BEECH 200 near Moorhead, MN — 2016-11-23

Probable cause

The pilot's failure to attain a positive climb rate during an attempted missed approach in night instrument meteorological conditions that were at/near approach minimums, which resulted in controlled flight into terrain.

NTSB narrative

The commercial pilot was conducting an on-demand passenger flight at night in instrument meteorological conditions that were at/near straight-in approach minimums for the runway. The pilot flew the approach as a nonprecision LNAV approach, and he reported that the approach was stabilized and that he did not notice anything unusual. A few seconds after leveling the airplane at the missed approach altitude, he saw the runway end lights, the strobe lights, and the precision approach path indicator. He then disconnected the autopilot and took his hand off the throttles to turn on the landing lights. However, before he could turn on the landing lights, the runway became obscured by clouds. The pilot immediately decided to conduct a missed approach and applied engine power, but the airplane subsequently impacted terrain short of the runway in a nose-up level attitude. The pilot reported that there were no mechanical anomalies with the airplane that would have precluded normal operation. It is likely the pilot lost sight of the runway due to the visibility being at/near the straight-in approach minimums and that the airplane got too low for a missed approach, which resulted in controlled flight into terrain. A passenger stated that he and the pilot were not wearing available shoulder harnesses. The passenger said that he was not informed that the airplane was equipped with shoulder harnesses or told how to adjust the seats. The pilot sustained injuries to his face in the accident.

Analysis

Primary failure mode

Human factors

First missed decision gate

Pilot should have diverted to Fargo instead of attempting the approach in deteriorating weather.

NTSB coding

• Controlled flight into terr/obj (CFIT) · Approach-IFR missed approach
• Missed Approach (IFR)

Evidence available

• 3 docket documents

Docket documents3

• Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1form
• FAA Inspector Statementinterview
• Part 135 Pilot Training Recordsother

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