Johnstown air controllers did not realize the danger a prop plane was in before the pilot crash-landed and the Cessna burst into flames, the National Transportation Safety Board’s preliminary report said.

When the Cessna 414 broke out of the clouds at 3:54 p.m. Dec. 26, air traffic controllers saw that it was off course and turning away from the runway. It was climbing slowly.

“All three controllers commented that they thought the airplane was executing a missed approach,” the NTSB preliminary report noted.

The supervisor picked up binoculars and tracked the remaining seconds of the fatal plunge, the report said.

Suddenly, the plane veered back toward the runway and dropped rapidly. The supervisor noticed the landing gear was not down and the trainee radioed, “check wheels down.”

Two seconds later, a controller trainee advised, “Go around. Go around.”

But the plane continued down and hit the runway hard, “like a Navy carrier landing,” about 2,000 feet along the 7,000-foot runway, controllers reported.

Evidence shows that the wheels were down at that time.

Almost immediately, the craft appeared to try to take off again, flying straight ahead another 2,000 to 3,000 feet before swerving to the right, shooting skyward and then nose-diving into the grass about 100 feet off another runway.

Within 20 or 30 seconds, witnesses said, the wreckage burst into flames.

Pilot Maureen McGee and nurse Diane Efaw, 47, were killed instantly. Both were employed by Flight Source LLC of Morgantown, W.Va. The medical flight was en route to Teterboro Airport in New Jersey to pick up a patient for further transport.

McGee, 47, had reported some ice buildup but never declared an emergency, air traffic Manager Dennis Fritz said.

“She was extremely calm,” Fritz said, recounting his controllers’ description of the flight’s final moments.

If McGee had declared an emergency, or if the tower expected trouble, the trainee would not have been the primary controller. A civilian supervisor and Air National Guard air traffic control specialist were in the tower, ready to take over.

McGee initially radioed Johnstown’s tower she was considering a deliberate “missed approach,” descending to near ground level in an attempt to get below icing conditions.

“It depends on if ice comes off or not,” McGee radioed. “If the ice does not come off, we’re gonna land.”

Those were McGee’s last recorded words, according to the report.

Icing is a common problem at Johnstown, said James Cover Jr. of Windber, the local representative for Aircraft Owners and Pilots Association.

The airport’s 2,283-foot elevation often puts it near low-level clouds during winter weather.

Anytime a plane encounters moisture and freezing temperatures, ice can form.

Ice changes the dynamics of aircraft, making them difficult to handle, impairing visibility and adding weight, which requires the pilot to increase air speed, Cover said.

“Ice can build up pretty fast,” Cover said.

It is not yet clear whether McGee realized she was off course, tried to land and lost control because of the ice, Fritz said.

“I don’t know that anyone will ever know what happened,” Fritz said. McGee’s was the first plane landing at Johnstown for about two hours. No earlier outbound aircraft reported icing, he said.

Weather observations included in the NTSB report show ideal conditions for icing, according to a pilots’ association safety advisory. The report notes a temperature of 32 degrees and a dewpoint of 31 degrees, which means there was lots of moisture in the air, Cover said.

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