Date & Time: Jan 8, 1996 at 1907 LT
Type of aircraft:
Cessna 401
Registration:
N117AC
Flight Type:
Ambulance
Survivors:
Yes
Schedule:
Pasco - Spokane
MSN:
401A-0040
YOM:
1969
Crew on board:
2
Crew fatalities:
2
Pax on board:
2
Pax fatalities:
1
Other fatalities:
0
Total fatalities:
3
Captain / Total flying hours:
3500
Captain / Total hours on type:
70
Aircraft flight hours:
5800
Circumstances:
The pilot received abbreviated weather briefing for emergency medical service (EMS)/air ambulance flight. Before flight, he expressed anxiety about possible low visibility for landing and timely transport of dying patient. During ILS runway 03 approach (rwy 03 approach), the aircraft remained well above the glide slope until close to the middle marker; aircraft's speed decreased from 153 to 100 kts, while vertical speed increased from 711 feet/min to about 1,250 feet/min descent. About 1 mile from runway and 500 feet agl (in fog), the aircraft abruptly turned left of localizer course and gradually descended with no distress call from pilot. The aircraft hit a pole, then flew into a building and burned. Low ceiling, fog and dark night conditions prevailed. Pilot (recent ex military helicopter pilot) had logged/reported 3,500 hours of flight time and about 150 hours in multiengine airplanes, but there was evidence he lacked experience with actual instrument approaches in fixed wing aircraft; he had difficulty with instrument flying during recent training and FAA check flights. No preimpact mechanical problem was found with aircraft/engines. No ILS anomalies were found. Flight nurse was using cellular phone, but no evidence was found of interference with aircraft's navigational system. Visibility and ceiling at destination were less than forecast at time of pilot's preflight weather briefing. Paramedic was only survivor.
Probable cause:
Failure of the pilot to follow proper IFR procedures, by failing to maintain proper alignment with the localizer course during the ILS approach and/or by failing to follow the proper missed approach procedure. Factors relating to the accident were: darkness; adverse weather conditions; and pressure on the pilot to complete the EMS flight, due to the circumstances and conditions that prevailed.
Final Report:
N117AC.pdf129.32 KB