Primary finding
Probable cause
The pilot’s failure to maintain aircraft control during the approach resulting in an aerodynamic stall and subsequent impact with terrain. Contributing to the accident was the pilot’s improper preflight planning and conditions conducive for structural icing.
Investigator assessment
Analysis narrative
The airplane was "cleared for the approach" and approximately eight minutes later was observed emerging from the clouds, flying from west to east. Witnesses reported that the nose of the airplane dropped and the airplane subsequently impacted terrain in a near vertical attitude. Impact forces and a post impact fire destroyed the airplane. Examination of the airplane's systems revealed no anomalies. Weather at the time of the accident was depicted as overcast with three to six miles visibility. An icing probability chart depicted the probability for icing during the airplane's descent as 76 percent. AIRMETS for moderate icing and instrument meteorological conditions had been issued for the airplane’s route of flight. Another airplane in the vicinity reported light to moderate mixed icing. It could not be confirmed what information the pilot had obtained in a weather briefing, as a briefing was not obtained through a recorded source. A weight and balance calculation revealed that the accident airplane was 1,000 pounds over gross weight at the time of departure and 560 pounds over gross weight at the time of the accident. It was estimated that the center of gravity was at or just forward of design limitations.
Source record
Factual narrative
HISTORY OF FLIGHT On January 15, 2009, approximately 0700 mountain standard time, a Gulfstream Aerospace Corporation Commander Division 690 C, N840NK, owned by A David Miller Trustee, and operated by J-W Operating Company was destroyed when it impacted terrain four miles north, northeast of Wray Municipal Airport (K2V5), Wray, Colorado. A post impact fire ensued. Instrument meteorological conditions prevailed at the time of the accident. The flight was being conducted under the provisions of Title 14 Code of Federal Regulation Part 91 on an instrument flight rules (IFR) flight plan. The airline transport certificated pilot, commercial certificated second pilot, and commercial certificated passenger were fatally injured. The cross-country flight departed Centennial Airport (KAPA), Denver, Colorado, approximately 0630 and was en route to K2V5. According to J-W Operating Company, the airline transport certificated pilot, an occasional contract pilot for J-W Operating Company, was on board the airplane for positioning purposes; after the flight from KAPA to K2V5 to Addison Airport, Dallas, Texas, (KADS), he intended to ferry another company airplane back to KAPA later that day. The accident airplane was based in KAPA and the flight was scheduled to pick up one additional passenger in Wray before continuing on to KADS. According to records provided by the Federal Aviation Administration (FAA), N840NK was in radio communications with Denver Air Route Traffic Control Center (ZDV) prior to the accident. Approximately 0634 the controller queried N840NK about which heading would take him direct to Wray. N840NK responded that a heading of 065 degrees would take them direct to ETUDE, the initial approach fix for the Global Positioning System (GPS) approach to Runway 17. The controller then cleared N840NK to fly direct to ETUDE. At 0646:06 the controller cleared the flight to "descend at pilot's discretion maintain six thousand." N840NK acknowledged this transmission. At 0646:28 the controller provided the special automated surface observation report for Akron, Colorado (52 miles west of K2V5). This weather included a visibility of four miles, mist, overcast at one hundred feet, and a temperature and dew point of minus twelve. At 0647:02 the controller provided the special weather report for Imperial, Kansas (42 miles northeast of K2V5). This weather included a visibility of three miles, light snow, and overcast at 1,600 feet. N840NK acknowledged the relay of both weather reports. At 0652:44 the controller cleared N840NK to "cross initial [approach fix] at or above six thousand, cleared [for the] approach to the Wray airport." Radar data, provided by ZDV in National Track Analysis Program (NTAP) format, depicted the accident flight from the time of departure from KAPA. The airplane initially climbed to 11,000 feet mean sea level (msl). At 0647:43 the airplane initiated a descent. The last radar information was recorded at 0649:14, at an altitude of 9,900 feet, 32 miles west of K2V5. Multiple witnesses reported seeing the accident airplane flying from the southwest to the northeast. The airplane was low to the ground and flew across highway 385. Shortly thereafter, the airplane pitched down to a near vertical attitude and began to rotate. The airplane impacted the ground nose first and a fire erupted. The Yuma County Sheriff’s Department took witness statements from nine individuals; six of whom observed the accident airplane prior to impact. The National Transportation Safety Board (Safety Board) Investigator in Charge (IIC) interviewed three witnesses. These witnesses were located west of the impact location. Several of the witnesses heard the accident airplane just to the northwest of their location. The airplane was not seen until it emerged from the clouds. The witnesses observed the airplane "flying low" and several stated that the "nose dropped" or that the airplane descended "nose first" towards the ground. PERSONNEL INFORMATION The pilot (seated in the left seat), age 33, held an airline transport pilot certificate with airplane single engine land, and multiengine land ratings last issued on September 26, 2008. He was issued a first class airman medical certificate on March 31, 2008. The certificate contained no limitations. The pilot’s flight logbook was not located. According to his last application for airman certification, dated September 26, 2008, he reported a total time of 2,454 hours; 220 of which was logged in instrument conditions. According to his employer (International Jet Aviation Services), he had logged approximately 2,728 hours. The second pilot (seated in the right seat), age 53, held a commercial pilot certificate with airplane single engine land, multiengine land, and instrument ratings last issued on December 3, 1996. He was issued a second class airman medical certificate on March 11, 2008. The certificate contained the limitation pilot "must wear lenses for near vision while flying." According to the second pilot’s logbook, he had logged no less than 10,211.3 hours total time; 1,149 hours were logged in multiengine “turbo propeller” aircraft, 615.9 hours in actual instrument conditions, and 91.4 hours in simulated instrument conditions. J-W Operating estimated that he had flown 9 hours during the week preceding the accident. According to J-W Operating Company, the commercial pilot lived in Wray and was very familiar with the airport, approaches, and geography. AIRCRAFT INFORMATION The accident airplane, a Gulfstream Aerospace Corporation Commander Division 690 C (serial number 11734) was manufactured in 1984, and subsequently refurbished earning the trade name of Grand Renaissance Commander. It was registered with the Federal Aviation Administration on a standard airworthiness certificate for normal operations. Two Allied Signal (Garrett) TPE-331-10T-513K turbine engines (as indicated by the engine data plates) limited at 717.5 horsepower at 1,591 rpm powered the airplane. The engines were equipped with three-bladed Dowty Rotol propellers. The airplane was registered to A David Miller Trustee, operated by J-W Operating Company, and was maintained under a periodic inspection program in accordance with the Twin Commander maintenance manual. A review of the maintenance records indicated that a 150 hour periodic inspection was completed on November 7, 2008, at an airframe total time of 7,189.9 hours. The airplane had flown approximately 25 hours between the last inspection and the accident and had an estimated total airframe time of 7,215 total hours. METEOROLOGICAL INFORMATION Aviation area forecasts were issued for Colorado by the Aviation Weather Center in Kansas City, Missouri, at 0445 the day of the accident. The forecast for the northern plains at the time of the accident predicted overcast sky conditions at 6,000 feet with cloud tops at 8,000 feet, and visibility 3 to 5 statute miles in mist. Airman's Meteorological Information (AIRMET) Zulu for icing and freezing levels was issued the day of the accident at 0145. Moderate ice between the freezing level and 14,000 feet was forecast. The freezing level was anticipated between the surface and 6,000 feet msl. AIRMET Sierra for IFR was issued at 0145. Ceilings below 1,000 feet and visibility below 3 miles in precipitation and mist was forecast. The accident airplane's route of flight was included in both AIRMET Zulu and Sierra. The closest official aviation weather observation station was Imperial Municipal Airport (KIML) Imperial, Nebraska, located 38 nautical miles (nm) northeast of the accident site. The elevation of the weather observation station was 3,275 feet msl. The routine aviation weather report (METAR) for KIML, issued at 0653, reported, winds, 140 degrees at seven knots, visibility, six miles in haze; sky condition, overcast 1,600 feet; temperature minus 12 degrees Celsius (C); dew point, minus 14 de