Hendrick King Air crew lost situational awareness

 - September 21, 2006, 7:24 AM

A Beech King Air 200 carrying members of the Hendrick Motorsports Nascar race team crashed near Martinsville, Va., on Oct. 24, 2004, because the pilots lost situational awareness while attempting to land at Martinsville/Blue Ridge Airport (MTV) in IMC, according to the NTSB.

The turboprop twin, N501RH, struck a fog-shrouded mountain near the ridge line about 10 miles past MTV while attempting the localizer Runway 30 approach, killing both pilots and all eight passengers, including the son, brother and two nieces of race team owner Rick Hendrick.

Throughout the approach, the airplane was about five miles ahead of where the 10,000-hour captain and 2,000-hour first officer apparently thought they were. For example, at the locator outer marker (LOM) the airplane should have been at an altitude of about 2,600 feet instead of 4,000 feet, and at the missed approach point (MAP) the airplane should have been at 1,340 feet rather than 2,600 feet.

Also, at the MAP the King Air should have made a climbing right turn back to the LOM and leveled off at 2,600 feet. However, after passing the MAP it continued to descend from 2,600 feet and leveled off at 1,400 feet. About eight miles past the airport, the airplane climbed straight ahead for another two miles before it hit the rising terrain.

The NTSB determined that the probable cause of the accident was the flight crew’s failure to properly execute the published instrument approach procedure, including the published missed-approach procedure, which resulted in controlled flight into terrain. Contributing to the cause of the accident was the flight crew’s failure to use all available navigational aids to confirm and monitor the airplane’s position during the approach.

After flying several possible test scenarios into Martinsville in a Beech 1900 (N503RH) provided by Hendrick Motorsports, NTSB investigators formed the opinion that the flight crew was relying on the Bendix/King KLN 90B GPS instead of the ADF and DME.

The GPS was mounted on the pedestal between the pilots and was reportedly used by Hendrick pilots for backup and position awareness. It was IFR-capable but not certified for use in IMC. “It’s a tempting resource,” said Brian Rayner, the NTSB investigator-in-charge. He characterized the accident aircraft’s approach “as very normal but to the wrong waypoint in space.”

The Wrong Reference
On the morning of the accident, the King Air 200 departed Concord Regional Airport, Concord, N.C., at 11:57 a.m. for the 35-minute flight to Martinsville, where there was a Nascar race that afternoon.

At 12:17 p.m., while N501RH was approaching the bales LOM, the Greensboro (GSO) air traffic controller issued holding instructions for the King Air. The flight was cleared to hold southeast at bales with an expected approach clearance time of 12:45 p.m., which the crew acknowledged.

Four minutes later the captain requested five-mile legs and the controller acknowledged five-mile or 10-mile legs at the crew’s discretion.

“I believe that the flight crew was using the GPS to navigate to the bales [LOM] waypoint rather than the ADF,” Rayner explained. “At the point where they entered the turn, I believe that they were going to use the GPS for their primary navigational tool to hold for those 28 minutes.”

At 12:24 p.m., the controller asked if the flight was established in the hold and the first officer replied that it was. However, because the aircraft in front of N501RH had already landed, the controller immediately cleared the crew for the localizer Runway 30 approach and instructed them to advise when they were established inbound on the approach.

Rayner speculated that because the crew received a clearance sooner than expected, they continued their turn for a hold onto the final approach course. Investigators believe that the captain, who was flying, thought he was approaching bales and began his descent. Had the crew been referring to the ADF, it would have told them where they were in relation to bales and the airport.

“I believe that had the flight crew navigated only on the elements of the localizer three zero approach and either ignored the GPS or turned it off, [the flight] would have had a more successful outcome,” he told members of the NTSB.

At 12:26 p.m. the crew radioed they were established inbound and the GSO controller approved a frequency change. He told the King Air pilots that the preceding aircraft had broken out of the clouds just below their minimums (that crew later told investigators they saw the runway when they were just a little bit above their minimums) and reported good visibility below the clouds.

Missed Approach
At 12:30, the minimum safe altitude warning system (MSAW) on the Greensboro controller’s radar generated an audible and visual alert. The last radar return was recorded at 1230:12 and the MSAW ended the alert at 1230:22. At 1233:15 the first officer said they were “going missed.” That was the last transmission ATC received from the flight crew.

Five seconds later the controller said, “Roger, climb and maintain four thousand four hundred.” After a short pause, the controller queried the flight crew, “1RH did you copy?” When there was no answer the controller made a series of calls attempting to contact the accident crew, as did two other airplanes on the Greensboro frequency.

Radar data shows that, after the airplane was cleared for landing, it did not descend at the proper point. About seven miles beyond the airport, the crew initiated a straight-ahead climb and the radar target was lost. The crew should have completed the missed approach over the Martinsville Airport by executing a climbing right turn. The King Air was not equipped with a ground proximity warning system.

The airplane crashed at about 12:35 p.m. into rising terrain about 7.5 nm beyond the LOC Runway 30 missed approach point. At the time closest to the crash, the weather at Martinsville according to the AWOS was 600 feet overcast and visibility of 10 miles. Fifteen minutes earlier, visibility was five miles, the temperature was 14 degrees C and the dew point was 13 degrees C.