NTSB CAROL · Event
Event ERA21LA124
Aircraft involved
Probable cause & findings
The pilot’s failure to follow the published instrument approach procedure by prematurely descending the airplane below the final approach fix altitude to fly under the low ceiling conditions, which resulted in controlled flight into terrain.
Factual narrative
HISTORY OF FLIGHTOn February 7, 2021, about 1647 central standard time, a Cessna 441, N44776, was destroyed when it was involved in an accident near Belvidere, Tennessee. The airline transport pilot and the commercial pilot-rated passenger were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to automatic dependent surveillance-broadcast (ADS-B) data, radar, and voice communications obtained from the Federal Aviation Administration (FAA), the flight departed from Thomasville Regional Airport (TVI), Thomasville, Georgia, about 1527 with a destination of Winchester Municipal Airport (BGF), Winchester, Tennessee. The flight was cleared to flight level 220 after departing TVI. About 1616, the flight was cleared to begin the descent into BGF. About 1640, as the airplane was descending to 4,000 ft mean sea level (msl), the pilot established contact with the Bowling Green, Kentucky, radar controller. The flight was then cleared for the area navigation (RNAV) GPS runway 36 approach into BGF. The airplane crossed the intermediate fix at an altitude of about 4,000 ft. The approach procedure allowed the pilot to cross the intermediate fix at or above 4,000 ft and then descend to cross the final approach fix at or above 3,000 ft. The airplane was observed descending slowly from 3,000 ft when the airplane was about 4 nautical miles (nm) south of the final approach fix. As the airplane descended through 2,300 ft, its radar target disappeared, which was expected due to the limited radar coverage in the area. The last ADS-B target for the airplane showed that it was about 0.6 nm south of the final approach fix and at an altitude of 2,100 ft on a northerly heading. Shortly thereafter, the controller attempted to contact the pilot but received no response. The airplane subsequently impacted trees and terrain about 0.25 nm north-northeast of the final approach fix, which was about 5 nm south of the runway 36 threshold. A postcrash fire ensued. No distress calls were received. PERSONNEL INFORMATIONThe logbooks for the pilot and the pilot-rated passenger were not located after the accident. All flight times were obtained from FAA sources. METEOROLOGICAL INFORMATIONA dissipating cold frontal boundary stretched eastward from Arkansas to Georgia and then northeastward into the mid-Atlantic states. A trough stretched from northeastern Arkansas to northern Tennessee and West Virginia. The accident site was located to the north of the dissipating cold front on the cold side of the front. The station models surrounding the accident site depicted air temperatures in the low 30s (°F), dew point temperatures in the upper 20s (°F), temperature-dew point spreads of 2°F or less, an easterly wind at 5 knots, and overcast sky cover. The weather at BGF at 1635, about 12 minutes before the accident, included a ceiling of 800 ft overcast. The BGF weather at 1655, 8 minutes after the accident, included a ceiling of 1,000 ft overcast. The tops of the clouds were about 4,000 ft, and light rime icing conditions prevailed in the clouds. The pilot received a weather briefing before the flight. The briefing revealed that the pilot was comfortable with ceilings above 500 ft and that he was aware of the icing conditions at the destination. The pilot reported that he had deicing equipment and “onboard weather” on the accident airplane. WRECKAGE AND IMPACT INFORMATIONThe airplane impacted elevated, wooded terrain at an elevation of about 1,880 ft. The debris path was about 260 ft long. The first piece of wreckage found along the debris path was the left-wing tip lens. The farthest piece of wreckage was a light housing. The debris path was on a magnetic heading of about 342°. The fuselage was found inverted on a heading of 260°. Tree strikes indicated that the airplane impacted trees in a left-wing, nose-low attitude before rolling inverted and colliding with terrain. The postaccident fire consumed most of the cockpit, fuselage, inboard left wing, and outboard left horizontal stabilizer. All structural components of the airplane were found within the wreckage debris field. Flight control continuity was established from the control surfaces to the cockpit controls except in areas with tension overload failures. The preaccident position of the main landing gear and the wing flaps could not be determined due to impact and postaccident fire damage. The nose landing gear was in the extended position. The fuel system components were damaged during the postimpact fire. The left fuel cap was securely installed; the right fuel cap separated during the impact sequence. Postaccident examination of the airframe revealed no evidence of a pre-existing mechanical failure or anomaly that would have precluded normal operation. Teardown and examination of both engines found no evidence of a pre-existing malfunction or failure was found that would have precluded normal operation. Both engines exhibited internal signatures consistent with normal operation at impact, including rotational scoring and metal spray on internal components and compressor blades bent opposite the direction of engine rotation. Teardown and examination of both propeller assemblies also found no evidence of a preexisting malfunction or failure that would have precluded normal operation. The pilot was conducting a cross-country flight and was beginning an instrument flight rules approach from the south. Weather conditions at the destination airport included a ceiling between 800 and 1,000 ft and light rime icing conditions in clouds; the pilot was aware of these conditions. Elevated, wooded terrain existed along the final approach course. Radar and automatic dependent surveillance-broadcast data revealed that the airplane crossed the intermediate approach fix at the correct altitude; however, the pilot descended the airplane below the final approach fix altitude about 4 miles before the fix. The airplane continued in a gradual descent until radar contact was lost. No distress calls were received from the airplane before the accident. The airplane crashed on a north-northwesterly heading about 5 miles south of the runway threshold. The elevation at the accident site was about 1,880 ft, which was about 900 ft higher than the airport elevation. Postaccident examination of the airframe, engines, and propellers revealed no evidence of a pre-existing mechanical failure or anomaly that would have precluded normal operation. Because of the weather conditions at the time of the final approach, the pilot likely attempted to fly the airplane under the weather to visually acquire the runway. The terrain along the final approach course would have been obscured in low clouds at the time, resulting in controlled flight into terrain. Source: NTSB Aviation Accident Database Retrieved: 2026-02-12
NTSB Findings
Hierarchical cause / factor breakdown from the FAA bulk avdata database. Each finding tagged C (Cause) or F (Factor).
- — Aircraft-Aircraft oper/perf/capability-Performance/control parameters-Altitude-Not attained/maintained
- — Personnel issues-Action/decision-Action-Incorrect action performance-Pilot
- — Environmental issues-Conditions/weather/phenomena-Ceiling/visibility/precip-Obscuration-Contributed to outcome
Verbatim from NTSB's published report. Source file
NTSB_2021_ERA21LA124.txt.
Findings + structured fields enriched from FAA avall.mdb.
Full investigation docket on
data.ntsb.gov ↗.
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Related research
What the literature says.
Academic papers and agency reports matching this event's aircraft type or causal vocabulary (icing, stall, controlled flight into terrain). Sourced from NASA NTRS, NTSB Safety Studies, FAA CAMI, AOPA Air Safety Institute, Embry-Riddle Scholarly Commons, arXiv, and the Semantic Scholar academic graph.
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- arXiv 2022 · arXiv preprint
Enhanced Prediction of Three-dimensional Finite Iced Wing Separated Flow Near Stall
Icing on three-dimensional wings causes severe flow separation near stall. Standard improved delayed detached eddy simulation (IDDES) is unable to correctly predict the separating reattaching flow due…
- NASA NTRS 2019 · Contractor Report (CR)
An Evaluation of an Analytical Simulation of an Airplane with Tailplane Icing by Comparison to Flight Data
This report presents the assessment of an analytical tool developed as part of the NASA/FAA Tailplane Icing Program. The analytical tool is a specialized simulation program called TAILSM4 which was de…
- NASA NTRS 2019 · Technical Publication (TP)
NASA/FAA Tailplane Icing Program: Flight Test Report
This report presents results from research flights that explored the characteristics of an ice-contaminated tailplane using various simulated ice shapes attached to the leading edge of the horizontal …
- NASA NTRS 2019 · Other
[Tail Plane Icing]
The Aviation Safety Program initiated by NASA in 1997 has put greater emphasis in safety related research activities. Ice-contaminated-tailplane stall (ICTS) has been identified by the NASA Lewis Icin…
- Embry-Riddle Scholarly Commons 2019 · Journal article (IJAAA)
Airport Policing in Pakistan: Structure, Training, and Issue
Airports are strategically and economically important installations of any country. Airports are the gateway of any country and any incidents at these gateways may harm the very aspects of a country i…
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