Extreme Low Pressure

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In its report on the accident, which was released Nov. 5, 2018, the Safety Board concluded that the probable cause of the accident was the pilot's decision to initiate and continue the flight into known adverse weather conditions, which resulted in spatial disorientation, a loss of airplane control and a subsequent in-flight breakup. But did the pilot really make a decision to initiate and continue the flight into known adverse weather conditions? Or did he believe early on that he would be able to remain clear of the adverse weather and later believe that he was making the correct decision to stay away from the worst of it by diverting to his alternate, Tallahassee, Florida?

The airplane involved in the accident was a twin-engine turboprop Fairchild SA-227AC Metro III. It was manufactured in 1990 and powered by Honeywell turboshaft engines. Metroliners like this one can carry up to 19 passengers, but this airplane had been configured to carry only cargo. The airframe had just over 23,233 hours on it at the time of the accident. It had undergone inspection as part of a continuous airworthiness program just over 60 flight hours before the accident.

The 39-year-old pilot held an ATP certificate with ratings for multi- and single-engine land airplanes, single-engine seaplanes and instruments. He held a current FAA first-class medical certificate. His total flight time was 8,431 hours, of which 4,670 were in SA-227AC planes. The cargo flight was scheduled to depart KECP every weekday night at 9:30 eastern time. The direct flight distance between KECP and KABY is 109 nautical miles, so he was a looking at only 25 or 30 minute flights. He would usually spend the night at the Albany airport and fly back to KECP in the morning.

The cargo manifest for the accident flight showed 51 loose packages being carried along with six bags for a cargo weight of 803 pounds. The manifest identified the aircraft as having a maximum gross weight of 14,500 pounds and a four-net barrier system for preventing the cargo from shifting around. The takeoff weight was figured to be 11,400 pounds, including a 1,400 pound fuel load. None of the cargo was identified as "air dangerous goods packages."

In an interview with the NTSB, Key Lime Air's technical programs director said that at the time of the accident, Key Lime operated 30 aircraft and employed 35 pilots. The company is a major operator of cargo flights as well as passenger charters. It had developed a Flight Risk Assessment Tool (FRAT), which had to be completed before every passenger flight but not for cargo flights. The FRAT gave numerical scores to various factors affecting a flight, such as expected weather and fuel on board. If the total of the scores given to all of the factors was too high, management permission would have to be sought to conduct the flight. Key Lime Air's director of operations was quoted by the NTSB as saying that management did not realize FRAT forms were not being prepared for cargo flights and that it was a management oversight. Investigators prepared a FRAT form for the accident flight and found that the risk factors were low enough and the flight could have proceeded without additional clearance being sought. This supports the pilot's decision to initiate the flight.

There were two flight followers on duty at Key Lime's headquarters and dispatch office in Englewood, Colorado, on the night of the accident. About an hour before the scheduled departure time, the pilot made a routine call to the flight follower assigned to handle cargo flights that night. That flight follower told investigators the pilot advised he was "holding on the ground" because of extreme convective activity, which included tornado activity.

About 10 minutes after the pilot checked in, the cargo flight follower received a call from the customer, UPS, wanting to know whether flight 308 had departed. The UPS representative expressed concern that if it didn't take off soon, the cargo would not arrive in Albany in time to be integrated into the UPS system. The other flight follower called the pilot and advised him of the call from UPS. The pilot said he would be departing immediately and would try to make it to Albany by following a corridor of clear weather. The pilot said that if he couldn't get through because of storms, which then were to the west of the flight path, he'd divert to Tallahassee International Airport (KTLH).

The flight was airborne at about 9:54 p.m. While the pilot did have to make slight deviations for weather, things apparently looked acceptable to him on the airplane's Bendix RDS-81 color radar. Key Lime Air's technical programs director told investigators that they had initial and recurrent radar training for pilots. "There are multimedia presentations (videos) about general radar usage along with the RDS-81 pilot guide," he said.

At 10:15:22, the pilot checked in with Jacksonville Center at 7,000 feet, saying he was heading direct to Albany. The controller advised, "...there's a ragged line of moderate-heavy and extreme precip all on this side of Albany. I don't show any breaks. Ah, just continue deviating. Whenever, when able, direct Albany, let me know if you're ready for lower." The pilot replied, "Okay, yeah, we can go ahead and take lower now and, uh, if you can help us pick through that, we got weather, weather radar on board, but, uh, any help we can get will be greatly appreciated." 

At 10:15:55, the controller advised, "Key Lime Three Eight Zero, like I said, I don't show any breaks. Uhm, there's a weaker point but you'd have to be on a zero four five heading for thirty or forty miles before making that turn. There's a pretty solid line of extreme precip between you and Albany right now, and (at pilot's) discretion (descend to) three thousand."

The pilot confirmed leaving 7,000 feet for 3,000 feet. At 10:16:42, the controller radioed, "I don't know if you have the gas, but, uh, if you were gonna stay east of that line and continue on a zero five zero heading for about 70 miles, that's the weakest point right there, to be able to swing back around towards Albany." The pilot replied, "We do have the fuel, uh, but we're gonna see what we can look -- we'll see what it looks like when we get down to about 3,000 and, uh, let's see what the radar is painting then." "All right, sir," replied the controller.

At 10:18:41, the controller advised the pilot, "I'm sorry, I just lost you on radar. I don't show a transponder. It might have something to do with the weather." The pilot radioed, "Uh, we're gonna have to deviate towards the right here a little bit, I think." The controller said, "I'm sorry, say again," and the pilot replied, "Uh, we're deviating a little bit here to the right. We gotta roll out zero six zero heading for Key Lime three oh eight."

At 10:19:36, the controller authorized the pilot to turn left and right as needed and advised, "If we can get you on the other side of that line, we'll have vectors for the ILS for ya."

At 10:20:31, the pilot came up on the radio again: "Jax, uh Key Lime (unintelligible) three zero eight, we're gonna just turn back around to Tallahassee." The controller responded, "Key Lime three zero eight, you want to return to Tallahassee airport?" "Affirm, sir," the pilot radioed. The controller immediately cleared him "present position direct, maintain 3,000 for now." The pilot confirmed, but about half of the transmission was unintelligible. A few seconds later, the controller asked, "Did you want to climb back up? I can offer any altitude you want, Key Lime three oh eight." The pilot asked for 3,000 and the controller approved that altitude and recommended a heading of about 180 to get him clear of the weather faster. The pilot acknowledged the turn to 180 degrees, and that was the last transmission from the airplane.

The Jacksonville Center controller used the interphone system to talk to a controller handling arriving traffic at Tallahassee and advised that the pilot is "!a little shaken up. I don't think he can get past that weather." He said, "I'm trying to vector him to a one eighty heading." A few seconds later, the controller remarked, "He's doing a three sixty or something there." The controller radioed the flight, "Key Lime three zero eight, it looks like you're doing some circling out there. See if you can fly due south, sir." There was no response, and the airplane was lost from radar. When investigators made a plot of the radar returns, the track showed that the airplane made a 540-degree turn to the right while losing altitude. The Jacksonville Center controller asked the pilot of another plane to try to contact the missing airplane and listen for an emergency locator transmitter signal, but there was nothing. Calculations later showed that the airplane was in a 40 to 50 degrees bank, and airspeed varied between 198 knots and 130 knots.

The wreckage was located about 3.4 miles east-southeast of Camilla, Georgia. The debris was spread over an area of about 1/4-mile by 1/2-mile, with pieces of the rudder, elevator and left wing at one end and the main fuselage at the other end. There was a post-crash fire.

Examination of the engines and propellers failed to find indications of mechanical problems. The airplane's cockpit voice recorder could record 30 minutes on magnetic tape. The engines could be heard making oscillating sounds, which the NTSB said were similar to what you'd expect to hear when the airplane was operating in turbulence.

Had the pilot been able to make it to KABY, he would have found weather conditions there were no big deal for an SA-227AC. An observation at about the time of the accident showed the wind was from 090 degrees at 13 knots, visibility was 8 miles in rain, there were scattered clouds at 2,600 feet AGL and broken clouds at 12,000 feet. The temperature and dew point were 16 degrees C.

A study of data recorded by the National Weather Service's weather radar at Tallahassee within a minute of the time of the crash showed that the airplane had been flying in light precipitation very close to the leading edge of a line of heavy-intensity weather. The weather radar antenna was about 50 miles from the accident site. Data recorded about 6 minutes later showed rapidly developing heavy-intensity weather echoes over what had been the airplane's flight path. Data recorded about 6 minutes later showed that the weather had increased from heavy to extreme intensity with activity that might lead to tornadoes.

The NTSB learned that Key Lime Air has a policy not to "retaliate or take negative action against a pilot who elects not to depart due to clear and justifiable reasons regarding excessive risk associated with the flight." If a pilot cancels because of weather, he or she does not lose any pay. Further, company policy stated that the pilot in command "is authorized to exercise operational control in all areas, allowing the safe completion of each flight to which he/she is assigned." It's impossible to know from the information in the NTSB's report whether the accident pilot felt under pressure, real or self-created, from knowing that the customer, UPS, was making inquiries about when he'd be flying. Under company policy, he needn't have been concerned.

The NTSB brought up the phenomenon known as "Get-There-Itis." It cited an FAA Advisory Circular, "Aeronautical Decision Making," which said, "Pilots, particularly those with considerable experience, as a rule always try to complete a flight as planned, please passengers, meet schedules, and generally demonstrate that they have 'the right stuff.'" The FAA said that Get-There-Itis "...clouds the vision and impairs judgment by causing a fixation on the original goal or destination combined with a total disregard for any alternative course of action." The accident pilot, however, had made a decision to abandon his original destination and divert to Tallahassee.

It seems from evidence in the NTSB's report that the pilot had a fairly good idea of what the weather would be like that night, had planned to follow a "clear" corridor, and elected to rely on the airplane's radar and clues from the controller to stay out of the worst of it. He did, after all, elect to head away from Albany and toward Tallahassee. If the pilot made a deliberate decision to fly into known adverse weather, it was not when he decided to take off but when he declined to accept the controller's suggestion of a 70-mile diversion to get around the storms. 

Peter Katz is editor and publisher of NTSB Reporter, an independent monthly update on aircraft accident investigations and other news concerning the National Transportation Safety Board. To subscribe, visit www.ntsbreporter.us or write to: NTSB Reporter, Subscription Dept., P.O. Box 831, White Plains, NY 10602-0831.