about 1655 CST, a Gulfstream Commander 690C (N840V), operated by a private pilot, was destroyed when it struck the ground near Bellevue, Tennessee, while on approach to Nashville’s John C. Tune Airport (KJWN). The pilot and three passengers were killed.
The flight had departed Great Bend Municipal Airport (KGBD), Great Bend, Kansas, where the aircraft was based. The group, all members of an agricultural company, were bound for a trade show; the pilot was the company president. The FAR Part 91 flight was conducted in instrument conditions.
According to the FAA, on the date of the accident, the pilot flew the airplane from Clarence E. Page Municipal Airport (KRCE), Oklahoma City, where it had been undergoing maintenance, which included a 150-hr. periodic inspection, to KGBD. The group then departed for Nashville at about 1445.
About 1628, the ATC controller cleared N840V direct to FUNJO. The pilot replied, “What is it?”, and the controller responded by spelling out the individual letters of the word. FUNJO was the initial approach fix (IAF) for the RNAV Runway 2 approach at KJWN and was located 12.7 nm south of the airport.
Subsequently, the controller instructed the pilot to maintain 3,000 ft. until FUNJO, and cleared him for the RNAV Runway 2 approach. The pilot did not respond. The controller repeated the clearance, and the pilot stated, “I’d like to climb and uh review the approach and uh do it again.”
At 1629:38, the on-the-job training instructor (OJTI) directed the pilot to maintain 3,000 ft. and turn right heading 020 deg. The pilot responded “Right heading zero two zero.” About 1631, the pilot informed the controller, “You can direct me back; I’ve got FUNJO on my system.” The pilot was subsequently provided a clearance for the GPS Runway 2 approach. The controller noted that the pilot had not flown the correct assigned heading but did not correct him as no traffic or terrain intersection was noted.
At 1637, the controller asked the pilot if he was established on the approach and the pilot responded that he was. The controller then advised him that the airplane was about one-half mile east of the final approach course, and the pilot replied, “That’s correct; I’m a little east of course.”
At 1642, the pilot reported that he was executing a missed approach. About 1653, the pilot was cleared for a third GPS approach to Runway 2.
Weather conditions were conducive to super-cooled liquid water droplets, and the airplane likely encountered moderate or greater icing conditions. Several pilot reports (PIREPs) for moderate, light, trace and negative icing were reported to ATC but were not distributed publicly into the National Airspace System (NAS), and there was no airmen’s meteorological information (AIRMET) issued for icing. The NTSB report goes into some systemic problems getting verbal reports into PIREP format. However, the pilot received standard and abbreviated weather briefings for the flight, and his most recent weather briefing included three PIREPs for icing conditions in the area of the accident site.
At 1655:37, the controller informed the pilot that radar services were terminated, instructed him to report cancellation of IFR in the air or on the ground, and advised him that traffic was 10 mi. in trail. The pilot did not respond, and there were no further transmissions received from the aircraft.
Radar data showed that the airplane was established on the final approach course as it passed the IAF; however, before it reached the final approach fix, its airspeed slowed to about 111 kt., and it began a left turn with a 25-deg. bank angle. About 18 sec. later, while still in the turn, the airplane slowed to 108 kt. and began descending rapidly. The airplane’s rate of descent exceeded 10,000 ft. per minute, and it impacted the ground about 9 mi. from the destination airport. The airplane had turned to a heading of about 210 deg. before radar contact was lost.
Due to impact damage to the cockpit, the positions of the switches for the ice protection systems at the time of the accident could not be determined. Although the airplane’s airspeed of 108 kt. when the steep descent began was above its published stall speed of 77 kt., both bank angle and ice accretion would have increased the stall speed. In addition, the published minimum control airspeed was 93 kt.
It is likely that, after the airplane passed the IAF, the left engine lost power, the airspeed began to decay, and the asymmetric thrust resulted in a left turn. At any rate, as the airspeed continued to decay, it decreased below either stall speed or minimum control airspeed, and the airplane entered an uncontrolled descent.
Pilot Information
The 62-year-old pilot held a private pilot certificate with multiengine and instrument ratings. His logbook was not located. However, when his most-recent third-class medical certificate was issued on Feb. 23, 2012, he reported a total flight experience of 3,000 hr., 30 of which were logged during the previous six months.
According to training records, he successfully completed a Turbo Commander 690 recurrent course in May 2013. At that time, he reported 3,205 hr. of total flight experience, which included 1,392 hr. in multiengine airplanes and 436 hr. of instrument flight experience. In addition, he reported 719 hr. flown in the accident airplane and 20 hr. flown during the previous 12 months.
Aircraft Information
The high-wing, all-metal, pressurized airplane, serial number 11727, was manufactured in 1982. It was powered by two Executive Wings Inc. supplemental type certificate modified Garrett TPE331-5-511K, 715-hp engines, equipped with Hartzell three-blade constant speed props.
According to maintenance records, the airplane underwent a 150-hr. periodic inspection on Feb. 1, 2014. At the time of the accident, the airframe and both engines had been operated for about 4,460 total hours since new. The airplane had been operated for about 70 hr. during the 13 months that preceded the accident.
The pilot operating handbook noted the airplane was equipped with deicing and anti-icing systems. The former included wing and empennage deice boots and prop deice. The anti-icing system included heated stall warning, rudder horn anti-ice, rudder tab anti-ice, generator inlet anti-ice, electrically heated windshield and pitot-static heaters. The anti-icing systems should be placed in operation prior to entering flight conditions conducive to the formation of ice. Engine inlet heaters used hot engine compressor bleed air to prevent icing. The ice protection systems were controlled by switches in the “ICE PROTECTION” group on the cockpit overhead switch panel.
The following warning was included under the Engine Inlet Anti-Ice
Systems:
“Warning: When icing conditions may be encountered, do not delay operation of the engine inlet heat systems. Turn the systems on before any ice accumulates. Engine inlet heat must be on if icing conditions exist or are anticipated.”
The airplane was also equipped with a negative torque sensing (NTS) system that was designed to reduce drag caused by a windmilling propeller in the event of a loss of engine power by moving the blades toward the feathered position to reduce drag and yaw.
Honeywell Operating Information Letter OI331-11R11, issued on Sept. 16, 2013, emphasized proper use of engine inlet anti-ice and provided additional information on the use of engine ignition in icing conditions. The operating letter stated, in part, that engine inlet anti-ice should be used during all flight phases during potential icing conditions. Further, icing conditions should be considered to exist when flying in precipitation or visible moisture (including clouds or fog) with an outside air temperature of 10C or 50F, or colder. In addition, it warned, “If the use of anti-ice is inadvertently delayed after encountering icing conditioning, ice may accumulate on engine and airframe inlet surfaces. In such instances, subsequent application of engine inlet anti-ice can cause ice shedding and ingestion, which may cause flameout. . . .”
Meteorological Information
ACCIDENT TIME 1657 CST
[1700 CST] KJWN 032300Z AUTO 35004KT 6SM OVC008 05/M04 A3029 RMK A01 $
[1705 CST] KJWN 032305Z AUTO 01004KT 6SM OVC008 05/M04 A3029 RMK A01 $
[1710 CST] KJWN 032310Z AUTO 36005KT 6SM OVC008 05/M04 A3029 RMK
AIRMET Sierra, issued at 1445, was valid at the time of the accident, and forecasted IFR conditions around the accident site with ceilings below 1,000 ft. and visibilities below 3 mi. There were no AIRMETs for icing conditions valid at the time of the accident. The pilot received standard and abbreviated weather briefings from Lockheed Martin Flight Service. The last weather briefing requested by the pilot was at 1538 and included three PIREPs for icing conditions in the Nashville area that were applicable to the pilot’s flight.
Geostationary Operational Environmental Satellite number 13 (GOES-13) data indicated abundant cloud cover over the accident site with approximate cloud-top heights of 19,500 ft. around the time of the accident.
Weather PIREPs that were publicly available in the NAS for the vicinity of the accident site, from about 3 hr. before the accident to about the time of the accident, were reviewed. Seven contained icing information that ranged from trace rime to a light to moderate mixed icing, with the reported icing conditions only occurring between 2,000 and 3,500 ft.
In addition, the current icing potential (CIP) images produced by the NWS Aviation Weather Center depicted light to moderate icing was likely at 2,000 to 3,000 ft. around the time of the accident. It was noted that CIP data was intended to be supplemental to other icing advisories such as AIRMETs and SIGMETs).
There were reports from a witness driving in the airport area that, at the time of the accident, he noticed icy patches and slush on the roads.
Wreckage Information
The airplane’s impact with the ground created a crater measuring 11-ft. long, 11-ft. wide and 6-ft. deep. There were broken tree branches that contained 45-deg. angled cuts at a height of about 50 ft. The airplane struck the earth at an approximate 70-deg. angle, and consistent with being in an inverted position. The wreckage was severely fragmented with debris scattered on a course of about 320 deg., for about 450 ft. In addition, a post-crash fire consumed a majority of the airframe.
Both propellers remained attached to their respective gearboxes, which separated from both engines. All three left prop blades separated from the hub. Two right prop blades remained attached to the hub, and one blade had separated. Both propeller assemblies were severely impact damaged and displayed evidence of rotational scoring; however, it was noted that the right propeller blades displayed a significantly greater degree of rotational scoring, tears and missing blade tips than the left blades.
Both engines were damaged by the impact and fire. Their respective fuel pumps and fuel control units were separated. They did not display any evidence of catastrophic failure and were forwarded to the engine manufacturer for further examination under the supervision of an NTSB investigator.
A subsequent teardown examination of both engines did not reveal any preimpact conditions that would have prevented normal operation. The type and degree of damage to the left engine was indicative of an engine that was not operating, with rotation consistent with a windmilling prop at the time of impact. The type and degree of damage to the right engine was indicative of an engine that was operating under power at the time of impact.
Extensive tests performed on the gyros in the airplane showed that they both appeared to be operating at impact.
Medical and Pathological Information
An autopsy was performed on the pilot by the Office of the Medical Examiner, Center for Forensic Medicine, Nashville. This report did not indicate any medical condition that might have prevented the pilot from normal operations.
Probable Cause and Findings
The NTSB determined the probable cause(s) of the accident to be:
The pilot’s failure to maintain airspeed with one engine inoperative, which resulted in a loss of control while on approach. Contributing to the accident were airframe ice accumulation due to conditions conducive to icing and the loss of engine power on one engine for reasons that could not be determined due to the extent of damage to the airplane.
Author's Analysis: Alone At Night
This accident is a tough one to figure. It appears to me that the pilot could have handled the situation, but since we’ll never know for sure, I offer some conjecture here for the purpose of discussion.
The single biggest difference is in the way that most professionals fly IFR as a crew whereas most private pilots do it alone.
When I flew military fighters, we often flew low ceiling and/or visibility approaches as single pilots. The approach controller came up on frequency when you were at 8,000-10,000 ft. and some 20 to 30 mi. from the airport. There were no changes in frequencies after that initial contact. Different controllers came up on the same frequency. Eventually, you were handed off to a final radar controller. Through that controller would come “3 mi. on final, on course, on glidepath, tower clears you to land,” after which precision commands continued to be issued. On the rollout, you were advised to contact tower when able.
In short, during those single-pilot, low-visibility approaches, I was not much more than a voice-actuated autopilot. All I had to do was maintain orientation, have a backup approach tuned up if I lost communications and then fly as instructed.
Flying with a highly rated fellow crewmember is not much harder. The approach is put into the boxes well ahead of the terminal area and, in the vast number of cases, unfolds in a very systematic approach. The other pilot monitors every move you make and stands ready to add something if you’ve missed something. This gets the job done.
In my 40-year career, I missed an ILS approach only twice. I should add that there were numerous times I didn’t even try the approach rather than trying and missing. Remembering that our job was convenience for the folks in the back of the plane, New Jersey’s Teterboro Airport (KTEB) often had 700- to 800-ft. ceilings when nearby Westchester County Airport (KHPN) was reporting below minimums. The execs got to the office at the same time. No brainer.
For a missed approach in a crewed airplane, all the pilot flying (PF) generally needs to do is establish attitude, keep the wings level while adding power, call for approach flaps, gear up and clean up. Then it’s keep the wings level, climb to a given altitude and follow guidance that, nowadays, comes up automatically. Usually a heading is assigned. While the PF’s doing that, the pilot not flying (PNF) re-racks the navigation equipment and generally confirms the position with the PF. Again, not hard. At no time does the PF have to do anything but fly the airplane while the PNF sets up the next approach and monitors how well the pilot is flying. Then the PNF takes control and the PF briefs the next approach.
In reviewing the official report on the crash of N840V, you can almost feel the pilot’s workload and pressure increase as the flight progresses. Picture that he probably got up early to get to a distant airport to pick up his plane, maybe flew a test flight, ferried to the departure location where he knew colleagues would be waiting, refueled and headed off into a very demanding situation.
I included all the related weather information in our review just because I always marvel at how much is available — so much that it’s virtually impossible to not miss some of it. The pertinent weather information for the accident flight was low ceilings, tops to FL 190 and reported light to moderate icing. With those three tidbits, most of us would have assumed all the other information and PIREPs were out there, whether we received them or not. You’re going to get into icing conditions and they’re most likely going to be serious. There’s no way out other than getting on the ground or going somewhere else.
Since the pilot had passed professional courses of instruction, it can be surmised that he was a capable instrument pilot. He got into the area. He made ATC wait while he figured out his course of action. (With an ILS to the other runway, it’s a good bet he figured that would be the approach and one might argue he should have insisted on it with only a 3- to 4-kt. tailwind on a 6,000-ft. runway.) He successfully executed a missed approach and got himself back into position for another approach.
Obviously, this all had to weigh on his mind. Imagine his employees, friends probably, watching over his shoulder, maybe one of them in the front with him.
By all accounts, this pilot took his flying seriously. He averaged approximately 100 hr. a year although he seemed to have fallen off that pace before the accident. He had attended several professionally given refresher courses with simulators. Instead of trying to dump a misaligned airplane at the runway from low altitude, he showed good judgment by going missed. However, that increased the pressure since he had flown well below minimums. The missed approach and climb back to the second approach appeared normal. That speaks well for his ability, but be assured, pressure was building. Under such circumstances, it’s possible to miss something.
Pressure kept increasing. The three passengers were probably peering forward at him, at the instruments and at the cold, blank scene beyond. There were probably indications of icing on the windshield. First approach missed. Nav equipment reset. Ice. Airspeed low. Power in to recover.
What would a copilot maybe have added to the scenario: “Anti-ice, boss.” But N840V’s pilot never got that cue.
Then . . . one engine doesn’t spool . . . what’s wrong?
Overload. Roll-off. Pull back.
Spin.
Obviously, the airplane was out of control just before the rate of descent exceeded 10,000 feet per minute and more than likely rolled under, rather than turned, to wind up impacting on a heading of 210 deg.
The situation deteriorated, and, as the pilot tried to cope, he eventually reached the limit of his ability when one of the engines didn’t spool. The only chance he had at that point was to ease in power, level the wings, clean up the airplane and try to get it flying again. But he had missed one approach, was inside the initial approach fix, had another plane behind him and by then, just wanted to get on the ground. The loss of engine, yaw, slow speed and roll-off presented a situation outside his ability to cope. At the end, there were four passengers.
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