Summary
A commercial cargo flight operated by a twin-engine turboprop airplane, with a solo airline transport pilot at the controls, ended in an accident after the pilot failed to adhere to the published missed approach procedure. The airplane collided with tree-covered terrain on an island near the destination airport. The official investigation identified the pilot's deviation from proper IFR procedures as the probable cause, with contributing factors including adverse weather, company management deficiencies, pilot impairment, and FAA oversight issues.
Flight History
The flight departed on a commercial cargo operation. As the flight neared the destination, visibility dropped below the 2-mile minimum required to initiate the approach. The pilot entered a holding pattern and waited for conditions to improve. After approximately 45 minutes, the ceiling and visibility improved, and the flight was cleared for the ILS 25 instrument approach. Following initial contact with air traffic control tower personnel, no further radio communications were received. When the flight did not arrive at the destination, it was reported overdue.
Search and Witness Reports
A search was initiated after an emergency locator transmitter signal was detected. The accident airplane was located on a hilly, tree-covered island. A witness north of the airport reported seeing a twin-engine turboprop airplane flying very low over water, heading east away from the airport. The witness described weather conditions at the time as very low clouds, fog, and rain, with zero-zero visibility. A local resident noted that weather over the water adjacent to the approach end of the airport was often significantly lower than at the airport itself.
Weather and Missed Approach Procedure
The missed approach procedure for the ILS 25 approach called for a climbing left turn to the south. About one minute after the accident, a special weather observation reported: wind 060 degrees true at 11 knots, visibility 2 statute miles in light rain and mist, ceiling 500 feet broken, 900 feet broken, 1,500 feet overcast, temperature 46°F, dew point 44°F.
Operational and Medical Findings
According to FAA records, the company was not authorized to conduct single-pilot IFR operations in the accident airplane. The accident pilot served as the operator's chief pilot. Toxicology tests revealed the presence of cocaethylene and chlorpheniramine in the pilot's blood and urine.
Probable Cause
The official probable cause was the pilot's failure to follow proper IFR procedures by not adhering to the published missed approach procedures, which resulted in an in-flight collision with tree-covered terrain. Factors contributing to the accident were a low ceiling, fog, rain, and the insufficient operating standards of company management by allowing unauthorized single-pilot instrument flight operations. Additional factors were the pilot's impairment from cocaine, alcohol, and over-the-counter cold medication, and the FAA's inadequate medical certification of the pilot and follow-up of his known substance abuse problems.