West Virginia

The flight crew was conducting a cargo flight in instrument meteorological conditions. Takeoff from the departure airport and the en route portion of the flight were normal, with no reported weather or operational issues. As the flight neared Charleston Yeager International Airport (CRW) at an altitude of 9,000 ft, the captain and first officer received the most recent automatic terminal information service (ATIS) report for the airport indicating wind from 080º at 11 knots, 10 miles visibility, scattered clouds at 700 ft above ground level (agl), and a broken ceiling at 1,300 ft agl. However, a special weather observation recorded about 7 minutes before the flight crew's initial contact with the CRW approach controller indicated that the wind conditions had changed to 170º at 4 knots and that cloud ceilings had dropped to 500 ft agl. The CRW approach controller did not provide the updated weather information to the flight crew and did not update the ATIS, as required by Federal Aviation Administration Order 7110.65X, paragraph 2-9-2. The CRW approach controller advised the flight crew to expect the localizer 5 approach, which would have provided a straight-in final approach course aligned with runway 5. The first officer acknowledged the instruction but requested the VOR-A circling instrument approach, presumably because the approach procedure happened to line up with the flight crew's inbound flightpath and flying the localizer 5 approach would result in a slightly longer flight to the airport. However, because the localizer 5 approach was available, the flight crew's decision to fly the VOR-A circling approach was contrary to the operator's standard operating procedures (SOP). The minimum descent altitude (MDA) for the localizer approach was 373 ft agl, and the MDA for the VOR-A approach was about 773 ft agl. With the special weather observation indicating cloud cover at 500 ft agl, it would be difficult for the pilots to see the airport while at the MDA for the VOR-A approach; yet, the flight crew did not have that information. The approach controller was required to provide the flight crew with the special weather report indicating that the ceiling at the arrival airport had dropped below the MDA, which could have prompted the pilots to use the localizer approach; however, the pilots would not have been required to because the minimum visibility for the VOR-A approach was within acceptable limits. The approach controller approved the first officer's request then cleared the flight direct to the first waypoint of the VOR-A approach and to descend to 4,000 ft. Radar data indicated that as the flight progressed along the VOR-A approach course, the airplane descended 120 feet below the prescribed minimum stepdown altitude of 1,720 ft two miles prior to FOGAG waypoint. The airplane remained level at or about 1,600 ft until about 0.5 mile from the displaced threshold of the landing runway. At this point, the airplane entered a 2,500 ft-per-minute, turning descent toward the runway in a steep left bank up to 42º in an apparent attempt to line up with the runway. Performance analysis indicates that, just before the airplane impacted the runway, the descent rate decreased to about 600 fpm and pitch began to move in a nose-up direction, suggesting that the captain was pulling up as the airplane neared the pavement; however, it was too late to save the approach. Postaccident examination of the airplane did not identify any airplane or engine malfunctions or failures that would have precluded normal operation. Video and witness information were not conclusive as to whether the captain descended below the MDA before exiting the cloud cover; however, the descent from the MDA was not in accordance with federal regulations, which required, in part, that pilots not leave the MDA until the "aircraft is continuously in a position from which a descent to a landing on the intended runway can be made at a normal descent rate using normal maneuvers." The accident airplane's descent rate was not in accordance with company guidance, which stated that "a constant rate of descent of about 500 ft./min. should be maintained." Rather than continue the VOR-A approach with an excessive descent rate and airplane maneuvering, the captain should have conducted a missed approach and executed the localizer 5 approach procedure. No evidence was found to indicate why the captain chose to continue the approach; however, the captain's recent performance history, including an unsatisfactory checkride due to poor instrument flying, indicated that his instrument flight skills were marginal. It is possible that the captain felt more confident in his ability to perform an unstable approach to the runway compared to conducting the circling approach to land. The first officer also could have called for a missed approach but, based on text messages she sent to friends and their interview statements, the first officer was not in the habit of speaking up. The difference in experience between the captain and first officer likely created a barrier to communication due to authority gradient. ATC data of three VOR-A approaches to CRW flown by the captain over a period of 3 months before the accident and airport security footage of previous landings by the flight crew 1 month before the accident suggest that the captain's early descent below specified altitudes and excessive maneuvering during landing were not isolated to the accident flight. The evidence suggests that the flight crew consistently turned to final later and at a lower altitude than recommended by the operator's SOPs. The flight crew's performance on the accident flight was consistent with procedural intentional noncompliance, which—as a longstanding concern of the NTSB—was highlighted on the NTSB's 2015 Most Wanted List. The operator stands as the first line of defense against procedural intentional noncompliance by setting a positive safety attitude for personnel to follow and establishing organizational protections. However, the operator had no formal safety and oversight program to assess compliance with SOPs or monitor pilots, such as the captain, with previous performance issues.

The airplane, operated by Oz Gas Aviation LLC, was substantially damaged when it struck a communications tower near Morgantown, West Virginia. The certificated airline transport pilot was fatally injured. No flight plan had been filed for the positioning flight from Nemacolin Airport (PA88), Farmington, Pennsylvania, to Morgantown Municipal Airport (MGW), Morgantown, West Virginia conducted under Title14 Code of Federal Regulations (CFR) Part 91. At 0924 on the morning of the accident, the airplane departed from Rigrtona Airport (13PA), Tidioute, Pennsylvania for PA88 with the pilot and three passengers onboard. The airplane landed on runway 23 at PA88 at 0944. The pilot then parked the airplane; shutdown both engines, and deplaned the three passengers. He advised them that he would be back on the following day to pick them up. After the passengers got on a shuttle bus for the Nemacolin Woodlands Resort, the pilot started the engines. He idled for approximately 2 minutes, and then back taxied on runway 23 for takeoff. At 0957, he departed from runway 23 for the approximately 19 nautical mile positioning flight to MGW, where he was going to refuel and spend the night. After departure from PA88, the airplane climbed to 3,100 feet above mean sea level (msl) on an approximately direct heading for MGW. The pilot then contacted Clarksburg Approach Control and was given a discrete code of 0130. When the airplane was approximately nine miles east of the Morgantown airport, the air traffic controller advised the pilot that he had "radar contact" with him. The airplane then descended to 3,000 feet, and approximately one minute later struck the communications tower on an approximate magnetic heading of 240 degrees. According to a witness who was cutting timber across the road from where the accident occurred; the weather was cloudy with lighting and thunder, and it had just started "sprinkling". He then heard a loud "bang", turned, and observed the airplane descending upside down, and then impact. About 20 minutes later it stopped "sprinkling". He advised that he could still see the top of the tower when it was "sprinkling".

The pilot attempted a night landing on a taxiway in front of the control tower, which was closed at the time. The airplane overran the end of the taxiway, rolled down an embankment and struck trees. The pilot, whose identity was not confirmed, was believed to have incurred minor injuries. He subsequently paid a passerby to take him to a local hotel, and after a night's rest, he left the area. Ownership of the airplane could not be determined due to a recent sale. Approximately 250 kilos of cocaine were found onboard the airplane. Further investigation was being conducted by federal authorities and local law enforcement.

An IFR flight plan and slot reservation were filed for the planned flight over mountainous terrain. The flightcrew intended to reposition to an airport about 30 miles southeast of the departure airport, pick up passengers, and then complete a revenue flight to another airport. The airplane departed VFR, and the flightcrew never activated the flight plan. A debris path was located, consistent with straight and level flight, near the peak of a mountain at 3,475 feet msl. Examination of the wreckage did not reveal any pre-impact mechanical malfunctions. Instrument meteorological conditions prevailed near the accident site, about the time of the accident. Further investigation revealed the aircraft operator was involved in two prior weather related accidents, both of which resulted in fatalities. A third accident went unreported, and the weather at the time of that accident was unknown. Over a period of 14 years, the same FAA principal operations inspector was assigned to the operator during all four accidents; however, no actions were ever initiated as a result of any of the accidents.

The pilot completed a flight without incident, and seemed in good spirits before departing, by himself, on the return flight. The second flight also progressed without a incident until cleared from 8,000 feet msl to 5,000 feet msl, which the pilot acknowledged. Visual meteorological conditions prevailed at the time, and radar data depicted the airplane initiate and maintain a 500-foot per-minute descent until radar contact was lost at approximately 400 feet agl. The pilot made no mention of difficulties while en route or during the descent. The airplane impacted trees at the top of a ridge in an approximate level attitude, and came to rest approximately 1,450 feet beyond, at the bottom of a ravine. Examination of the wreckage revealed no preimpact failures or malfunctions. The pilot had been diagnosed with Crohn's disease (a chronic recurrent gastrointestinal disease, with no clear surgical cure) for approximately 35 years, which required him to undergo several surgeries more than 20 years before the accident. The pilot received a letter from the FAA on June 11, 1998, stating he was eligible for a first-class medical certificate. In the letter there was no requirement for a follow up gastroenterological review, but the pilot was reminded he was prohibited from operating an aircraft if new symptoms or adverse changes occurred, or anytime medication was required. His condition seemed to be stable until approximately 5 months prior to the accident. During this time frame, he experienced weight loss and blood loss, was prescribed several different medications to include intravenous meperidine, received 3 units of blood, and had a peripherally inserted central catheter placed. On the pilot's airmen medical application dated the month prior to the accident, the pilot reported he did not currently use any medications, and did not note any changes to his health. A toxicological test conducted after the accident identified meperidine in the pilot's tissue.

The airplane touched down about 1/3 beyond the approach end of Runway 28, a 5,000 footlong, asphalt runway. The PIC stated, 'as usual,' he applied 'light' braking and attempted to actuated the airplane's thrust reverser (TR) system; however, the TR handles could not be moved beyond the 'Deploy-Reverse-Idle' position. After the PIC cycled the levers two or three times, he began to apply maximum braking. A passenger in the airplane stated he looked out of the cockpit window, saw the end of the runway, and the airplane seemed like it was still moving 'pretty fast.' As the airplane approached the end of the runway, he could see smoke, which he believed was coming from the airplane's tires. He then sensed the airplane was falling. The co-pilot stated he had no memory at all of the accident flight. Review of the CVR revealed the co-pilot said that the airplane was 'Vref plus about twenty,' when the airplane was 100 feet over the runway threshold. The PIC could not recall the airplane's touchdown speed, however, he stated that it seemed like the airplane was still traveling 50 to 60 knots when it departed the end of the runway. A pair of parallel tire marks were observed 3,200 feet beyond the approach end of the runway. The tire marks extended past the end of the runway and onto a 106 foot-long grass area. The airplane came to rest on a plateau about 90 feet below the runway elevation. Examination of the airplane, including the optional TR system did not reveal any pre-impact malfunctions. The airplane's estimated landing distance was calculated to be about 3,100 feet. The PIC reported about 4,700 hours of total flight experience, of which, 107 hours were in make and model. The PIC stated he had never performed a landing in the accident airplane without using the TR system. Winds reported at the time of the accident were from 290 degrees at 15 knots, with 21 knot gusts.

The airplane was flown from Morgantown to Charleston to drop off passengers. Once there, the pilot called the mechanic who was scheduled to replace the right transfer pump, and told him the right boost pump was also inoperative. The mechanic told the pilot, he would replace both pumps the next morning in Charleston. Adding that de-fueling the airplane would take longer than changing the pumps. The mechanic recalled that the pilot was concerned about the amount of time necessary for the repair. The airplane was then repositioned back to Morgantown for another flight the next day to Charleston. The morning of the accident, the airplane departed Morgantown, and was being vectored for the ILS approach to Charleston when the copilot declared an emergency. He then announced that they had 'a dual engine failure, two souls onboard and zero fuel.' Examination of the wreckage and both engines revealed no pre-impact failures or malfunctions. With the right transfer pump inoperative. 28 gallons of fuel in the right wing would be unusable. In addition, the flight manual states that 'both boost pumps must be operable prior to take-off.'

The pilot/owner and a flight instructor had flown in to pick-up passengers. The owner was not multiengine rated and was receiving instruction from the instructor. The airplane was fueled and two adults and three children were boarded about 1 hour later. The owner was the flying pilot in the left seat. The owner stated that the 4,500 foot long runway was covered with 2 1/2 to 3 inches of snow and slush. He further stated that during the takeoff roll, 'The snow was so bad we could not get off the ground...' The pilot estimated that he aborted the takeoff at 100 mph, the braking action was zero, and the airplane went off the end of the runway. According to a witness, the five passengers arrived with 'lots of heavy bags.' After the accident, the baggage was removed before it could be weighed. An estimated airplane takeoff weight of 7,856 pounds was computed without baggage, based upon weights from the airplane weight and balance form, the police report, and FAA records. According to the Pilot's Operating Handbook, the maximum takeoff weight was published at 7,560 pounds.

The pilots reported they experienced an engine fire during a missed approach in night, IMC conditions, and feathered the propeller and shut down the engine. On an approach to another airport, the airplane touched down short of the runway, traveled onto the runway, and then departed the left side of the runway. The pilot reported he could not maintain altitude due to ice accumulations, and the lack of power with one engine shut down. Examination of the wreckage revealed rotational damage to both engines and propellers consistent with operating engines. Neither propeller was in the feathered position. The pilot had been briefed about known moderate icing conditions, and isolated severe icing. The AFM recommended a minimum speed in icing conditions of 140 knots, and at less than 140 knots, ice could accumulate on the wings in unprotected areas. The pilot reported he flew the approach at 114 knots.

The flight had been delayed due to severe weather over the departure airport. The preflight weather briefing received by the pilot included AIRMETS and SIGMETS for icing and severe thunderstorms, possible tornadoes, hail to 2 inches, and wind gusts to 70 knots near the ground. The Beech 18 was not equipped with a storm scope or weather radar. Prior to takeoff, a passenger stated to a witness that the weather was 'really really bad,' and that they would have to 'do some deviating to get around it.' After takeoff, the airplane cruised at 10,000 feet uneventfully for 1 hour and 50 minutes, when a center controller advised that radar contact was lost, which the pilot acknowledged. The next and last transmission occurred 13 minutes later when the controller received a 'Mayday' radio transmission that the airplane was 'going down.' The last radar target revealed a 6,000 foot per minute rate of descent. Training records revealed the pilot, also the company chief pilot, had flown solo 6.3 hours in the Beech 18 and credited it as dual flight instruction. He then passed a Part 135 evaluation with the FAA Principal Operations Inspector (POI), which lasted 1.6 hours. The next day the POI issued the pilot check airmen authorization for the Beech 18, all models. According to the POI, the airplane was not approved for Part 135 operations; however, the company had a bogus approval for the airplane, signed by the POI, that allowed the company to apply to Canadian Authorities for authorization to operate in Canada. The bogus approval had been used to justify the accident flight.